“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. "

Kidney Transplants in Pakistan. Many patients unaware that paying donors is illegal.

Here's a recent paper on  "Barriers to Kidney Transplants in Pakistan.  A striking fact is that only 4.9% of patients with kidney failure were aware that paying a donor is illegal in Pakistan.

 Afzal, Aurangzeb, Muhammad Ahmad Rauf, Zohra Khanum, Hafiza Sumaira Rahman, Zahid Rafique, Areeba Gulzar, Waqas Rasheed, Jehangir Afzal Mobushar, Beenish Abbas Bajwa, and Muhammad Ahmad Rauf IV. "Barriers to Renal Transplant in Pakistan." Cureus 17, no. 5 (2025).

 

  ...

"The study revealed limited knowledge regarding legal restrictions on kidney donation, with only 9.8% aware that non-related persons cannot donate kidneys according to the law, and a mere 4.9% knowing that financial compensation for donation is illegal. This lack of awareness may perpetuate illegal organ trade and exploitation [4]. Educational initiatives targeting both patients and the general public are essential to promote ethical transplantation practices and protect vulnerable populations."

JAMA declined to publish this letter on kidney donation

 JAMA recently published the following Viewpoint, whose title adequately summarizes its main point:

The End Kidney Deaths Act Risks Irreversible Harm to Organ Donation
by Thomas F. Mueller, MD, PD1; Maria A. Matamoros, MD2; Gabriel M. Danovitch, MD3; Sanjay Nagral, MD, JAMA. March 26, 2025. doi:10.1001/jama.2025.2409

I promptly submitted the letter below, in reply, and received a rejection from the journal yesterday. 

“Irreversible Harm to Organ Donation”? Strong opinions based on weak evidence 

Alvin E. Roth,  Ph.D., Word count: 391
 
 From 2002- 2022, the number of Americans newly diagnosed with kidney failure increased from 99,956 to 131,194 per year (1).  The total number of Americans suffering from kidney failure nearly doubled to over  800,000, with over 500,000 on dialysis (2).   In 2024 there were only 27,759 kidney transplants in the U.S. from both deceased and living donors, so most patients with kidney failure will die without  receiving  a transplant.

Mueller et al.(3)   claim that a proposed experiment involving modest compensation of a limited group of living kidney donors “risks irreversible harm to organ donation.” Their arguments are those also used to argue against compensation of donors of Substances of Human Origin generally (4).   But the case of blood plasma suggests these strong opinions are based on very weak evidence.

Five of the twenty-seven EU nations allow plasma donors to be compensated. Those five are the only EU nations self-sufficient in plasma. The twenty-two nations in which payment of donors is banned must import a significant portion of the plasma and plasma derivatives they need. Much of those imports comes from the U.S, which also has legal, regulated markets in which plasma donors may be paid for donation (5).   Consequently, many lives are saved by American plasma, in the U.S. and around the world.  Paying plasma donors  hasn’t reduced  plasma donation: any reduction in unpaid donation has been more than replaced by paid donors.

The regulation of markets in the U.S. has been strong enough that the catastrophic predictions of black markets, exploitation, and devastation of donors that support the establishment of bans on compensation in many other countries have not come to pass in the U.S.  This provides reasons to doubt the dire forecasts also made about the consequences of a U.S. experiment involving modest payments to kidney donors.
 

Kidney donation is not the same as plasma donation, so effective regulation of compensation for kidney donors would be different. We need to experiment to gather evidence of whether and how to proceed.  Pilot programs such as the tax credits proposed by the End Kidney Deaths Act would provide evidence.  
 

New markets and regulations may need modification as experience accumulates.  If the experiment increases non-directed donations, it could be expanded to include more kinds of kidney donation. And the experiment could be abandoned if generosity to donors turned out to be uncontrollably negative, as opponents predict.

References:

1  Annual Data Report | USRDS, https://usrds-adr.niddk.nih.gov/2024/end-stage-renal-disease/1-incidence-prevalence-patient-characteristics-and-treatment-modalities.

