The American Society of Transplantation prepares to consider a pilot study of financial incentives for living organ donation

 As I prepare to speak later this month at the American Transplant Congress in Boston, I note that  the American Society of Transplantation (AST) has, among its Key Position Statements  one from late last year called A Roadmap for Removing Disincentives for Living Organ Donors 

As the title suggests, the statement focuses on removing financial disincentives for organ donation. 

But I'm struck by the last item on the list:

"Additional Steps
"In advocating for the elimination of disincentives to living donation, AST will examine, in parallel, the legal,ethical, and practical considerations involved in a pilot study of financial incentives for living organ donation."

  

Survey of economists, concerning Living-Donor Kidney Transplants

Romesh Vaitilingam writes to draw my attention to the recent survey of economists, concerning Living-Donor Kidney Transplants, conducted by the Clark Center for Global Markets at Chicago Booth.

He says 

" I’m writing now as I thought you might be interested in the results of this survey, which was inspired by reading your recent Wash Post column."*

Below are the three questions they asked, and the results to each one. At the survey link above you can find the responses of the individual economists surveyed.

 

 

 Only one economist appeared to be skeptical about kidney exchange, and I was surprised at who it was (respondents may answer these questions very quickly...).

 

The next question concerns the End Kidney Deaths Act, which was introduced to the respondents at these links:

"There is draft legislation in Congress to increase the supply of human kidneys by encouraging donations to strangers: https://www.congress.gov/bill/119th-congress/house-bill/2687

"It is summarized here: https://www.hawaiibusiness.com/bipartisan-bill-aims-to-prevent-kidney-deaths-by-compensating-donors/ "

 

 

 The End Kidney Deaths Act gets a good deal of support (above) while an unspecified decentralized market gets considerably less support, below.

 

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*Earlier posts

Friday, May 8, 2026 It’s time to carefully but urgently rethink payments to kidney donors. My op-ed in the Washington Post

 

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 

It’s time to carefully but urgently rethink payments to kidney donors. My op-ed in the Washington Post

 This morning the Washington Post published my op-ed online (which is scheduled to appear in the print edition on Sunday). 800 words is hardly enough to explain why I think what I do...I could write a whole book about that.

But here's the op-ed: 

Why paying people to donate kidneys is a good idea

With 90,000 patients waiting for a kidney, compensating living donors would save lives.

May 8, 2026 at 6:30 a.m. EDT

 

By Alvin E. Roth

Alvin E. Roth is an economics professor at Stanford University and co-recipient, with Lloyd Shapley, of the 2012 Nobel Prize in economics. This article was adapted from his new book, "Moral Economics: From Prostitution to Organ Sales, What Controversial Transactions Reveal About How Markets Work."

It’s time to carefully but urgently rethink payments to kidney donors.

There are approximately 130,000 new cases of kidney failure annually in the United States. It is disproportionately a disease of the poor, and is four times as likely to affect Black people as White people. Kidney failure costs Medicare alone more than $55 billion per year, mostly for dialysis. More than 500,000 people are presently on dialysis, about half of whom will die within five years of beginning treatment. The best treatment for kidney failure is transplantation, but in 2025 fewer than 30,000 people in the United States received kidney transplants. So most people who could benefit from a lifesaving transplant will die without one.

 About 90,000 people are registered on the national waiting list to receive a deceased-donor kidney, and many more would be, if there were enough transplants for all who need them. Thousands die each year while waiting, and thousands more are removed from the waiting list when they become too sick to undergo transplant surgery.

The law in the U.S. and most of the world says kidneys must be gifts; their price must be zero. So, any attempt to raise the supply of kidneys by compensating donors would have to overcome the almost worldwide repugnance for payment.

About three-quarters of kidneys transplanted in the U.S. come from deceased donors, and the rest come from living donors: Healthy people have two kidneys and can remain healthy with one. But sometimes potential donors can’t donate to the person they love, because kidneys have to be medically compatible with the recipient. It’s a challenge even within families. For example, often a mother can’t receive a kidney from her spouse or children because during pregnancy, her immune system developed antibodies to some of their proteins.

