“Voluntary, Unpaid, and Handsomely Rewarded: Donor Benefits in the World's Whole-Blood Systems,” by Krawiec and Roth

 Around the world, "non-compensation" of blood donors allows for a variety of incentives.

Kimberly D. Krawiec and Alvin E. Roth, “Voluntary, Unpaid, and Handsomely Rewarded: Donor Benefits in the World's Whole-Blood Systems,” SSRN, Virginia Law and Economics Research Paper No. 2026-12,  1 July 2026, https://papers.ssrn.com/sol3/papers.cfm?abstract_id=7030818  

 Abstract
The ideal of the unpaid blood donor is nearly universal; the practice is more complicated. Whole-blood systems around the world preserve a formal commitment to voluntary, nonremunerated donation-and then provide donors with gift cards, sweepstakes entries, cash "expense allowances," paid leave, tax relief, priority service, medals, and, in some places, extra points on a child's school exam. This Essay maps the gap between label and practice. Drawing on examples from thirteen countries spanning five continents, it organizes donor benefits by institutional mechanism: gift cards and sweepstakes; direct monetary transfers; paid work leave; other material and recognition-based benefits; and replacement donation and the informal cash markets it can generate. We demonstrate that "voluntary, nonremunerated donation" frequently coexists with substantial material benefits. Whole-blood donors nearly always receive something of value in exchange for their generosity; what varies is how those benefits are structured, funded, routed, and legally classified. 

 

Jurisdiction	Representative donor benefits	Legal classification / routing
United States	Nontransferable gift cards; sweepstakes (e.g., Super Bowl LX trip; $5,000–$7,000 raffles); promotional items (shirts, mugs, bags, movie tickets).	“Volunteer donor” label retained where benefits are not readily convertible to cash; sweepstakes framed as “no donation necessary.”
South Korea	Promotional K-pop photo cards; vendor and restaurant vouchers (5,000–8,000 won); merchandise; transferable blood-donation card.	Prohibited “consideration” distinguished from “commemorative gifts” and donor encouragement.
Kazakhstan	~$18.75 (2 MCI) for reimbursable donation; ~$2.34 meal equivalent for gratuitous donation.	Categorized as payment; reimbursable donation invited for shortages and rare types.
Bulgaria	Payment in narrow statutory cases (shortage, vaccine/serum/immunoglobulin production, research/diagnostics).	Voluntary/unremunerated rule with “against payment” exceptions.
Germany	Direct monetary transfers at some collection centers; refreshments and health checks only at DRK.	“Aufwandsentschädigung” (expense allowance), set per collection service.
China	Family exam-point awards (Pujiang: 1–3 points); platelet shopping cards $31–$386; paid leave, tax benefits; prepaid phone/transport cards, movie tickets.	“Gratuitous” system plus “appropriate subsidies”; tolerated monetary-equivalent and family-directed rewards.
South Africa	Data/streaming vouchers, raffles, merchandise; private wellness rewards (Discovery Vitality, Momentum, Bonitas).	Donor benefits supplied through blood-service promotions and private wellness programs.
Brazil	One paid day off per 12 months (private employees); donation-day leave (public servants); 120-day priority service at banks, hospitals, etc.	Donation converted into paid-leave entitlement and legally recognized priority status.
Spain	Donor medals, honors, and milestone recognition.	Recognition-based; no direct monetary transfer.
India	Replacement donation; illicit “professional donor” cash market.	Patient-side payment associated with replacement donation.
Nigeria	Tokens, certificates, badges, transport refunds; in practice 68% family replacement and 12.2% commercial donors.	Patient-side payment associated with replacement donation; commercial donors openly reported in donor categories.
Sierra Leone	Predominantly family replacement donors (~90%); paid donors recorded as replacement donors.	Patient-side payment associated with replacement donation; paid donors recorded as family replacement donors.
Argentina	Post-donation meal; medical certificate; 24-hour work-absence justification; 2026 shift away from replacement model.	Statutory donor benefits plus replacement-donation phase-out.

