You trudge along the Huron, absorbed in wonder at what the miracle of compound interest is doing to your college debt. Suddenly, a splash, a cry. A man flails in the water. He can’t swim; you can. “Please, help me!” You (1), plunge in and do your best to rescue him, or (2), cup your hands and inquire: “What’s it worth to you?”

Michigan men and women would choose Option One. But why is it the right choice? No need to invoke scripture or catechism where Kant can explain: “[T]o help others where one can is a duty.”1 In a rescue situation, if we have the special competence and unique opportunity, we have the moral obligation to aid a neighbor in need.

The present kidney shortage is a situation in need of rescuers: more than 5,000 of our neighbors will die this year awaiting a transplant. However, proposals to legalize compensation for kidney donors are the moral equivalent of Option Two: “What’s it worth to you?”

What’s-it-worth is official policy in Iran.2 In an attempt to eliminate their shortage of kidneys for transplant, the government guarantees kidney-sellers a base fee of $1,200. Patients then meet privately with seller-candidates to negotiate an add-on price, usually many times more. If the parties cannot agree on “what it’s worth”, the seller walks. If the patient has enough cash, they make a deal.

Iranian sellers are not blameworthy. They are desperate people being treated like means. Eighty-four percent are poor. The state doesn’t monitor their post-sale health. Reflecting on their ordeal, 76 percent think kidney sales should be banned!3 The true culprit is a regime that has legitimated trade in body parts.

Iran is the poster child for those who advocate compensating kidney donors. Yet Cash-for-Kidneys hasn’t achieved its putative goal of eliminating the shortage of transplant organs.4 Officials admit they don’t know the full extent of national need, and many Iranians with renal disease go undiagnosed. Hundreds who do need a transplant but can’t pay the added fee languish on the wait list for cadaver organs.

Doubtless a US kidney-sale system would be more sensitive than Iran’s. Seller and patient would be kept apart. Third parties – certainly government, maybe insurers – would pick up the entire tab. Yet the program we would establish in law would be the equivalent of the Iranian Cash-for-Kidneys program.

Well, why not? Paying for kidneys may be distasteful, but why is it wrong?

The first principle of practical reason directs us not just to pursue the good but to avoid evil.7 Commodifying kidneys is an evil because it reduces the human person to a means.8 It depersonalizes us, literally renders us an object with a market price.

Pricing kidneys reduces constitutive parts of the human person to the status of pork bellies.9 Moral laws apply universally. We can’t bracket ourselves. If it’s wrong to treat a human being as an object, and you’re a human being, it’s wrong to treat yourself as an object. It’s wrong also for others to collude in the extracting and selling – surgeons, technicians, bureaucrats, lawmakers, taxpayers.

The Iranian state has chosen a path that we must reject.5 The logic of supply and demand is relentless. Just think “outsourcing.” Reduce the kidneys of US citizens to a commodity and soon enough we will be importing cheaper organs sold in desperation by the world’s poor. We’d probably draw the line at kidneys from executed Chinese prisoners.6 But if a healthy human kidney is just another spare part bought at a market price, why squirm?

Your body is not a building inhabited by the real, unseen “you”. Properly understood, you are your body. A human being is a substantial unity of a material and a spiritual principle intrinsically self-integrating and self-directing.10 Some human beings once had a market price slapped onto their chests, but we fought a civil war to put an end to that injustice. Owning a whole human being is wrong. Paying for parts of human beings is similarly wrong. Our living bodies, along with the fundamental goods that we pursue and which fulfill us by actualizing our basic potentialities – life, health, friendship, marriage, knowledge of truth, self-integration, worship – do not have a market exchange value. They are incommensurable goods beyond supply and demand.11

But, to rescue a neighbor, we may give as a gift that which we may not sell. Donation of a kidney, whether in life or at death, is a gesture of the deepest friendship. The grammar of the deed affirms: “You are not alone, I stand with you.” We gift something of our very self. Ideally, the gesture evokes a response equally generous. This is how, concretely, we build a culture of solidarity.12 If these gestures by living donors are few, no wonder: they are acts of heroism. Yet even the least heroic of us can do something bold: sign the “anatomical gift” commitment on the reverse of our Michigan drivers’ license.

