Responses to Compensation Opponents

Compensation of organ donors has been banned since the National Organ Transplant Act (NOTA) of 1984.  NOTA’s lead sponsor stated that if we have a shortage of organ donors, the first thing we should consider is tax credits for donors.

Responding to the concerns raised by opponents of compensating donors:

Disproving Myths:

Myth: “Kidney donation is too dangerous to pay people to do.”

A just-released study found that the donor’s risk of death in the actual surgery, which was already very low, has dropped by two-thirds over the past decade.

Roofers, fishers, and truck drivers all had annual death rates at least twice as high as the risk of death from kidney donation. Loggers death rate is 10 times larger than the one-time risk of kidney donation. No one is seeking to ban the practice of logging, fishing, truck driving or or roofing because it’s too dangerous. Why should that argument work for kidneys?

Myth: “Reimbursing donors for just lost wages and travel costs will increase the number of living donors.”

Most donors are currently reimbursed for wages and costs, but, for the past 20 years, there has been no noticeable increase in the number of living donations. 22 states offer tax credits and deductions to reimburse donors. The federal reimbursement system reimburses 20% of donors. The National Kidney Registry reimburses 40% of donors. All donors should be cost neutral at the end of donation. The current system of reimbursement has not resulted in an increase in living donation rates.

Myth: “Fixing the deceased donation system will provide far more kidneys.”

From this article in JAMA Surgery, “There is currently a considerable emphasis on minimizing the number of deceased donor kidneys recovered but not transplanted; however, at best, that alone might result in approximately 2,000 more transplants per year, a mere dent in the problem.”

Myth: 13 people on the kidney transplant waitlist die waiting for a kidney every day.

Every day, ≈24 people who are on the waitlist either die directly from the waitlist or are removed because they become too sick to be transplanted, meaning they will die on dialysis. That’s 10,000 people a year who were well enough to be transplanted when they joined the waitlist and were killed by the long waiting times for a kidney. In total, 115 Americans die each day as a result of the kidney shortage. For a number of reasons, many people are not waitlisted even though they would be eligible for a kidney transplant.

Myth: “Incentivizing donors is horrific.”

Providing an incentive for a living kidney donor who goes through the work (time loss, stress and pain) of donation to save a stranger’s life is lifesaving, not horrific. What is truly horrific is that more than 100,000 Americans died who were on the kidney waitlist died from 2010-2021. Far more than that died from the kidney shortage.

In the last four decades since the passage of NOTA, opponents to compensation claimed that it’s more horrific to incentivize kidney donation than to watch someone who did not need to die have a miserable death from kidney failure. Since 1988, over a million Americans died from the kidney shortage. They would have survived and thrived instead of died if the End Kidney Deaths Act had already been passed. 

Myth: “The End Kidney Deaths Act will create a market in body parts.”

This is plainly false. Tax credits have traditionally been used to encourage prosocial behavior. And nothing is more prosocial than saving the life of a stranger through kidney donation. Tax credits are not “markets.” When people receive a tax credit for adopting a child, they are being rewarded for their prosocial choice. The government has not created a market in the adoption of children by providing a tax credit. A market is one where the rich have superior purchasing power. The End Kidney Deaths Act will provide a uniform incentive for those who save both lives and billions of tax dollars. 

Myth: “Incentivizing kidney donation to strangers could undermine efforts to end illicit organ markets in some foreign countries, where people in poverty may be coerced into selling a kidney or driven to make a decision they’ll regret.”

In fact, the opposite is true. Transplant tourism in developing countries is directly linked to the kidney shortage in developed countries like the US. Those with kidney failure are desperate to survive and thrive with a new kidney, as 60% of dialysis patients die within the first five years. If they live in a state like California with a ten-year waitlist, kidney failure patients are aware that they are unlikely to survive the wait. So some make the decision to buy a kidney on the underground market so they can survive. Once we have a far greater supply of living kidneys, those who would seek kidneys in a risky surgery abroad will instead receive a kidney in this country. The illicit organ market will have far less demand. The End Kidney Deaths Act will contribute to the decline of the catastrophic black market for kidneys that is estimated to provide 10% of all kidney transplants currently world-wide. 95% of kidney donors surveyed state they would donate again if they could.

Myth: “Incentivizing donors is not acceptable because “kidneys are a finite resource” and do not regenerate.”

