Foreword: this is an essay I wrote for my philosophy class called Markets and Morality. I really liked the essay and thought it was a very interesting argument so I wanted to toss it on my website for posterity and all. Enjoy!

Aidan Gerber

April 30th, 2024

A Social Service Model For Kidney Donations

In the United States alone, thousands of people die every year waiting for kidney transplants. These lives can be saved by implementing a new system to make sure more kidneys are transplanted. There are 4 main systems that could govern kidney giving. I will discuss all 4 of the following models and ultimately demonstrate that the social service model is the best option for governing kidney donations.

1. A free market model where all types of kidney sales are allowed.
2. A sophisticated market model where the government can purchase kidneys from citizens and then distribute them fairly.
3. A donation model where all kidney sales are banned.
4. A social service model where the government randomly selects citizens to donate their kidneys.

Based on the immense value of life and the shortcomings of market and donation-based solutions in regards to commodification, exploitation, and effectiveness, the social service model of kidney donations is best. In this model, the government would select the correct number of qualified donors at random to satisfy the total demand for kidneys including those under dialysis and those who receive deceased donor kidney transplants. Drawing on the works of Elizabeth Anderson and Nancy Leong, I will discuss the horrors of commodification, exploitation, simply not receiving a kidney, and more to demonstrate why the social service model of kidney donation is the best option.

First, some background on kidney donation is necessary. In the United States, there are almost 150,000 adult candidates on the kidney transplant waiting list (Lentine et al.). In 2022, the highest number of new candidates ever was added at almost 50,000. The year 2022 also set a record for the most kidney transplants ever performed at 26,000 (“Organ donation from”). Out of these, 20,000 kidneys were from deceased donors and 6,000 kidneys were from live donors.

Adults can require kidneys transplants due to diabetes, hypertension, glomerulonephritis, or many other types of kidney diseases. Of those on the waiting list, over 25% have been on dialysis for at least 5 years. Dialysis represents a substantial decrease in quality of life and future life expectancy (“Kidney Project Statistics”, “Kidney Transplant”).

When someone without working kidneys receives a kidney transplant, they can receive that transplant from either a living or deceased donor. Transplants from living donors on average last 17 years whereas transplants from deceased donors last for an average of 10 years. A patient receiving a kidney donation is based on blood type, HLA antigens, and waiting time (“Deceased-Donor Kidney Transplant”). The blood and antigens of the kidney donor must match the potential recipient for the greatest chance of success. Prospective kidney donors undergo substantial evaluations to be able to donate their kidney (“Living Donor Evaluation”). Kidney donation does not change a donor’s long term life expectancy, but after controlling for health, it does increase the risk of kidney failure by 76 in 10,000 (“Kidney Donation Risks”). This statistic is with the caveat of controlling for healthy people since kidney donors undergo rigorous health evaluations and are much healthier than the average person (Levea). The risk of death from donation is 7 in 100,000 (“Risk and Benefits”). Recovery in the hospital is typically 24-48 hours with an expectation of 6-8 weeks to fully heal. After this time, no lifestyle changes are needed.

Now that a factual background has been established, it is time to discuss the different proposals for how to save these lives. The most basic proposal to fix the problem of not enough kidneys being donated is a completely unregulated market for kidneys. Within this system, kidneys could come from anywhere in the world and be purchased by anyone at a market-set price. This free market allows bodily freedom for an individual. As true sovereigns of the body, the ultimate expression of this autonomy would be to be able to sell parts of it. However, this proposal greatly suffers due to potential for wrongful exploitation, misallocation, and rights violations. Based on the definitions of Jason Brennan and Peter Martin Jaworski in their work Markets without Symbolic Limits, wrongful exploitation is when a market “encourages the strong to exploit the vulnerable” (1053). If there are no limits placed on kidney sales, only the rich would buy kidneys and only the poor would sell theirs. This dynamic could occur regardless of the safety of the procedure and without respect to geographic limits. People from across the world could end up selling their kidney to people in rich nations without respect to the health and safety of the donors. The free market proposal also leads to misallocation where goods are allocated unjustly. Since kidney transplants would be awarded due to financial status instead of time waiting, need, or some other qualification, an unregulated market would lead to misallocation. Moreover, this lack of regulation could easily result in rights violations where people are trafficked and coerced into donating their kidneys.