 

 For the last quarter-century, living-donor transplants have also been arranged through kidney exchange, in which each patient receives a compatible kidney from another patient’s intended donor. Some of these transplants take place in long chains initiated by a nondirected donor, who donates a kidney, anonymously, to anyone who needs one. That begins a chain of donations in which each recipient’s intended donor passes the gift forward. Kidney exchange has made possible thousands of additional transplants, without payments to donors.  

Nevertheless, kidneys for transplant remain in tragically short supply. So it is past time to consider amending the 1984 law that prohibits giving “valuable consideration” for a kidney for transplant.

This would have to be done with care, because there are good reasons that the phrase “payments for kidneys” arouses repugnance. We wouldn’t want inappropriate donors to be unduly influenced to give up a kidney. (This is something already considered when screening the thousands of people who donate one of their kidneys each year without payment.) Another concern is that we wouldn’t want to live in a world in which only rich people could get kidneys, by buying them from poor people.

In the United States, we might think about letting individual states experiment with different regulations. Or we could explore a national system in which only the federal government could buy kidneys — from carefully qualified donors, after a significant period devoted to medical and psychological screening, and having obtained carefully informed consent. Those kidneys could then be allocated without regard to patients’ income, much as we presently allocate deceased-donor kidneys, which are treated as a national resource. 

 

It would be financially feasible to pay donors quite generously without requiring recipients to pay anything at all. Donors could be paid entirely from the savings to the health care system by taking patients off dialysis.

There is a long history of thoughtful arguments in favor of allowing kidney donors to be legally paid or compensated in some way, with carefully considered precautions. These include a current proposal called the End Kidney Deaths Act, which would establish a limited pilot program for a tax credit to nondirected kidney donors.

To be clear, we should keep trying for big long-term goals, such as vastly reducing the incidence of kidney disease by preventing or curing diabetes, hypertension and other causes. We should keep trying to expand deceased donation (perhaps by offering funeral benefits in gratitude to the next of kin who allow it). We should keep exploring cures that don’t require transplants of human organs. But we can save many lives now by being more generous to living donors, and it makes sense to start experimenting with ways to do this legally, ethically and equitably."

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And here's the picture they chose to accompany the op-ed.

 

 

 

 

 

 

 

Australia has more unpaid beekeepers than blood donors

 If only there were some way for Australia to become self-sufficient in blood plasma, so it could stop having to buy it from the US...

The Financial Times has the story:

Australia’s drive to get more blood flowing
The country has more recreational beekeepers than regular donors and is forced to rely on imports  by Nic Fildes 

" Australia needs 100,000 new donors every year to meet its need for blood and plasma. But there are more recreational beekeepers in Australia than people who have actively donated their blood three times or more.

"This is not only an Australian challenge. Most countries have a supply gap. One problem is that the legion of older donors that has kept donations flowing for decades is dwindling and younger generations are not donating or do not return after they’ve tried it once. 

...

"The situation is particularly acute for plasma — the yellow-coloured component of blood sometimes called liquid gold — which is a vital ingredient for 18 different life-saving procedures ranging from immune deficiency treatment to heart surgery. 

Australia supplies only 38 per cent of its own plasma and spends about A$600mn a year to import it — more than double what was spent a decade ago. A report published by the state of New South Wales suggests imports needed could rise to 66 per cent of the total by 2030, meaning taxpayers are set to foot an even larger plasma bill.

For now, Australia relies on the US, where people earn up to $70 per donation, which supplies about 70 per cent of the world’s plasma."

 

Funeral expenses for deceased organ donors in Taiwan

 In Taiwan, the Ministry of Health and Welfare helps pay for the funerals of deceased organ donors.

 From the Taiwan Organ Sharing Registry and Patient Autonomy Promotion Center

(2)  Grants and Assistance for Donors' Families

a.        Funeral Subsidies:
The MOHW provides funeral subsidies to the donor's family, including NT$50,000 for corneal donations and NT$100,000 for multiple organ donations in addition to the cornea.

b.        Farewell Care Service:
In order to express our gratitude to the organ donors and their families, we provided flower baskets and certificates of appreciation at the farewell ceremony of the donors. In addition to affirming the selfless dedication of the organ donors, we also thanked the family members for their decision. 

