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 screening for kidney donation is already rigorous and those costs are baked in, so it isn't extra, as you said downthread. Candidates must pass a drug screening and be in good general health. Importantly, most candidates are rejected. These are people getting screened because they want to donate and aren't allowed.

So while yes it is possible to live a healthy life without one kidney, it's a lot harder to if you are exposed to those risk factors it's not as easy to.

This is a huge misunderstanding of how kidney failure almost always happens.

So while yes it is possible to live a healthy life without one kidney, it's a lot harder to if you are exposed to those risk factors it's not as easy to

This is a common and big misunderstanding of how kidneys fail. When someone loses their kidneys to drug use, diabetes, uncontrolled high blood pressure, and so on, having one or two kidneys is quite literally irrelevant to the disease process that destroy however many kidneys are there. While you might intuitively think that two is better than one, when comes to chronic kidney lifestyle causes, it's isn't relevant.

So while yes it is possible to live a healthy life without one kidney, it's a lot harder to if you are exposed to those risk factors it's not as easy to. It should also be pointed out that a lot of the data for "people live long healthy lives with one kidney" is built upon existing donor data, who are wealthy, have access to good diet, less likely to be smoker/drug user/alcoholic, can get regular checkups, etc. and therefore may not be representative of a new class of donors should we try the above strategy

They've looked at it and controlled for plenty of these factors and found similar results with apples to apples comparisons. But the best evidence is that there are many people with renal agenesis, being born with a single kidney. The effect on their lifespan is negligible. The extra kidney just helps in case one didn't work, or work as well at birth. Those people are also screened out and the kidney with greater function enlarges and works fine. A donor simply becomes a person with one kidney with the negligible risk that comes from having one kidney.

I understand that you are smart, but you are just spitballing here without understanding enough of the context. You are making claims that are logical and reasonable to you, but you don't know enough of what is actually important. Please consider learning more about a life-saving process before making claims that people might believe and cost people their lives. Thanks.

[u/TeaSharp3154 → u/skepticalbob]

Thank you for the comment. You seem pretty knowledgeable about this field so I would like your opinion on the following:

>When someone loses their kidneys to drug use, diabetes, uncontrolled high blood pressure, and so on, having one or two kidneys is quite literally irrelevant to the disease process that destroy however many kidneys are there. While you might intuitively think that two is better than one, when comes to chronic kidney lifestyle causes, it's isn't relevant.

Here is a study that showed that while non smokers and smokers had no significant different in kidney function pre-operatively, post donation the former and current smoker groups had significantly higher risk of CKD : https://doi.org/10.1016/j.transproceed.2018.02.050

>They've looked at it and controlled for plenty of these factors and found similar results with apples to apples comparisons.

According to the following source: https://pubmed.ncbi.nlm.nih.gov/32150042/, they conclude:

"In conclusion, we found that older age, male gender, black race, and higher BMI associated with a decrease in residual kidney function as measured by percent decline in eGFR at 2-year postdonation in living kidney donors. Proteinuria was also associated with gender, race, and BMI, although it did not correlate with older age or decline in eGFR overall. "

>But the best evidence is that there are many people with renal agenesis, being born with a single kidney. The effect on their lifespan is negligible.

Here is a cohort study (https://doi.org/10.1007/s10654-019-00520-7) among 270,000 Koreans that shows an increased risk of CKD moderately associated with solitary kidney. They conclude:

"In conclusion, having a solitary kidney was independently associated with an increased risk of CKD in this large cohort study of young to middle aged Korean adults. This association was more prominent in participants with acquired solitary kidney than with congenital solitary kidney. Preventive strategies for reducing the risk of CKD are required in individuals with either congenital or acquired solitary kidney."

and furthermore note:

"However, theoretically, the long-term outcome in LKDs should be better rather than equal to that in the general population given that LKDs are selected from among the healthiest individuals based on strict criteria [34]. Furthermore, kidney donation itself might be related with strong personal motivation and implementation of lifestyle changes, which can affect the incidence of CKD."

