In Los Angeles County and six neighboring counties, more than 6,000 people await donated kidneys to replace their own failing organs. Nationally, the waiting list for those precious organs has nearly 75,000 names on it. Unfortunately, only a little more than one-fourth of that number will have their needs met. The others face an uncertain future that for many will end in death.

This doesn't have to happen. There are literally millions of people in this country who could make up that shortfall of 56,000 kidneys. Tests have long shown that healthy human beings can function normally with just one of the two kidneys they were born with. So how can more of those healthy people be motivated to give up a kidney?

At present, the satisfaction of helping others to survive is the only reward that exists for organ donation in the United States. But living donors are providing only about 6,000 kidneys a year (the rest come from deceased donors). So it's quite apparent that a stronger incentive is needed.

It isn't difficult to identify a stronger incentive. If potential donors were offered cold, hard cash and made aware that they can lead a normal life with a single kidney, there's little doubt that the donation rate would be much higher.

The United States wouldn't be breaking any new ground if it started authorizing the purchase of kidneys. In at least three countries Iran, Pakistan and the Philippines paying cash for kidneys has been a standard practice for many years.

But to do so in this country would raise a number of concerns.

How much should be paid for a kidney and who should pay it? The recipient, or the government, via Medicare? A payment of $5,000 would probably be sufficient to attract more than enough donors to erase the current shortage of 45,000 kidneys a year.

Or, instead of a fixed amount for the kidney itself, should the payment also cover expenses for hospitalization and recovery? And what about wages lost by the donor during the donation and recovery period? Should donors get guaranteed insurance coverage rather than cash?

But these technical questions pale in comparison to other issues that would be involved in paying for kidney donations.

A major concern is whether this country would be creating an organ-growing class. In Iran, according to a recent study, 81 percent of those who were paid for kidney donations are illiterate. They use the money they make from selling their kidneys to eke out a living.

In India, the literacy rate among kidney donors is a little higher but most are very poor. A recently published study of kidney donation in that country found that although donors might receive $5,000 to $10,000 for a kidney, little if any of that sum was used to improve their lot or that of their families; 70 percent to 80 percent went to repay debts.

Medical underclass?

This is not to suggest that paying for kidneys in America would create a new layer of economic stratification. Few in this country are as poor as in the countries that allow and encourage kidney donation. But there is little doubt that if payment for donation were permitted in this country, a huge percentage of the donors would be poor people. And if the recipients of kidneys, and not the government, were paying for them, the practice would be viewed by many Americans as allowing the rich to take advantage of the poor.

Such a perception would indeed be unfortunate. But it would not be the worst-case scenario. It is possible that potential donors of other organs livers, hearts, lungs, pancreases and small intestines would react negatively upon learning that people were being paid for their kidneys. It might be that fewer drivers would sign up as potential donors when getting or renewing their licenses because they assumed that paid donors were filling the need.

Well aware of all of the questions and issues involved in this matter, most of us in the field of organ donation and transplantation are reluctant to call for a nationwide effort to pay for kidney donation. I believe the best way to proceed would be with small-scale pilot programs that offer donors lifetime insurance coverage and see what the effect would be.

If such programs do not indicate that there would be any negative effect on the national organ donation process, then the practice of paying for kidneys through insurance coverage and similar non-cash incentives should be allowed.

Thomas Mone is chief executive of OneLegacy, a non-profit organ procurement organization serving L.A. and six neighboring counties. He is also president of the Association of Organ Procurement Organizations, and is a director of the United Network for Organ Sharing.

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