Iran's market for kidneys in the NY Times

Tina Rosenberg writes about the Iranian kidney market: Need a Kidney? Not Iranian? You’ll Wait.

Here's a part:

"Iran’s system has many deficiencies — not least that the very idea clashes with ethical norms observed in many other countries — and the program varies greatly from region to region. But its chief advantage is this: People who need kidneys get them rapidly, rather than die on the waiting list.

In the vast majority of cases, donors know in advance what they will be paid and receive appropriate screening and good medical care before and during the operation. And by getting patients new kidneys instead of keeping them on dialysis, the society saves a lot of money and avoids much misery.

The Iranian model suffers from insufficient funding, lack of follow-up for donors and other problems. But as waiting lists for kidneys grow around the world, Iran offers an important lesson: With good design and regulation, a system that pays donors need not be exploitative or immoral. In Iran, the legal kidney market has prevented the development of the abusive black markets and kidney tourism seen in other countries. As the kidney crisis intensifies, governments should look closely at what Iran has achieved.

For many people, the specifics of how a kidney market works are beside the point — the very idea of paying people to donate organs ends the debate before it starts.

One reason the idea of organ-selling is repugnant is that the human body has a special dignity. But if there’s an ethical barrier to selling the pieces, it was crossed long ago. We sell blood products, sperm and eggs. We pay people to do weird things to their bodies in risky clinical trials.

Perhaps kidney donation is different because kidneys do not grow back (although one healthy kidney is sufficient), and donation requires surgery. It is very safe surgery, but there is always some risk for donors. Perhaps the biggest moral issue in economically unequal societies is that a paid donor is almost always in dire straits, willing to do desperate things for money.

Yet people, especially poor people, take risks for money all the time. “We should ask ourselves why some people find accepting money to donate a kidney and save a life repugnant, but accepting money for being a policeman or miner or soldier — all of which are statistically riskier than donating a kidney — is O.K.,” said Mohammad Akbarpour, a research fellow in the Becker-Friedman Institute of the University of Chicago. “Is there a fundamental difference?”

The Shi'a religious jurisprudence behind Iran's legal market for kidneys

An anthropology graduate student named Elham Mireshghi is studying the market for kidneys in Iran, and includes in her study some interesting observations about the Shi'a fatwas on donation, brain death, and donor compensation that give the market its religious justification.

I haven't seen her paper yet, but she is presenting a paper in Chicago at the U. Chicago Program on Medicine and Religion's
2nd Annual Islamic Bioethics Workshop--Dissecting the Ethics of Organ Donation (June 5-7). Her tantalizing slides are here.

She writes that concern whether transplantation itself was permissible loomed larger than the issue of sales, and that Ayatullah Khomeini initially prohibited transplantation, but that this ruling was changed after it became accepted that the transplanted organ became part of the body of the recipient once blood flowed through it.

Regarding compensation of the donors, she argues that the distinction between a gift and a sale was avoided by framing the question not as

“Can a kidney be bought and henceforth removed and transplanted into a new body,”

but rather as

 “now that a kidney has been removed for the legitimate purpose of being transplanted, can the owner of the kidney receive payment for it?”

I'm looking forward to reading the paper...


HT: Jim Childress, Mario Macis

The Guardian on Iranian kidney sales

The Guardian reports on a bad outcome in Iran's market for kidneys--the recipient dies, and the donor isn't doing well: Kidneys for sale: Iran’s trade in organs

"Iran is the only country in the world where it is legal to sell a kidney. Donors get money from the buyer and from the state, a system which eradicated waiting lists but, detractors say, exploits the poor and vulnerable. Here, we follow one terrible story"

More on the Iranian kidney market, from Tehran U.

Here's a further comment: Perfect Is the Enemy of Good: The Iranian System of
Paid Donation, by S. M. Khatami and M. Mahdavi-Mazdeh, American Journal of Transplantation 2014; 14: 1222–1223.

(It follows up on this earlier article.)

Iranian blog with ads for selling kidneys

Here's a website (in Persian) in which prospective kidney sellers advertise.

Google translate worked well enough to give me an idea of what the ads say; here are some of them translated by Afshin Nikzad...

The first line of each ad is bold, and has the following format:

Name (gender), Age, Blood type, Price.

Manizhe (female), 22, AB, $14.5K
single, athlete, bachelors in psychology.
Due to financial needs, I'm selling my kidney.