 

"If there is a lesson in this tour of the world’s whole-blood systems, it is that “voluntary, nonremunerated donation” is a phrase asked to carry a great deal of freight. It accommodates a $7,000 gift card, so long as the gift card is offered through a sweepstakes that does not require a blood donation to enter. It accommodates €60 in cash, so long as the cash is legally categorized as an expense allowance. It accommodates extra points on a child’s high-school entrance exam, paid leave, free public transit, priority service at the bank, and a tote bag—often all while the governing statute insists that blood may not be given for reward. "

The Organ Donation Dilemma: Ethics, Economics, and Life-Saving Solutions: Debate at Hopkins, today

Today's debate at Hopkins aims to focus on the proposed End Kidney Deaths Act.

 The Organ Donation Dilemma: Ethics, Economics, and Life-Saving Solutions
May 15, 2026 09:00 AM 
 

"With organ shortages claiming thousands of lives annually, this session explores whether carefully designed market mechanisms can increase donation rates while maintaining ethical standards and preventing exploitation.

Panelists:
-    Alexander Capron, USC Law/Bioethics  https://gould.usc.edu/faculty/profile/alexander-capron/ 

-    (TBC) Gabriel Danovitch, UCLA David Geffen School of Medicine, https://www.uclahealth.org/providers/gabriel-danovitch 

-    Kimberly Krawiec, UVA Law, https://www.law.virginia.edu/faculty/profile/kdk4q/1181653 

-    Elaine Perlman, President, Coalition to Modify NOTA and Executive Director, Waitlist Zero https://elaineperlman.com/ 

Moderator: 
-    Mario Macis, Johns Hopkins Carey Business School and HBHI https://mariomacis.net/index.html 

 

End Kidney Deaths Act summary /sites/default/files/2026-05/The%20End%20Kidney%20Deaths%20Act%20Summary.pdf

 

The list of 50+ supportive organizations, the legislative text, the podcast with Kim and Elaine and the Niskanen Center's economic analysis of the End Kidney Deaths Act 

Felix Salmon, at Bloomberg, reviews Moral Economics

  Felix Salmon, at Bloomberg, reviews Moral Economics, which starting today is now sold in stores (at least in the U.S.):

An Economist’s Case for Selling a Kidney.  In a new book, Nobel laureate Alvin Roth argues that decriminalizing taboo markets can save lives.  

He tells this story from the book:

"Roth gave a talk in 2017 at the Organ Donation Congress in Geneva about one such chain that started in 2015. A woman from the Philippines, known in the literature as FW, was willing to give up one of her kidneys to save the life of her husband, FM. The two flew to the US, where FM received a kidney from an altruistic donor in Georgia, and FW’s kidney was transplanted into a man in Minnesota. A friend of the Minnesota man, who had been willing to give up one of her kidneys to save his life, instead gave one to a man in Washington, whose father-in-law gave a kidney to a woman in Georgia, and so on. By the end of the year there had been 11 successful transplants, and the chain was still continuing.

" After his talk, Roth was confronted by a Spanish doctor who was deeply concerned about the potentially problematic implications of the economic inequality between the Philippines and the US. Roth pointed out that without the transplant, the patient would surely have died. Replied the Spanish nephrologist: “He should be dead!” Spain’s National Transplant Organization later denounced Roth as an organ trafficker.

"Roth tells this story in his most recent book, Moral Economics (Basic Venture, May 12), which, at least in part, is an attempt to apply the empiricism of economics to domains that are often resistant to such analysis. The opposition to the 2015 kidney chain, for instance, comes from nephrologists who have no problem with chains but who draw the line at international chains, or at least chains linking poor and rich countries."

######

Much of the objection to cross-border kidney exchange appears to be fading, some of it was based on the idea that countries should be self-sufficient in transplants.

See earlier posts:

Friday, January 9, 2026  WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood by Krawiec and Roth (now open source)

 

Friday, September 11, 2020  Global Kidney Exchange supported by the European Society of Transplantation's committee on Ethical, Legal, and Psychosocial Aspects of Transplantation .

WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood by Krawiec and Roth (now open source)

The published version of our paper is now widely available:

Kimberly D. Krawiec and Alvin E. Roth, “WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood,” in James Stacey Taylor and Mark J. Cherry, eds., Markets in Human Organs for Transplantation: Controversy and Contention., Routledge, November 2025 (open source) https://www.taylorfrancis.com/reader/download/5885e1ba-c9af-4547-941c-821a2afaa7ee/chapter/pdf?context=ubx  

From the introduction:

[The nonremuneration principle] is only half of a WHO policy, broadly accepted around the world, that mandates both national (or sometimes only regional) self-sufficiency and an absence of remuneration for both blood products and transplantable organs (hereafter, the “twin principles”) (WHO 2009, 2023). This self-
sufficiency mandate, though less examined than the ban on  remuneration, presents a real hurdle to progress in transplantation, especially for smaller and low and middle income (LMIC) countries. 

"WHO’s insistence on self-sufficiency inhibits cooperative kidney
exchange efforts (as well as other innovations) among countries that
would benefit all concerned, especially the LMIC that the policy is purportedly designed to help. As will be discussed, the policy’s effect on blood products, especially when combined with the no remuneration rule, is even more stark – no country that fails to compensate donors is self-sufficient in plasma collection and few LMIC collect sufficient supplies of whole blood.
 

"This chapter critiques these twin principles, making several central points. In Section 2.2, we discuss the twin principles as applied to blood products, noting the particularly pernicious effects on plasma supply and availability, especially in poorer nations. In Section 2.3, we turn to transplantation, emphasizing the numerous benefits of international cooperation and cross-border transplantation – benefits that would be undermined by self-sufficiency, especially in smaller countries and those without well-developed domestic exchange programs. We illustrate this point with examples drawn from several noteworthy instances of cross-border kidney exchange.
 

"In Section 2.4, we argue that the current discourse around remuneration and organ donation is frequently overdramatic and unhelpful. Although nearly every effort to increase organ donation and transplantation presents ethical challenges, not every such effort amounts to “trafficking” or “a crime against humanity.” These labels stifle helpful deliberation, progress, and consensus. Section 2.5 concludes with recommendations for a saner approach to the scarce resources of blood products and transplantable organs – one that is focused on international cooperation, rather than self-sufficiency; evidence-based policies, rather than a reliance on decades-old
assumptions and understandings; and the use of pilot studies and trials to test the ethics, safety, and efficacy of incentives in various settings."

######

Here's the book:

 

The UN General Assembly issues a call for surrogacy to be outlawed

 A growing number of families are formed by gestational surrogacy, in which a woman bears a child for another couple.  Surrogacy is legal throughout the US, and regulated state by state.

United Nations General Assembly has issued a report saying that surrogacy in all its forms should be regarded as a crime against women, and banned outright.

Report of the Special Rapporteur on violence against  women and girls, its causes and consequences
The different manifestations of violence against women and girls  in the context of surrogacy 

Summary: In the present report, the Special Rapporteur on violence against women and  girls, its causes and consequences, Reem Alsalem, examines the different manifestations of violence against women and girls in the context of surrogacy.

...

Conclusion and recommendations :

69. The practice of surrogacy is characterized by exploitation and violence against women and children, including girls. It reinforces patriarchal norms by commodifying and objectifying women’s bodies and exposing surrogate mothers and children to serious human rights violations. 

70. Considering the above, the Special Rapporteur recommends that Member States and other relevant stakeholders: 

(a) At the international level, take steps towards eradicating surrogacy in all its forms. Pending its abolition, States must take action to prevent further  harm and strengthen the protection of the rights of women and children involved in surrogacy arrangements;

(b) Work towards adopting an international legally binding instrument prohibiting all forms of  surrogacy..." 

 

HT: Kim Krawiec

 

Blood supply in West Africa

 Here are some thoughts on blood shortages in West Africa by Jappah and Tao. (Jappah has just returned from Sierra Leone...)

