The recent important report by Sesso and colleagues [1] confirms that transplantation of kidneys from living, unrelated donors (LUDs) is at least as effective as transplantation from cadaveric donors. The authors' conclusion, however, that "payment for the donor or ‘rewarded gifting’ is unacceptable" ignores a wealth of literature, which suggests that, under certain circumstances, financial incentives for living organ donation may indeed be reasonable.

Almost all agree that rampant commercialism, where the care of the donor is less important than the profit, is reprehensible [2]. Yet, some have suggested that rewarded gifting, wherein the donor is compensated under strict controls without middlemen, may be acceptable. Perhaps the most extensive published experience comes from Reddy and colleagues in Madras [3, 4]. In India, because the supply of dialysis facilities and kidneys from cadaveric donors are extremely limited, the diagnosis of end-stage renal disease is for many the equivalent of a death sentence. This situation led the group in Madras [3] to ask "Do we buy or let die?" They decided to embark on a program that accepted LUDs, using a system of rewarded gifting. Under their program of tightly regulated, paid donation, excellent medical care is provided for the donor in addition to 3 years of medical insurance. In more than 300 transplantations of kidneys from LUDs, they have achieved excellent results with no donor mortality and no decrease in the number of living, related donors [3, 4]. Other prominent transplant physicians have also concluded that rewarded gifting may be acceptable, at least in some parts of the world [2]. Even the Transplantation Society [5], which strongly opposes commercialization, agrees that "reimbursement for loss of work earnings and any other expenses related to the donation is acceptable."

As we encounter new and complex ethical problems in medicine, we must remain open-minded and be willing to explore creative new plans and ideas. Dogmatic statements that ignore the views and experience of others should be avoided.