Massoume (female), 45, A+, negotiable price
Hello. I am a 45 year old woman, bachelors in business administration,
fluent in English, can work with computers, experience of work in a
real estate agency. I migrated from Tehran to a village in Mazandaran
6 month ago. I can't find any job fitting my work experience, and have
spent all my savings in the past 6 month. I am willing to sell an organ
(to save my dignity).
contact: 09376606455, http://zh32329292.blogfa.com

Sarah (female), 30, A+, negotiable price
urgent, urgent, urgent, urgent, urgent, urgent
I need to sell my kidney because I am in a lot of debts, and I am
broke [bankrupt].
Contact: 09385786869

unknown, 23, B+
I am in serious need of money, I am getting homeless; soon please.
please text your offered price. I really need money. Can travel to any
where, the buyer is responsible for all the expenses.
Contact: 09306890335

vahid (male), 28, A+, $20K
from Tehran. completely healthy. doesn't smoke or drink.
want to sell my kidney for financial problems.

Shahin (male), 24
Hello. I am in charge of the family since my father is ill. It has been
very difficult to go at work and study at the same time, I have quit
university since a few months ago. I'm really tired of this situation.
Please offer a fair price, cause I am in need; I am doing this cause I
see no other way.

? (female), 22, A+, negotiable price
Hello, I am a 22 year old woman, and I need to sell my kidney for my
college expenses. athlete. Can travel to any where in Iran. Price is
negotiable.
Contact: 09308665458.

Maryam (female), 25, AB+, $26K
healthy. need the money to pay debts.
The buyer is responsible for all other expenses.
contact: 09189978478

Amin (male), unknown, unknown, $8K
Hello. express sale. My child had eye-surgery and is in hospital right
now. I need to pay the expenses before the surgery. The price is $8K.
Sorry that I am writing like the dealers.
With best wishes for kidney patients.

Ali (male), 22, A+, negotiable price
For serious financial problems, and for my father's surgery, I need to
sell my kidney.
Contact: 09359818234

Amir (male), 41, A+
in urgent need to sell my kidney. I have two families and 8 children, I
am in debt because of my housing rents.
Contact: 09335751908

Milad (male), 19, O+, $40K
I have been under a lot of pressure in life, and it made me do such a
thing [selling his kidney] in this age. I hope no one would ever
experience a similar situation.
Very healthy. If you are determined to buy, the price is negotiable.
contact: 09337339240, http://miladmadise@yahoo.com

mojtaba (male), 31, O+, $8K.
very healthy.
Blood type: o+
Price: $8K"

More on the market for kidneys in Iran

Here's an article on the market for kidneys in Iran that I missed when it came out, recently pointed out to me by Mohammad Akbarpour

Kidney International (2012) 82, 627–634; doi:10.1038/ki.2012.219; published online 6 June 2012

The Iranian model of living renal transplantation

Mitra Mahdavi-Mazdeh¹

¹Iranian Tissue Bank Research & Preparation Center, Tehran University of Medical Sciences, Tehran, Iran

Correspondence: Mitra Mahdavi-Mazdeh, Iranian Tissue Bank Research & Preparation Center, Tehran University of Medical Sciences, Tehran, Iran. E-mail: mmahdavi@sina.tums.ac.ir

Received 6 March 2012; Revised 28 March 2012; Accepted 5 April 2012
Advance online publication 6 June 2012

Topof page

Abstract

Organ shortage for transplantation remains a worldwide serious problem for kidney patients with end-stage renal failure, and several countries have tried different models to address this issue. Iran has 20 years of experience with one such model that involves the active role of the government and charity foundations. Patients with a desperate demand for a kidney have given rise to a black market of brokers and other forms of organ commercialism only accessible to those with sufficient financial resources. The current Iranian model has enabled most of the Iranian kidney transplant candidates, irrespective of socioeconomic class, to have access to kidney transplantation. The Iranian government has committed a large budget through funding hospital and staff at the Ministry of Health and Medical Education by supporting the brain death donation (BDD) program or redirecting part of the budget of living unrelated renal donation (LURD) to the BDD program. It has been shown that it did not prevent the development and progression of a BDD program. However, the LURD program is characterized by several controversial procedures (e.g., confrontation of donor and recipient at the end of the evaluation procedure along with some financial interactions) that should be ethically reviewed. Operational weaknesses such as the lack of a registration system and long-term follow-up of the donors are identified as the ‘Achilles heel of the model’.

