Compensation of organ donors has been banned since the National Organ Transplant Act (NOTA) of 1984. NOTA’s lead sponsor stated that if we have a shortage of organ donors, the first thing we should consider is tax credits for donors.
Responding to the concerns raised by opponents of compensating donors:
Myth: “Kidney donation is too dangerous to pay people to do.”
A just-released study found that the donor’s risk of death in the actual surgery, which was already very low, has dropped by two-thirds over the past decade.
Roofers, fishers, and truck drivers all had annual death rates at least twice as high as the risk of death from kidney donation. Loggers death rate is 10 times larger than the one-time risk of kidney donation. No one is seeking to ban the practice of logging, fishing, truck driving or or roofing because it’s too dangerous. Why should that argument work for kidneys?
Myth: “Reimbursing donors for just lost wages and travel costs will increase the number of living donors.”
Most donors are currently reimbursed for wages and costs, but, for the past 20 years, there has been no noticeable increase in the number of living donations. 22 states offer tax credits and deductions to reimburse donors. The federal reimbursement system reimburses 20% of donors. The National Kidney Registry reimburses 40% of donors. All donors should be cost neutral at the end of donation. The current system of reimbursement has not resulted in an increase in living donation rates.
Myth: “Fixing the deceased donation system will provide far more kidneys.”
From this article in JAMA Surgery, “There is currently a considerable emphasis on minimizing the number of deceased donor kidneys recovered but not transplanted; however, at best, that alone might result in approximately 2,000 more transplants per year, a mere dent in the problem.”
Myth: 13 people on the kidney transplant waitlist die waiting for a kidney every day.
Every day, ≈24 people who are on the waitlist either die directly from the waitlist or are removed because they become too sick to be transplanted, meaning they will die on dialysis. That’s 10,000 people a year who were well enough to be transplanted when they joined the waitlist and were killed by the long waiting times for a kidney. In total, 115 Americans die each day as a result of the kidney shortage. For a number of reasons, many people are not waitlisted even though they would be eligible for a kidney transplant.
Myth: “Incentivizing donors is horrific.”
Providing an incentive for a living kidney donor who goes through the work (time loss, stress and pain) of donation to save a stranger’s life is lifesaving, not horrific. What is truly horrific is that more than 100,000 Americans died who were on the kidney waitlist died from 2010-2021. Far more than that died from the kidney shortage.
In the last four decades since the passage of NOTA, opponents to compensation claimed that it’s more horrific to incentivize kidney donation than to watch someone who did not need to die have a miserable death from kidney failure. Since 1988, over a million Americans died from the kidney shortage. They would have survived and thrived instead of died if the End Kidney Deaths Act had already been passed.
Myth: “The End Kidney Deaths Act will create a market in body parts.”
This is plainly false. Tax credits have traditionally been used to encourage prosocial behavior. And nothing is more prosocial than saving the life of a stranger through kidney donation. Tax credits are not “markets.” When people receive a tax credit for adopting a child, they are being rewarded for their prosocial choice. The government has not created a market in the adoption of children by providing a tax credit. A market is one where the rich have superior purchasing power. The End Kidney Deaths Act will provide a uniform incentive for those who save both lives and billions of tax dollars.
Myth: “Incentivizing kidney donation to strangers could undermine efforts to end illicit organ markets in some foreign countries, where people in poverty may be coerced into selling a kidney or driven to make a decision they’ll regret.”
In fact, the opposite is true. Transplant tourism in developing countries is directly linked to the kidney shortage in developed countries like the US. Those with kidney failure are desperate to survive and thrive with a new kidney, as 60% of dialysis patients die within the first five years. If they live in a state like California with a ten-year waitlist, kidney failure patients are aware that they are unlikely to survive the wait. So some make the decision to buy a kidney on the underground market so they can survive. Once we have a far greater supply of living kidneys, those who would seek kidneys in a risky surgery abroad will instead receive a kidney in this country. The illicit organ market will have far less demand. The End Kidney Deaths Act will contribute to the decline of the catastrophic black market for kidneys that is estimated to provide 10% of all kidney transplants currently world-wide. 95% of kidney donors surveyed state they would donate again if they could.
Myth: “Incentivizing donors is not acceptable because “kidneys are a finite resource” and do not regenerate.”