2  The National Forum of ESRD Networks. Quarterly National ESRD Census www.esrdnetworks.org.

3. Mueller TF, Matamoros MA, Danovitch GM, Nagral S. The End Kidney Deaths Act Risks Irreversible Harm to Organ Donation. JAMA. Published online March 26, 2025. doi:10.1001/jama.2025.2409

4  Cuende, Natividad, et al. "Promoting equitable and affordable patient access to safe and effective innovations in donation and transplantation of substances of human origin and derived therapies." Transplantation 109.1 (2025): 36-47. January  https://journals.lww.com/transplantjournal/fulltext/2025/01000/promoting_equitable_and_affordable_patient_access.6.aspx

5  Elias, Julio, Nicola Lacetera, Mario Macis, Axel Ockenfels, and Alvin E. Roth, “Quality and safety for substances of human origins: scientific evidence and the new EU regulations, BMJ Global Health, Volume 9, Issue 4 April, 2024,  https://doi.org/10.1136/bmjgh-2024-015122

How the Trump administration is ignoring judicial orders halting blanket payment bans

Federal judges have issued injunctions against President Trump's Federal payment bans, for example for foreign aid.   But payments haven't resumed. It turns out that bureaucracies have big strategy sets (and, nowadays, some contempt for courts).

Each foreign aid contract, for example, typically has a clause that allows payments to be ended if the terms of the contract are violated.  So newly appointed heads of agencies are  claiming that all contracts were uniformly being violated, or must be certified as in compliance before payments (on each particular contract, not as part of any blanket order, no sir) can be resumed.

The NYT has the story:

Trump Team Finds Loophole to Defy Spirit of Court Orders Blocking Spending Freezes. Officials cite other legal authorities — not Mr. Trump’s court-blocked directives — to keep withholding foreign aid and domestic grant money.  By Charlie Savage

"The Trump administration is systematically exploiting loopholes to effectively keep much of the president’s blanket spending freezes in place, accounts by officials and court filings show, despite restraining orders from judges who have told agencies to disregard the directives.

"The administration’s strategy is to have political appointees embedded in various agencies invoke other legal authorities to pause spending, while posturing as if those officials had undertaken the efforts independent of President Trump’s original directives.

"In short, critics say, administration officials are paying lip service to complying with the letter of the court orders while violating their spirit. The tactic shows how aggressively and nimbly the Trump administration is working to keep funds jammed up, and the complexity judges face if they want to compel the administration to unblock the money."

Anti trans leads to anti transplant in Indiana Senate

 In Indiana, the Daily Journal reports on a debate that has at least temporarily stalled a bill meant to protect organ donors' access to insurance.

Living organ donor bill sparks emotional discussion in the Senate
By TheStatehouseFile.com -January 27, 2025 

"During Thursday afternoon’s Senate hearing, 10 bills were brought up for their final vote before moving to the House of Representatives. While nine of the bills passed without discussion, one of the bills, SB 111, which would, among other provisions, protect organ donors from being denied coverage by insurance companies, sparked debate

...

"Sen. Andrea Hunley, D-Indianapolis, who authored the bill with Sen. Scott Baldwin, R-Noblesville, and Sen. Kyle Walker, R-Lawrence, began the discussion by describing the necessity of protecting Hoosier organ donors. She was then questioned by Sen. Liz Brown, R-Fort Wayne.

“My concern is that if a trans woman wanted a uterine transplant, that would be covered under the bill,” said Brown.

"Brown, who mentioned her concern about uterine transplants repeatedly during the discussion, was also concerned about possible raises in insurance rates for Hoosiers."

HT: Martha Gershun

#######

The uterus is just a muscle, so some transplant surgeons  I've talked to think such a transplant could be done.  The pregnancy would start with IVF, and the delivery would be by C-section…

 

The right to contraception is open to question again in the U.S.

 Here's a paper in the J. of Women's health that brings us up to date on contraception law in the U.S.