Cash for kidneys: letters to the editor of the WSJ

The recent Becker-Elias article, about which I blogged about my thoughts here, has drawn some letters to the editor, which the WSJ published under the headline Is a Market in Kidneys the Right Answer to Shortage? It is a tragedy when people die while waiting for a lifesaving transplant, but paying for organs isn't the answer.

One of them, by Sigrid Fry-Revere, doesn't fit the sub-headline. She advocates adopting something like the market approach in Iran. Her unedited letter, which she shared by email, is below:

Letter to the Editor of WSJ

Edited version ran Sat. Jan 2014

The Rest of the Story

I read with great interest Gary S. Becker and Julio Elias article “Cash for Kidneys: The Case for a Market for Organs” in Saturday’s WSJ.  Like so many others who have written on this subject, their article misrepresents the Iranian system of compensated donation.

Usually not much is said about Iran, because not much is known, but I went to Iran and spent nearly two months interviewing paid kidney donors for a documentary film I was planning. I visited six different regions and returned with over 200 transplant stories.  There are too many misconceptions about what is going on in Iran to explain in one letter, but the most important thing I would like to point out is that paid kidney donors are people, not commodities, and no matter what the economics of the situation, there is a human element that can’t be ignored.

You might think I’m going to say we should not pay kidney donors, or that I’m going to rage about how exploitive kidney selling is. Not so. I learned many things on my trip to Iran, but the most important was sometimes money is what makes helping others possible.

The issue isn’t how much a kidney is worth, but how to make helping economically feasible and how best to show appreciation. I disagree with economists who say you can put value on someone giving up part of their body to save another person’s life. A conscious, informed decision, to risk oneself for another is an invaluable gift both to the person and to society.

Iran is the only country in the world that has solved its kidney shortage, and it has done so by legalizing and regulating compensated donation.  In the rest of the world there are two options:  Altruistic donation and the black market. The third option only exists in Iran where the rule of law protects donors and recipients alike. Paid donors are not treated like criminals, as is the case when the underprivileged are exploited for their kidneys on the black market. 

The Iranian system has developed over 30 years and continues to improve.  Today, paid donors are secure in their knowledge that the system works to protect their rights as much as the rights of recipients. Their money is put in escrow, the middlemen who arrange kidney matches are NGO volunteers, not black market profiteers, and they are treated on the same medical wards and in the same post-operative clinics as kidney recipients.  

How much are Iranian kidney donors paid for their service to humanity? Much more than the thank you, travel expenses, and occasional lost wages, paid altruistic donors in the United States. Iranian kidney donors receive the equivalent to six month’s salary for a registered nurse in Iran, or approximately $32,000 in the United States. But in addition to monetary compensation, they receive many goods and services that are hard to quantify in dollars.  All receive at least one year of health insurance, not just care related to their nephrectomy, as is the case in the United States. They also receive automatic exemption from Iran’s two-year mandatory military service.

Furthermore, Kidney donors often receive extra health insurance, sometimes for their whole family and often under terms where it can be renewed annually. They receive dental care at the NGO dental clinics that serve diabetes patients and kidney recipients. They receive job services, small business loans, and household goods.  I estimate the total average package paid donors receive in Iran is close to $45,000 in value. 

Most importantly, these paid donors know the government supports them for having done something honorable, like a paid firefighter or a paid emergency medical professional. They have saved a life -- and their contribution to society is invaluable.  Mohaghegh Damad, the ethicist for the Iranian Academy of Medical Sciences told me no payment could ever be enough. But, the payment Iranian kidney donors get, makes doing the right thing easier. 

In the United States 20-30 people die every day because they can’t get a kidney. Iran is the only country in the world where almost everyone who medically qualifies to get a kidney gets one, and in many regions of the country there is a waiting list for people who want to donate.  Maybe its time we learn something from their experience.

Sigrid Fry-Revere, J.D., PhD, is a bioethicist and founder and president of the non-profit organization Stop Organ Trafficking Now and author of The Kidney Sellers (Carolina Academic Press, 2014).

