However, the debate surrounding the Gurgaon scandal actually threw up some new ideas suggesting ways to increase the organ donor pool in India. If examined superfluously, they have the potential to cause a jump in the availability of organs. However as a surgeon involved with transplantation I feel that these deserve serious discussions in the public domain.

One idea is the plea by some commentators that it may be best to legitimise the trade by having a legal framework for the buying and selling of organs. This proposal is not new but has seldom been articulated in the national press.

Over the last decade a section of philosophers in the West have built up arguments in favour of such a project using two broad premises. The first is that since every individual is the owner of his or her body he or she has the right to sell a part of it and restrictions impinge on their liberty Also, since anyway we are in a mar . ket-driven society why not apply those principles to organs. Such arguments conveniently make some assumptions. First, that it is legitimate and acceptable to apply market principles to all aspects of life. Also, individuals selling their organs do so of their volition, ignoring the social deprivation which is the basis. Studies of such donors from India have shown that most of them find it humiliating. Incidentally although there is a shortage of organs all over the world, no country, including the US with its free market economy, has as yet sanctioned a legal trade in organs. The other argument is that since anyway we cannot stop the organ trade we may as well legalise it as this will ensure proper medical standards and protect the donor from being duped. This is perverse logic and smacks of a quick fix approach as the alternatives are much more challenging to confront and implement. In any case the votaries of the regulated organ trade need to tell us how this will be bound by the rules of fair play, transparency and equity for all the players involved. How will the prices of organs be fixed? Also why, if there is such a market, will those affording it ever motivate the relatives of patients for organ donation? Also won't it perpetuate the already undesirable situation of the rich invariably benefiting from the organs of the poor?

The other idea from the post Gurgaon churning is the Union Health Minister's announcement that the government is considering ‘presumed consent' to boost ca daveric donation. This presumes that or- gans can be removed from the brain dead unless they have expressed a desire dur- ing their lifetime to ‘opt out' of this scheme. Thus instead of the worldwide practice of people pledging their organs by signing a donor card (opt in) or rela- tives giving consent, this law would sanc- tion removal of organs without the fami- ly's consent. When the Human Organs Transplant Act was passed in 1994 it had a dual purpose. Besides banning trading in organs, it legalised ‘brain death', making removal of organs from brain dead cadav- ers permissible after the families consent. This is the commonest form of consent worldwide and only a handful of countries have moved to presumed consent after extensive public debate.

In India where the concept of cadaver donation has not even sunk in, to move to ‘presumed consent', where the relatives will not be informed and not requested for removing organs, can only unleash chaos and conflict. The lack of progress on ca daver donation, the basis for such propos als, is inaccurately ascribed to ‘lack of public awareness'. This is not the whole truth. In the hospital in Mumbai where I work, a concerted effort with the appoint ment of a dedicated transplant co-coordi nator and education of staff has yielded a consent rate of around 50 per cent, a fig ure close to Western countries.

The recent experience from the Armed Forces medical institutions is similar. It seems that if there is an effort by any in stitution to promote organ donation and identification of brain-dead donors by ICU personnel, the consent rate is likely to be good. Cadaveric transplants are not being performed not because of lack of awareness and refusal by families to do nate but because of absence of institu tional mechanisms to approach families of brain dead individuals. It is the same story as in eye and blood donation which have a much longer history in India. Perhaps this reflects the state of health care in India where activities like organ donation suffer because government institutions are grappling with basic problems and private institutions do not see these translating into profits.

Transplantation currently benefits a minority of pa tients suffering from end-stage disease. This perspective is important as it would be sobering to note that any solution is unlikely to change this dramatically and trying to increase organ donation by buying organs or forcing consent is dangerous and shortsighted. As individuals who may be in need of an organ in the future for ourselves or for one of our dear ones, we need to appreciate that transplantation in India needs to be restored to what it actually represents: a voluntary gift of life to the dying and an example of solidarity among human beings. This may mean joining in the struggle for an evolved care system on one hand and promoting human solidarity on the other.

Dr Sanjay Nagral is Consultant Surgeon, Jaslok Hospital and Research Centre, Mumbai