We appreciate Dr. Meshkov's letter. As researchers and clinicians who work with persons awaiting renal transplantation, we are sympathetic to the difficulties that accompany the waiting list experience for patient and family.

Because Dr. Meshkov asks others to understand his situation, however, we find it concerning that he expresses little compassion for families suffering an equally devastating event. His comment that "the usual reason for rejection involves some poorly defined religious principle" shows a lack of respect for families. If families cannot (or will not) articulate their spiritual beliefs to his satisfaction, it may be because they sense that he or others are not truly interested in how they feel but only in persuading them to consent to donation.

We must also point out that Dr. Meshkov has confused the ease with which the police can, equipped with a driver's license, verify a person's driving record with what would be needed under mandated choice. Without a license, and potentially without any confirming identification, hospital personnel would have to search all 50 states to find a person's driving record, verify beyond doubt that this was in fact the record of this patient, and produce evidence to override the family's refusal.

The ethics of the situation are extremely weak. A double standard for donation permission would exist, and the logic would be as follows: If you are a registered driver, you must declare your donation intentions, and your family will have no say in your donation. However, if you do not drive, your family will be the final decision maker, unless you voluntarily sign a donor card. This is an unusual distinction-drivers' families have no rights, but nondrivers' families do.

We are not ready as a society to push families away at the deathbed. Currently, we do not uniformly do so, even in circumstances in which donor cards exist. We believe that until we have resolved the issue under voluntary registration, there is no utility in broadening the arena of conflict.

We must also take issue with Dr. Meshkov's (and Dr. Spital's) belief that our current approach to procurement is inefficient. Procurement has increased at rates that any other public health initiative would envy.

Frustration about the organ shortage should not be directed against families who have lost a relative; they did not cause end-stage organ disease to occur. Funds used for mandated choice could be better spent on public education; on organ donation; or on primary and secondary prevention of such diseases as hypertension, diabetes, and alcoholism, which lead to organ failure. All these are proven strategies to close the gap between organ supply and demand. If a finite number of procurable cadaveric organ exists, this is an issue we must all address, not just those who have lost a loved one.