The implicit idea in this argument is that because we cannot regenerate our kidneys like we regenerate blood, we should not incentivize people to donate kidneys. But the finitude is not what’s important — it’s the risk. Blood is renewable, but we would not let people donate it if it were risky.  The reality is that people can thrive with only one kidney. One person in every 500 is born with only one working kidney. Hilary Steinour and Matt Cavanaugh who both donated kidneys to strangers ran twelve marathons in 2023 to demonstrate that one kidney can provide all that is needed for such a physically demanding feat. To be sure, kidney donation carries some risk - around 1 death in 10,000 donations - lower than appendectomies or giving birth (which is for surrogates generously incentivized.) Those who are willing to donate kidneys are screened for both mental and physical health in order to qualify. Only two out of every one hundred people who step forward to donate actually donate, often due to being medically disqualified. Kidney donors range in age from 18 to 91. Donors take a minimal risk to save a stranger’s life. Firefighters do this every day at a greater level of risk.

Myth: “It would send the wrong message to countries that already struggle with unsanctioned transplant tourism — wealthy patients who travel to acquire a kidney.”

Again, the opposite is true. By reducing the kidney waitlist in the US, the End Kidney Deaths Act reduces the demand for transplant tourism. 

Myth: “Kidneys are not renewable like sperm, eggs and plasma and therefore should not be donated.”

Kidney donors live longer lives than the general population because donors need to be in top health in order to qualify for donation. When people donate, their kidney grows in size and takes over the job of filtering blood. Health outcomes for living donors are excellent.

Myth: “The tax credit proposal would be burdensome for people who don’t normally file full income tax returns. Also, donors might have to wait months to receive the tax benefit.”

For low income donors (“those who don’t normally don’t file full income tax returns”), filing for a tax credit is not burdensome. The fact that donors will need to wait for the funds is a built-in safeguard that a donor will not immediately receive the financial support that could motivate someone who is desperate. Instead, the End Kidney Deaths Act will gradually provide the incentive over five years, beginning the year after the kidney donation. 

Myth: “Compensated kidney donation exploits or coerces the poor.”

Low-income people suffer most from the kidney shortage. The most important thing we can do for low-income Americans is increase the number of donations. 

The current system makes it prohibitively expensive for low-income people who want to become kidney donors. For someone living paycheck to paycheck, making donation cost-neutral is simply not enough given how disruptive donation is to work. The End Kidney Deaths Act is the only bill that actually levels the playing field. 

The concern that low-income people will donate their kidney against their better judgment if there is a tax credit is unscientific, paternalistic, and ignorant of the actual mechanisms of the End Kidney Deaths Act.

The wealthy have the financial resources to list at multiple transplant centers in several states as well as run campaigns, hire a team to help them find a kidney, put up billboards and conduct a search on social media. Low-income Americans do not have the same resources and are therefore at a disadvantage.

Coercion means using threats or force to limit a person’s options so they do what you want. Paying for kidney donation expands options, rather than limiting them.

Myth: “We’ll get fewer kidney donations if donors are compensated because it will no longer feel altruistic.”

A recent survey conducted by the National Kidney Donation Organization (which represents living kidney donors) found that 97.9 percent said they would’ve been as likely or even likelier to donate had they gotten a tax credit.

Monetary incentives are not counterproductive. Does paying salaries to doctors, nurses and firefighters “crowd out” their altruistic reasons for doing life-saving work?

People donate more plasma when they’re paid to donate plasma. Paying people to donate kidneys will result in more kidney transplants.

Myth: “If you’re donating a kidney to someone you care about, you’re going to tell the truth. But if you’re doing it because you need some money, well, why would you necessarily?”

Without evidence, the speaker asserts that someone would lie to get money but not to save the life of a loved one. Donating a kidney to a friend or family member has value to the donor because the donor will enjoy more years with a spouse, child or friend. Just because the benefit isn’t financial does not mean it doesn’t exist. The fact that donors live longer than the general population and the comprehensive mental and physical health qualification tests to donate result in only 2% of willing donors passing and actually donating demonstrate that the testing evaluation process works now and will continue to work after the End Kidney Deaths Act passes.

