On the Vox website, Dylan Matthews offers a compelling defense of the proposed End Kidney Deaths Act. His arguments are valid, and I agree that the act would be a major improvement over the status quo. But full legalization of the organ market would be even better. Here is an excerpt from Matthews’ article:
What if I told you there was a way the United States could prevent 60,000 deaths, save American taxpayers $25 billion, and pay a group of deserving people $50,000 each? Would you be interested?…
I’m not a spokesperson. I am simply a fan and supporter of the End Kidney Deaths Act, a bill crafted by a group of kidney policy experts and living donors that would represent the biggest step forward for U.S. kidney policy since…well, ever….
The plan is simple: Every nondirect donor (that is, any kidney donor who gives to a stranger rather than a family member) would be entitled, under the law, to a tax credit of $10,000 per year for the first five years after the donation. That $50,000 in total benefits is fully refundable, meaning even people who don’t have to pay taxes get the full benefit.
Elaine Perlman, a kidney donor who leads the NOTA Change Coalition, which supports the law, based the plan on a 2019 paper that estimated current disincentives to donating a kidney (from travel expenses to lost income while recovering from surgery pain and discomfort) amounted to approximately $38,000. That’s nearly $50,000 in today’s dollars, after inflation in recent years.
The paper also found that by eliminating disincentives by paying this amount to donors, the number of living donors would increase by 11,500 per year. Because the law would presumably take some time to encourage more donations, Perlman reduces it to about 60,000 in the first 10 years, with more donations toward the end as people learn about the new incentives. But 60,000 is still nothing to complain about….
The End Kidney Deaths Act is trying to solve a fundamental problem: not enough people are donating their kidneys….
In 2021, an estimated 135,972 Americans were diagnosed with end-stage kidney disease, meaning they would need dialysis or a transplant to survive. Only 25,549 transplants were performed that year. The remaining 110,000 people had to resort to dialysis.
Dialysis is a miraculous technology, but compared to transplants it is terrible. More than 60% of patients who started traditional dialysis in 2017 died within five years. Of patients diagnosed with kidney failure in 2017 and subsequently received a transplant from a living donor, only 13% died five years later.
Life on dialysis is also terrible to live. It usually requires four-hour sessions three times a week sitting next to a machine, where the blood is processed. You can’t travel for real time, as you have to stay close to the car. Even more critically, even part-time work is difficult because dialysis is extremely physically taxing.
An estimated 40,000 Americans die each year due to a lack of available kidneys for transplant. If implemented, the End Kidney Deaths Act would save many of these people. Furthermore, as Matthews points out, tax credits of $50,000 per kidney would easily pay for themselves, because kidney dialysis is much more expensive and Medicare ends up paying for most of that expense. If more people with kidney failure could get a new kidney quickly, the government would save a lot of money on dialysis costs, and those people would be able to be more productive (as well as avoid great pain and discomfort).
Matthews also has a good response to claims that paying for kidneys amounts to problematic “commodification”:
When you think of donor compensation as payment for work done, the injustice of the current system becomes much clearer.
When I donated my kidney, many dozens of people got paid. My transplant surgeon got paid; my recipient’s surgeon got paid. My anesthesiologist was paid; his anesthesiologist was paid. My nephrologist, nurses, and support staff were all paid; so did her. My recipient didn’t get paid, but hey, he got a kidney. The only person who was expected to carry out their labor without any reward or compensation was me, the donor.
This would outrage me less if the system didn’t also lead to tens of thousands of people dying needlessly every year. But a system that refuses to pay people for their work, and in the process leads to needless mass deaths, is truly indefensible.
I agree and have made similar points too. And Matthews deserves high praise for donating a kidney, thus possibly saving a life! At the very least, she probably saved the recipient from having to endure additional years of painful kidney dialysis.
The main flaw of the End Kidney Deaths Act is the implicit price controls it creates. By setting the payment at $50,000, you avoid higher payments where this would be necessary to ensure an adequate offer. Even if the law would save thousands of lives, the estimates cited by Matthews (6,000 to 11,500 additional kidney donations per year) would still leave us many thousands of kidneys short, thus condemning many people to unnecessary deaths, or at least to more years of renal failure. dialysis. This problem may be particularly acute for patients whose genetics make it unusually difficult to find a compatible donor. Conversely, if some potential donors are willing to sell for less than $50,000, there is no good reason to prohibit such transactions.
Full legalization of organ sales, without price controls, would solve these problems. According to basic economics, markets work best if prices can fluctuate in response to supply and demand. In a free market, insurance companies, medical providers and others have every incentive to pay for what is needed, since the alternative to kidney dialysis is much more expensive. If necessary, the government could subsidize the consumption of the poor, as it already does for kidney dialysis and many other health expenses.
Matthews includes a passage that partially praises the End Kidney Deaths Act precisely because it fails to authorize a full-blown organ market:
The most common objection to compensating kidney donors is that it amounts to letting people “sell” their kidneys, a phrase also adopted by some supporters of compensation. For opponents, this seems dystopian and disturbing, as it violates their belief that the human body is sacred and should not be sold for parts.
But “selling kidneys” in this case is just a metaphor, and a negative one at that. The End Kidney Deaths Act would not legalize organ sales in any sense. The rich would not be able to beat the poor to get organs first. There would be no kidney market or kidney auctions of any kind.
What the proposal would do is pay kidney donors for their work. It is the payment of a service, that of the donation, not the purchase of a good. It’s a service that puts a strain on our bodies, but it’s not at all unusual. We pay a premium to those who carry out jobs such as logging and roofing precisely because they risk physical harm; this is no different.
This wording is clever. And I myself have noticed parallels between the organ market and paying people to do jobs that involve physical risks, such as the work performed by loggers and professional football players (both of whom accept far greater risks than those faced by kidney donors ). However, if we compensate kidney donors, it is difficult to deny that this compensation is at least partly due to giving up a kidney.
And there’s nothing wrong with that! If you believe in the principle “my body, my choice”, the right to sell organs is one of the freedoms that ideal entails. And there is no good reason to distinguish organ selling from other potentially risky activities that people may engage in for compensation. If anything, the organ market is more defensible, because it can save many thousands of lives. In contrast, NFL players take greater risks to provide entertainment for all of us.
As for the fear that the rich will hoard or monopolize kidneys, that is highly unlikely given that few people – rich or not – are likely to need more than one. In a nation of more than 300 million people, full legalization would induce enough sales to fully cover demand (roughly an additional 40,000 kidneys per year). If necessary, as noted above, the government could subsidize the purchase of kidneys for poor people suffering from kidney failure, as it does other types of medical care for the poor.
A free market could be politically difficult to implement. But survey data suggests it may not be as difficult as is usually assumed.
In summary, the End Kidney Deaths Act would represent a dramatic improvement over the status quo. Matthews is absolutely right on this point. But a more fully free market would be even better.
In previous writings on organ sales, I have discussed the scope of the problem and addressed the standard arguments against legalizing the organ market, such as concerns that it would be too dangerous for organ donors, claims that it would amount to “commodification.” immorality of the body organs, and fears that this could lead to the exploitation of the poor (see also here).