Joan Smith: Why are we quite so squeamish?

There are endless arguments over our capacity for altruism, but it's an incontrovertible fact that 16.5 million individuals have placed their names on the organ donor register

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The American crime writer Patricia Cornwell has had phenomenal success with a series of novels containing blow-by-blow accounts of post-mortem examinations. Her heroine, Dr Kay Scarpetta, is forever getting ready to dissect her latest cadaver, a process Cornwell describes in authentic and sometimes excruciating detail. It hasn't put off her legions of fans, but it sits oddly with the squeamishness about death and post-mortem dissection which affects so many people when they consider the subject of organ donation.

Each year, fewer than half the 8,000 individuals waiting for transplants in this country are able to have them because of a chronic shortage of donors. Around 1,000 patients die because of the shortage, which is why an independent think tank has launched a consultation which will consider radical options such as paying for organs.

The Nuffield Council of Bioethics has suggested other ways of encouraging more people to register, such as offering to pay donors' funeral expenses or giving priority to individuals on the register if they need a transplant; its three-month consultation will look at all kinds of donations, including organs, skin, blood, corneas, bone, sperm, eggs and embryos.

Professor Dame Marilyn Strathern, who will chair the inquiry, summed up the dilemma facing doctors seeking to boost the supply of donated organs to meet the needs of gravely ill patients: "We could try to increase the number of organ donors by providing stronger incentives, such as cash, paying funeral costs or giving priority for an organ in future, but would this be ethical?" The council's director, Hugh Whittall, pointed out inconsistencies in the present system, which allows modest expenses to be paid to egg and sperm donors (up to a cap of £250) while banning payment for blood and organs.

This is not the case in every country, and I have friends who resorted to selling blood when they ran out of money during student travels 20 or 30 years ago. They regarded it as a harmless one-off but the argument against paying for blood – which also applies to allowing living donors to sell body parts – is that it's an invitation to people with limited resources to risk their health. I don't think you would find many millionaires offering to sell a kidney, even if it were legal to do so in this country, but a healthy young man or woman with £30,000 in credit card debts might be desperate enough to consider it. The fact that India has a booming market in organs, even though the practice is illegal, is directly linked to that country's huge discrepancies in wealth; poor people sell kidneys for as little as $2,000, not realising that they are unlikely to get the after-care they need and may never fully recover.

It would be possible, of course, to allow payments to donors or their families in strictly regulated circumstances. A majority of transplant surgeons oppose the idea, according to Keith Rigg, a kidney transplant surgeon and member of the inquiry team, and many non-experts will feel an instinctive revulsion. There are endless arguments about the role of altruism in human behaviour but it's an incontrovertible fact that 16.5m individuals have placed their names on the organ donor register, motivated by nothing more than a wish to help someone (more than likely a total stranger) after their own death.

The problem, to put it bluntly, is that they are dying in insufficient numbers to meet demand for hearts, lungs, livers and kidneys. There are many reasons for this imbalance, from increased longevity – more kidneys are needed as the population ages, for instance – to the decline in deaths of healthy people in road traffic accidents.

Clearly the key question is how to persuade more individuals to register, and some of the incentives suggested by the Nuffield team are certainly worth considering. Offering to pay donors' funeral expenses helps their families and is thus a gesture of reciprocal generosity, while there may be a principled case for giving priority to individuals who are themselves prepared to register as donors.

But it's just as important to establish why so many people refuse to allow the organs of family members to be removed for re-use after death; it's a depressing fact that this happens in between 40 and 50 per cent of cases when a request is made, even when the deceased had placed his or her name on the organ donor register.

Religious objections appear to play a relatively small part, but a sizeable number of relatives simply cannot bear the notion of body parts being removed post-mortem; there's widespread ignorance about what organ donation actually involves and some relatives even express fears about death being hastened because another patient is waiting for a transplant. Studies have also thrown up a gender divide, with women showing a greater willingness to become donors themselves or agree to the use of deceased relatives' organs.

One way to deal with all this is to operate an opt-out system, where everyone is presumed to be willing to donate organs after death unless they express a wish to the contrary. That hasn't been tried in this country, and it might not be necessary if more attention were paid to studies suggesting that class and education have a big influence on decisions about registering as a donor or agreeing to the use of a relative's organs.

Some objections are superstitious in origin or rooted in a distrust of doctors, but that doesn't mean they can't be overcome; when people are given practical information in discussions with health professionals, they become much more willing to consider donation.

In that sense, it may even be that the graphic descriptions of post-mortems in crime fiction are unhelpful, encouraging readers to think about the damage inflicted on cadavers instead of the prospect of restoring someone else's health. I don't doubt it would be possible to create a market in organs, but far better to persuade many more people to consider making the immeasurable gift of life.

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