“The End Kidney Deaths Act is novel and has potential to save lives.  Given that despite the rhetoric from others that there has been no increase in living donation for two decades, it is reasonable to try something new.

The Act is a pilot that will be regulated and overseen; if problems emerge, the program could be modified or stopped. This is an opportunity to make a difference in a situation where all objections are hypothetical and without data.

- Dr. Arthur Matas, MD, Transplant Surgeon

Economist and kidney donor Kurt Schuler:

Response to “The End Kidney Deaths Act Risks Irreversible Harm to Organ Donation” by Thomas F. Mueller, MD, PD; Maria A. Matamoros, MD; Gabriel M. Danovitch, MD; Sanjay Nagral, MD

A cardinal principle of public policy is to judge policies by their results, not their intentions. The results of U.S. policy on organ donation, which were set by the National Organ Transplant Act of 1984, have been terrible. All major organs are in short supply. We focus here on kidneys here because they are the most widely demanded organ for transplant, accounting for roughly 85% of the total. 

The current system has had 40 years to prove itself. It has failed. It is estimated that more than 40,000 Americans a year die waiting for kidney transplants. Most of them are not even on the national organ transplant list because they are “no-hopers” whose chances under the current rules are so marginal. Because few people understand that things could be otherwise, the premature deaths of tens of thousands of kidney patients a year do not arouse the concern that occurs if, for instance, a few dozen people die from salmonella in supermarket chickens.

The End Kidney Deaths Act (H.R. 9275) is a proposal to take a principle that already works in other areas of medicine and apply it to the kidney shortage. That principle is monetary recognition of value. Without donated kidneys there can be no kidney transplants. Nondirected (stranger-to-stranger) donations are particularly valuable. They enable chains of donations to occur under which donors who want to give a kidney to somebody they know but are not good matches for that person to ensure that the recipient does receive a transplant. That is the rationale for the End Kidney Deaths Act proposing a refundable tax credit of $10,000 a year for five years to nondirected donors.

The surgeons who perform kidney transplants get paid for their skills. So do the makers of the anesthetics that enable the patients to undergo the operation tranquilly. So do the nurses who help donors and recipients of transplants recover from the operation. 

So do many of the donors of blood plasma that may be necessary to aid recovery for some patients. In an analogy to the situation with kidneys, many countries forbid compensation to local plasma donors. They are able to maintain adequate supplies of plasma only because they buy it from countries where compensation to donors is legal, above all the United States. Blood plasma is in fact a major U.S. export. Thousands, perhaps millions of people in rest of the world, are able to live because an understanding exists in the United States that plasma is a valuable resource, and that paying donors a fraction of the value of the lives their plasma saves is well worth the cost. There are many people who donate plasma without compensation, as an act of charity, but even for their donations, it is the commercialization of the distribution chain that ensures that supplies go where they are most needed.

Why is there such reluctance to recognize the principle of monetary recognition of value for kidney donations? One can only speculate that is has something to do with the invasive nature of surgery and the instinctive disgust that many people feel when the subject is organs. Such aesthetic scruples should not outweigh the lives of tens of thousands of Americans who die prematurely from kidney disease each year.

The authors claim that in other countries, paid donation has decreased or destroyed voluntary donation. Most living donations, though, are directed donations from relatives or friends, and the motive for making those donations voluntarily remains strong even if nondirected donations are compensated. Moreover, the authors fail to note that apparently the only country in the world without a shortage of kidneys for transplant, Iran, is also that only country with a well developed system of compensation for donors. Its innovative kidney transplant system contrasts with the repressive governance that has hindered the country’s progress in other areas.

The authors propose several ideas for increasing the supply of kidneys. They are worth trying, but as complements rather than as substitutes for the End Kidney Deaths Act. To repeat, the current system has had 40 years to prove itself and it has proved to be tragically inadequate. It is well past time to adopt the principle of monetary recognition for value that applies elsewhere in medicine. We have doctors and nurses because we pay them rather than expecting them to work for free. We have medicines because we pay their makers rather than expecting them to supply for free. If we want adequate numbers of kidneys for transplantation, we need to apply the same principle.