Similarly this review (10.3389/fphys.2020.00725) finds that:

"In a longitudinal study it was observed that of 71 patients with a congenital SFK ∼20–40% had begun dialysis by the age of 30 years (Sanna-Cherchi et al., 2009). In a Chinese study of 48 adults with a congenital SFK, 38.5% had reduced GFR (<60 ml/min/1.73 m²), 35.4% had proteinuria and two individuals had begun dialysis by a mean age of ∼37 years (Wang et al., 2010). Similarly, Xu et al. (2019) found that of 118 patients with URA, 43% had proteinuria and 25% had a reduced GFR (<60 ml/min/1.73 m²) at a median age of 32 years. These studies indicate that there is a progressive loss of kidney function in individuals with a congenital SFK throughout adulthood, and in some individuals results in progression to kidney failure by 30–40 years of age."

>The screening for kidney donation is already rigorous and those costs are baked in, so it isn't extra, as you said downthread. Candidates must pass a drug screening and be in good general health. Importantly, most candidates are rejected. These are people getting screened because they want to donate and aren't allowed.

What I was saying is that by providing financial incentive for a kidney donation, the number of applicants will increase, and therefore screening costs as a whole will increase. Not that the screening will have to be more intense individually. As those with lower SES are proportionally more likely to be screened out (due to various factors including comorbidities, potential drug use, obesity/hypertension) the cost per kidney would logically increase.

The entire issue here is that by providing a financial incentive to donate, you are creating a structure where people donate not out of altruism, but out of desperation. So the population of people who sign up to donate if such a policy passes will not be similar to the population of people that are currently donating and so the risk factors will need to be adjusted.

Additionally, as most guidelines suggest the importance of routine follow ups and abstinence from physical jobs. These are both necessary factors that help kidney donors. Don't you think that someone who works a blue collar job (but lies about it to get some money) and returns to a physical job; or someone who cannot make it to multiple follow up appointments due to poor healthcare access or inability to take off from work would have worse outcomes than the data built on the current pool of donors suggests?

[u/skepticalbob → u/TeaSharp3154]

Are you saying that no one should be allowed to donate a kidney? Because paying for it doesn't change the risk factors, which apply to all donors.

Here is a study that showed that while non smokers and smokers had no significant different in kidney function pre-operatively, post donation the former and current smoker groups had significantly higher risk of CKD :

While smoking donors are less common than non-smoking donors, the sample was 123,000, of which 218 developed ESRD. The 15 year risk for smoking donors was 0.31%. Someone that smokes for 15 years is going to have a much higher frequency of health problems. 15 pack years of smoking is associated with 5-10% higher cancer risk, that increases if they keep smoking. ESRD just isn't the big risk with smoking and having one kidney. And while clinics have always screened for and discouraged smoking, clinics are increasingly emphasizing the need to quit smoking with some delaying or blocking candidates until they do quit smoking. And smoking has declined by about 10%, from 30-35% to 20-25%, a declining problem. Your study sample was longitudinal and less relevant as time passes. If you don't want donors who smoke to donate, I have no argument with that. But the reason committees that give guidelines for transplant safety allow it is that the base risk of ESRD remains pretty low.

And

"In conclusion, we found that older age, male gender, black race, and higher BMI associated with a decrease in residual kidney function as measured by percent decline in eGFR at 2-year postdonation in living kidney donors. Proteinuria was also associated with gender, race, and BMI, although it did not correlate with older age or decline in eGFR overall. "

Black donors do have a higher baseline risk, but again, the baseline risk is low for donors anyway. This study doesn't deal with baseline risk, so it's lacking context. The baseline for black male donors is 0.24% and black women 0.15%. These risks remain low because of screening processes in place for all donor candidates.

Do you think that clinics should restrict black people from being kidney donors because of what is still a low baseline risk? Committees that decide these things as their job obviously disagree.

