The moral case for paying kidney donors

By Scott Sumner.

"A recent study in the American Journal of Transplantation just reached what to many people may be a shocking conclusion: Taxpayers would be able to save thousands of lives and about $12 billion per year if the government started compensating people for kidney donations. According to the study, “these numbers dwarf the proposed $45,000-per-kidney compensation that might be needed to end the kidney shortage and eliminate the kidney transplant waiting list.” For economists who have long advocated for the creation of a market of organ transplants, this news is not surprising.

Shortages occur when regulations hold prices below equilibrium — that is, where the demand of a product and supply of a product meet. Often the result is simply inconvenience, as with the shortage of apartments in New York or the long gas lines in the 1970s.

But in terms of kidneys for transplantation, regulations lead to more than an inconvenience. The prohibition of payment to organ donors has led to a kidney shortage leading to the preventable loss of 5,000 to 10,000 lives each year. The cost of treating people with kidney disease is so high that an organ transplant market would not merely save lives, but would actually save money as well.

According to the study, “the net benefit from saving thousands of lives each year and reducing the suffering of 100,000 more receiving dialysis would be about $46 billion per year, with the benefits exceeding the costs by a factor of 3.” Given this “win-win” situation, why hasn’t an organ market been created?

The main reason is that many people find the idea to be morally repugnant. Yet the two most common arguments against paying people for organ donations are both flawed.

One concern is that an organ market would exploit those with fewer resources. The impoverished or low-income would be more likely to donate organs for money, as $45,000 means much more to a poor person than a rich one. However, this exploitation argument seems at odds with the moral calculus we use to justify most of our lives. Our entire economic system is based on rewards for doing things, and it’s always true that those rewards will mean more (per dollar) to a poor person than a rich one. Working in a coal mine is certainly more unpleasant and dangerous than working in an office. Does this mean that coal miners are exploited? And recall that people both rich and poor donate even without compensation. If paying for kidney donation is unfair because it would appeal more to the poor, then much of the economy we rely on daily would have to be rejected on similar grounds.

In a market economy, we tend to assume that people who voluntarily enter into an exchange will benefit from that transaction. There may be exceptions (say, a heroin addiction). But as far as I can see, organ donation should be more like the decision to work in a coal mine — a rational decision to improve one’s economic situation at a modest but acceptable health risk.

Many other objectors have the moral intuition that there is something unethical about turning the human body into a commodity. Economists have a hard time countering this argument, as our moral framework tends to be somewhat blind to non-utilitarian considerations. But can we always trust our moral intuitions? 

During the Middle Ages, lending money at interest was viewed as immoral. Just a few hundred years ago, life insurance was viewed as repulsive — like wagering on the death of one’s spouse. I’m old enough to recall when homosexuality was widely viewed as unnatural, and the notion of gay marriage went against the moral intuitions of even a fair number of politically liberal people. 

Obviously, I can’t prove that our current queasiness about organ markets will someday seem as quaint as the earlier squeamishness about life insurance. But I’d ask people to consider the precautionary principle, our usual propensity to avoid enacting public policies known to cost thousands of lives with very uncertain benefits. We went into Iraq unsure of whether the move was justified, and lost about 5,000 troops. Here is a policy (prohibition on paying donors) that is estimated to cost that many lives every single year, if not more.

Before doubling down on a policy that we know will cost thousands of lives each year, don’t we need to be pretty sure that our moral intuitions on the issue are correct and not something that will later change, as they so often do? I don’t know about you, but when I think of all the actual suffering caused by this regulation, I find it hard to justify not giving individuals a choice."