Thinking the unthinkable: selling kidneysBMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7557.51 (Published 29 June 2006) Cite this as: BMJ 2006;333:51
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Roff’s recent article, by providing numerous examples where society
(such as through the legal system and the health sector) determines
payment for body parts, highlights an important perspective in the debate
over whether payment should be offered for kidney donors (1). It dispels
the myth that the value of life and limb cannot be put into monetary
terms. In this paper we will not enter into the general debate about
whether payment for organs should be offered (see 2-4). Rather, we assume
the acceptance of the general principle of payment and propose a scheme
that we believe maximises the incentive for organs to be donated but at
the same time preserves an element of altruism or ‘gift relationship’ in
Here we propose a two-part payment scheme. This, like other methods
of payment previously proposed in the literature, would involve the
purchase of organs through the State and then their allocation free of
charge to patients on the basis of existing algorithms (4,5).
A feature of the proposal put forward here is in how the price paid
for an organ would be determined. It would have two components: a base
payment which would be paid by government and then a top-up payment
sourced from a pool established through private donations but administered
by an appropriate government agency.
As a starting point for determining the base payment, it would be
relevant to consider the cost savings associated with transplant vis-a-vis
dialysis. In the US, this has been estimated to be US$90,000 (although
this figure increased to US$260,000 when differences in outcomes in terms
of Quality Adjusted Life Years were also taken into account) (6).In
largely government financed health systems such as the UK and Australia,
such cost savings from each transplant tend to be appropriated in full by
government. A payment scheme would, in a sense, be a vehicle by which
these savings could be shared with the donor and thus one might mount an
argument for this proposal on the basis of distributive justice. However,
the question of ‘how much?’ seems very much a political question (maybe a
50:50 split?). Probably a fair way of determining these relative shares
would be through community consultation. Alternatively, as indicated by
Roff, the figure of US$40,000 based on estimates of lifetime earnings and
risk associated with the procedure could act as a guide (1,7). The issue
here ultimately is that such a payment can be viewed as a means of giving
back to the donor some of the economic benefit associated with their role
in providing a transplant and that it would be a fixed amount which we
propose would be a base payment paid upon completion of the procedure.
The feature of this scheme is that this would then be augmented by a
payment from top-up pool established through private donations. The top-up
payment would be calculated and paid at the end of the year e.g. if, in
that year, £5 million were collected and 500 kidneys donated, each donor
would be allocated a top-up payment of £10,000.
The most obvious rationale for a top-up pool is that the additional
payment strengthens the incentive to sell one’s kidney. However, it also
allows for contributions, how ever small, from individuals who may
otherwise be unable or unwilling to take the step of actually donating
their organs. The feature of this particular scheme is that it preserves
some element of altruism or ‘gift relationship’ by allowing individuals to
contribute in this way – addressing an often raised ethical objection that
payment undermines altruism as a motivating factor in organ donation
The key to ensuring the viability of such a fund is that it is
appropriately quarantined. This requires government committing firstly to
not using these monies for any other purpose and secondly maintaining a
fixed base payment thereby avoiding concerns that contributions to the top
-up fund are used to offset reductions in government spending on base
payments. Essentially, there needs to be a guarantee to potential
financial donors that any contribution would directly impact upon the
price offered. Clearly, if the situation arises some time in the future
that supply increases to the extent where there is no longer an excess
demand, government would maintain the ability to suspend the program in
the short term to avoid the potential for oversupply.
Given that this proposal renders large sums of money as part of the
transplantation procedure, the danger for exploitation increases
accordingly. The experience of the kidney trade in developing countries
such as India certainly indicates the potential for the physical and
economic exploitation of donors (and, in many cases, recipients as well).
