It was June 2019. I was in a hospital in Hong Kong, sitting beside my grandfather’s bed, listening to the steady beeping of the dialysis machine. As a late-stage kidney failure patient, my grandfather had been tethered to those machines for months. The doctor told us a transplant was his only chance at a better life, but we were stuck in a painfully long waiting list, with no matching donor in sight. Weeks turned into months, hope into dread.

“I think it’s time we talk about the worst-case scenario.”

It was by then, the theme of death arose with all hopes shattered. Yet, my grandfather’s story is just one of millions across the world, where patients suffer and die because of organ shortage.

In the status quo, kidney donations mostly rely on cadaveric donors, meaning deceased individuals, or living donors willing to sacrifice. Both forms of donation must be bound by strict requirements, with the former dying of brain death while still on life support and the latter should have excellent physical and mental health. In fact, most jurisdictions prohibit financial compensation to ensure donors aren’t under coercion, in turn lowering incentives as many potential donors lack support for surgical costs or lost wages. Now, we face the grim fact: 10% of the global population is affected by chronic kidney disease and millions die annually [1].

In light of that, there seems to be a new way out — a commercial human kidney market. To determine whether this will be an ideal solution to the matter at hand, we must first understand how it works by examining the sole nation that legalized the sale of kidneys, Iran.

On the streets of Iran, handwritten ads reading “Kidney for sale” advertisements are plastered across telephone poles, bus stops and alleyways [2]. Iran had always been meagre in providing resources to cure ESRD patients, with the 1979 Iranian revolution aftermath adding on to the expensive and short supply of dialysis. Unfortunately, altruistic supply of organs has been less than adequate in Iran. In 1988, the Iranian government introduced monetary compensation for living donors to establish a regularized system of kidney selling. Managed by the Dialysis and Transplant Patients Association, and monitored by the Ministry of Health, donors and recipients undergo comprehensive medical and psychological tests. The government provides a cash reward of about USD$1200, one year of medical insurance, while donors can legally receive additional compensation from the kidney recipient in private transactions. Surgery and hospital costs are fully covered by the state, but this policy only applies to Iranians or Afghan refugees to prevent transplant tourism. [3, 4]

By raw numbers, Iran’s system seems to have solved the problem completely. Compared to the giant pool of over 103,000 people on the US transplant waiting list [5], in just 2 years, the waiting list for kidney transplants had almost disappeared. Today, more than 1,480 people receive a kidney transplant from a living donor in Iran each year, about 55% of the total 2,700 transplants annually [6]. In 2015, the estimated waiting time decreased to just 7 months with the reported survival rate of recipients being 88%, 65% and 12% at 1, 3, 10 years respectively [7]. However, the system hasn’t always worked as it’s been billed. Sellers have learnt that they can cut side deals to earn up to thousands more from affluent Iranians eager to bypass the waiting time for a transplant under the government system. Some doctors have also been caught attempting to perform transplants for foreigners who obtained forged Iranian IDs [2].

Nonetheless, with black-market organ sales pervading in countries like India, Pakistan and many dying each year waiting for kidneys, Iran’s system undeniably shortens waiting lists and eliminates some illicit markets.
So, the question is, should countries put this in place?

From a practical perspective, this system solves shortage quickly by financial incentives. In a world where altruism alone cannot meet the staggering demand, we cannot dismiss the fact that everyone wants more money, especially for individuals trapped in a vicious cycle of poverty. Instead of engaging in illicit black markets to cover their debts, stealing or trafficking, they now have a lawful route to financial relief. Despite the WHO stating that “transplant commercialism targets impoverished and otherwise vulnerable donors [8],” it’s also true that, for many, this is the only viable option available to escape extreme poverty, and even restart their lives. In this case, a kidney market will become a transaction of survival on both ends: one gains life, the other gains livelihood.

