The issue of living organ donation is important to Congress because it represents one important set of possibilities for balancing the needs of people seeking organs with one another, and with the needs of potential organ donors. On one side of the balance, the drive to increase the supply of transplantable organs is fueled by people awaiting organ transplants. They are, in a sense, competing with one another on waiting lists for potentially life-saving scarce resources. On the other side of the balance, the drive to ensure that the transplant system is ethical and equitable precludes some mechanisms that would increase the supply of transplantable organs. Some options that have been rejected to date in the United States include paying healthy persons to donate their organs, and mandating that transplantable organs be harvested from all cadavers. To maintain the most ideal balance for the organ transplantation system, Congress may now wish to clarify whether certain new types of living organ donation should be adopted to increase the supply of transplantable organs, or prohibited for ethical and/or equitable reasons. The demand for transplantable organs is outpacing the supply at an increasing rate. In the United States in 1988, there were 16,026 individuals on the waiting list for an organ transplant. By 1995, the waiting list had increased almost 175%, to 43,937. Since then, it has more than doubled again. As of March 12, 2010, the waiting list held 106,131 candidates, including 83,754 people seeking kidneys. Each day, an average of more than 300 people are added to the transplant waiting list, yet less than 80 organ transplants are performed. One patient dies approximately every hour and a quarter awaiting a transplant. In order to help ensure that organs are equitably distributed, Congress passed the National Organ Transplant Act of 1984 (NOTA). NOTA authorized the Secretary of the Department of Health and Human Services (HHS) to establish the Organ Procurement Transplantation Network (OPTN), by contract. Currently, the OPTN is administered by the United Network for Organ Sharing (UNOS) under contract with the Health Resources and Services Administration of HHS. The OPTN and UNOS have established a national system for matching organs and individuals in need of organs. In addition, the OPTN and UNOS set policies for United States transplant centers and organ procurement organizations (OPOs). The 1984 NOTA also prohibited the buying and selling of human organs by making it unlawful to exchange valuable consideration for human organs for use in transplantation. The 1984 Act did, however, allow reasonable payments to be made to living donors for expenses relating to travel, housing, and lost wages in connection with the donation of an organ. Currently, the United States organ procurement system is composed of 58 OPOs, which provide all the deceased and some living donor organs for the nation's 249 transplant centers. Each OPO has a contiguous geographical service area designated by the federal government for recovering organs in all hospitals in that region. Each OPO is required to be a member of and provide transplant candidate information to the OPTN, which maintains the master waiting list of individuals seeking transplants in the United States. OPOs may also implement regional organ allocation systems different from the national OPTN system for the purpose of increasing organ availability and/or organ quality, reducing or addressing an inequity in organ allocation/distribution unique to a local area, and/or examining a policy variation intended to benefit the allocation/distribution system overall. In 1986, in order to help increase the organ supply available for transplantation, Congress passed legislation requiring virtually all hospitals to establish protocols requiring health professionals to make organ donor requests. In 2004 Congress passed the Organ Donation and Recovery Improvement Act, the first federal law directly applicable in part to living donors (i.e., living people who donate either an organ they can survive without, such as one of their two kidneys, or a portion of an organ, such as a liver). Living donation is preferable for transplant recipients, because kidneys recovered from live donors typically outlast those from deceased donors. The law amended the Public Health Service Act to authorize the HHS Secretary to award grants to states, transplant centers, qualified organ procurement organizations or other public or private entities to reimburse travel, subsistence, and incidental nonmedical expenses incurred by individuals toward making living organ donations. The law also authorized the Secretary to establish and maintain mechanisms to evaluate the long-term effects associated with living organ donations by individuals who have served as living donors. For all types of donations, the law created and authorized funding for donor awareness programs. Government oversight of the living donation process is limited, and some OPOs have organized non-traditional programs for living donors. A typical living donor program allows individuals to receive transplants from living spouses, parents, or friends who are willing to donate and are biologically compatible. Questions