To meet demand, blood donation should not rely solely on volunteers
A misalignment between supply and demand especially hurts people in low-income nations. by Jlateh Vincent Jappah and Ruoying (Carol) Tao, Harvard Public Health, December 4, 2024

"The World Health Organization advocates for 100 percent voluntary, non-remunerated blood donation—a position that was more defensible in the 1970s, before widespread screening for bloodborne diseases like hepatitis. Today, two-thirds of the world face shortages of blood and blood products, leading to many preventable deaths, especially among women and children. More than 80 percent of the world’s population has access to only 20 percent of the global blood supply. These global inequities in blood and blood product supplies are unacceptable.

"Africa, in particular, faces a disproportionate demand for blood and blood products. The continent relies heavily on family-based donation, which is not sustainable. Policies about blood supply in Africa, meanwhile, are generally based on research generated outside the continent—and in that research field, the idea of addressing blood shortages in Africa by providing adequate incentives and compensation to blood donors is met with skepticism.

"We are conducting research with nonprofit organizations such as Lifeline Nehemiah Projects and with government agencies in West Africa, and shortly we will begin field experiments, to study whether non-cash incentives increase blood donation.

...

"The misalignment between blood supply and demand is especially acute in low-income countries, where the demand for blood is high due to disease burdens, traumatic injuries, and medical conditions that require transfusions. Blood shortages in these regions are also driven by factors such as a higher prevalence of sickle cell anemia and bloodborne pathogens. And yet problems such as poor nutrition limit people’s ability to donate blood voluntarily.

...

"Blood donation should not rely solely on charity but also on empowering individuals and communities to meet their own needs. In Sierra Leone, for instance, humanitarian organizations provide food and transportation to blood banks, to encourage blood donations. These incentives have significantly increased donation rates, though blood banks sometimes struggle with supply shortages, such as blood bags and needles."

Jlateh Vincent Jappah is a physician and a Ph.D. candidate in health policy at Stanford University. He is a fellow at the McCoy Family Center for Ethics in Society at Stanford.

Ruoying (Carol) Tao
Ruoying (Carol) Tao is a Ph.D. student in health care management and economics at The Wharton School at the University of Pennsylvania. She previously worked in health care management consulting.

##########

Earlier:

Wednesday, August 28, 2024 WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood, by Krawiec and Roth

 

Medical Treatments for Transgender Minors--Oral argument in Supreme Court

 Yesterday the Supreme Court heard oral arguments about the Tennessee ban on transgender treatment for minors.

Supreme Ct. Hears Case on Medical Treatments for Transgender Minors
"The Supreme Court heard oral argument in United States v. Skrmetti, a case on whether Tennessee’s ban on transgender medical treatments for minors violated the Equal Protection Clause of the 14th Amendment. Tennessee enacted its law in March of 2023, which stated that there was a “compelling interest” to protect minors from physical and emotional harm by banning health care providers from administering hormone/puberty blockers and surgery to minors for transgender purposes. Transgender minors and their families sued the state, and the Justice Department intervened on their behalf, arguing the law discriminated on the basis of sex. A district court then stopped the ban on hormone and puberty blockers, but the Sixth Circuit Court of Appeals reversed that decision. The Justice Department then appealed to the Supreme Court. Chase Strangio, who argued on behalf of trans minors and their parents, was the first openly transgender lawyer to argue before the Court. 

Opening statement (text compiled from uncorrected Closed Captioning):