The implicit idea in this argument is that because we cannot regenerate our kidneys like we regenerate blood, we should not incentivize people to donate kidneys. But the finitude is not what’s important — it’s the risk. Blood is renewable, but we would not let people donate it if it were risky. The reality is that people can thrive with only one kidney. One person in every 500 is born with only one working kidney. Hilary Steinour and Matt Cavanaugh who both donated kidneys to strangers ran twelve marathons in 2023 to demonstrate that one kidney can provide all that is needed for such a physically demanding feat. To be sure, kidney donation carries some risk - around 1 death in 10,000 donations - lower than appendectomies or giving birth (which is for surrogates generously incentivized.) Those who are willing to donate kidneys are screened for both mental and physical health in order to qualify. Only two out of every one hundred people who step forward to donate actually donate, often due to being medically disqualified. Kidney donors range in age from 18 to 91. Donors take a minimal risk to save a stranger’s life. Firefighters do this every day at a greater level of risk. Kidney donation is so rewarding that 95% of donors surveyed would do it again if they could.
Myth: “It would send the wrong message to countries that already struggle with unsanctioned transplant tourism — wealthy patients who travel to acquire a kidney.”
Again, the opposite is true. By reducing the kidney waitlist in the US, the End Kidney Deaths Act reduces the demand for transplant tourism.
Myth: “Kidneys are not renewable like sperm, eggs and plasma and therefore should not be donated.”
Kidney donors live longer lives than the general population because donors need to be in top health in order to qualify for donation. When people donate, their kidney grows in size and takes over the job of filtering blood. Health outcomes for living donors are excellent.
Myth: “The tax credit proposal would be burdensome for people who don’t normally file full income tax returns. Also, donors might have to wait months to receive the tax benefit.”
For low income donors (“those who don’t normally don’t file full income tax returns”), filing for a tax credit is not burdensome. The fact that donors will need to wait for the funds is a built-in safeguard that a donor will not immediately receive the financial support that could motivate someone who is desperate. Instead, the End Kidney Deaths Act will gradually provide the incentive over five years, beginning the year after the kidney donation.
Myth: “Compensated kidney donation exploits or coerces the poor.”
Low-income people suffer most from the kidney shortage. The most important thing we can do for low-income Americans is increase the number of donations.
The current system makes it prohibitively expensive for low-income people who want to become kidney donors. For someone living paycheck to paycheck, making donation cost-neutral is simply not enough given how disruptive donation is to work. The End Kidney Deaths Act is the only bill that actually levels the playing field.
The concern that low-income people will donate their kidney against their better judgment if there is a tax credit is unscientific, paternalistic, and ignorant of the actual mechanisms of the End Kidney Deaths Act.
The wealthy have the financial resources to list at multiple transplant centers in several states as well as run campaigns, hire a team to help them find a kidney, put up billboards and conduct a search on social media. Low-income Americans do not have the same resources and are therefore at a disadvantage.
Coercion means using threats or force to limit a person’s options so they do what you want. Paying for kidney donation expands options, rather than limiting them.
Myth: “We’ll get fewer kidney donations if donors are compensated because it will no longer feel altruistic.”
A recent survey conducted by the National Kidney Donation Organization (which represents living kidney donors) found that 97.9 percent said they would’ve been as likely or even likelier to donate had they gotten a tax credit.
Monetary incentives are not counterproductive. Does paying salaries to doctors, nurses and firefighters “crowd out” their altruistic reasons for doing life-saving work?
People donate more plasma when they’re paid to donate plasma. Paying people to donate kidneys will result in more kidney transplants.
Quotes from Supporters:
Elaine Perlman; Non-directed kidney donor; End Kidney Deaths Act Campaign Leader; Executive Director of Waitlist Zero and the leader of the End Kidney Deaths Act team.
“Ultimately it comes down to the question: is it better for someone to die while waiting for a kidney or for them to get a kidney from an incentivized, willing, and healthy stranger?
So what about those who are opposed to the End Kidney Deaths Act? They are out of touch with the majority of Americans surveyed, who agree that compensating kidney donors is the right thing to do. In a research study published in JAMA Surgery, 66% of voters surveyed approved of compensating kidney donors and 60% said being paid $50,000 would make them even more likely to donate a kidney.”
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Sophia Jackson; Non-directed kidney donor; Property and Leasing Administrator; donated kidney to Vadrien Alston, a stranger at that time
“The inequities are staggering. Increasing the number of living kidney donations will disproportionately help African Americans survive and thrive with a kidney transplant. Deceased donor kidneys last only half as long as living donor kidneys. Less than 9% of African Americans receive transplants from a living donor compared to around 34% of white patients. Kidney donation is safe, and I would donate again if I could.”
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Vadrien Alston; New York City Police Department Officer; Kidney Recipient, Donation from Sophia Jackson
“I was on dialysis until Sophia Jackson, a stranger who heard my story on the news, donated her kidney to me and saved my life.