Forthcoming book on the Iranian kidney transplant market

Carolina Academic Press is advertising a forthcoming book,

The Kidney Sellers

A Journey of Discovery in Iran

by Sigrid Fry-Revere

Their blurb:
Rarely does an adventure story carry such social significance as in this groundbreaking ethnographic research book. Dr. Fry-Revere’s exploration of the medical ethics of compensating organ donors takes us deep inside Iranian culture to provide insight and understanding into how Iran has solved its kidney shortage. The Kidney Sellers: A Journey of Discovery in Iran addresses the question: How it is possible that in Iran there is a waiting list to be a donor, while in the United States hundreds of thousands of people have died­ for lack of a kidney?

The sale of kidneys in Iran: a report from Shiraz

A recent article, and an accompanying editorial, in the American Journal of Transplantation concern the health of kidney sellers in Iran, based on a comparison of paid donors with unpaid related living donors at the Shiraz Transplant Center in Iran.

The article is Comparison of Health Status and Quality of Life of Related Versus Paid Unrelated Living Kidney Donors  by M. K. Fallahzadeh, L. Jafari, J. Roozbeh, N. Singh2, H. Shokouh-Amiri, S. Behzadi, G. A. Rais-Jalali1, M. Salehipour, S. A. Malekhosseini1, M. M. Sagheb

Abstract
The aim of this cross-sectional study was to assess the health status and quality of life (QOL) of paid unrelated versus related living kidney donors postdonation at Shiraz Transplant Center in Iran. We invited all donors (n = 580, 347 paid unrelated, 233 related) who underwent donor nephrectomy at our center from 2004 to 2010 to participate in a health survey and physical examination. Of 580 donors, 144 consented to participate; participation of paid unrelated donors was significantly lower than related (52/347 vs. 92/233; p < 0.001). Participants underwent a complete physical examination, QOL assessment (using a 36-item short form health survey [SF-36] questionnaire) and laboratory work-up. The paid unrelated donors compared with related donors were younger (34.2 ± 7.2 vs. 40.7 ± 9.7 years, p < 0.001), had shorter time since donation (2.9 ± 1.6 vs. 3.8 ± 2 years, p = 0.004), had higher estimated GFR (72.6 ± 22 vs. 63.8 ± 15.3 mL/min/1.73 m2, p = 0.006) and had a higher percentage of patients with microalbuminuria (35% vs. 0%, p < 0.001). Additionally, general health and social functioning scores among paid unrelated donors were significantly lower (p < 0.001 and p = 0.02, respectively) than related donors. Other SF-36 scores, although lower in paid unrelated donors, did not reach statistical significance. Iranian paid unrelated donors have lower QOL and higher incidence of microalbuminuria compared with related donors.


In their concluding discussion the authors note
"To our knowledge, this is the first study comparing the health status and HRQOL of Iranian PUKDs with those of LRKDs. Our results show that Iranian PUKDs, compared with LRKDs, have poor follow-up, lower HRQOL scores and higher incidence of microalbuminuria.

One of the major drawbacks of the Iranian model of living donor kidney transplantation is the lack of long-term follow-up of LKDs [2, 3]. In our study, the rate of participation of PUKDs was significantly lower than LRKDs. Similarly, in a previous report from Iran, only 6 of 500 LKDs who were invited to participate in a health survey responded [2]. In another Iranian study, a majority (79%) of PUKDs were reported to have no regular follow-up after donation [6]. Inability to pay for follow-up visits, and insufficient knowledge of the complications of the nephrectomy and the need for regular follow-up postdonation have been suggested as the major reasons for lack of long-term follow-up among PUKDs [2, 6, 9]. Educating the LKDs, providing an extended long-term government sponsored medical insurance program beyond 1 year, and probably even payment for clinic visits could enhance their adherence with postdonation follow-up."
***************************

The accompanying editorial is Where There Is Smoke There Is Fire: The Iranian System of Paid Donation by E. J. Gordon, J. S. Gill

"Nearly 30 years after its introduction, the Iranian model remains an enigma to the Western transplant community. Established in 1988, the government-funded, compensated living unrelated kidney donor program was Iran's answer for its urgent transplantation needs. The modest fixed sum (currently about $400 US dollars) provided by the government was intended as a reward rather than as a payment for the donated kidney. The real incentive for those who have submitted to nephrectomy was a supplementary payment negotiated directly between the recipient and living donor (typically in the amount of $10 000 US dollars). Putative oversight by a not-for-profit organization maintains a buyer's market by providing a back-up donor in the event that a recipient and potential donor cannot agree on a price. The government pays for all transplant-related expenses and provides the donor with medical coverage for 1 year after the nephrectomy. It is worth noting that such depictions of the Iranian model have been contested as disingenuous by members of the Iranian transplant community [1]. Accordingly, one must interpret any analyses of the Iranian model with caution.

