With the gift-giving season upon us, it is as good a time as any to think about the gift that keeps on giving — your organs. Another reason to think about organ donation is that on Tuesday the Matsuyama District Court will sentence a 59-year-old man who was convicted of buying a kidney from a woman. Under the Organ Transplant Law, paying for an organ is a crime, and the case has drawn attention to the medical options of thousands of people suffering from kidney disease.

Suzuo Yamashita admitted to paying the donor 300,000 yen after his operation in September 2005. He also gave the woman a car worth about 1.5 million yen. According to various media reports, the woman thought she should receive more and complained to the police, even though selling an organ is also a crime. (She ended up paying a 1 million yen fine)

In Japan, the transplant of an organ from a living donor can only be carried out when the donor is related to the patient. Since 2003, however, the family-only rule can be waived if the surgery is approved by a transplant ethics committee. In the Matsuyama case, the donor pretended to be Yamashita’s sister-in-law. The imposture was necessary since the surgeon, Makoto Mannami, and his brother, Rensuke, also a surgeon, don’t belong to any medical association and have had trouble with ethics committees in the past.

But it should be noted that the family-only rule does not limit living donors to blood relations — in-laws or third cousins through adoption can give their organs to patients just as easily as siblings or parents can. In the past 15 years, the development of antirejection drugs has made it possible for a person of one blood type to donate a kidney to someone of a different blood type, so the only reason for the relative-only restriction is that it presumably prevents the kind of cash-for-organ practice characterized by the Matsuyama case.

In a related article in the Asahi Shimbun, a psychiatrist who advises people planning to donate organs to family members says that the rule is related to the idea of “voluntary donation,” but some of the donors he talks to are unwilling to give up their kidneys. In almost a third of the cases he’s handled, the donors say they are pressured by family and feel they cannot refuse. In such situations, they secretly ask the surgeon to tell their families that their kidneys are unfit for transplantation.

Along with corneas, kidneys are the only organs that can be transplanted from donors whose hearts have stopped, as opposed to so-called brain-dead donors. Either way, a donor still has to have given permission for organ donation while he or she was alive, and, since organ donation still carries a stigma in Japan, it’s difficult to get people to register and difficult to get their families to grant permission to harvest their organs after they die.

According to a recent TBS news report, in 2005 there were 257,000 people in Japan on dialysis, 11,800 of whom were waiting for kidneys. However, only 994 received new organs, be they from living or dead donors. Consequently, Japanese people with kidney diseases will go to great lengths for a transplant. The TBS report followed a Chiba man in September to China, where he paid 5 million yen for a new kidney that was obviously taken from an executed criminal. International outrage over the practice has since prompted the Chinese government to suspend all transplants to foreigners.

Kidneys are doubly special in transplant terms in that every human is born with two and almost everyone can function normally with only one. The Mannami brothers have tried to stress this point, but the scandalized coverage of their operations has characterized them as being mad scientists who treat patients as meat.

A closer look at the Mannamis’ situation shows that it is more complex and problematic than the coverage would indicate. Makoto insists that kidney transplants are no big deal. There is very little loss of blood and only a 5- to 7-cm scar as evidence that one has donated an organ.

However, the main controversy is that Makoto transplanted so-called unhealthy kidneys into some of his patients. The government found that 13 unhealthy kidneys were removed by Mannami and transplanted into people who needed new kidneys. Four of these organs were cancerous and the tumors were removed before being transplanted. When asked by TBS why Makoto didn’t just put the repaired kidney back in the original body, Rensuke replied that the patients said they didn’t want them anymore.

Rensuke’s explanation raises more questions than it answers, but most of his patients located by various media have said they completely support him, regardless of his methods, and several have said that they are glad that he offered them the unhealthy kidney option. Rensuke said he and his brother expected the Matsuyama case to expose their unorthodox practices, and while they regretted the trouble it might cause colleagues who assisted them, they welcome the scrutiny.

A representative of a transplant-related nonprofit organization told TBS that the Mannamis’ practices should be discussed openly rather than be condemned automatically because, under current medical association restrictions, options for kidney patients are too limited. In addition, Japanese people need to know more about kidney transplants since it is mainly ignorance that prevents them from registering as organ donors. In 2002, 14,776 living and dead people donated kidneys in the United States, while in Japan only 634 did so.

And it’s not as if the registration procedure is difficult. If you’re suddenly hit by the gift-giving impulse, you can even pick up a donor card at the nearest convenience store. What better way to celebrate the spirit of the season?