Irrespective of personal wealth, people regularly make lifestyle decisions to engage in risky behaviors (e.g., skydiving, volunteering for military service, working on oil rigs, and smoking cigarettes). Lacking wealth does not pre-empt making a rational decision. Prohibiting the poor from donating organs leaves them still poor; consequently, according to Matas, withholding the ability to be paid for donation eliminates one path to improve a person’s financial situation (Clin Transplant. 2008;22:378-384).

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Ethical considerations

Why is selling a kidney so ethically wrong? And how is it different or any worse than selling one’s sperm or egg cells, actions now legal and widely advertised in newspapers and magazines? Commercialization of semen and ova is more morally questionable than organ sale because reproductive cells, like stem cells, have the potential to create entirely new human beings, while an organ does not.

Further to the point that we may only see what we wish to see is the exclusion from debate, up to now, of the NIH policy permitting payment to healthy volunteers for their participation in experiments that may intubate, induce pain, cause stress, or biopsy healthy organs on the grounds that such payment is “an incentive to facilitate adequate and timely recruitment for and/or completion of a study.” Searching for the term “normal tissue volunteer” in the NIH clinical trials database ( on July 15, 2008, returned 737 current studies.

Why legalize kidney marketing?

Establishing a national regulatory council to coordinate and regulate marketed kidneys would be a logical extension of the present end-stage renal disease (ESRD) network collaborating with UNOS and OPTN. Eliminating black-market brokers would divert funds to actual kidney donors.

Also, money saved from decreasing the number of prevalent dialysis patients might conceivably generate the total funding for additional kidney transplants. Positive points and main objections to legalizing living donor kidney marketing have been thoroughly analyzed. Before rejecting the concept of allowing kidney sales, it is helpful to consider those who are dying because of unavailable donor kidneys and might benefit from innovative thinking and fresh approaches.

Though only partially described, Iran’s compensated live donor kidney allocation plan sustains a compensated and regulated living unrelated donor renal transplant program (Exp Clin Transplant. 2005;3:351-354). By providing financial incentives to volunteer living kidney donors, Iran is the only developed nation without a substantive renal transplant wait list. Iranian law proscribes “transplant tourism,” meaning foreigners are not allowed to undergo renal transplantation from living-unrelated Iranian donors nor are foreigners permitted to volunteer as kidney donors for Iranian patients.

Of 17,718 renal transplants done in Iran through the end of 2004, 3,196 were from live related donors, 13,920 from live unrelated donors, and 602 were from deceased donors. Political stresses have limited scientific exchange with greater detail that must be obtained before advocating extension of the Iranian plan to other nations.

As this is written, the U.S. health-care system is under scrutiny, with the cost of uremia therapy a great concern. It is reasonable to worry that adoption of a federal organ-marketing scheme would necessitate greater “socialization” and expense.

Nephrologists and transplant surgeons, who now have to follow numerous regulations, would react to yet one more federal supervisory and inspection agency with muted enthusiasm. Nevertheless, weighing a controlled initiation and study of potential regimens to increase donor kidney supply in a scientifically and ethically responsible manner is better than doing nothing more productive than complaining about the current system’s inadequacies.

Dr. Friedman is distinguished teaching professor of medicine at SUNY Downstate Medical Center in Brooklyn, N.Y.