It's time to legalize organ markets
Why is it legal to sell your entire body, but not a part of it?
Nearly 786,000 Americans are living with End-Stage Kidney Disease, 71% of whom are currently on dialysis. Sadly, the existing backlog of Americans waiting for a kidney transplant is over 120,000. Held, et. al., (2016) estimate that between 5,000 and 10,000 Americans die annually waiting for an organ transplant, and about 100,000 suffer from the debilitating side effects of living on dialysis, resulting in a total economic loss of $46 billion each year in terms of excess deaths, degraded quality of life, and forsaken productivity.
Ghods et al. (2012) reports that within a decade of the legalization of kidney sales in Iran, the country succeeded in eliminating 100% of the backlog in renal transplants, irrespective of the socioeconomic status of the recipients. This is because people can live a healthy and normal life with only one kidney, and kidney diseases are mostly all-or-nothing: either both your kidneys fail or neither do.
The purchase and sale of cadavers is already legal in the United States, and far from there being a shortage, Harrington and Sayre (2007) report there is actually a surplus supply as a result. This is further evidence for thinking the supply shortage of kidneys could be relieved by legalizing a market in kidneys.
Since 1984, it has been illegal to financially compensate someone for giving away an organ in the United States. I believe that the problem of end-stage renal failure is one of the clearest cases of a failure of public policy in recent history. This is because a ready solution is available. The least we could do is overturn this outright ban in favor of permitting a regulated market in which the government (as opposed to private citizens) compensates living kidney donors $45,000 for making a donation and gives $10,000 to the families of voluntary cadaveric donors.
The Exploitation Argument
One rationale for the current prohibition against the sale of kidneys is that it would create an exploitative dynamic between the rich and poor. This concern isn’t inherent to a legal market for kidneys, however, because we could simply build an income floor into the policy above the exploitable level (that is, the level after which a person is expected to be made worse-off after making the trade), which for the sake of being specific I would place at a household income of $60,000 per year.
This being said, I am skeptical of the need for an income floor. We already allow the poor to risk their whole bodies—kidneys included—for the sake of greater financial compensation by assuming greater on-the-job risk as lumberjacks, oil rig operators, firefighters, and police officers, and it is currently legal to purchase their blood, sperm, and eggs.
Unless one wishes to legally prohibit the employment of poor Americans in such jobs, it is unclear to me how one can consistently deny the poor the opportunity to be compensated for saving a life by making a kidney donation. Indeed, we already allow the poor to donate their kidneys for no compensation, and do not consider the risks of the operations too great for this to be reasonable.
The exploitation argument gets it backwards: the poor are actually greatly overrepresented among those waiting for a kidney transplant, so the harms of our current system of a legally enforced shortage in renal transplants disproportionately burdens the poor, and the benefits of a legalized market would disproportionately redound to this very group.
Although we may worry that they cannot afford a kidney even when the supply greatly increases after compensation becomes possible (though it is worth noting that this did not occur in Iran), subsidy vouchers could be provided to low-income patients in need of a kidney in order to correct for this.
As a result, the poor would receive the greatest net benefit because they would receive the $1.3 million average value (as I will explain in due course) in gaining longer and healthier lives, and the overwhelming majority of the cost of the operations would be sustained by the taxpayer via Medicare and Medicaid. The United States has a progressive tax system whereby the rich pay nearly the entirety of the tax burden, with the top quintile of earners paying 68% of all federal taxes, and the top 50% of all taxpayers paying 97.7% of all federal taxes.
We already have a system in place for carefully consulting with donors in order to ensure they are sufficiently informed of the risks, and we can continue to provide after-care at no charge to kidney providers. Together with financial compensation, this would ensure that compensated donors, far from being worse-off, are better-off all things considered after the procedure.
Held, et. al., (2016) estimate that this proposal would prevent 5,000 to 10,000 premature deaths each year, and it would be a tremendous relief to the over 100,000 Americans currently suffering from ESKD on dialysis. Moreover, because recipients would no longer have to wait an additional five years on dialysis in order to receive a transplant, they would be even healthier and younger when the operation is performed, increasing the chances of a successful outcome.
It would even become easier to ensure that the donors and recipients are biologically compatible because physicians would have a greater pool of potential transplant specimens to choose from, and when transplants fail, a patient would be in a position to undergo a transplant again. Taxpayers would benefit from about $12 billion in savings annually, as dialysis is four times as expensive per year as a transplant. This would also undercut the incentive to participate in organ tourism or black markets, as a safe and considerably more reliable source would be made available as compared with that provided by organized crime.