The market economy is a valuable human invention. It enables us to allocate scarce resources efficiently, but we choose the ends to pursue. We are not obliged to subject human kidneys to market mechanisms. In fact, we are obliged to resist that temptation.

The most straightforward approach is to simply legalize cash payments for living kidney donors within a regulated market with government controls. Surprisingly maybe, Iran first legalized financial compensation for kidney donors in the late 1980s and its organ shortage was eliminated within a decade. The Iranian system of financial compensation involves a combination of government-funded cash payments and free health insurance for donors, supplemented by cash payments from the recipient. For kidney recipients who are too poor to afford the normal payment, private charities provide funding.

A good place to start a discussion about whether it should be legal for kidney donors to receive financial compensation is a review of some statistical data.

Consider that:

1. Almost 51,000 patients have died on the kidney waiting list since data started being collected in 1987 - almost as many Americans who died in the Vietnam War.

2. The kidney waiting list has increased almost 6 times since 1988 while the number of annual kidney transplants has not even doubled (see chart).

3. For those patients suffering from renal failure and in desperate need of a kidney transplant, 2009 was not a good year to join the growing national waiting list. The list for kidneys last year swelled to a new record of 83,146 waiting patients. This wouldn’t be so bad if the number of kidney transplant operations was increasing, but it’s not. There will likely be about 17,000 transplant operations in 2009, which is just barely higher than the previous year, and below the record-high 17,095 operations in 2006 (see chart).



Given these two trends (an increasing waiting list for kidneys, with no significant increase in transplant operations), those who joined the waiting list in 2009 will be facing the worst chances ever – only about 1 in six patients will actually receive a kidney this year, and thousands will die waiting.

The data paint a pretty grim picture of the current situation, and it worsens every year. Simply put, the current system of organ procurement is not working and we need a new approach.

What is the current approach that leads to so much unnecessary and preventable suffering and death? Federal law (National Organ Transplant Act of 1984) makes it illegal to accept any form of financial compensation for providing a kidney to another human being, though such a transaction may save those in need from years of debilitating dialysis and a premature death sentence.

In other words, the price of a life-saving kidney is artificially set by the government at price of zero, and current law relies exclusively on altruism as the only legal means of providing a life-saving kidney. Economics tells us that an artificially low price, regardless of the commodity, guarantees a certain outcome: a shortage.

When it comes to kidneys, the result of an artificially low price of $0.00 results in exactly what economic science predicts: a huge and growing kidney shortage that gets worse every year. Current law ensures that needless suffering, life-draining dialysis, and premature death for kidney patients continue to increase year after year. However, if we are willing to consider the alternative – financial compensation – we could easily solve the kidney shortage.

What would a system that allows financial compensation for kidney donors look like?

What has been advocated for the U.S. is a modified financial compensation program for living kidney donors, which would not involve direct cash payments like the Iranian model. Instead, it’s been proposed that there be some type of “in-kind” financial compensation for living kidney donors that might include a contribution to an IRA retirement plan, tuition vouchers for the donor or his or her children, a tax credit, early access to Medicare, or subsidized health insurance for the donor.

Even under a modified program of financial incentives, we could realistically expect to see the number of living kidney donors increase enough to eliminate organ shortage and end the preventable suffering and premature deaths. It’s not that the current emphasis on altruism isn’t a legitimate, partial solution to the growing kidney shortage, but, more importantly, altruism alone will never be a complete solution to the problem. That’s why we need to legalize financial compensation for donors.

Interestingly, recent polls show that a majority of Americans agree that we should move towards a system that makes it legal to provide financial incentives for living kidney donors; the general public now understands that donor compensation is the one way to solve the growing organ shortage.

The grim reality is that a suffering patient with renal failure dies every two hours – more than 12 every day – waiting for a kidney under the current policy. A system of altruism has not worked in the United States, it hasn’t worked anywhere else, and it will never work as the sole legitimate motive for donating kidneys. The only way to effectively address the growing kidney shortage in the United States is to make it legal to receive financial incentives as a living kidney donor. The market-based approach has worked in Iran and it will work here.