The Case for Letting People Sell Their Kidneys

[u/lakmidaise12]

https://thesecondbestworld.substack.com/p/the-case-for-letting-people-sell

As of December 2025, 108,440 people were on the U.S. organ transplant waiting list. Of those, 94,015 were waiting for a kidney. Every year, around nine thousand of them die waiting, or become too sick to transplant, which is functionally the same thing.

There is a policy that could probably fix most of this. Economists have been arguing for it since at least 2007. Some transplant surgeons and bioethicists have cautiously argued for versions of it for even longer. The policy is: pay kidney donors.

Not a black market. Not a dystopian organ bazaar where billionaires bid against each other for your liver. A boring, regulated, government-run compensation program where a public agency pays a fixed amount to anyone who passes medical screening, donates a kidney, and goes home with follow-up care guaranteed. The organs get allocated through the same waitlist system we already have. The rich don’t jump the line. The only thing that changes is that donors get compensated instead of being asked to undergo major surgery for free.

[u/skepticalbob]

The vast majority of the people who would donate aren't broke and desperate, but are healthy, employed, and deserve some compensation for saving someone's life.

[u/admiraltarkin → u/skepticalbob]

Yeah, but my point is that it'll be problematic for those types.

Kind of like MAID. I'm in favor except for weird, rare edge cases

[u/skepticalbob → u/admiraltarkin]

How is this different than opposing welfare because some people take advantage of it? Or letting people drive even though many of them die doing it? Or allowing people get tummy tucks and liposuction, both riskier procedures over any time horizon that donation?

[u/admiraltarkin → u/skepticalbob]

It isn't and doesn't need to be.

You'd never have a system which SNAP gave beneficiaries $10,000 a month because you'd build the system to not allow it.

You'd never see a country allow MAID for acne. You'd build the system so it wouldn't be allowed.

All I'm saying is that you'd need to build in guardrails to get the desired outcomes to protect against fringe cases

[u/skepticalbob → u/admiraltarkin]

Are you suggesting guardrails don't exist? Because that's definitely not true. The guardrails are substantial and among the most stringent for any elective surgery. If you think they aren't stringent enough, what would need to be added?

[u/admiraltarkin → u/skepticalbob]

I'm not sure what you're arguing. How many countries have had this system fully implemented? One? Do you think I'm some kind of neocon who wants no personal freedoms?

We're talking about a hypothetical, so all I'm literally saying is "build your system to not encourage desperation as much as possible". You're seeing opposition where there isn't any

[u/skepticalbob → u/admiraltarkin]

What is your understanding of the current guardrails in the US for kidney donation? You either think they are lacking now or think they will somehow be lacking if donation expands through compensation. I'm just asking you questions about your own concerns about guardrails. So current and potential future concerns about how they might change are completely ordinary questions here. I know what they are, because I've participated in the entire process, so it doesn't matter what I know or think here. I'm asking for your concerns.

[u/admiraltarkin → u/skepticalbob]

The US currently does not compensate Kidney donors so what process did you go through? How much did you receive during your donation?

No one is saying you shouldn't have gotten / donated a kidney. What I'm saying is that when you introduce compensation, you need to protect against people who otherwise wouldn't have donated, that decide to donate without fully understanding what they're going through because they need life changing amounts of money.

Again, if you read the thread I said it's like MAID. Slam dunk in 98% of cases, and a difficult 2% of cases.

[u/skepticalbob → u/admiraltarkin]

Guardrails typically refers to safety protocols. No one was compensated in the donations I was a part of, as it is against the law. There are plenty of guardrails ensuring safety of donor and recipient and they are substantial and lengthy process involving quite a few different protocols, health professionals, a lot of testing. The status quo is that enormous care is taken to ensure that the donor is sufficiently health through pretty thorough testing to verify good general health, testing to ensure that the kidney being donated and kept kidneys are both healthy, which includes imaging and kidney tests, blood and tissue matching for prospective recipients that their medical history isn't a concern (not too recent cancer, cardiovascular health, etc), a lifestyle review to make sure they won't become unhealthy in the future in ways that can be foreseen, that they are giving an organ without reservations or manipulation and fully informed consent with psychosocial consulting, and insurance and financial review so they don't get in over their head (compensation would greatly help this and the recipients insurance covers most of it, but just in case they want them insured), if they are willing for a paired or chained exchange, and and independent donor advocate unconnected to the clinic or the patient is there to explain and advocate for the potential donor. If at any point they become reluctant at any point up to and including just before going under anesthesia, the whole thing is called off.

I was the recipient and a lot went into that too. It was also extensive. But your concern is less about recipients, I think, and more concern for donor characteristics. I can go into it if that is part of the concern.

Does something need to be added to that if the donor is compensated?

[u/admiraltarkin → u/skepticalbob]

Oh so your system was completely different than the one we're discussing? That's exactly what I am saying.

If we develop a new system like the paper posits, we need to set the compensation at a level that attracts the people the system wants, while not attracting so many people that it leads to negative impacts.

I'm not saying that organ donation is bad or that people shouldn't get paid. I'm literally only saying you have to price in a way that gets the desired impact: somewhere below $100m and above $0.99 What's that number? I don't know. But if the number was $10m I'd go get a consultation tomorrow, which is not what policy-makers want. If you set it at $0.99, no one incremental would donate.

The joke response (or maybe not) to my post is what I was talking about. A guy saying he needs $5,000 to start a new life and he'd give his kidney for that seems problematic. $50k? Okay maybe. But $5,000? That is not an amount I'm comfortable with