America’s Silent Kidney Crisis

The New York Times investigation into “organ transplant tourism” exposes something more than merely deeply unsettling. Wealthy foreign patients are receiving organs in American hospitals faster than Americans who have waited for months or years. Hospitals collect millions of dollars from this source while half of U.S. patients die on the waitlist.

This is not just an ethics failure. It is a predictable consequence of a government policy failure.

When lifesaving goods are scarce, markets emerge. When desperation meets money, rules bend. That dynamic drives the underground organ trade abroad. It is also now playing out in broad daylight in the United States, where wealthy individuals effectively outbid Americans for access to scarce organs.

Ordinarily, we accept that the rich outbid those with low incomes. The former gets the Rolex, the latter the Timex. But all bets are off when half of the 90,000 waiting on the kidney waitlist die due to stultifying policies.

Wealthy foreign patients are cutting to the front of the line. This is not conjecture. International patients are being prioritized by some transplant centers because they bring in millions of dollars in revenue. When supply is artificially constrained, those with money find ways around the rules. This has created a version of a black market operating openly and legally. This raises the fundamental question: why are organs like kidneys so scarce in the first place?

The answer is simple and uncomfortable. Donating a kidney is real work. It requires extraordinary health, time, physical risk, and recovery. Yet we have insisted on relying entirely on benevolence to supply this life-saving resource.

We do not rely on benevolence to feed, clothe, or transport ourselves. The people who provide those essential goods are compensated for their labor. As Adam Smith, the father of economics, observed: “It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own self-interest.”

If we want to end preventable deaths from kidney failure, we must apply the same logic here. The brave and compassionate Americans who donate kidneys to strangers should be recognized for their life-saving public service by compensating the work required to save another human life. A person who donates a kidney to a stranger performs an act of public service equivalent to a compensated firefighter rescuing someone from a burning building. The only difference is speed. One act is immediate; the other unfolds over time. Both save a life.

More than 100,000 Americans need an organ transplant today. Nearly 95,000 are waiting for a kidney.  Half of the 550,000 Americans on dialysis would benefit from a kidney transplant. Over the past several decades, policy choices that preserved the profitable kidney shortage have condemned more than one million Americans to needless suffering and death. 

Dialysis keeps people alive, but it does not allow them to live fully. It comes with profound physical limits, shortened life expectancy, and an enormous public cost. Roughly one percent of all federal spending, about $50 billion a year, goes to dialysis. A kidney transplant, by contrast, saves lives and allows people to return to work. Each transplant saves taxpayers roughly $500,000 over time.

Yet the number of living kidney donors in the United States has been essentially flat for 25 years. Nothing the experts have enacted has changed that.  

Those who donate kidneys to strangers can start a kidney chain; the longest provided 35 kidneys. Living donation is safe and is already among the most tightly regulated medical procedures in the country. Only about 2 percent of people who express interest in donating are ultimately approved and complete the process. Individuals with addiction risk, medical instability, or signs of coercion are screened out. The End Kidney Deaths Act (H.R. 2687) does not change any of these safety or screening standards. It simply removes financial barriers for people who already qualify. It is transformative. And it works. 

But it is also demanding. Only those in top mental and physical health are approved. Donors often face lost wages, travel costs, and lingering financial harm. For many Americans, those burdens make donation impossible, even when the desire to help is strong.

The End Kidney Deaths Act offers a solution equal to the scale of the problem. A 2026 nationally representative NORC poll further underscores the strength of this proposal: 57 percent of Americans support this policy approach, while only 12 percent oppose it. This is unusually strong public backing for a major health care reform proposal and underscores that this is not only good policy, but politically safe policy.

The bill would provide financial support to people who donate a kidney to a stranger, recognizing the real costs of participation. By doing so, it would finally increase living donation at scale.

The results would be profound. Up to 10,000 American lives could be saved each year. This would amount to billions in federal savings. And an end to the moral contortions created by shortages, including the quiet acceptance of transplant tourism in American hospitals. 

Other countries show what is possible. Israel began incentivizing living kidney donation in 2008 and has seen a dramatic increase. The United States, despite its wealth and medical leadership, continues to allow 10,000 Americans to needlessly die annually due to the preventable kidney shortage.

Some argue that future technologies like those that would allow the use of pig kidneys will solve the problem. These innovations may help some patients temporarily, much like dialysis does. They will be short-term bridges, not cures. Only human kidneys, donated by human beings, can, given present levels of medical technology, end the shortage.

Meanwhile, the shortage worsens. Newsweek recently reported a “mass exodus” of Americans from donor registries, a trend that will only deepen the crisis. How can this best be addressed?

The answer is not to police shortages more tightly. It is to end  shortages themselves. And this can only be done with monetary compensation for hard work, a la Adam Smith, precisely the effect of our proposed bill.

President Trump could act now through an Executive Order authorizing compensation for living kidney donors who donate to strangers. Congress could make passing the End Kidney Deaths Act, that has bipartisan support and dozens of cosponsors, a top priority for 2026. Either path would save lives, reduce wasteful spending, and restore fairness to a system that has drifted far from its moral foundation.

A country as wealthy as ours should not tolerate a system where Americans die waiting for life-saving care that provides decades of health instead of suffering and death. The kidney shortage is solvable. What we lack is not innovation. It is urgency. 

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Elaine Perlman is a living kidney donor who initiated a multi-state kidney chain that saved four lives. Her son Abraham also donated a kidney to a stranger. She works with the Coalition to Modify the National Organ Transplant Act and Waitlist Zero, organizations founded and led by kidney donors to address the national kidney shortage and reduce preventable deaths among patients on the transplant waitlist.

Walter E. Block is Harold E. Wirth Eminent Scholar Endowed Chair and Professor of Economics Loyola University New Orleans and a supporter of free enterprise.