Give a Kidney, Get a Check

Some people in poorer countries are compelled to sell their organs on the black market. Why not build a regulated system that compensates them fairly and ensures their safety?

A 60-year-old man in Nepal who sold his kidney lifts his shirt to show the scar from the operation. In the end, his broker cheated him out of his payment.  (Navesh Chitrakar / Reuters)

When I donated a kidney a few months ago to a total stranger, I wasn’t thinking about market forces. I had simply realized that I couldn’t bear to have two healthy kidneys while knowing that someone out there would certainly die of renal failure. When I was wheeled out of the hospital, I began wondering what could be done, economically or socially, to make more people open to the idea of organ donation.

It’s illegal to buy and sell organs in the U.S., and the inflexibility of the market can be unbearable for someone hooked up to a dialysis machine. The problem isn’t low supply—in the U.S., there are millions of kidneys that could be donated without any risks beyond those of any typical surgery—so much as overwhelming, unfilled demand. Kidney disease is common, but treating it with dialysis is effective for usually a decade at most, not to mention very costly. While there were more than 17,000 kidney transplants performed in the U.S. last year, about 8,000 people became too sick to receive one or died waiting for a transplant. Another 100,000 people ticked off another year on a waiting list, on which the average stay is about six years.

The simplest solution—paying healthy people for their organs—quickly becomes complicated. Opening organ donations to the free market, even with robust regulations, invites some concerns. Would desperately poor people be forced into selling their organs? Would unwilling people have their kidneys forcibly removed and then sold? These nightmare scenarios are probably overblown, but the idea of selling organs is knotted up with the idea of sovereignty over one’s body.

Still, it’s a cause that many people advocate for. Alvin Roth, a Nobel-winning economist, has seriously considered what a kidney market would look like. “I've become interested in the fact that it’s against the law to pay for a kidney anywhere in the world,” he told NPR. “But it's not against the law to remove financial disincentives.” Roth has noted that steps could be taken so that hospitals could easily reimburse donors’ costs, and then in turn be reimbursed through Medicare or private insurance. He says that, in the big picture, this would pay for itself, given how many people it would exempt from the costs of frequent dialysis and hospitalizations. Unfortunately, though, it won’t be enough to assure donors they’ll be reimbursed—they need a stronger incentive.

As distasteful as it seems to commodify organs, the current situation is simply too catastrophic not to change something. Defenders of the status quo should put aside their belief finding “the mixing of kidneys and cash repugnantin order to help arrive at an alternative that will not leave millions dead.

Moreover, in the current unregulated system, the world’s poor are being exploited en masse. As of 2010, one in every five kidneys transplanted each year originated in the black market. The vast majority of people currently selling their organs are poor and live in developing nations—many do so in order pay off their debts. When one of these people sells his or her kidney, the World Health Organization estimates, it will go for about $5,000. The brokers who buy them can then turn around and sell them for as much as $150,000. Though it may seem cold and dystopian to use a market to incentivize poor people to sell their body parts, the truth is that some of them are doing it anyway.

So, as unsavory as compensation for live-organ donations may seem, a highly-regulated global market with an emphasis on equitable compensation could allay these concerns, as well as ensuring that operations are performed safely. It would be important to make sure such a market doesn’t devolve into “transplant tourism,” but if orchestrated properly, it could simultaneously satisfy the needs of wealthy countries with long waiting lists and poorer countries with rampant poverty.

Such a market is not just some nebulous item on the world’s wish list—a successful regulated market currently exists in Iran, the only country in the world that allows paid donations. (Even though the words "donors" and "donations" may seem out of place in the context of transactions, these terms are commonly used when discussing compensation for organs.) In the 1990s, after years of war and economic slumps, the country decided to pay donors for kidneys rather than incur the health-care expenses of treating people with kidney disease. Within a few years, the program eliminated the national waiting list for kidney transplants and these days, the black market is virtually nonexistent.

It works like this: Donors-to-be go to a regional office run by volunteers, receive medical testing, and then get matched with a potential recipient based on their blood type. If further tests go well, the donation proceeds. The government assumes any costs if recipients cannot pay for the kidney, and most surgeries take place in hospitals with university affiliation. As an added incentive, male donors are granted exemptions from military-service requirements.

The system is not without its limits. Iran bans paid transplants for most foreigners, and a lack of state funding has inhibited the program—due to high inflation, government payouts have decreased dramatically in value. Sometimes, poorer rural areas run out of funds and donors lack follow-up care.

Even with these flaws, kidney donation is much safer in Iran than in nearby countries, according to Farshad Fatemi, an economist at the Sharif University of Technology, in Iran. If compensating donors were illegal, he told The New York Times, “We might be more like India or China and have illegal clinics … where nobody looks after patients and donors.”

The ban that most of the world has on paying donors—and the icky feeling that prevents many people from supporting such a system—doesn’t entirely hold up to logic. As Mohammad Akbarpour, a research fellow at the University of Chicago, has observed, “[A]ccepting money to donate a kidney and save a life is repugnant, but accepting money for being a policeman or miner or soldier—all of which are statistically riskier than donating a kidney—is O.K.” All told, Iran has implemented a system that eliminates the terror of waiting lists and the danger of the black markets. Another nation, one with more public funds, would probably be able to implement an even more effective program.

In the U.S., people may finally be warming up to the idea. A recent survey of Americans by researchers from Argentina, Canada, and the U.S. published in the American Economic Review found that while barely half of respondents initially favored a system that would pay organ donors, the number rose significantly—to 71 percent—once those surveyed were given information about how the system would actually work. Perhaps if such a program were presented more clearly to the public, it’d be more widely supported. The country already has a strong donor culture—more than nine million Americans give blood annually—and with the proper system, we can intertwine our bodies, fairly and safely, in a way that might be able to save everyone involved.