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Response Letter to Opposition Opinion Piece:

We, the undersigned—healthcare providers, organ donors, kidney patients, and their loved ones—strongly support the End Kidney Deaths Act (HR 9275), a groundbreaking initiative that will save thousands of lives and billions in taxpayer dollars. Below, we refute the objections raised by Drs. Thomas F. Mueller (Switzerland), Maria A. Matamoros (Costa Rica), Sanjay Nagral (India) and Gabriel M. Danovitch (Israel/ USA) in their March 26, 2025, JAMA Surgery opinion piece. The objections raised in the opinion piece rely on outdated fears, dismiss overwhelming evidence, and overlook a crisis that is both deadly and solvable. 

The Kidney Shortage Crisis: Over the past decade, 100,000 Americans have died while waiting for a kidney. Each year, only 6,000 living kidney transplants occur, leaving 90,000 patients on the waitlist—half of whom will die without intervention. The End Kidney Deaths Act seeks to reverse this crisis by offering living kidney donors—who donate to strangers—a $10,000 refundable tax credit annually for five years, totaling $50,000. 

Refuting the Arguments Against the End Kidney Deaths Act 

Argument 1: Financial compensation for organ donation will not significantly reduce the organ shortage. 

Refutation: The End Kidney Deaths Act’s structured compensation will motivate new donors who might not otherwise consider kidney donation. Similar compensation models—such as sperm, egg, plasma, and surrogacy donations—have long ensured stable supply levels, proving that financial compensation effectively increases donor participation without ethical compromise. 

Argument 2: Financial compensation will commodify organs and exploit vulnerable populations. 

Refutation: The End Kidney Deaths Act establishes a well-regulated compensation system that protects donors and ensures informed consent, reducing reliance on the illicit organ trade. 

Argument 3: Countries with compensation see fewer voluntary donations. 

Refutation: Unlike existing international models, the End Kidney Deaths Act is uniquely structured to safeguard donors while dramatically reducing waitlists and dialysis-related deaths. Countries that compensate kidney donors have demonstrated how financial support can slash wait times, lower dialysis-related mortality, and increase overall donation rates. 

Argument 4: Paid donors experience regret, and compensation does not address their hardships. 

Refutation: The paid donors referenced by the authors are victims of the black market. 95% of surveyed American kidney donors would donate again because they had a positive experience. A National Kidney Donation Organization survey found 97.9% of kidney donors would donate again if a $50,000 refundable tax credit existed. 

Argument 5: Legalizing compensation in the U.S. will increase global exploitation. 

Refutation: By prohibiting compensation, the U.S. has inadvertently fueled demand for black-market transplants, where an estimated 10% occur illegally. The End Kidney Deaths Act replaces this dangerous underground system with a transparent, government-regulated alternative that protects donors, eliminates exploitation, and saves lives. 

Argument 6: Other strategies (reducing discard rates, providing financial neutrality, and improving dialysis) are better solutions. 

Refutation: These strategies have been pursued for decades without significantly expanding the donor pool. Despite over half of American kidney donors being fully reimbursed for costs and lost wages, donation rates have not increased. Even if far fewer kidneys were discarded, the shortage would persist. A more comprehensive approach, including financial compensation, is needed to resolve the kidney shortage. 

Conclusion 

The End Kidney Deaths Act is a ten-year pilot program designed to directly combat the national kidney shortage crisis. We strongly urge Congress to pass the End Kidney Deaths Act to prevent the unnecessary loss of life and provide hope for those in urgent need of a kidney transplant.

Signed by the Coalition to Modify NOTA Community

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Sources:

“The moral case for paying kidney donors; Kidney donors save lives. Why aren’t we compensated for it?” Vox News, Dylan Matthews, September 18, 2024

“Most Americans Favor Compensation for Kidney Donors if it Leads to More Saved Lives,” Johns Hopkins University, July, 2019

“Poll: Americans Show Support for Compensation of Organ Donors,” National Public Radio, May, 2012

“A regulated system of incentives for living kidney donation: Clearing the way for an informed assessment,” American Journal of Transplantation, Dr Arthur Matas, MD and Dr. Luke Semrau, PhD, July, 2022

“Would You Donate a Kidney for $50,000?” Vox News, Dylan Matthews, April 2024

“Views of US Voters on Compensating Living Kidney Donors,” JAMA Surgery, Dr. Thomas Peters, MD, Dr. Jonathan Fisher, MD, Dr. Robert Gish, MD and Dr. Richard Howard, MD

“Report from a Multidisciplinary Symposium on the Future of Living Kidney Donor Transplantation,” Dr. Thomas Peters et al, 2023