Is the Canadian legal framework too restrictive and based on false premises?

Introduction Given the increasing shortage of organs in recent years, there has been an abundant empirical and theoretical literature on incentives to improve organ donation [1,2]. Some of these incentives, such as reimbursement of donor expenses, are uncontroversial whereas others, such as payment for organs, are matters of heated debate. In this issue of the Journal, Caulfield and colleagues provide an in-depth legal analysis of various incentives in the Canadian context [3]. They show us that in Canada, organ donation is based on altruism; organs are viewed as a gift; and the law dictates that organ donation should be “gratuitous” and without any “rewards and benefits” or “valuable consideration”. This means there can be no measures that might encourage or influence organ donation. As the authors demonstrate, this legal framework is restrictive and bans not only the trade of organs, but also most of the monetary and non-monetary incentives currently used in organ donation. In this editorial, I will discuss the relevance of the principle of altruism in organ donation and the contradiction between the legal definition of a gift and gift-exchange theory and show how the current Canadian legal framework is out of sync with the empirical data on incentives.