Part of the problem in India and many other settings is that the trade in
organs is illegal and uncontrolled. Because it operates outside the law,
the authorities have very little ability to implement more pragmatic harm
minimisation strategies (9). Ensuring that potential donors are adequately
counselled and fully informed of the potential harms is therefore key to
the viability of this proposal and needs to be part of the regulatory
response. One obvious danger is the coercion of individuals (although such
a danger also exists without payments) and clearly regulatory mechanisms
need to be equipped to deal with this possibility.
Although the principle of payment for organs through a regulated
market is not new, the feature of the scheme presented here is the two-
part payment strategy. We believe that this offers a means by which the
shortage of organs can be addressed by strengthening the economic
incentive to do so through tapping into both government and community
willingness to pay. Furthermore, it promotes altruism by opening up the
‘market’ to donations from individuals who may not otherwise have been
able or willing to donate their own organs. It would also represent a
potentially cost-effective use of health care resources because it would
take individuals off costly dialysis treatment and, in most cases,
significantly improve their quality of life. Finally, from a policy
maker’s point of view, it has been shown that payment for organs is a
policy that has some public appeal (10). Therefore, this proposal
represents an unusually good opportunity to deliver a policy change that
would be both popular with the general public and represents a win-win
situation amongst the key players, notably recipients, donors, donors’
families and government.
1. Roff SR. Thinking the unthinkable: selling kidneys. BMJ 2006; 333:
2. Radcliffe-Richards J, Daar AS, et al. The case for allowing kidney
sales. Lancet 1998; 27: 1950-2.
3. Scheper-Hughes N. The global traffic in human organs. Current
Anthropology 2000; 41: 191-211.
4. Friedman EA and Friedman AL. Payment for donor kidneys: Pros and
cons. Kidney International 69: 960-962.
5. Erin CA, Harris J. An ethical market in human organs. J Med Ethics
6. Matas AJ, Schnitzler M. Payment for Living Donor (Vendor) Kidneys:
A Cost-Effectiveness Analysis. Am J Transplant 2004; 4: 216-21.
7. Becker GS and Elias JJ. Introducing incentives in the market for
live and cadaveric organ donations. Conference on Organ Transplantation:
Economic, Ethical and Policy Issues, University of Chicago, May 16, 2003.
8. Israni AK, Halpern SD, Zink S et al. Incentive models to increase
living kidney donation: encouraging without coercing. Am J Transplant
2005; 5: 15-20.
9. Muraleedharan VR, Jan S, Ram Prasad S. The trade in human organs
in Tamil Nadu: the anatomy of regulatory failure. Health Economics, Policy
and Law 2006: 1; 41-57.
10. Guttman A and Guttman RD. Attitudes of healthcare professionals
and the public towards the sale of kidneys for transplantation. J Med
Ethics 1993; 19:148-153.
Competing interests: No competing interests
The article written bravely by Roff (1) generated discussion in our
morning ICU round. There were ten physicians including two nephrologists
in the round. Only four out of ten physicians were against the regulated
selling of kidneys for renal transplantation. One nephrologist took right
sided view and the other stuck to his left sided viewpoint, aptly
confirming the presence of two kidneys in human body.
Realizing that there is an urgent need for doctors to lead the debate
on this topic and help the society in arriving at a correct decision, we
offer following points in favour of regulated sale of kidneys. Firstly,
regulated sale of kidneys will bridge the gap between demand and supply of
kidneys for transplantation. Secondly, it will reduce if not abolish the
rampant illegal kidney trade. Most physicians are aware of this illegal
trade but adopt an ostrich like behaviour and rarely even get involved in
this trade. We are aware of patients from rich countries visiting poor
countries for purchase of kidneys and renal transplantation. Some poor
villages in South India having a sizeable population of persons who have
sold their kidney have been given the name ‘kidneypakkam’ in a lighter
vein. Thirdly, monitory compensation to donors is a well known and well
accepted practice. We have seen brothers and sisters demanding and taking
money for the so called voluntary donation of kidneys. Fourthly, we agree
that most of the kidneys will be purchased by rich patients because of the
cost involved. There may even be flight of kidneys from poor countries
with population explosion to rich nations. $40000 seems to be a fair
compensation to a kidney donor. The amount seems to be tempting to even us
to offer our kidney services. A collateral benefit of the regulated kidney
trade may be redistribution of some wealth in this seemingly unjust world.