In 2003, Charles Erin and John Harris suggested a solution that solves the problems of wrongful exploitation, misallocation, and rights violations with the free market proposal. In this sophisticated proposal, Erin and Harris recommend creating a market for kidneys where the government of a specific geopolitical region pays a generous price for organs and then gives them to the most deserving citizens. This proposal limits misallocation since the government would be the purchaser and then could allocate the kidneys to those most deserving by socially acceptable principles. In fact, the generous price could even be enough so that everyone that needs a transplant would be able to get one in a timely manner. The geographical restrictions would make rights violations where people are trafficked for their organs much less likely. However, despite these improvements, the sophisticated proposal still does not fix the issues of commodification and wrongful exploitation.

To explain how commodification and exploitation will still exist, one just needs to look at Iran, the only country in the world that has legal organ markets. Starting in 1988, Iran has allowed this market to help encourage more live donations and limit premature deaths and suffering across the country. To do this, the government of Iran pays a fixed fee of 10 million rials (~$250) to donors although donors can also individually negotiate additional compensation with the recipient at an average amount of 135 million rials (~$3,375). The government Ministry of Health and Medical Education oversees this process and provides medical care to the donor or even a military exemption. Analysis of this market has led to a few conclusions: “most of the Iranian kidney transplant candidates, irrespective of their socioeconomic class, have access to kidney transplantation,” there is definite “stigmatization of donors,” a “crowding out effect which defeats altruistic and prosocial donation,” and finally “commercialization and commodification which exploits the poor and disrespect human integrity” (Moeindarbari & Feizi). The Iranian proposal is somewhat in between the free market model and the sophisticated market model since it is heavily regulated by the government but still contains some elements of direct sales. Moeindarbari and Feizi highlight that there are life saving properties of the Iranian model but that it comes at the expense of exploitation and commodification.

The Iranian system is not a true implementation of the sophisticated model and it is possible that some of the problems would be erased given a more comprehensive realization. However, in any situation where a price is placed on a part of the human body, commodification ensues. In her work, The Ethical Limitations of the Market, Elizabeth Anderson discusses commodification through the lens of fraternal relations. Fraternal relations occur in a social democracy when goods are provided in common and distributed in a need-based manner. This class of goods differs from economic goods which are impersonal, want-regarding, and exclusive. Applying Anderson’s framework of goods to the different systems of kidney giving, the donation and social service models enhance fraternal relations since they provide the good of kidneys in common distributed through a need-regarding system. This contrasts with a basic market model that turns kidneys into an economic good and undermines fraternal relations. The sophisticated model of kidney donation attempts to avoid this problem by distributing kidneys with regards to need after the government purchases them. However, Andersen also notes that a core part of a fraternal relation is that it appeals “to a sense of civic duty” (197). The sophisticated proposal destroys the value of virtue and makes individuals feel as though they should receive a “personal advantage” for their kidney rather than feeling the reward of enhancing their community. In the donation and social service models, donors can feel as though they have enhanced their community.

Even if the market model is rejected, many may still argue that the donation model in the U.S. is superior to the social service model. Another author that looked at commodification was Nancy Leong in her article Racial Capitalism. She highlights that “we tend to place our loftiest ideals beyond the reach of the market” and then continues to discuss what types of commodification should be objectionable (2199). She brings up two concerns about commodification which are coercion and corruption. Coercion can occur in a market when commodification is “carried out against a background of inequality” and corruption argues that “commodification inherently degrades certain goods and practices under conditions of equality and inequality alike.” (2199).

The donation model that the U.S. currently uses prioritizes non-coercion to the largest possible degree. There are extremely limited incentives for kidney donors and little encouragement to donate. Live kidney donors must either be convinced by their own altruism or by someone they know that needs a kidney. Because valuable considerations are illegal, economic inequality is irrelevant in terms of live kidney donors.

