Kidneys For Sale

By Peyton R. Miller (Harvard University, Class of 2012).  Mr. Miller is a government concentrator.  An alternative Tuesday contributor to the Harvard Crimson.

Most proposed changes to the healthcare system involve a tradeoff between costs and health outcomes. A potential exception to this rule would be a policy that increases kidney donation, which would allow substantial savings on dialysis therapy for patients with end-stage renal disease. The policy would also improve these patients’ quality of life and reduce the kidney shortage that causes black market organ trafficking. While it would be controversial, a regulated market in which living persons could accept monetary compensation for kidney donations may be the best way to boost transplants.

About half a million Americans are being treated for kidney failure, also known as end-stage renal disease. The average wait for a kidney transplant, which is usually the optimal treatment, is about five years, and those without access to a donated kidney receive expensive dialysis therapy. Dialysis patients experience deteriorating health and living conditions, and many die waiting for a transplant. While donations have increased modestly in the past few years, demand has surged thanks to success with transplantation as well as an aging population and higher rates of chronic disease that cause kidney failure.

Although the risks of organ donation cannot be dismissed, the mortality risk for live kidney donors has been estimated at 0.03 percent. The reason supply does not rise to meet demand has less to do with the consequences of surgery than with the fact that U.S. law prohibits individuals from being paid for their organs, meaning transplants are provided entirely by altruistic donors.

The shortage created by this policy has led to another problem: illegal organ trafficking.  Legally prohibited from paying American donors, dialysis patients have been known to seek paid transplants from desperately poor people in developing countries. Americans travel abroad for transplants, particularly to South America, and there are even reports of third world donors being brought to the United States. Under-the-table transplants take place in medically precarious circumstances and are facilitated by organ traffickers, who often take advantage of donors’ poverty and ignorance. Murder for organ extraction and outright organ theft are rare, but it is not uncommon for traffickers to fail to pay willing donors their promised amount or to mislead them about the nature of the procedure. While there have been no comprehensive evaluations of the magnitude of organ trafficking, the heinous nature of the crime as well as its potential for growth in light of the ever-growing demand for kidneys, demands that it be addressed.

What can be done about the kidney shortage? The limited supply of viable organs from deceased donors and comparatively low rates of successful cadaveric transplants suggest that boosting deceased organ donation is only a partial solution. Attempts to increase altruistic donations by living donors have had limited success. On the other hand, economists Gary S. Becker of the University of Chicago and Julio J. Elias of Stanford estimated in 2007 that a payment of about $15, 200 per living kidney donation would generate enough willing donors to eliminate the shortage. Monetary compensation has worked in Iran, which created a government-run donor payment system in 1988, and for the past twelve years has been the only country in the world without a kidney waiting list.

Compared to the average medical cost of transplantation, which Becker and Elias put at $160,000, donor compensation would amount to a small price increase. The move could even be a cost saver. Dr. Arthur J. Matas of the University of Minnesota estimates payments on the order of $100,000 could be made to donors and still be cost-neutral given the savings on dialysis therapy. Since treatment for end-stage renal disease is covered by Medicare, an increase in kidney transplants would go a long way toward mitigating the program’s unsustainable budget trajectory.

The obvious caveat is that the market would need to be closely regulated to prevent the kind of exploitation that occurs in developing countries. The government would need to ensure that donors are fully informed of the consequences of surgery and receive adequate compensation and post-operative care. Even with such protections, an organ market might still be subject to criticism of exploitation of poor and lower middle-class donors, as well as its “commodification” of the human body and possible social repercussions for paid donors. These are legitimate objections, but it is doubtful that they outweigh the relief for dialysis patients, reduced incentives for organ trafficking, and substantial cuts to healthcare costs that would accrue from monetary compensation.

To establish a functional kidney market, Congress needs to repeal the ban on compensation and establish a regulatory framework. In the meantime, states can at least reimburse donors for the expenses of surgery. In January 2004, Wisconsin created a state income tax deduction for costs incurred by living donors in terms of travel, lodging, and lost wages, and seven other states have since enacted similar legislation. Altering incentives at the state level may be the best way to build support for a broader system of monetary compensation for organ donors. With proper oversight, such a system could eliminate a tremendous amount of suffering and waste.

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11 Responses to Kidneys For Sale

  1. admin says:

    Prior to reading Mr. Miller’s article, my view as to the sale of organs was a shady deal taking place in some impoverished country. He presents quite an alternative solution in the regulated sale of kidneys. Not only would this eradicate the present kidney donation shortage (well over 100,000 of us are in need of a kidney transplant) but it would also save insurance companies upwards of 65 billion dollars annually in funding dialysis treatments. (Not to mention the benefit of a better lifestyle for dialysis patients once they receive a kidney transplant.)

