How to get more kidneys

Bioethicists have a chance at redemption

Photo by Zoe Richardson

Last month, I wrote about the growing shortcomings of America’s system for allocating organs. More organs are being wasted, and the ones that are being transplanted are increasingly being given to people far down the list instead of those at the top. This is bad. Organs are scarce, so we need a just way of allocating them, and any waste means someone likely dies who could have been saved.

This is a classic supply constraint. There simply aren’t enough organs available for all the people who need them. But, as I argued in my last post, while bioethicists usually focus on the demand-side aspects of this sort of problem—namely, how should we distribute the organs?—we should also care about supply. If we make organs less scarce by getting more of them, the allocation issues disappear. Put another way, instead of figuring out how to carve up the organ pie, we can get more organs to make a bigger pie.

Scientists are making progress in some areas. An Australian patient recently went a hundred days with a completely artificial heart. For now, it’s an effective bridge to transplant, but researchers are hoping it will eventually be a destination therapy. There’s also xenotransplantation, which uses a genetically modified pig organ. Last year, an American patient lived two months with a pig’s kidney.

Both technologies are promising supply-side solutions, but neither is going to replace transplanted human organs in the foreseeable future, which means that thousands of people will die every year awaiting a transplant. We need other options.

Policy changes are one possibility. In 2021, Nova Scotia became the first jurisdiction in North America to switch from an opt-in organ donation system to an opt-out system. If a Nova Scotian dies, she’s presumed to consent to organ donation unless she has formally opted out.

Unfortunately, so far, the results are underwhelming. As the chart below shows, for unknown reasons, there was a spike in deceased donations in 2020, before the opt-out program took effect. Donations have been flat since then. Given that the switch doesn’t seem to have worked, and that opt-out programs have other downsides—presuming consent is ethically fraught—we need to boost supply in other ways.¹

By far, the easiest way is to offer people incentives to donate, including paying them. In a 2007 paper, Gary Becker, who won the Nobel Prize in economics, and Julio Jorge Elías calculated that it would cost around $15,200 ($23,470 in 2025) per kidney to create “a very large supply of live kidney donors”. Anything close to this number would be an amazing deal relative to other options.

The problem is that such a proposal won’t fly with bioethicists. Just as Puritanism is the haunting fear that someone, somewhere, might be happy, bioethics is often the fear that someone, somewhere, might receive money, especially for an organ. In a survey of American bioethicists last year, eighty-two percent said that it’s not ethically permissible to pay organ donors. (I’m kind of joking about the Puritanism comparison: the majority of surveyed bioethicists are okay with paying blood donors.)

When it comes to paying organ donors, bioethicists’ views are at odds with the general public’s. There’s a great 2019 paper on the public’s opinion of paying donors by Mario Macis, Nicola Lacetera of the University of Toronto, and Elías, who co-authored the kidney-cost paper. They gave 2,666 Americans various proposals to test how much people support paying for organ donation. Helpfully, they also asked half the participants about their moral judgments.

The big finding is that around seventy percent of participants support paying donors if it would fully satisfy demand (i.e., everyone who needs an organ gets one), but some options do even better. For instance, support increased to seventy-seven percent if the payment was made by a public agency instead of the transplant recipient. As the authors put it, “although most respondents are in favor of donors being paid, there is strong opposition to patients paying.” Support was also higher when the payment wasn’t cash, but “tax credits, tuition vouchers, loan repayment, or contributions to a tax-free retirement account” instead.

Bioethicists and the public have essentially opposite views on this issue. Around eighteen percent of bioethicists support paying organ donors in some situations, while around twenty-one percent of non-bioethicists oppose paying donors in all cases, even when payment would fully address the organ shortage.

This opposition perfectly captures how scarcity is a choice. As it happens, the arguments against paying people are all bad. If you think incentives are exploitative, then we should pay people more, not make them do it for free. If you think that offering money will unfairly recruit poor people, then we can set an income minimum so that poor people can’t participate. (Does that sound bad to you? Me too.) But even if you think financially compensating people is bad, something has gone wrong with your moral reasoning if you think that compensating people is worse than letting 10,000 Americans die each year and tens of thousands more remain on dialysis. Minimally, compensation is the lesser of two evils.

Thankfully, the rest of society isn’t waiting for bioethicists to come around on this issue. The End Kidney Deaths Act is a bipartisan bill introduced in the House of Representatives last year. If enacted, people who donate a kidney to a stranger will be given a federal tax credit of $10,000 a year for five years. It’s currently being reviewed by the Subcommittee on Health. Canada should pass a similar law.

Bioethicists have written thousands of papers trying to figure out the best way to allocate kidneys when there aren’t enough for everyone. But this scarcity is a choice. The better choice is to compensate people for saving thousands of lives every year.

1. In a 2021 interview, Richard Thaler, who co-authored Nudge with Cass Sunstein, denied that they ever endorsed an opt-out system for organ donation. Although they say in Nudge that presumed consent is “hardly a panacea”, 2021 Thaler is gaslighting us. In Nudge, they write “we think that states should give considerable thought to presumed consent or mandated choice, on the grounds that either approach would be likely to save many lives while also preserving freedom,” though they note that other factors also matter.