Even though the donation system eliminates opportunities for coercion, it does not limit corruption. For example, wealthy donors have the option to fly around the country to numerous hospitals and enter multiple waiting lists (Marchione). Moreover, many of the alternatives to kidney donation that exist because there are not enough live donors are extremely expensive. In fact, the government pays on average over $100,000 a year for Medicare patients on dialysis (Holmes). Dialysis does save lives, but it is overall vastly inferior to receiving a kidney transplant both in terms of cost but also quality of life. Technology is also improving and just over a month ago, a genetically modified pig kidney was successfully transplanted into a human for the first time ever (“In a First”). This surgery is potentially pioneering for humans receiving animal organs of many different types and may eventually save many lives. However, artificial or non-human organs are not ready yet, and the best option for many is deceased organ donors, which are a vast improvement over dialysis yet still worse than live donors. The average kidney transplant from a deceased donor lasts for 10 years versus 17 years for a live donor. Moreover, transplants where the recipient has not been on dialysis at all lead to better health outcomes than when a patient is on dialysis intermittently. The current system of kidney donation shuffles tens of thousands of people towards health outcomes that are much worse than what modern transplant science can offer because not enough living people donate their kidneys.

Overall, the market models for kidney giving suffer due to commodification and the donation model does not provide enough kidney donors. The social service model for kidney donation avoids these problems. Below is a table summarizing the benefits and harms of the different kidney giving models as discussed prior.

The social service model of kidney donation fixes many of the problems with the other models and trades them for violations of physical autonomy. The way this model would work at its most basic level is that when someone across the country suffers from kidney failure, the government summons a citizen with matching kidney characteristics, verifies their health, and then performs a live kidney transplant. This donor would then receive a small amount of non-financial compensation in government-paid healthcare for a year. More optimizations are possible such as the government predicting kidney transplant volume in advance and allowing months or even years of advance warning before surgery. The social service model is further supported because similar systems of mass government collection already exist in the form of jury duty, taxes, and the military draft. The military draft is in many ways similar because it requires people to put their lives on hold and risk their health for the greater good of their country. This good of the country may be considered in terms of values supported or freedom protected, but why could it not be based on the health and lack of suffering of the citizens? The social service model of kidney donation prioritizes this health and is a more acceptable tradeoff than the draft. Kidney donation is extremely safe, takes under 2 months for a full recovery, and directly saves a life. The draft could take years and being in the military can lead to PTSD, permanent injuries, or death.

Next, the social service model is prima facie unpalatable to many because of its forceful nature. Maintaining the sanctity of the human body and the choice of an individual over their body is extremely important but saving lives is as well. Throughout society, the government makes balancing decisions between the freedom of individual citizens and the lives of the population: jailing murderers, imposing safety regulations on dangerous workplaces, collecting taxes for police and fire services, and more. However, from our current cultural context, forced kidney donation seems much more invasive because of the physical violation of bodily autonomy required by surgery that cuts open the body and removes the kidney. For example, many would balk at the idea of forced kidney donation just from violent criminals or even from people on death row despite the fact that society can fully restrict their mobility and social relations for life. However, in terms of the value of practical bodily autonomy within a different cultural context, kidney donation is irrelevant to bodily autonomy. It has no change to life span, no change to fitness abilities, and does not even leave a scar. A full recovery is possible within 4-6 weeks, a small price to pay for saving a life. The physical impact is large but the practical effects are minimal in trade for a life.

Additionally^[a], kidneys are a unique organ because humans have two of them and only need one and there are no other substitutes. Theoretically, the government could force everyone to become doctors or force everyone to research artificial organs and potentially save more lives or at least not forcefully cut anyone open. However, those policies have alternatives. There are many ways the government can encourage more people to become doctors through existing channels such as student loan forgiveness, tax incentives, or medical school financial aid. These methods of encouragement do not violate the ability to choose a path in life. However, a live kidney donation has no substitute. All other technological solutions are inferior to the quality of life provided by a live kidney donation.