Kidney failure disproportionately impacts the African American community.While 13% of the population is African American, 35% of kidney failure patients are African American. African Americans are far less likely to receive a living kidney transplant, which is the gold standard of kidney care. Around 28% of African Americans on the waitlist receive transplants, compared to 47% of white Americans.”
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Abie Rohrig; Non-directed kidney donor; former bioethics researcher at University of Oxford, published in Journal of Medical Ethics, British Medical Journal, and American Journal of Bioethics
“Donating my kidney was the best decision I ever made, but tragically, the number of people who donate kidneys has not increased in 24 years. We need to provide tax credits for kidney donors who donate to strangers in order to end the kidney shortage.”
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Al Roth; Nobel Prize Laureate; Stanford University Professor of Economics, Senior Fellow, Stanford Institute for Economic Policy Research
“Kidney disease is a big part of the medical economy. There is a terrible shortage of organs around the world. It’s long past time to modify the 1984 National Organ Transplant Act.”
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Dr. Robert Montgomery, MD; New York University Transplant Surgeon; Heart Recipient
“A consequence of this organ shortage is that each year many candidates die while waiting, and many others are removed from the waiting list because they become too sick to receive a transplant. Comparing the rate of living donation in 2000 to now, conventional living donation has decreased. In the past two decades, waiting list placement has not improved, and those less likely to be placed on the waiting list are disproportionately racial/ethnic minority individuals and those with low socioeconomic status. There appears to be no possibility that any further increase in deceased donation will be sufficient to eliminate the shortage.”
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Vaughn Whittaker; NYC Health + Hospitals/Harlem and Veterans Hospital Transplant Surgeon
“800,000 Americans are currently in kidney failure. By 2030, this number is expected to rise to one million. Volunteer firefighters receive tax credits for saving the lives of strangers. "Similarly, individuals who donate kidneys to strangers should be rewarded for saving the lives of people they do not know.
We have never had enough kidneys for those who need them. The End Kidney Deaths Act is game-changing legislation that will save thousands of lives and billions of tax dollars.”
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Steven Levitt; University of Chicago Professor of Economics; Podcast host of Freakonomics and People I (Mostly) Admire
“A big problem is that would-be donors are not given very strong incentives to step forward. Even though most people can live safely on one kidney, there is still a price to be paid in discomfort, risk, fear, and lost wages. Consider the parties who stand to profit from a kidney donation: recipients, certainly, as well as the transplant surgeons, the nurses, the hospital, the drug companies. Everyone will be paid in some form — except for the donor.”
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Martinez Majors, Senior; Information Technology and Services Professional; Dialysis Patient awaiting a kidney transplant
“Total kidney transplants have been stagnant for the last 24 years, and the shortage of transplantable kidneys is killing people. No policy has successfully increased the number of living kidney donors. Incentivization will work to save lives. Kidney donation is uncompensated, stressful, painful, and time-consuming work. Compensating kidney donors is the right thing to do for donors, kidney failure patients, and their loved ones.”
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Peter Jaworski; Bioethicist; Georgetown University Professor of Ethics, Strategy, Economics, and Public Policy at the McDonough School of Business
“It should be uncontroversial that if we can save lives with relatively low risks to others, we should. Kidney donations save lives and typically involve relatively minor risks to healthy donors. That is a reason to encourage donation however we can, including by compensating donors.
Treating all compensation as morally impermissible is a grievous moral error, comparable to anything else that prevents us from saving lives when we can.”
Sources:
“The moral case for paying kidney donors; Kidney donors save lives. Why aren’t we compensated for it?” Vox News, Dylan Matthews, September 18, 2024
“Most Americans Favor Compensation for Kidney Donors if it Leads to More Saved Lives,” Johns Hopkins University, July, 2019
“Poll: Americans Show Support for Compensation of Organ Donors,” National Public Radio, May, 2012
“A regulated system of incentives for living kidney donation: Clearing the way for an informed assessment,” American Journal of Transplantation, Dr Arthur Matas, MD and Dr. Luke Semrau, PhD, July, 2022
“Would You Donate a Kidney for $50,000?” Vox News, Dylan Matthews, April 2024
“Views of US Voters on Compensating Living Kidney Donors,” JAMA Surgery, Dr. Thomas Peters, MD, Dr. Jonathan Fisher, MD, Dr. Robert Gish, MD and Dr. Richard Howard, MD
“Report from a Multidisciplinary Symposium on the Future of Living Kidney Donor Transplantation,” Dr. Thomas Peters et al, 2023