The Right to Contraception Act: A Present-Day Imperative, by Eli Y. Adashi, Daniel P. O’Mahony, and I. Glenn Cohen, Journal of Women's Health, published online Dec 2024

"For nearly 60 years, the right to contraception was deemed a constitutional right secure by dint of the landmark 1965 U.S. Supreme Court decision in Griswold v. Connecticut.1 The court found unconstitutional a Connecticut law declaring that “[a]ny person who uses any drug, medicinal article or instrument for the purpose of preventing conception shall be fined not less than fifty dollars or imprisoned not less than sixty days nor more than one year or be both fined and imprisoned,” as well as aiding and abetting that act, as applied to a physician and professor who “gave information, instruction, and medical advice to married persons as to the means of preventing conception.”1 In so doing, the U.S. Supreme Court affirmed the protection afforded by the U.S. Constitution to the “right to marital privacy” and thus to the liberty of married couples to deploy contraceptives absent governmental restriction.1 Seven years later, in Eisenstadt v. Baird, the U.S. Supreme Court extended the constitutional protections of Griswold v. Connecticut to unmarried couples.2
 

"More recently, however, in 2022, doubts have arisen as to the durability of the Griswold v. Connecticut precedent. Specifically, in his concurring opinion in Dobbs v. Jackson Women’s Health Organization, Justice Clarence Thomas urged that “in future cases, we should reconsider all of this Court’s substantive due process precedents, including Griswold, Lawrence, and Obergefell.”3 It is with an eye to protecting against potential reversal of the right to use contraceptives, especially those viewed by some antiabortion advocates as abortifacients, that congressional Democrats saw to the introduction of the Right to Contraception Act.4,5

...

"All indications are that the Right to Contraception Act is unlikely to advance in the current divided Congress. While some states saw to the establishment of legal or constitutional measures with an eye toward protecting the right to contraception, the trend was hardly uniform. A relevant health care bill in Missouri remains unenacted.7 Uniform Republican opposition to the right to contraception has been underway for some time in Arizona as well.7 Comparable legislation proposed in the Democratic-controlled Virginia legislature by Sen. Ghazala Hashmi (D-Richmond) and Del. Cia Price (D-Newport News) was vetoed by Governor Glenn A. Youngkin.7 A house divided has yet to reunite in the spirit of Griswold v. Connecticut."

The market for (ethical) pornography

 Will regulation, lawsuits and competition for creators increase the supply of ethical porn?

Wired has the story:

The Sticky Dilemmas of Pornhub’s Next Chapter
Videos of minors. Illegal data collection. Lack of oversight. Lawsuits. Problems have dogged the popular porn site for years. Is its promise of transparency enough for a reset? By Jason Parham

"Kekesi empathized with the performers. It’s part of her job. As vice president of brand and community at Pornhub, the monstrously popular adult entertainment site, she puts in plenty of face time with creators, as well as fans of the platform, the press, and critics. 

...

"She was thrust into the role in 2023, following a particularly turbulent period for the company. On some level, Pornhub has always been controversial—it comes with the territory—but the problems of the platform in recent years represented an existential threat.

"Rumblings began in 2019, when the owners of the GirlsDoPorn and GirlsDoToys websites were charged in a sex trafficking conspiracy for deceiving and forcing women to perform in adult films, which they then uploaded online, including to platforms like Pornhub. In March 2020, Senator Ben Sasse of Nebraska urged the US Department of Justice to open an investigation into Pornhub, citing incidents from “the past year,” including the GirlsDoPorn case. A New York Times column by Nicholas Kristoff that December brought even more attention to accusations that Pornhub hosted videos depicting sexual abuse, including of children. At first Pornhub denied any wrongdoing, but reaction swiftly snowballed.

"In Canada, where Pornhub is based, a parliamentary committee launched an investigation into the allegations. Visa and Mastercard suspended payment processing. Dozens of women sued Pornhub’s parent company, then called MindGeek and since renamed Aylo Holdings, alleging it had created and profited from a “bustling marketplace for child pornography, rape videos, trafficked videos, and every other form of nonconsensual content.”

...

