There is little doubt that successful organ transplants make miracles out of miserable lives. Quality of life increases and patients are able to return to a fairly normal life. A parent survives to see kids get married. A child is gifted with a bright disease-free future. A sibling receives an organ from a brother or a sister. When it all works properly the feel-good stories are hard to miss.

However, there are many other stories that end in loss as significant numbers of people on donor lists die before a match is found or before they have moved up the list enough to be considered. It's a simple case of supply and demand, and in the case of organ donation demand outstrips supply across the world.  Fretting bioethicists and the wider medical community all tell the same tale: That people are dying while waiting for organs. Supply is severely limited. A greater organ supply would inevitably mean that many premature deaths could be avoided and that many more lives could be saved.

At the very core of the transplant world is the idea of altruism - that there are many people in the world who will selflessly volunteer to share an organ or to give permission for organs of a loved one to be harvested after death. The sense of contributing to the general good is, indeed, a very powerful idea, but it's not enough. There just aren't enough people willing to sign up to be donors (in spite of concerted education efforts) or to give permission for the sharing of others' organs.

How, then, to address this vexing problem? Many solutions have been debated over the last 20 years and several countries have made good faith efforts to rectify the situation. For example, Israel has begun to implement guidelines giving preference for donor organs to those who sign a donor card. Essentially this creates a distinct class of people who will be able to access organs while those who do not sign donor cards would not. Spain several years ago introduced an opt-out solution. That is, you were presumed to be an organ donor unless you specifically indicated that you did not wish to be a donor. This has been seen by some as preferable to what we have in the US, an opt-in model that has meant far fewer potential donors. The only country that has faced the supply/demand issue head-on has been Iran, where an actual donor market legally exists and where there are very few donor shortages. In 1998 the Iranian government began compensating live donors and in 2000 extended benefits to the families of dead donors. The government compensates live donors as do the recipients of the organ. There is also money available to assist recipient payments to the donors if they are unable to do so themselves.

Furthermore, altruism alone is being questioned as the only way to procure organs from living or dead donors. Several alternatives to altruism are currently being discussed and it should surprise nobody that these incentives revolve around money or the demolishing of ethical standards.

In fact, things are taking a decidedly darker turn.

First is the burgeoning illegal trafficking in human organs where people are prepared to pay handsome black market prices for a no-questions-asked kidney, liver, or heart. Unscrupulous middlemen prey not only on the potential recipient, but also on the poor and vulnerable who are often cheated out of organs for a pittance. Nowhere is this practice more odious than in China, where organs are harvested from the corpses of freshly killed prisoners and sold to recipients anxious to survive at any cost. Legal regulation may lessen the demand for available organs but is also likely to drive unethical procurers deeper underground.

Second, some countries are looking at the bottom line of cost. Recently, the UK's Nuffield Council on Bioethics floated an idea to monetarily incentivize organ donors by suggesting that the funerals of dead donors be paid for by the state. Financially, everyone wins. It's way cheaper for the government to pay for a funeral than for the extensive medical care for someone who can't get a kidney, for example. However, reducing an altruistic act to a cold-hearted financial contract in and of itself may well change the motivations of both potential donor and recipient. Again, the poor and vulnerable are likely to be targeted and perhaps manipulated into signing up based on financial considerations.

Another more chilling alternative has been offered recently by several Belgian doctors attempting to increase the number of organs available for transplantation: Harvesting the organs of euthanized patients. Euthanasia is legal in Belgium and most often occurs in the patient's home. However, the Belgian doctors saw an opportunity to determine the exact moment of death, thereby providing optimum conditions for removing the euthanized patient's organs. They describe in detail their procedure from admission of the patient about to be euthanized, how the living patient was medically prepared for organ harvesting after death, how the patient was killed and how the organs were removed by a waiting surgical team in an operating theater adjoining the death room. It's a clinically grizzly read, made all the more chilling by the assurance that the euthanized patients had agreed to have their organs harvested after being killed. Whether this can be classified as an act of altruism on the part of the patient is debatable.

The Belgian example also touches on another area: When is a patient really dead? There are two types of recognized definition of death. One is cardiac death, where the heart has stopped beating. The other is brain death, where all brain function is lost. What is problematic, though, is the time between cardiac death and brain death because even if the heart has stopped brain activity occurs at some level. Waiting for brain death takes quite a bit longer than cardiac death. The longer the wait, the more likely it is that the organs for donation will begin to deteriorate. In the Belgian case, they were in a hurry. They confirmed that the patients had no heartbeat and were not breathing, but offered no evidence that they waited for brain death to occur. So, when was dead really dead and were the doctors cutting ethical corners in a rush to harvest organs?

Obviously, solving the supply/demand dilemma is complex. The question, however, should perhaps not be how we can find more organs for donation and how quickly we can retrieve them, but whether we are really comfortable with moving from noble altruism to medically killing people for their organs.

And it might be said that euthanizing patients in a hospital for their organs is not that far removed from getting organs from executed Chinese political and other prisoners in a prison.

Dr. Mark P. Mostert lives in Virginia Beach, VA. His bioethical news blog can be found at drmarkaliveandkicking.blogspot.com and on Twitter @No2prodeath.  E-mail at markpmostert@gmail.com.