Predictably, critics of commercialization have opposed the program primarily out of concerns of exploitation and disrespect for human integrity [2, 3]. Aside from such opposition, the model fails to meet many of the proposed standards for a regulated system of organ sales, including nondirected donations, provisions to ensure long-term donor follow-up, and access to health care [4]. Despite the facilitation of tens of thousands of transplants, the lack of public reporting and transparency have precluded acceptance of the Iranian model as a solution to the organ shortage internationally, and have fueled questions about the integrity of the program.

The report by Fallahzadeh et al [5] in this issue of the journal provides a novel glimpse into the Iranian model. The study shares many of the limitations of other studies from Iran, including a small and selected study sample. However, their identification of a difference in microalbuminuria postnephrectomy between paid and unpaid donors fuels concerns that the clinical evaluation of donors may be compromised when donor payments are allowed. Although the absence of prenephrectomy information precludes definitive conclusions, the short time since donation suggests that abnormalities may have been present prior to nephrectomy and accordingly, that the donor clinical evaluation may not have been as thorough as necessary. The potential presence of predonation abnormalities is worth considering given the ethical ramifications. A scrupulous pretransplant evaluation and conservative approach to donor acceptance may be particularly important for paid donors who may be vulnerable to adverse health outcomes for other reasons. Subjecting paid donors to unnecessary harms without sufficient safeguards in place during the evaluation process tips the delicate risk–benefit balance against living donation.

The most plausible alternative explanation for the findings is that the proteinuria was in some way related to the higher level of poverty in the paid donors. There is limited research to suggest a link between poverty and development of proteinuria in living donors. In a cross-sectional study of living related donors from Hyderabad, India, 40% of the 50 donors studied developed microalbuminuria, and 14% developed overt proteinuria (>300 mg/day) after an average of 63 months postdonation [6]. Irrespective of the basis for the observed difference, it is not clear that the Iranian system will financially support the authors' recommendation for long-term follow-up of the individuals who developed microalbuminuria in the study.

Sadly, the risk factors for and clinical significance of proteinuria in living kidney donors remain unclear. The existing literature on this subject is hampered by use of nonstandardized definitions, a paucity of controlled studies, and virtually no information regarding progression over time. Therefore, although it is tempting to criticize the lack of organized donor follow-up in the Iranian model, to do so would be hypocritical [7]. The findings of this study therefore serve as a reminder of our collective responsibility to better understand the long-term consequences of living kidney donation.

The findings of Fallahzadeh et al [5] add to the accumulating literature that there are problems with the existing Iranian model and that the program must evolve. It is clear that the majority of paid donors are poor males, whose quality of life after nephrectomy is lower than that of the general Iranian population, and who are frequently dissatisfied with their decision to undergo nephrectomy [8]. Further, the program has been a contributing factor limiting the advancement of deceased donation and living related donation in Iran. For these reasons, a program that was once justified on the basis of need, may now be a barrier to the advancement of transplantation in Iran. How much harm to living donors' health and quality of life should Iranian transplant centers tolerate? As transplant centers are responsible for ethically sound clinical care, all potential living donors must be assured a high standard of clinical and psychosocial evaluation before the Iranian model can publicize its success.

As Fallahzadeh et al [5] point out, studies have found that few paid unrelated donors undergo follow-up care due to insufficient finances to pay for care, and donors lack knowledge about living donor complications or the need for follow-up care [9, 10]. Accordingly, transplant centers operating within the Iranian model should take extra care to optimally inform donors about the short- and long-term complications of living donation, as well as inform, encourage and enable living donors, particularly donors most at risk—paid unrelated donors—to undergo long-term follow-up care. The government's provision of health insurance to living donors for 1 year is a start toward removing some of the disincentives to donation; however, the recognition of paid donors as a particularly vulnerable group behooves the government to provide long-term follow-up care.

New in Iran: Donate one of your kidneys to be exempted from military service

There's a new development regarding kidney donation and sales in Iran. Google translate renders the headline Donate one of your kidneys to be exempted from military service

I am assured on good authority that the story says that kidney donors will be exempted from military service.