The negative point of this kidney market is that such business of
dealing in human spare parts superficially appears to be indecent and
immoral. But where is the justification in denying the sale of a part of
human body in a world where body and soul are sold and resold daily? There
is always a danger of such business spiraling out of hand and leading to
immense social, legal and ethical problems. However we are sure that with
proper and honest checks, this business has the potential of producing
more benefit than harm. We sincerely hope and pray to God that our
thinking is correct.
1. Roff SA. Thinking the unthinkable: selling kidneys. BMJ 2006;
Competing interests: No competing interests
In her article Sue Rabbitt Roff1 raises several examples where money
does change hands and then argues that the step from not paying for organs
to paying for organs is small and justifiable. Let us consider her
arguments in turn.
A fixed compensation model with the price set by specialists and
prize winning economists may well increase the supply of organs but it is
unlikely to preclude a (black)market from developing. Logically a person
selling their kidney is likely to be donating for the money. They know it
is a one off transaction. Where the market price is higher that the
offered price the donor will be entitled to ask why shouldn’t they get the
Alternatively where the market price of kidneys is lower that the
offered price kidney brokers could operate. A broker could obtain a kidney
from a donor at a low price and then make a profit on the supply of the
organ to a recipient where the price was higher. Their activity would
increase the supply of kidneys. At a level of societal values is this a
price worth paying?2
Justice demands that a kidney donor who subsequently suffers renal
failure should have an equal or perhaps better chance of receiving a
transplant compared to the recipient of the kidney. Where the flow of
organs is from people in poorer countries to those in richer countries
commodification of organs will be unlikely to make this reality.
The sale of regenerative body tissues is not analogous to the sale of
non-regenerative tissues. Kidney donation would be a one off sale of a
vital organ. Essentially a capital transaction rather than income stream
possibility. Within an expenses model of compensation the actual decision
faced by a live organ donor is whether to donate or not. Compensation for
the additional pecuniary and time costs of donation means that the
altruism of the donor need not extend to donation of time, money and an
organ. The fact that a compensatory payment is made does not support the
proposition that the donation itself should be transformed into a purely
Drug testing and similar research is generally undertaken by
commercial pharmaceutical companies as part of their product research and
development. Research subjects knowingly enter a process that is aimed at
ultimately generating commercial reward for the pharmaceutical company.
The payment to the research subjects for their role in what is in essence
a commercial process again does not support the reduction of altruistic
organ donation to a commercial activity.
Compensation for injuries paid in personal injury cases or by the UK
Criminal Injuries Compensation Authority (CICA) are fundamentally grounded
in justice. These sums are the payment a wrongdoer must make to an
innocent victim to make up for the harm done to the innocent victim by the
wrongdoer. The CICA is a statutory body3 that steps into the shoes of the
absent wrongdoer providing compensation to the innocent victim where the
wrongdoer cannot be found. Surely this is not the correct analogy upon
which to base a case for the commodification of organ donation.
The fact that monies change hands in the context of other areas of
medical practice or science do not constitute an argument in favour of
commodifying human kidneys for transplantation. The core argument in
favour of commodification rests on the need to increase the supply of
available organs. This is set against two arguments (1) the hard fact that
paying for kidneys means that the supply of organs will flow from the poor
to the rich and; (2) there is intrinsic societal value in an organ
donation program based on altruism.
1 Roff SR. Thinking the unthinkable: selling kidneys. BMJ
2 Mohindra R. An ethical monopoly. Really? bmj.com 2002.
3 Criminal Injuries Compensation Act 1995
Competing interests: No competing interests