    Can a pay for a kidney program be successful? Mr. Miller presents Iran as an example of such a program with the result being no kidney transplant waiting list. He also mentions Wisconsin which offers certain financial benefits to living kidney donors. Any wonder there is a shorter waiting time for a kidney transplant in Wisconsin than in most other states such as here in New England with our 4 to 5 year wait?

    Mr. Miller is in his junior year at Harvard. I am confident he is going to make a difference in the lives of many people in his future endeavors.


    P.S. Being a hopeless romantic, I still feel that a suitable living kidney donor match will come forward and be an altruistic donor to me (white horse and knight’s garb optional) as well as other altruistic donors for the other 100,000+ on waiting lists nationwide.

  2. Vicky Quillian says:

    At first, when I saw the title of this blog, I was sceptical. but after reading it, I am thinking positively about the article. Maybe it can work. I would not want to exploit lower and middle class people. The state of Wisconsin has a good plan. Perhaps it would be feasible to start on the state level. Thanks to the young man at Harvard for expanding our minds.

    • admin says:

      Thanks, Vicky, for taking the time to comment. I agree with you on the exploitation factor. This is why I also agree with Mr. Miller’s proposal that such a program would have to be regulated. I have heard wonderful things about Wisconsin’s transplant program. As a matter of fact, if anyone has more info on this program, please let me know ( ) so that I can add it to my research and present it as a blog post here on Kidney Transplant Blog.


  3. Insightful piece! Parts of the mssing puzzle – we already have an organ market in the US and we have to contend with a government granted monopoly. This monopoly was granted to a private government contractor, United Network for Organ Sharing (UNOS) and 58 Organ Procurement Organizations (OPO) across the country. All are so-called non-profits. Nevertheless, this is a multi-million dollar a year business.

    Under the provisions of the National Organ Transplant Act (NOTA) of 1984, UNOS came into being in 1986 along with the OPO network. NOTA also permits the OPO to levy a “reasonable processing fee” for each organ recovered from a willing ‘donor’. In fact, no one ever gets an organ donated. The OPO gets the organ and resells it charging what is referred to as an organ procurment fee. UNOS and the OPO have fought tooth and nail to maintain this monopolistic, closed system. These efforts have also included blocking altruistic, non-related, living donors due to the fact they cannot, by law, be involved in living donor transplants. In recent years UNOS and the OPO have tried to get NOTA modified to eliminate that prohibition to allow organ procurment fees to include living donor organs.

    Some of the largest OPO have annual revenues of $100 million and more from these procurment fess. These same organizations have hundreds of millions of dollars worth of real estate holdings. They pay huge salaries! For example, OneLegacy, an LA OPO pays its CEO more than $650,000.00 annually on total revenues of $68 million from procurment fees in 2008. A Tampa OPO pays its top 2 executives $602,000.00 and $597,000.00 annually. This is the pattern across the country. A recent audit by the HHS Office of Inspector General rvealed that OneLegacy spent $341,000.00 partying at a recent Rose Bowl Week then charged those fees to Medicare as direct patient services and patient education. The parties included more than $100,000.00 for a New Year’s Eve event.

    Sally Satel, M.D., a kidney transplant recipient, psychiatrist, and Fellow at the American Enterprise Institute has written widely on the topic of a regulasted organ market. She has been the target of ridicule for suggesting such an approach. As Mr. Miller observes, there are other examples of how these markets will work. Israel announced 2 months ago the government will pay $2,500.00 to deceased organ donor families.

    Finally, in a regulated market, the US will save millions. Today, the average fee for a cadaver kidney is $45,000.00 levied by the OPO. Transplant centers then add their own Organ procurment fee. We recently reviewed a bill for a patient who received a kidney transplant at Shands Hospital, Jacksonville. The total procurment fee from both the OPO and the transplant center was $62,000.00 exclusive of other hospital, surgeery, and physician fees.

    The system we have now is broken, unfair, unethical, and corrupt. We are worried about corruption in a regulated market! Why?

  4. admin says:

    Thank you, Dr. Hickey, for your insightful “behind the scenes” look at UNOS and other OPO(s).