 Ultimately, the social service model is the best option for a kidney giving system. Despite its costs to physical bodily autonomy, it effectively saves lives while preventing commodification and exploitation. The social service model correctly treats kidneys as an element of the body that is both unnecessary to the donor yet lifesaving to the recipient. The social service model for kidney donation is rooted in the existing effectiveness of government policies like the draft and taxation and similarly serves a critical purpose of saving lives in a way not possible with other policies. When considering the different methods of managing kidney giving, the social service model prevails.

Anderson, Elizabeth. (1990). The Ethical Limitations of the Market. Economics and Philosophy. 6. 179-205. 10.1017/S0266267100001218.

Brennan, Jason, and Peter Martin Jaworski. “Markets without Symbolic Limits.” Ethics, vol. 125, no. 4, 2015, pp. 1053–77. JSTOR, https://doi.org/10.1086/680907. Accessed 30 Apr. 2024.

Leong, Nancy. “RACIAL CAPITALISM.” Harvard Law Review, vol. 126, no. 8, 2013, pp. 2151–226. JSTOR, http://www.jstor.org/stable/23415098. Accessed 30 Apr. 2024.

Charles A Erin and John Harris. “An Ethical Market in Human Organs.” Journal of Medical Ethics, vol. 29, no. 3, June 2003, p. 137, https://doi.org/10.1136/jme.29.3.137.

“Deceased-Donor Kidney Transplant.” Duke Health, 4 Apr. 2022, https://www.dukehealth.org/treatments/transplant-program/kidney-transplant/deceased-donor-kidney-transplant.

Holmes, Tamara. “How Much Does Dialysis Cost?” GoodRx Health, 10 Nov. 2022, https://www.goodrx.com/health-topic/kidneys/dialysis-cost.

“Kidney Donation Risks.” National Kidney Registry, https://www.kidneyregistry.org/for-donors/i-want-to-learn-more-about-living-kidney-donation/kidney-donation-risks/.

Kidney Project Statistics. 2019, https://pharm.ucsf.edu/kidney/need/statistics.

“Kidney Transplant.” National Kidney Foundation, https://www.kidney.org/atoz/content/kidney-transplant.

Lentine, Krista, et al. OPTN/SRTR 2022 Annual Data Report: Kidney. U.S. Department of Health & Human Services, 2022, https://srtr.transplant.hrsa.gov/annual_reports/2022/Kidney.aspx.

Levea, Swee-Ling. “What Potential Donors Need to Know about Living Kidney Donation.” UT Southwestern, 30 Nov. 2017, https://utswmed.org/medblog/living-kidney-donation/.

“Living Donor Evaluation.” National Kidney Foundation, https://www.kidney.org/transplantation/livingdonors/evaluation.

Marchione, Marilynn. “Wealth May Give Advantage for Getting Organ Transplants.” AP News, 9 Nov. 2015, https://apnews.com/wealth-may-give-advantage-for-getting-organ-transplants-07ba7ae4b7d5458e860845b697208e0e.

MASS GENERAL BRIGHAM COMMUNICATIONS. “In a First, Genetically Edited Pig Kidney Is Transplanted Into Human.” Harvard Medical School, 21 Mar. 2024, https://hms.harvard.edu/news/first-genetically-edited-pig-kidney-transplanted-human.

Moeindarbari, Tannaz, and Mehdi Feizi. “Kidneys for Sale: Empirical Evidence From Iran.” Transplant International : Official Journal of the European Society for Organ Transplantation, vol. 35, 2022, p. 10178, https://doi.org/10.3389/ti.2022.10178.

“Organ Donation from Deceased Donors Continues 12-Year Record-Setting Trend.” UNOS, 10 Jan. 2023, https://unos.org/news/2022-organ-transplants-again-set-annual-records/.

“Risks and Benefits of Living Kidney Donation.” Weill Cornell Medicine, https://weillcornell.org/services/kidney-and-pancreas-transplantation/living-donor-kidney-center/about-the-program/risks-and-benefits-of-living-donation.

Wilkinson, Stephen. “The Sale of Human Organs.” The Stanford Encyclopedia of Philosophy, edited by Edward N. Zalta, Winter 2016, Metaphysics Research Lab, Stanford University, 2016, https://plato.stanford.edu/archives/win2016/entries/organs-sale/.