"MR. CHIEF JUSTICE, AND MAY IT PLEASE THE COURT, THIS CASE IS ABOUT ACCESS TO MEDICATIONS THAT HAVE BEEN SAFELY PRESCRIBED FOR DECADES TO TREAT MANY CONDITIONS INCLUDING GENDER DYSPHORIA. BUT SB-1 SINGLES OUT AND BANS ONE PARTICULAR USE. IN TENNESSEE THESE MEDICATIONS CAN'T BE PRESCRIBED TO ALLOW A MINOR TO IDENTIFY WITH OR LIVE AS A GENDER INCONSISTENT WITH THE MINOR SEX. IT DOESN'T MATTER WHAT PARENTS DECIDE IS BEST FOR THEIR CHILDREN. IT DOESN'T MATTER WHAT PATIENTS WOULD CHOOSE FOR THEMSELVES, AND IT DOESN'T MATTER IF DOCTORS BELIEVE THIS TREATMENT IS ESSENTIAL FOR INDIVIDUAL PATIENTS. SB 1 CATEGORICALLY BANS TREATMENT WHEN AND ONLY WHEN IT'S INCONSISTENT WITH THE PATIENT'S BIRTH SEX. TENNESSEE SAYS THAT SWEEPING BAN IS JUSTIFIED TO PROTECT ADOLESCENT HEALTH, BUT THE STATE MAINLY ARGUES THAT IT HAD NO OBLIGATION TO JUSTIFY THE LAW AND THAT SB 1 SHOULD BE UPHELD SO LONG AS IT'S NOT WHOLLY IRRATIONAL. THAT'S WRONG. SB 1 REGULATES BY DRAWING SEX-BASED LINES AND DECLARES THAT THOSE LINES ARE DESIGNED TO ENCOURAGE MINORS TO APPRECIATE THEIR SEX. THE LAW RESTRICTS MEDICAL CARE ONLY WHEN PROVIDED TO INDUCE PHYSICAL EFFECTS INCONSISTENT WITH BIRTH SEX. SOMEONE ASSIGNED FEMALE AT BIRTH CAN'T RECEIVE MEDICATION TO LIVE AS A MALE, BUT SOMEONE ASSIGNED MALE CAN. IF YOU CHANGE THE INDIVIDUAL SEX, IT CHANGES THE RESULT. THAT'S A SEX CLASSIFICATION FULL STOP, AND A LAW LIKE THAT CAN'T STAND ON BARE RATIONALITY. HERE TENNESSEE MADE NO ATTEMPT TO TAILOR ITS LAW TO ITS STATED HEALTH CONCERNS. RATHER THAN IMPOSE MEASURED GUARDRAILS SB 1 BANS THE CARE OUTRIGHT NO MATTER HOW CRITICAL IT IS FOR AN INDIVIDUAL PATIENT. THAT IS A STARK DEPARTURE OF PEDIATRIC CARE IN ALL OTHER CONTEXT. SB 1 LEAVES THE SAME MEDICATIONS AND MANY OTHERS ENTIRELY UNRESTRICTED WHEN USED FOR ANY OTHER PURPOSE EVEN WHEN THOSE USES PREVENT SIMILAR RISKS. THE SIXTH CIRCUIT NEVER CONSIDERED WHETHER TENNESSEE COULD JUSTIFY THAT SEX-BASED LINE BECAUSE THE EQUAL PROTECTION CLAUSE REQUIRES MORE, THIS COURT SHOULD REMAND SO THAT SB 1 CAN BE UNDER THE CORRECT STANDARD. I WELCOME THE COURT'S QUESTIONS. 

########

HT: Kim Krawiec

 

Medpage Today summarized the hearings under this headline:

Supreme Court Appears Likely to Uphold Bans on Transgender Care for Minors
— Justices' decision is not expected for several months

Arguments against paying for plasma and other Substances of Human Origin (SoHO)

 Substances of Human Origin (SoHO) have a growing, often lifesaving role in modern medicine, from breast milk for premature babies, to kidneys for transplant, to blood and blood plasma, which the World Health Organization categorizes as an essential medicine for a wide variety of ailments and injuries.  However concern for protecting the donors of SoHO from exploitation has led to a considerable debate about whether donation must always be uncompensated, and motivated purely by altruism.
 

Two important cases are donation of kidneys and of blood plasma. Payment to donors of kidneys for transplant is banned almost everywhere, but a few countries (among which the U.S. is prominent) allow payment to plasma donors. Kidneys are in short supply, so patients with kidney failure very often die prematurely without receiving a transplant, but among high and middle income countries almost no one is today dying from a shortage of plasma and plasma products.  That isn’t because countries that don’t pay plasma donors generate sufficient supply for their domestic needs, it is because they can import plasma pharmaceuticals from countries that do pay donors, chiefly the U.S. which exports tens of billions of dollars of plasma products annually.
 

Here's an article arguing that payment for plasma and other SoHOs is always and everywhere wrong and should be stopped. (The  authors seem to agree with the WHO that countries should raise enough plasma domestically from unpaid donors, although no country has yet managed to do this.)  Furthermore, they suggest that companies that collect and process plasma must be nonprofits.

