A Market for Donor Kidneys Is Not the Reform the U.S. Needs


Apr 25, 2024

Surgeon James Guarrera harvests the damaged kidney of a patient as part of a five-way organ transplant swap in New York City, August 1, 2012, photo by Keith Bedford/Reuters

Surgeon James Guarrera harvests the damaged kidney of a patient as part of a five-way organ transplant swap in New York City, August 1, 2012

Photo by Keith Bedford/Reuters

This commentary originally appeared on Newsweek on April 25, 2024.

In a recent op-ed in the New York Times, freelance journalist Dylan Walsh made the case for a regulated market for kidneys in the United States in which donors would be paid. He isn't the first. Two living kidney donors advocated for this in a Los Angeles Times op-ed last summer. The Wall Street Journal explored the pros and cons from a capitalist standpoint in November.

These articles all compellingly point to the more than 100,000 Americans currently waiting for a donated kidney, many of whom will die before receiving one. That makes the prospect of a market solution enticing. It seems easy, as if we could simply flip a switch, legalize selling donor organs, and fix a complex social problem. But the real world of reforming the transplant system is more complicated than that.

The good news is that there is a much larger ongoing federal effort to reform the organ transplantation network.

In 2017, the Bridgespan Group, a nonprofit consulting firm, released a landmark report (PDF) that highlighted waste and fraud in the U.S. organ transplant system. Much of the transplant system is run by 58 nonprofit entities called organ procurement organizations (OPOs), each responsible for overseeing organ donation and transplantation in a specific region. Specifically, the report identified significant variation in OPO donation rates and estimated that if the lowest-performing OPOs matched the performance of the highest-performing OPOs, up to 17,000 additional kidneys could theoretically be recovered for transplant each year.

This report and subsequent advocacy led to federal reform to hold poor-performing OPOs accountable to federal regulators. After that, a bipartisan group of senators and members of Congress pushed for more substantial improvement and modernization of the entire transplant system. In 2023, years of comprehensive research, diligent reporting by journalists, and advocacy by patient organizations finally led to laws to reform and overhaul the organ transplantation system, including planned changes to the governance and operations of the transplantation network, an update of information systems, and increased requirements for transparency and accountability.

Increased transparency is already paying off. One very important issue for racial equity in transplant was the systematic miscalculation of the estimated glomerular filtration rate for Black people; this widely used algorithm for estimating kidney function was overestimating results for many Black patients, causing them to be deprioritized for transplantation. In the time since this problem was identified, hospitals have implemented new algorithms, leading to shorter wait times for transplant for Black patients.

Economists also have done a lot of good for the transplant system. Alvin Roth won the Nobel Prize in 2012, in part for his work designing algorithms (PDF) to match people with organs. Since then, researchers have improved these matching algorithms and further optimized transplant system performance. However, in promoting solutions like establishing a market for kidneys as simple and win-win, advocates fail to account for the actual logistics of running a complex, national system involving hospitals and other stakeholders in 50 states and risk shifting the national conversation away from ongoing system-wide reform efforts.

In promoting a market for kidneys as simple and win-win, advocates fail to account for logistics, and they risk shifting the conversation away from ongoing system-wide reforms.

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Not all economic theories pan out, as illustrated by the organ donor opt-in versus opt-out debate. Economists suggested that by switching from an opt-in system, in which people must check the box to become registered as an organ donor upon death, to an opt-out system, in which everyone is registered as a donor by default and must submit a form to be removed as a donor, would lead to a substantial increase in the number of organs available for transplant. This “nudge” was hailed as a similarly simple solution to the organ shortage and hyped as a potentially lifesaving for thousands of people. However, subsequent research has shown that, in practice, opt-out systems have had little impact on organ-donation rates.

Instead, other efforts to increase the number of organs available can be looked to for examples of how to reform the transplant system. In 2013, Congress unanimously passed the HIV Organ Policy Equity (HOPE) Act, which permitted the donation of organs from people with HIV to others with HIV, with the goal of increasing the number of organs for transplant for people with HIV. Passing the law was only the first step. It took years of effort by hospitals, OPOs, and others to change processes, train staff, and build buy-in. But because of the HOPE Act, more than 350 of these transplants have occurred, greatly improving the lives of these patients and their families.

Efforts like the implementation of the HOPE Act give me optimism for the transplant reforms already underway in the Unites States. Though it takes hard work, it is possible to increase the number of organ donations and benefit patients. We should not look to quick fixes that may or may not actually improve the system. Rather, the focus needs to continue to build off what we already have to progress to a point where everyone who needs a kidney gets one.

Zachary Predmore is an associate policy researcher at RAND, where his research focuses on assessing how patients view and value health care services, including new technologies, medications, and health system improvements.