The Case for an American Kidney Market

By Andrew Garber


The waiting list for organ donations in the United States is over one hundred thousand people long and growing. Due to a shortage of organ donations, twenty people die each day on the waiting list. Although hearts are hard to procure, solving the shortage of kidney donations is tractable. Even though kidney donations carry little risk for the donors, there is a huge gap between the number of kidneys needed for transplantation and the number of donations. As distasteful as it might initially seem, the United States should legalize the sale of kidneys, so long as it regulates the market well.


The case for a market in kidneys is simple: if people receive compensation for donating a kidney, then more people will give their kidneys, mitigating the supply shortage. Potential donors will give a kidney if they judge the benefits to donating to outweigh the costs. The main costs of donating a kidney are a slightly increased risk of kidney failure, complications with surgery, and lost wages from the recovery period after surgery. In monetary terms, these costs amount to an estimated $15,200. This price is uncertain: people might under- or overestimate the risks of kidney transplants or be willing to accept less compensation if they act altruistically. Unless this estimated cost is wildly off the mark, however, the increased cost of procuring a kidney from the market rather than through donations is small compared to the price of the transplant itself -- about $160,000. Thus, the kidney shortage could be largely solved by legalizing the sale of kidneys with only about a 12% increase in cost for the receiver of the kidney, since that is the cost to make donors break even. Even with a much higher estimate of the costs of donating kidneys, the welfare gain from legalizing the sale of kidneys would be to the tune of tens of billions of dollars per year, saving taxpayers significantly. Moreover, rather than advancing efficiency at the cost of equity, a market for kidneys would benefit both. People on the kidney waiting list are disproportionately poor, probably due to having worse health on average, so solving the shortage of kidneys would be equitable.


Of course, a kidney market needs to be well-regulated. Extensive measures should be taken to ensure that donors are aware of the risks of donation. The market price for kidneys should be public knowledge, so that donors are not duped into selling a kidney well below the market rate. The government could be an intermediary between buyers and sellers so as to further mitigate this problem. To avoid compulsive decisions by sellers, the government could enact a mandatory months-long period between deciding to give away one’s organs and when the donation occurs, giving donors ample time to change their minds. There are many other regulations worth looking into; the point is that most problems, such as those described below, are not problems with kidney markets per se, but rather with improper regulations.

The argument above might seem unfair: it compares a well-regulated market for kidneys to a deeply flawed status quo, instead of a more effective non-market donation system. Yet, even when compared to the most efficient donation systems, legalizing the sale of kidneys is still superior. Increasing the number of kidneys donated through cadavers, such as by enacting presumed consent laws, would not close the gap between supply and demand. The comparison with other countries is telling: even the countries with different policies and with the highest donation rates have long waitlists for kidney transplants. Iran, which has a market for kidneys, has no such waitlist.


Critics argue that the costs of an organ market are inequitable, since people who more desperately need money will be those most likely to sell their organs. Some go as far as calling this a form of coercion, in the case that sellers must sell their kidneys to pay their bills. This objection misses the mark. If people are forced into selling their kidneys because they need money, then that points to a problem with the society’s wealth distribution, not a problem with kidney markets. It is worse to paternalistically decide that people cannot get money for giving their kidneys, leaving them without money. Comparing this situation to the labor market makes the point clearer. Often poorer people work in more dangerous and unpleasant jobs, such as garbage collection and construction. Surely this inequity does not mean that such work should be provided voluntarily rather than through wages. Doing so would not only ensure shortages of needed goods but also would deny people jobs that they need to survive.


Critics retort that there will still be coercion, since relaxing the standards of who can donate will ensure that criminals will extort or blackmail people for organs. In other words, the unregulated, exploitative organ trade that exists on the black market would become more prevalent once the sale of kidneys became legal. To the contrary, legalizing kidney sales would largely eliminate the black market. If sellers know that they can sell their kidneys legally and much more safely than they could on the black market, the supply of kidneys on the black market would dry up. The trade on the legal market would not be nearly as exploitative given that there are legal protections. Moreover, fewer people would request transplants from black market sellers, since they would have no legal recourse in the event of a botched operation.


Critics sometimes support their argument by pointing to surveys of kidney sellers in other countries. When there was a legal market for kidneys in India, most donors sold their kidneys to pay off debts. Although hardly any reported being coerced into selling their kidneys, most respondents thought that selling kidneys was a bad idea and reported poor health and income outcomes. In a survey of Iranian kidney sellers, again most respondents regretted having sold their kidneys. These data are sobering and make clear that sellers should be well-informed of the risks of selling kidneys and the importance of proper medical care. Yet the data do not justify abandoning a kidney market altogether in a rich country like the US. The experience of kidney donors in the US has been positive, in large part because of the superior surgery and care before and after the surgery. It is thus highly likely that in a properly regulated kidney market in the US, donors would experience far better outcomes than they would in developing nations, such as India and Iran.


There are many more objections to the sale of kidneys. One prominent criticism is that organ sales devalue the worth of the human body. Yet this and many other objections -- including the ones above -- miss the moral point. The market for kidneys does not just involve sellers, who, according to critics, face the coercive pressures and devaluation of their organs. On the other side of the market are the people who desperately need new kidneys. The moral force of arguments against the sale of kidneys evaporates once one considers the buyers’ end of the market. Does society express kindness and altruism or value kidney patients’ bodily integrity by leaving them with dysfunctional bodies? Certainly not. American society is trading thousands of deaths a year for almost nothing.