Prevention of Trafficking in Organs, Tissues, and Cells by Martin, Dominique E. PhD1; Capron, Alexander M. LLB2; Fadhil, Riadh A. S. MD3; Forsythe, John L. R. MD4; Padilla, Benita MD5; Pérez-Blanco, Alicia PhD6; Van Assche, Kristof PhD7; Bengochea, Milka MD8; Cervantes, Lilia MD9; Forsberg, Anna PhD10; Gracious, Noble MD11,12; Herson, Marisa R. PhD1; Kazancioğlu, Rümeyza MD13; Müller, Thomas PhD14; Noël, Luc MD15; Trias, Esteve MD16; López-Fraga, Marta PhD17 Transplantation, October 22, 2024. | DOI: 10.1097/TP.0000000000005212
 

“It is essential that all national laws “concerning the donation and human application” of human organs, tissues, and cells, as well as all derived therapies, conform to the principle of financial neutrality, prohibiting financial gain in the human body or its parts.9,70 Healthcare professionals, service providers, and organ, cell, and tissue procurement organizations, as well as other industry stakeholders involved in processing, manufacture, storage, and distribution of SoHOs and SoHO-based therapies, are all entitled to “reasonable remuneration” for their work and coverage of the costs associated with various sector activities.66,71 However, what may be considered a reasonable and proportionate remuneration in this context is ill defined. There have been reports of service providers and professionals generating disproportionate profits from such activities, creating potential financial conflicts of interest in service provision and potentially violating ethical norms and legal standards prohibiting trade in SoHOs.30
 

“Development of innovative therapies using human cells and tissues has increased, with the potential therapeutic value of these resources spurring commercial interests that, in some cases, has led to practices in which donated SoHOs are treated as commodities.30,72–75 Furthermore, some SoHOs may undergo substantial processing, resulting in these therapies being regulated outside the regulatory framework governing the transplantation of organs, tissues, and cells as such, and rather being considered as medicines, where commercial profits are expected and guide the production and distribution activities.74,75
 

“Mechanisms should be developed to ensure that strategies used in donor recruitment, which may involve actual or perceived financial incentives, are routinely disclosed and open to scrutiny.70 Transparency of practice is also required to enable scrutiny of the fees charged to cover costs of procuring, processing, storing, manufacturing, and distributing cells, tissues, and SoHO-based therapies and to assess the potential influence of financial interests on decision-making about the use of SoHOs in particular SoHO-based therapies, or distribution of SoHO-based therapies.74 These measures would furthermore help to facilitate equitable access to treatments for all patients.21
…
Box 1, first recommendation
“Recommendations for action to prevent trafficking in SoHOs
•    1. All countries should establish laws that prohibit payment for donation of SoHOs, trafficking in SoHOs, and trafficking in human beings to obtain SoHOs.
o    a. Legislation should prohibit activities that make the human body or its parts a source of financial gain exceeding the recovery of the costs of obtaining, processing, storing, and distributing those parts or the products made from them and of ensuring the sustainability, safety, and quality of donation and transplantation systems.”

##########

They also suggest that there is widespread human trafficking in SoHO, although they acknowledge that there isn’t a lot of data to support this:

“since 2010, there have been few empirical studies of organ trafficking, with more recent studies often consisting of qualitative interviews or surveys with individuals who participated in organ trafficking or were victims of human trafficking for organ removal several years earlier.7,32,52 Legal case analyses have focused primarily on seminal cases that detail activities that occurred in the early 2000s.33,38 Much of what is known about current trafficking activities is gleaned from sporadic media reports, which make clear the global prevalence of organ trafficking.”

#########
 

Earlier:

Wednesday, August 28, 2024  WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood, by Krawiec and Roth

Monday, April 22, 2024 Plasma donation in the EU: compensated and uncompensated

Saturday, November 4, 2023  The EU proposes strengthening bans on compensating donors of Substances of Human Origin (SoHOs)--op-ed in VoxEU by Ockenfels and Roth