[Organ donation: scarce and fragile resources]

Organ transplantation, the gold standard therapy for end-stage organ failures, has become a victim of its success. Indeed, the number of patients listed for transplantation has been increasing faster than that of available grafts. The number of brain-dead donors, the primary source of organ donation in France, is limited, but this figure is becoming more and more comprehensive, thanks to the work carried out by hospital transplant coordination units. The room for manoeuvre is limited: to increase the transplantation rate in this respect, the only possibility would be to reduce the rate of donation refusals, which still accounts for more than 30 percent of all identified brain deaths. It is thus more and more critical to resort to other donor sources: living donors and non-heart-beating donors. Each donor source is associated with different constraints and limitations in terms of available resources, removal organization and ethics. For cadaver donors, the key ethical issues are the acceptance of presumed consent, the difficulty in diagnosing the exact time of death and the notion of body integrity. For living donors, the ethical issues are related to the quality of the consent and the assessment of the risk undertaken by the donor, when no personal benefit is expected.