The acute shortage of transplantable organs has affected patients across the country. To save more lives, a change in attitude is needed.

Yes. Half the children waiting for a new heart or liver die without one. About 16,000 adults are on kidney dialysis awaiting a transplant. A third of those waiting for livers die. Tens of thousands are waiting for skin, bone and corneas.

Thousands more aren't even put on waiting lists because doctors know there are no organs for them. How could there not be an obligation to donate?

Historically, we've treated organ donation as a heroic gift. But it is not heroic; it is a duty. People should feel a strong obligation to donate organs and tissue unless they have a powerful religious reason to oppose it.

Doctors and nurses have an obligation to request organ and tissue donation. They must do it in a way that shows they don't think it is some trivial, bureaucratic task. The budget for educating professionals about how to ask for organs is between nothing and almost nothing. Church groups, civic groups, high schools and business and social organizations could make it clear that being a good citizen means carrying a donor card.

And people who've signed donor cards don't realize that if they're in a serious accident, the chance of a driver's license and donor card making it to the hospital are slim. It's best to reinforce the card with discussions with your physician, family, friends and a member of the clergy.

Also, there's still need for education about brain death. Some people feel their doctors are not being honest when they say their loved ones are brain dead. And despite all the pious rhetoric, society must make sure access to transplants is fair. The fastest way to decrease organ availability is to make access contingent on ability to pay. If only the rich can get transplants, people won't donate. -- Arthur Caplan, PhD Director, Center for Biomedical Ethics, University of Minnesota

No. There are more important issues in medical care, and we need to face them squarely. One is effective allocation of funds. The other is whether quality or quantity of life is more important.

While I agree that people should be willing to donate organs and tissues, I am not sure that we should call it a duty. We should donate out of love, out of the idea that it's a blessing to share our life with someone else. We should do it not out of law or obligation but out of a sense of sharing and participation, which should extend to other areas of medical care. For example, in Oregon in 1987, we had a child on Medicaid who needed a marrow transplant, which then cost about $70,000. At the same time, we had a number of women on Medicaid with absolutely no prenatal care. The legislature was faced with the question of using limited Medicaid funds to give 2,000 children a fairly decent chance of coming into this world healthy, or taking the chance that the transplant would save the life of one child. They chose the former.

This doesn't mean the people of Oregon are inured to the suffering of people who need transplants. Four marrow transplants have been funded through charity events.

But because of rising costs, the community's ability to meet such costs is about at its limit. And given the kind of biomedical research we're engaged in now, we're going to create all sorts of possibilities for keeping people alive.

One way we could curtail the demand for organs and tissue is for people to decide, as we did in Oregon, how their health care dollars will be spent. The prevailing notion that we can all have everything cannot continue. -- Ralph Crawshaw, MD Clinical professor of psychiatry and of environmental health, Oregon Health Sciences University

1990, Physician's Weekly, a Whittle Communications Publication; reprinted with permission