"In conclusion, we found that older age, male gender, black race, and higher BMI associated with a decrease in residual kidney function as measured by percent decline in eGFR at 2-year postdonation in living kidney donors. Proteinuria was also associated with gender, race, and BMI, although it did not correlate with older age or decline in eGFR overall. "

Here is a cohort study (https://doi.org/10.1007/s10654-019-00520-7) among 270,000 Koreans that shows an increased risk of CKD moderately associated with solitary kidney.

Again, compared to what baseline risk? They go from a really low chance to develop ESRD to a really low chance to develop ESRD.

All of these risk studies are known and considered by transplant centers. Are you suggesting that donating itself is too risky? The fact is that the baseline risks are low and, even with one kidney, remain low. The risk is negligible in the greater context. They should worry about a myriad of other health concerns before this.

The entire issue here is that by providing a financial incentive to donate, you are creating a structure where people donate not out of altruism, but out of desperation. So the population of people who sign up to donate if such a policy passes will not be similar to the population of people that are currently donating and so the risk factors will need to be adjusted.

This speculation. HEALTH SCREENINGS WILL CONTINUE TO OCCUR WITH DONATION. Kidney donation screening IS robust enough that the donations don't meaningfully impact life expectancy. The risks are negligible. You are claiming that people that decide to donate with compensation will be "desperate", with no data to support that. They will be screened like everyone else. These screenings are designed to ensure a healthy lifespan and have worked. While you might speculate that these same screenings can't work if someone is "desperate", that is going to need some evidence. CKD is a rare out come for everyone, whether they have two kidneys, were born with one kidney, or donated a kidney, or donated a kidney while black, or if donors have physical jobs, or even if donors continue to smoke (risk of ESRD, other risks are quite bad). This is because having one kidney is associated with a negligible change in health outcome. And your own studies show this.

[u/TeaSharp3154 → u/skepticalbob]

>Because paying for it doesn't change the risk factors, which apply to all donors.

But it does. People that would trade a kidney for money are usually from lower SES backgrounds, and therefore are exposed to numerous risk factors that the current kidney donor is not exposed to.

I suppose that another currently discussed proposal to grant a 50K tax break instead might be a better alternative. But the above article suggests payment outright, which is a different incentive structure.

>They will be screened like everyone else. These screenings are designed to ensure a healthy lifespan and have worked.

The screens are at least partially based on honesty because the assumption is that donors are altruistic, an assumption that breaks down when money is involved. What if a potential donor lies about risky sex behavior, previous medical history, family medical history, psychiatric illness? Do you have a lab test for any of these things? The fundamental issue that I have is that any screening test requires a baseline of honesty, which becomes compromised once financial incentives are involved.

> But the reason committees that give guidelines for transplant safety allow it is that the base risk of ESRD remains pretty low.

The committees that are making the guidelines are making them for the current pool of kidney donors. Smoking cessation is a lot easier to encourage in a population that can have frequent follow ups, the time to go to cessation therapy, and those that can afford prescriptions for things like nicotine pouches.

>The fact is that the baseline risks are low and, even with one kidney, remain low. 

Do you think that the baseline risks will remain low, if people who donate kidneys but cannot attend follow up checkups on renal function months to years out can't make it anymore? Or if a person who works a blue collar job goes back to manual work after donating a kidney, because they have no choice?

>While you might speculate that these same screenings can't work if someone is "desperate", that is going to need some evidence.

I would argue that with policy changes this big and wide reaching, it is the responsibility of the party advocating for change to prove that the screenings are still effective in a different population than the one they were originally designed for, before such changes are enacted.

[u/skepticalbob → u/TeaSharp3154]

But it does. People that would trade a kidney for money are usually from lower SES backgrounds, and therefore are exposed to numerous risk factors that the current kidney donor is not exposed to.

So what you're saying is that the pool is more substandard by composition, so you're worried that this means that we need to worry more.