Alex Chan on deceased organ donation

 The Harvard Gazette points to this interview with HBS professor Alex Chan:

Designing Incentives That Matter—Even After Death: Interview with Alex Chan By Avery Forman 

"In “Reimagining Transplant Center Incentives Beyond the CMS IOTA Model,” published in January in the Journal of the American Medical Association, Chan explores a government experiment that pays kidney centers for volume and efficiency—not just outcomes—which could increase transplant numbers. Chan cowrote the article with Alvin E. Roth, the George Gund Professor of Economics and Business Administration, Emeritus, at HBS.

In addition, covering funeral costs for organ donors could increase donation rates by up to 35%, and save up to 419,000 life years and as much as $800 million in Medicare expenses, Chan and coauthor Kurt Sweat of the University of Texas Southwestern Medical Center write in “Funeral Expense Reimbursement as a Strategy to Enhance Organ Donation and Transplantation Access,” published in October in NPJ Health Systems.

 ...

"Why Chan felt compelled to study the organ market

“Two things pulled me in. First, this is a market where the stakes are brutally clear. Organ transplantation is one of the few places where inefficiency shows up not as a deadweight loss in a textbook, but as people dying on a waiting list. When a market fails here, it fails loudly.

Second, the level of inefficiency is staggering. Each year, more than 5,000 organs are recovered and then discarded, while roughly the same number of people die waiting for an organ. These are million-dollar transactions once you account for surgery, lifelong care, and avoided dialysis. So even small improvements in incentives can save lives directly and save the healthcare system billions of dollars.

For an economist or market designer, that’s a rare alignment: moral urgency and economic leverage pointing in the same direction.”

Incentives must consider what’s socially acceptable

“Incentive design is much harder than we like to admit. Organ transplantation is a supply chain. You have procurement organizations, hospitals, surgeons, patients, regulators, all responding to different incentives.

Designing a good incentive for one actor is already difficult. Designing incentives so that the entire chain works well is not just adding up the optimal incentives for each link. Sometimes improving one part of the system quietly breaks another.

The choice isn't between market and no market. It’s between a system we design on purpose and a system that fails by accident.

This is a market with moral and political constraints embedded in it. In healthcare, and frankly now in most markets, the incentives that are economically sensible also need to be socially legitimate.

Incentives don’t just change behavior; they express values. In markets that touch life, death, or dignity, people react not only to what the incentive does, but to what it seems to say. That makes incentive design less like tuning a machine and more like negotiating a fragile social contract.

 ...

"The ‘ick factor’ might prevent progress

“Very often people do not want to use the right incentives because they have this concept of it being repugnant.

[For instance], we would pay for the funeral of someone who gives their life for their country when they serve in the military. We will pay for the funeral of someone who donated their body for scientific research to advance society. But if people want to donate an organ to save another person's life? If [that donor’s] family would very much welcome some support at a moment of crisis, we are not going to pay for the funeral. Even a very sensible incentive sometimes is bound by social norms, or even what we call the ‘ick factor,’ and we have a less effective system at the end.

People worry that incentives will corrupt the gift of life. But the truth is that we already have incentives; they’re just accidental and poorly distributed. The choice isn't between market and no market. It’s between a system we design on purpose and a system that fails by accident. Ignorance of incentives doesn't make a system moral; it just makes it inefficient.”

 

Paid plasma donations are becoming more middle-class

 The NYT has the story:

The Middle-Class Suburbanites Who Sell Their Blood Plasma to Get By.  Across the United States, plasma centers are opening in wealthier areas as more people struggle with the high cost of housing, groceries and health care.   By Kurtis Lee and Robert Gebeloff   March 20, 2026

"Every day, an estimated 215,000 people donate plasma, the yellowish liquid component of blood. Mr. Briseño is among them. He is not jobless or facing eviction, but, like many in the American middle class, he is caught in the vise of rising expenses and wages that aren’t growing fast enough to cover them. So he is turning to a method more commonly associated with the lowest-income Americans. For people like him, an extra $600 or so a month can mean making a mortgage payment or covering increased health-insurance costs.