    I would think the insurance companies who are footing the bill for a kidney transplant would be screaming at the high procurement costs both at the OPO level as well as the additional procurement fee at the transplant center. I am sure all of us can understand the necessity of charging a procurement fee at the supplier level (OPO) as I assume that they must run extensive (and rapid) testing on the cadaver kidney before offering it to a transplant center. The transplant center also must run their own series of tests to verify the quality of the organ with who would be a close match (so that the kidney is not rejected) and feel confident, to the best of their ability, that the organ is free of any diseases such as cancer. The question is, how much does all this testing cost which I would think is included in the procurement fee? $62,000 for both the OPO and transplant center’s procurement fees as you mention was charged in the Shands Hospital example? That does sound excessive and worthy of the insurance company screaming upon being invoiced.

    The part of your comment dealing with both the revenues received by UNOS and OPO as well as the salaries of their top executives: I’m sure you are well aware of other large organizations that take in huge amounts of money and pay their executives the big bucks. The fact that they are able to take in “hundreds of millions” is either through their fundraising efforts or they have developed a way to insert themselves into the overall marketing mix so a “fraction of the action” (or as you point out, the procurement service fee) has to pass through them. Since most of these organizations are shielded to a degree by our government blessing their monopolistic operations by providing restrictive regulation, what is the alternative? And, the fact that they offer their executives bloated salaries hopefully attracts the best of the best…not the greediest of the greedy.

    Of course, Sally Satel, M.D. would be the subject of ridicule for suggesting a regulated organ market. Why make any changes such as a paid, ETHICAL, regulated organ market? To those having financial interests in the status quo, the present system is fine the way it is. To those of us on the UNOS waiting list, now over 110,000, we live one day at a time and pray that we can last until our transplant organ becomes available.

    Again, thank you, Dr. Hickey, for your eye-opening comment.


  5. Thanks Andy! Appreciate your comments. Any one managing a nonprofit entity should be paid a reasonable salary. No question! However, those same people should be expected to have some modicum of altruism.
    In recent discussions regarding tax breaks for the rich the line at which that designation is to be reached is $250,000.00. Such a salary represents the low levels of salaries paid to UNOS & OPO executives. Congressional representatives are paid $174,000.00/yr. Two months ago the White House Press secretary left that post. It was learned he was paid $172,000.00/yr. That salary was roundly criticized.
    Given that too many people are dying because they cannot afford an organ transplant never mind being waiting on the list, is it not reasonable to expect more frugality to save lives? My daily contact with patients trying to get organ transplants leads me to believe a $200,000.00/yr salary for anyone running a nonprofit OPO is quite satisfactory.
    As for fund raising revenue, I suggest anyone interested can go to and review the fund raising pages on the IRS 990, nonprofit tax returns for any OPO. It is curious that most lose money on these fund raising efforts. One OPO I find most interesting spent hundreds of thousands of dollars for New Year’s Eve parties and another $80,000.00 for a CEO retirement party. These are just 2 of many examples of waste. Is this fair to people suffering and dying while depending on these entities to bring them relief?

  6. admin says:

    Insightful, Dr. Hickey. Very insightful.

    I can tell that you have been studying the organ transplant system for quite a long time. You might say I’m a relative newbie at this with the catalyst for prodding my interest being my own need for a kidney transplant. However, the more I realize that it comes down to financially-driven decisions, the more I feel that the entire organ procurement/allocation industry must be brought under scrutiny…perhaps even some sort of regulatory agency beyond awarding a single entity, a continuously renewing monopolistic contract.

    If you know when the current UNOS contract is up for renewal, please let me know. I’m sure that some of our blog readers would like to learn more about (and even participate in) the UNOS contract award process.

  7. Swami says:

    Instead of kindey for sale it must be renamed into Kidney In relationship like kidney marriage , livein relationship ect, the donor deserves share with the patient like marriage. Kidney Marriage is the answer

  8. Riki says:

    My question. Who is to pay the $15, 200 to the donor? Will the government foot this bill? or will it be left to the patient, who most likely does not have that kind of money, especially after the mountains of medical bills they have to pay, before they are even accepted into Medicare or Medicaid. This will just be another way for the rich to get what they want, and the poor to continue to suffer.

    • admin says:

      Thanks for the comment, Riki. Actually it would be in the best interest of the insurance companies to pay for a kidney transplant as opposed to years and years on costly dialysis. Also, insurance companies are footing the bill for HUGE procurement fees now running into the 10’s of thousands to the organ procurement system. I’ve read that these fees run into the hundreds of millions of dollars. Again, it would be in the best interest of the insurance industry to pay for kidneys from living donors than the exorbitant amount of fees paid out in organ procurement fees for cadaver kidneys.

      Again, thanks for the comment.

      All the Best,

  9. Antony says:

    A very good article,indeed!As for me and my friends,we are absolutely sure that paid unrelated transplants should be legalized.Everyone has the right to dispose their bodies.

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