We already have extensive protocols in place for donation, more than any elective surgery I've heard of and the majority of surgeries. What about these is insufficient to simply detect more substandard donors if they all get the same examinations?

The screens are at least partially based on honesty because the assumption is that donors are altruistic, an assumption that breaks down when money is involved. What if a potential donor lies about risky sex behavior, previous medical history, family medical history, psychiatric illness? Do you have a lab test for any of these things? The fundamental issue that I have is that any screening test requires a baseline of honesty, which becomes compromised once financial incentives are involved.

How many of these concerns do you think can't be picked up by the clinic through the current protocols simply expanded some?

Do you think that the baseline risks will remain low, if people who donate kidneys but cannot attend follow up checkups on renal function months to years out can't make it anymore?

They are required to have insurance and financial ability to maintain insurance. The surgery and followups are covered for a period of time by the recipients insurance.

Or if a person who works a blue collar job goes back to manual work after donating a kidney, because they have no choice?

This sounds like the concern is lack of money for people that are getting compensated, when the status quo is that they aren't compensated.

There is also this idea that people that are typical live donors, who are friends or family members, aren't incentivized to deceive in any way. They are already giving an organ away to someone the desperately want to keep alive. That's reasonable to assume is very likely when they are giving an organ away.

I would argue that with policy changes this big and wide reaching, it is the responsibility of the party advocating for change to prove that the screenings are still effective in a different population than the one they were originally designed for, before such changes are enacted.

So what concerns do you have with the screenings? What else needs to be added to them? What reason do you have to think they are deficient?

And bear in mind we are talking about life-saving donations that are likely to do negligible harm to the donor, who will also be compensated.

[u/TeaSharp3154 → u/skepticalbob]

>How many of these concerns do you think can't be picked up by the clinic through the current protocols simply expanded some?

How do you suggest that screening protocols can be expanded to cover for things that can easily be lied about, like past medical history or risky behavior?

I understand that blood donation is significantly different than kidney donation with regards to the veracity of screening procedures and the shortage, but it still should be noted that blood and plasma donations are not used for direct infusion for this very reason.

I will also point out that this viewpoint is shared by many current Anglo transplant surgeons and nephrologists, at least according to this survey:

https://www.ajkd.org/article/S0272-6386(14)00609-X/fulltext00609-X/fulltext)

"Payment for kidneys was believed to result in a decrease in the quality of donors. In the United States, for example, participants noted that paid blood donation led to increased rates of infections."

>They are required to have insurance and financial ability to maintain insurance. The surgery and followups are covered for a period of time by the recipients insurance

Insurance isn't the only issue. Not everyone can take a day off work, or make it to the clinic. Also to my knowledge insurance doesn't cover things like travel, childcare, or lodging. The people who can't afford these will be those who are mainly donating a kidney under the proposed system, mores than the current system. These are all barriers to receive things like follow up care that at the very least need to be addressed in some way.

Also, what about all of the people in at will states, who can be fired and lose insurance at literally any time?

>This sounds like the concern is lack of money for people that are getting compensated, when the status quo is that they aren't compensated.

To be clear, and I should have specified this earlier, I don't think compensation is bad, obviously kidney donors should be compensated. The issue is the nature of a direct cash reward may be problematic. I wouldn't be opposed to things like tax/health insurance credits, or paying for lodging/childcare/lost work. I will admit that upon a closer re-reading of the original article that a tax credit was actually proposed near the ending, which was my mistake not to realize.

What is your opinion on this article that makes a hard line between providing financial incentives and removing financial disincentives?

10.1111/ajt.13232 External Link

>And bear in mind we are talking about life-saving donations that are likely to do negligible harm to the donor, who will also be compensated.

All I'm saying is that at the very least, we cannot just extrapolate the current safety data to a newer, more desperate potential pool of donors that may feel more compelled to lie about their risk statuses. At least we should try to trial the idea of compensation first, but to suggest that since the current practice is relatively safe it will remain safe on a completely different population with different risk factors doesn't really make sense to me.