"A recent study by researchers at Washington University in St. Louis and the University of Colorado, Boulder, observed that while older plasma centers are clustered in low-income areas, newer centers were increasingly likely to open in middle-class neighborhoods. A New York Times analysis shows the trend has continued: Centers have sprung up in more than 100 such neighborhoods, in suburbs and wealthier sections of cities, since researchers finished collecting their data in 2021."

 

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Here's an earlier post on the study that sparked the NYT report:

Wednesday, November 16, 2022  Blood Money, by John Dooley and Emily Gallagher

 

The States as the laboratory of democracy: helping organ donors

News from the States:

Pa. senators mull inheritance tax cut, deductions for organ donors 

"While employers across the state are allowed to claim tax deductions for time off offered to living organ donors, donors themselves receive no such benefits.

That would change if lawmakers pass a bill sponsored by Sens. Lindsey Williams (D-Allegheny) and Lynda Schlegel Culver (R-Northumberland), who testified to members of the Senate Finance Committee almost five years to the date after receiving her sister’s kidney.
...
“I’ve seen firsthand the gift of donation and what it means,” Culver told lawmakers. “It has allowed me and so many others the opportunity to have a full life.”

According to the University of Pennsylvania Health System, more than 6,000 Pennsylvanians were on the transplant waiting list in 2025.

Culver and Williams’ proposal would allow living organ donors to deduct up to $10,000 in unreimbursed expenses related to the donation from their taxable income. That would include costs like travel, lodging, lost wages and medical expenses.

According to Culver, studies show the average living organ donor faces roughly $5,000 in expenses, which includes things like travel, lost wages and child care during recovery.
...
The measure was passed unanimously by members of the Senate Finance Committee." 

International statistics on plasma donation show that it is quite safe

 Peter Jaworski collects the statistics from Europe and North America:

Plasma donation is safe
And commercial plasma donation is not less safe than non-commercial donations
Peter Jaworski
Mar 16, 2026 

"Source plasma donation (also called “plasmapheresis”) is inordinately safe (so is whole blood donation). And the best publicly-available donation safety data give us no reason to think that commercial plasma collection is less safe than non-commercial plasma collection.

" That claim may be surprising in light of the recent heartbreaking deaths reported after plasma donations in Winnipeg. These tragedies have raised questions about the safety of plasma donation in general, with some critics suggesting that commercial plasma donation is inherently less safe than non-commercial plasma donation.

"The evidence for the claim that plasmapheresis, including commercial plasmapheresis, is safe can be found in countries with the largest plasmapheresis programs, which publish annual reports on serious donor adverse events. Some of these countries have exclusively non-commercial plasma collection, while others have predominantly commercial systems. "

How safe is plasma donation?

 Here's a story from the NYT, about the recent regularization of paid plasma donation in (some provinces of) Canada.

How Safe Is Plasma Donation?
Two recent deaths tied to for-profit clinics in Canada raised concerns about the health effects of having plasma drawn as often as twice a week. By Roni Caryn Rabin and Vjosa Isai

"Donating plasma, which is used to make lifesaving medicinal products, is widely perceived as low-risk. But questions about the safety of the practice arose this week when Canadian health authorities confirmed they were investigating two recent deaths of people who gave plasma at for-profit clinics in Winnipeg operated by Grifols, a Spanish health care company. 

"Millions of people donate frequently in North America. An estimated 60 to 70 percent of plasma-derived medicinal products worldwide are made from plasma donated in the United States.

And demand for plasma is growing. The market for plasma-derived medicinal products is valued at $40.35 billion and is expected to double over the next eight years, as the products are used to treat an expanding number of conditions, including immune deficiency syndromes and bleeding disorders.

But the health impact of frequent plasma donation on the donors themselves has not been well studied, and there is no consensus among health regulators about how long donors should wait between plasma draws.

In both Canada and the United States, companies can pay people an honorarium for donating their plasma, and health regulations say that people can donate up to twice a week.  

...

"A 2020 investigation by the F.D.A. into 34 deaths reported as being associated with plasma donation did not determine that donation was the cause of death in any of the cases. It ruled donation out entirely as a cause in 31 cases. "