Here's how Google Translate renders the story:

"Acting Human Resources department Stadkl Armed Forces exemptions from military service the soldiers announced the donor organ. According to ISNA, General Moussa Kamali on donor exemption from military service, said the donor organ to make it happen efficiency, We'll exempt him from military service. According to him, for example, people who donate one of his kidneys has been the inclusion of medical waivers are exempt from military service. Stadkl Armed Forces Acting Human Resources department stating Srfdashtn donation card member, was not the reason for exemption from military service, said those who donate their organ, even during military service are exempt from military service."


Here's the article in Farsi: http://www.alef.ir/vdcgnu9qzak9774.rpra.html?187850 for those who can make your own translation.

HT: Mohammad Akbarpour

Ads for kidneys in Iran

An article in Haaretz describes the market for kidneys ("kidney bazaar" בזאר הכליות) in Iran, and includes this picture of ads written on a wall  in Tehran.

"Qasemi Mustafa, head of Kidney Patients Support Association in Iran, said the average sum received by the donors ranged around $ 6,000 [paid by the recipient]. The Government adds that another thousand dollars."

HT: Ran Shorrer

Here's a closely related story in the Guardian: In the only country where the organ trade is legal, the streets near hospitals have been turned into a 'kidney eBay'

"Iran is the only country where the selling and buying of kidneys is legal. As a result, there is no shortage of the organs – but for those trying to sell a kidney, there is a lot of competition.
... "Competition means that some ads have been torn down. Some have added their information to ads by other donors. Others have placed their ads on people's doors or simply written them in marker pen on trees where they think they will catch people's attention.

"At the heart of the capital, near the Charity Association for the Support of Kidney Patients (CASKP), the number of ads has made the streets of Tehran into a sort of kidney eBay.
...
"Iran's controversial kidney procurement system, which has been praised by many experts and criticised by others, allows people to sell and buy kidneys under the state-regulated surveillance of two non-profit organisations, the CASKP and the Charity Foundation for Special Diseases. These charities facilitate the process by finding potential vendors and introducing them to the recipients, and are charged with checking the compatibility of a possible donation and ensuring a fair trade.

"After the transplant, the vendor is compensated by both the government and the recipient. In an interview with the semi-official Mehr news agency, the CASKP's director, Mostafa Ghassemi, estimated the total official price list to be around 7m rials, of which 1m is paid by the government. Iranians are not allowed to donate kidneys to non-citizens.

"In 2010, a total of 2,285 kidney transplants took place in the country, of which 1,690 kidneys were supplied from volunteers and 595 from those clinically brain-dead," he said. According to Mehr, the majority of people selling kidneys are aged 20-30. Despite the state control, bureaucracy and time-consuming procedures have left the door open for non-official direct negotiations, making the Iranian system more like a kidney market.

"Dr Benjamin Hippen, a transplant nephrologist with the Carolinas medical centre in North Carolina, US, has studied successes, deficiencies and the ambiguities of the Iranian system.

"Making a judgment about whether the 20-year-old system as a whole has been successful was complicated, he said. "The majority of those selling kidneys in Iran are disproportionately poor, and information about the long-term outcomes for sellers is quite limited. Too, it is increasingly clear that there are many different systems, rather than a single unified system in Iran.

"That said, Iran appears to have successfully addressed the shortage of organs, incentives for organs have not substantially attenuated the growth and development of organ procurement from deceased donors, and reported outcomes for recipients have been favourable."

"Comparing Iran with Pakistan, where organ trafficking is nominally illegal but still occurs, Hippen, who is an associate editor of the American Journal of Transplantation, said: "It seems to me that if Iran had not developed a system of incentives, the situation there today would look very much like the state of affairs in countries such as Pakistan."

"In the US, more than 100,000 people were estimated to be on the waiting list for kidney transplants in 2010 – waiting lists were eliminated in Iran in 1999.

"Hippen has pointed out that "since 1999, more than 30,000 US patients with kidney failure have died waiting for an organ that never arrived".

"Arguing in favour of allowing people to sell their kidneys, Sue Rabbitt Roff, a senior research fellow at the University of Dundee, said last year that it was time to "pilot paid provision of live kidneys in the UK under strict rules of access and equity".