Of course, when strictly regulated, donors are guaranteed compensation while recipients, poor or rich, are promised a kidney. However, can this utopia really exist, or will it mirror the existing class division, rebranding exploitation under state control? Studies in Iran show the overwhelming majority of donors coming from lower-income backgrounds, while recipients are generally better-off [9], resulting in a world where the affluent can purchase life, while the economically disadvantaged are left to sell parts of themselves. Corruption or under-the-table payments allow the wealthy to secure a donor quickly, leaving the poorer with fewer options. Moreover, not all countries can provide long-term medical and financial support for donors, making uninformed donors’ lives worse.

From a moral perspective, organs are integral parts of our bodies that should be valued, symbolizing one’s identity, autonomy and inviolability of the self. Commodification of kidneys not only belittle medical care as a market transaction, but also erodes human worth and dignity, leading to troubling ethical dilemmas. While a kidney market can save lives, can we truly justify putting a price tag on a human organ? Philosopher Immanuel Kant argued that humans must always be treated as ends in themselves, not merely as means to someone else’s ends, meaning it is immoral to use someone else’s organ as a tool to one’s survival. Because the body is not a property and legalizing the sales of kidneys means there will be a normalization of a dehumanized society over time, denigrating our views of how goods are properly valued.

In all, the Iranian kidney market undeniably offers an efficient, regulated path to solve organ shortages and benefits the ones who struggle financially, but it does so at a social cost of institutionalizing inequality, trading off human value. Instead of replicating this model, countries can adopt presumed consent donation. Rather than opt in, citizens are automatically on the kidney donation list since birth, but have the free choice to opt out at their own will, whether religious concerns or personal reasons. Countries like Singapore and Spain have proved this approach successful, with Spain boasting the highest organ donation rate of 122.1 per million population [10]. In tandem, the government should promote altruistic donation through public education while providing more support for living donors.

Because in a world where ethical alternatives exist, no one should have to sit in a hospital room, like I did with my grandfather, counting the beeps of a dialysis machine, knowing a kidney will never come. The answer to organ shortage is not to put a price tag on ourselves, but reforming our current donation system that protects ethics, equity, and the true value of life.


Citations:
1. National Kidney Foundation. Global facts about kidney disease [Internet]. Available from: https://www.kidney.org/global-facts-about-kidney-disease
2. Los Angeles Times. ‘Kidney for sale’: Iran has a legal market for the organs, but the system doesn’t always work. 2017 Oct 15 [Internet]. Available from:
https://www.latimes.com/world/middleeast/la-fg-iran-kidney-20171015-story.html
3. Rosenberg T. On the kidney market in Iran [Internet]. EconTalk; [cited 2025 Jun]. Available from:
https://www.econtalk.org/tina-rosenberg-on-the-kidney-market-in-iran/
4. Ghods AJ, Savaj S. Iranian model of paid and regulated living-unrelated kidney donation. Clin J Am Soc Nephrol. 2006 Nov;1(6):1136–45. Available from: https://pubmed.ncbi.nlm.nih.gov/17699338/
5. US Health Resources and Services Administration. Organ donation statistics [Internet]. OrganDonor.gov; [cited 2025 Jun]. Available from:
https://www.organdonor.gov/learn/organ-donation-statistics
6. Stat News. Organ donation in Iran: living donors make up majority [Internet]. 2016 Aug 25 [cited 2025 Jun]. Available from:
https://www.statnews.com/2016/08/25/organ-donation-kidneys-iran/
7. Najaran HS, et al. Survival statistics after kidney transplantation in Iran. [Internet]. Available from: https://www.sciencedirect.com/science/article/pii/S0014292124002162
8. World Health Organization. Transplant commercialism targets impoverished and vulnerable donors. Transpl Int. 2015; 28(4): 45-49.
https://pmc.ncbi.nlm.nih.gov/articles/PMC4571160/
9. Malakoutian T, Hakemi MS, Nassiri AA, Rambod M, Haghighi AN, Broumand B, et al. Socioeconomic status of Iranian living unrelated kidney donors: a multicenter study. Transplant Proc. 2007 May;39(4):824–5.
10. La Moncloa: Government of Spain. Donation and transplant data. 2024 Jan 17 [Internet]. Available from:
https://www.lamoncloa.gob.es/lang/en/gobierno/news/Paginas/2024/20240117_donat ion-and-transplant.aspx