The moral case for paying kidney donors

A few months ago, I wrote about a proposal called the End Kidney Deaths Act, which seeks to make sure that every one of the more than 135,000 Americans who get diagnosed with kidney failure every year has access to a kidney transplant. 

Its method is simple: a federal tax credit worth $10,000 a year for five years, paid to anyone who donates a kidney to a stranger. It’s the kind of thing that would’ve helped a lot when I donated a kidney back in 2016. Elaine Perlman, a fellow kidney donor who leads the Coalition to Modify NOTA, which is advocating for the act, estimates the measure will save 100,000 lives over the first decade it’s enacted, based on conversations with transplant centers on how many surgeries they can perform with their current resources. Polling has shown this kind of measure has overwhelming public support, with at least 64 percent of Americans supporting a system where a government agency compensates donors.

Since we last covered it, the Act has taken some huge strides forward. It has been introduced in the House of Representatives with two Republicans (Reps. Nicole Malliotakis of New York and Don Bacon of Nebraska) and two Democrats (Reps. Josh Harder of California and Joe Neguse of Colorado) in support of it. Dozens of supporters took to the Hill last week for a lobby day, meeting with staff for over 50 other senators and representatives.

But it’s also started to generate some real opposition. This is to be expected. In the half-century or so that organ donation has been a safe and reliable procedure, many people, including those running some kidney care advocacy groups, have expressed opposition to the idea of compensating kidney donors for our work. Compensation has been banned ever since the National Organ Transplant Act of 1984, the law Perlman’s coalition seeks to modify. Admitting we’ve made a mistake for 40 years and counting is hard. Each year, about 47,000 people die prematurely due to the kidney shortage. Over 40 years, the death toll reaches into the millions. Failing to pay donors has killed a whole lot of people.

Surveying the whole landscape of anti-compensation arguments could fill up a whole book (and has!), so I’ll only address a few here. But none of them are persuasive, and members of Congress weighing the bill should reject these arguments in favor of paying donors fairly for the work we do to prevent deaths from kidney failure.

3 bad arguments against paying kidney donors

1) Kidney donation is too dangerous to pay people to do: This would be a very good argument against donation if it were true — but it’s wildly false. While kidney donation comes with risks, they’re quite small. 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. For the decade from 2013 to 2022, which includes my donation in 2016, there were 58,656 living kidney donors in the US. Five died within 90 days of the operation. That’s a mortality risk of 0.9 per 10,000.

For comparison, in 2022, there were over 100 deaths from work injuries for every 100,000 working loggers in the US, a death rate every year that’s about 10 times larger than the one-time risk of kidney donation. Roofers, fishers, and truck drivers all had annual death rates at least twice as high as the risk of death from kidney donation. For sure, these workers deserve better safety protections, just as even five deaths among donors is five too many. But no one would credibly argue for banning the practice of roofing because it’s too dangerous. Why should that argument work for kidneys?

2) Kidney donation exploits or coerces the poor: This argument takes a number of forms, but it’s based on the intuition that offering money to donate will disproportionately push poor people to become donors and that this constitutes exploitation because they would not have donated without compensation, and thus are donating in part because of their own financial deprivation.

The Oxford philosopher Janet Radcliffe Richards notes that this argument, like the one above, proves too much. “It applies to just about all paid work,” she writes in The Ethics of Transplants, “Unless you would do your job for no payment … anyone who employed you or bought what you offered for sale would in this sense be exploiting you.” While the idea that all wage labor is exploitative is hardly new, it would be silly to draw the conclusion that wage labor should be banned and that workers should not be allowed to be paid.

A similar but distinct argument is that this kind of payment is not exploitative but coercive: The lure of cash actively forces people to donate, like a blackmailer or extortionist does. This just isn’t what the word “coerced” means. 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. 

The late philosopher Alan Wertheimer, who literally wrote the book on coercion, puts it bluntly: “Genuine offers do not coerce. Period.” The End Kidney Deaths Act’s offer of money for donors is a genuine offer. It cannot be coercive.

I should note that the End Kidney Deaths Act could be altered to avoid this concern. It could be written so that only wealthy people (perhaps those making $400,000 or more) are eligible for the tax credit, so we can be sure they were not exploited. Is that better? Or does it offensively cut off poor people from a valuable benefit? I think the latter.

3) We’ll get fewer kidney donations if donors are compensated because it will no longer feel altruistic: This is known as the “crowding out” hypothesis, and it was the argument longtime compensation critic Alexander Capron made to NPR in their piece on the End Kidney Deaths Act: “When something goes from being something which people give to being something that is bought, the givers stop giving.” The problem is that Capron has no evidence for it. (I emailed him asking for some and never heard back.)

When it comes to blood donation, the most recent meta-analysis on the topic found that the bulk of estimates point to cash or cash-like incentives increasing it, not decreasing it. In the case of blood plasma, which is more time-consuming and physically draining to donate than whole blood, monetary incentives have proven dramatically and obviously more effective than altruistic ones. The United States and Germany compensate plasma donors, while Canada, the UK, and Australia do not. 

Sure enough, the latter three countries import a majority of the blood plasma they use from countries where donors are paid. In a shocking twist, paying people for their work results in more work being done.

In the kidney case, the same would likely be true. A recent survey conducted by the National Kidney Donation Organization (which represents living kidney donors) of 288 of its members, shared privately with Vox, found that 97.9 percent said they would’ve been as likely or even likelier to donate had they gotten a tax credit. 

If you believe kidney donors, incentives work. The country with the shortest kidney waitlist in the world is Iran, which not coincidentally is the only country that currently allows compensation.

More to the point, the whole theory that paying people to donate blood or kidneys would make them less likely to do so is sufficiently bizarre that it’s hard to see how it even theoretically could be true, except perhaps at very low levels of compensation. 

There’s no other area of human life where we assume that monetary incentives are actively counterproductive. We do not worry that paying salaries to doctors and nurses will “crowd out” their altruistic reasons for working in health care, or that letting firefighters accept wages “crowds out” their natural desire to save people from burning buildings.

The correct response to “people donate more blood when they’re paid to donate blood” is “well, duh.” And the correct expectation to have about paying people to donate kidneys is that they’ll donate more kidneys.

Enough thought experiments, it’s time for real experiments

I studied philosophy in college, and I enjoy dissecting the meanings of concepts like “exploitation” and “coercion” and “commodification” as much as the next dork. But I must admit I find the tendency of some philosophers to use kidneys as a kind of playground for thought experiments about the limits of markets to be borderline offensive.

Their arguments aren’t just theoretical. They lend respectability to policy statements from practitioners like the jaw-droppingly inane Declaration of Istanbul, a joint statement by various transplant doctor and nephrologist organizations that states compensating donors “leads inexorably to inequity and injustice.” 

The document offers exactly zero empirical evidence for this statement because there is none. “There is no argument whatsoever here, only smoke and mirrors,” Radcliffe Richards rightly notes. “For a major international statement, widely endorsed, this is appalling.”

It is appalling, and it has contributed to a situation where each year in the US sees only about 25,500 kidney transplants but over 135,000 new end-stage kidney disease diagnoses. That means some 110,000-odd people, each year, who plausibly could use a kidney donation cannot receive one because there is not enough supply. The way you increase labor supply, in any field, is to raise the wage.

Not enough nurses? Pay nurses more. Not enough waiters? Pay your waiters more. Not enough kidney donors? Here’s a crazy idea: Pay us.

Correction, September 18, 1:15 pm: A previous version of this article misstated the Coalition to Modify NOTA’s estimation of how many lives the End Kidney Deaths Act would save. It is now estimated to be 100,000.