have been raised about the entire process of living donation and the multitude of health, financial, and social post-operative risks that the living donor faces. (For a detailed discussion of these, see the final section of this report.) In part to help answer some of these questions, in 2007, Congress passed the Charlie W. Norwood Living Organ Donation Act ( H.R. 710 ; P.L. 110 - 144 ). One provision of the law requires the HHS Secretary to submit annually to the appropriate committees of Congress a report that details the progress made toward understanding the long-term health effects of living organ donation. In addition, as discussed in detail below, this law clarified that human paired organ donation does not violate NOTA's prohibition against the exchange of valuable consideration. Over time, Congress has considered a range of legislation aimed at encouraging the practice of living organ donation. Some bills aim to increase donation by providing a tax credit, as proposed in H.R. 218 , the Living Organ Donor Tax Credit Act of 2009. Others, such as H.R. 2776 , the Living Organ Donor Job Security Act, would entitle certain employees to unpaid leave under the Family and Medical Leave Act of 1993 (FMLA) if they provide a living organ donation. A third type would have directed the Secretary of the Treasury to design and strike a bronze medal to be awarded to organ donors and/or their families, as proposed in H.R. 4753 / S. 2283 (109 th ). As described above, in traditional living donation, a specific donor, who is biologically compatible with his or her intended recipient, donates an organ to that person. To accommodate willing living donors who are not biologically compatible with their intended recipients, some other types of directed exchanges—in which a donor specifies who is to receive his or her organ—have emerged. One is paired donation (also known as paired organ donation or human paired organ donation ). In paired donation, two or more donors whose kidneys are incompatible with their own intended recipients, but compatible with each other's, trade donations. Each recipient receives a compatible kidney from a living donor. P.L. 110 - 144 clarified that NOTA's prohibition on the exchange of valuable consideration for organs does not extend to paired donation. Prior to the passage of this law, the exchange element of paired donations triggered questions about whether such arrangements represented the exchange of valuable consideration for an organ. If so, these arrangements would have been illegal. P.L. 110 - 144 contains the following definition of human paired organ donation: (A) An individual (referred to in this paragraph as the 'first donor') desires to make a living donation of a human organ specifically to a particular patient (referred to in this paragraph as the 'first patient'), but such donor is biologically incompatible as a donor for such patient. (B) A second individual (referred to in this paragraph as the 'second donor') desires to make a living donation of a human organ specifically to a second particular patient (referred to in this paragraph as the 'second patient'), but such donor is biologically incompatible as a donor for such patient. (C) Subject to subparagraph (D), the first donor is biologically compatible as a donor of a human organ for the second patient, and the second donor is biologically compatible as a donor of a human organ for the first patient. (D) If there is any additional donor-patient pair as described in subparagraph (A) or (B), each donor in the group of donor-patient pairs is biologically compatible as a donor of a human organ for a patient in such group. (E) All donors and patients in the group of donor-patient pairs (whether 2 pairs or more than 2 pairs) enter into a single agreement to donate and receive such human organs, respectively, according to such biological compatibility in the group. Prior to the passage of the law, OPOs in Washington, D.C., and New England had implemented two types of programs for the exchange of kidneys. One was paired donation, which was addressed in P.L. 110 - 114 , and the other was list donation , which was not addressed in the law. In a list donation exchange, a donor who is incompatible with an intended recipient makes a donation to a stranger on the waiting list. In return, the intended recipient advances on the waiting list for a deceased donor organ. While receiving a kidney from a living donor may be preferable to receiving one from a deceased donor, recipients of organs from deceased donors still have a much greater chance of survival than those who remain on dialysis. (Dialysis is a mechanical process designed to partially perform kidney functions.) List donation is similar to paired donation in that it is a directed living organ donation exchange program that may facilitate increased organ donation. However, it is different in two distinct ways. First, unlike paired donation, list donation disadvantages people seeking transplants who have blood type O. (See the " Ethical and Policy Issues Related Living Organ Donation, and Paired and List Donation " section of this report for details). Second, the effect of the passage of P.L. 110 - 114 on the permissibility of list donation is unclear.