To the Editor The End Kidney Deaths Act (HR 2687) is a data-informed, ethically grounded proposal developed by nondirected kidney donors (individuals who donate kidneys to strangers) to address the persistent shortage of transplantable kidneys. Backed by 38 organizations,1 the End Kidney Deaths Act will provide a $10 000 annual tax credit for 5 years (totaling $50 000) to individuals who donate a kidney to a stranger. The End Kidney Deaths Act has the potential to increase living kidney donation, save lives, and reduce taxpayer costs.

In their Viewpoint,2 Dr Mueller and colleagues argue that the End Kidney Deaths Act risks irreversible harm to organ donation. However, we believe their objections are speculative and lack empirical support, while the urgency of the organ shortage demands action. Nearly 100 000 patients remain on the transplant waiting list, and living donation has stagnated for more than 2 decades. The End Kidney Deaths Act offers a novel, government-regulated model to responsibly compensate donors, ensure donor safety, and help close the widening gap between organ supply and demand.

Mueller and colleagues state that “[p]roviding tax credits to nondirected donors is unlikely to significantly reduce the organ shortage.” However, compensation has increased participation in gamete donation, plasma donation, and surrogacy. Their statement regarding “exploitation of vulnerable donors” overlooks the End Kidney Deaths Act’s regulatory framework, which we believe preserves ethical standards while reducing reliance on illicit markets.

The assertion that countries with compensation see fewer voluntary donations is not applicable. No country has implemented a model like the End Kidney Deaths Act, and, in our opinion, comparisons with unregulated programs abroad are misleading. Mueller and colleagues also warn that paid donors often regret their decision. The majority of respondents in 2009 and 20153 American Society of Transplantation and American Society of Transplant Surgeons member surveys, and in 4 public surveys, most recently in 2019,4 supported pilot programs for donor compensation. A recent National Kidney Donation Organization survey reported that 97.9%5 of respondents would still donate under the End Kidney Deaths Act. Historically, 95% of US living kidney donors say they would donate again.

Mueller and colleagues suggest that legal compensation will worsen global exploitation. However, the current prohibition and organ shortage have not prevented unethical practices, they have merely driven them into illicit, underground markets. A transparent US model would set a global ethical precedent, demonstrating how regulated compensation can be ethically implemented. Although other solutions have been proposed by the authors, none have meaningfully addressed the shortage. Maintaining the status quo leaves tens of thousands vulnerable to suffering and dying.

We urge rigorous, empirical engagement with the legislation’s potential rather than reliance on speculative concerns. The End Kidney Deaths Act is a practical, evidence-based policy that could help reduce preventable deaths.

Article Information

Corresponding Author: Elaine Perlman, MA, Coalition to Modify NOTA, (ElainePerlman@modifynota.org).

Published Online: July 21, 2025. doi:10.1001/jama.2025.8240

Conflict of Interest Disclosures: Dr Ambagtsheer reported receiving grants from Dutch Research Council (406.XS.03.075). No other disclosures were reported.

References
1.
Modify NOTA. 38 Organizations supportive of the End Kidney Deaths Act. January 1, 2024. Accessed May 21, 2025. https://www.modifynota.org/new-page-1
2.
Mueller  TF, Matamoros  MA, Danovitch  GM, Nagral  S.  The End Kidney Deaths Act risks irreversible harm to organ donation.   JAMA. 2025;333(19):1663-1664. doi:10.1001/jama.2025.2409
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Salomon  DR, Langnas  AN, Reed  AI, Bloom  RD, Magee  JC, Gaston  RS; AST/ASTS Incentives Workshop Group (IWG).  AST/ASTS workshop on increasing organ donation in the United States: creating an “arc of change” from removing disincentives to testing incentives.   Am J Transplant. 2015;15(5):1173-1179. doi:10.1111/ajt.13233PubMedGoogle ScholarCrossref
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Elías  JJ, Lacetera  N, Macis  M.  Paying for kidneys? a randomized survey and choice experiment.   Am Econ Rev. 2019;109(8):2855-2888. doi:10.1257/aer.20180568Google ScholarCrossref
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Matthews  D. The moral case for paying kidney donors. Vox. Updated September 18, 2024. Accessed May 21, 2025. https://www.vox.com/future-perfect/372412/end-kidney-deaths-act-kidney-donor-tax-credit