"Pornhub has taken steps to address at least some of these problems. Following the Times article, it scrubbed the site of all “unverified content,” Kekesi said. Now anyone who wants to upload content to Pornhub has to not only verify their own identity; they also must supply proof of consent for everyone who appears in the scene, including documentation, IDs, and other paperwork. Pornhub also started issuing annual “transparency reports,” which it now does twice a year, publishing its content moderation practices. 

...

"Already, 12 US states have instituted age-verification laws around porn consumption. Because PornHub doesn’t want to open itself to litigation under these new laws, it went on the offensive, blocking all access to its site in those states regardless of age.

...

"In general, though, porn is more accessible than ever. Platforms like OnlyFans customize desire for a small fee. The riskier side of the social media site X operates in the vein of the former Backpage.com, where creators use the app to promote their work, engage with fans, and find gigs. That has also meant more competition for Pornhub. Kekesi never says it outright, but this is likely why the company has made a noticeable effort to appease the concerns of adult creators. “We are catching up and trying to be more visible and more present with the creator community,” she said."

Adultery is no longer a crime in New York State.

 Not only is jaywalking no longer a crime in New York City, the seldom-enforced criminal law against adultery in New York State has now been repealed. 

My sense is that the jaywalking ban was rolled back in part because it was inequitably enforced, while the ban on adultery was so rarely brought to trial that it was simply obsolete.

NPR has the story:

Adultery is no longer illegal in New York, By Ayana Archie 

"Adultery is no longer a crime in New York.

"Gov. Kathy Hochul on Friday signed off on repealing a 1907 law prohibiting the act.

"New York's penal law previously said that "a person is guilty of adultery when he engages in sexual intercourse with another person at a time when he has a living spouse, or the other person has a living spouse."

"It was considered a Class B misdemeanor, which carries a jail sentence of up to three months.

"The New York State Senate called the law "outdated."

#########

Interestingly, surveys indicate  both that most Americans disapprove of adultery, but that the frequency of adultery is quite high. So it's the law that is outdated, not the act.

Also interesting is that adultery is still forbidden under the Uniform Code of Military Justice.  This comes up in discussions about President Trump's nominee to be Secretary of Defense (where he will preside over servicemen and women who are forbidden to follow the examples of their Secretary and their Commander in Chief...)

Here's the NYT on that:

Pete Hegseth’s Mother Accused Her Son of Mistreating Women for Years  by Sharon LaFraniere and Julie Tate

"Reports of his infidelity have focused attention on his character and leadership, particularly for a civilian overseeing the military, where active-duty service members can be subject to prosecution for adultery under the Uniform Code of Military Justice."

America Has an Organ Shortage. Could Paying Donors Close the Gap? Podcast from BYU radio.

 Here's a podcast on the shortage of organs for transplant, and on the controversies about compensating organ donors, and plasma donors.

America Has an Organ Shortage. Could Paying Donors Close the Gap?   Top of Mind with Julie Rose | BYU radio
 

"There are more than 100,000 people on the waitlist for an organ transplant. Every day 17 of them die. Most organs for transplant come from deceased donors. But the organs in highest demand for transplantation are kidneys and livers – both of which can be donated while a person is still alive. So, we could save thousands of lives each year if more people were willing make a living organ donation. Some advocates say giving donors money would increase organ donations enough to eliminate the entire waitlist. But federal law makes it illegal to buy or sell organs. Ethicists have real concerns about coercion and exploitation, too. In this podcast episode, we're exploring America's organ shortage and asking whether paying donors could close the gap.  
Guests:
David Galbenski, liver transplant recipient and co-founder of the Living Liver Foundation (https://livingliver.org/)

Elaine Perlman, kidney donor, Executive Director of Waitlist Zero and leading advocate for the End Kidney Deaths Act (http://waitlistzero.org/)

Kathleen McLaughlin, journalist and author of Blood Money; The Story of Life, Death, and Profit Inside America's Blood Industry

Al Roth, Nobel-prize winning economist, Stanford University, expert in market design and game theory (https://marketdesigner.blogspot.com/)"

I'm interviewed at the end of the podcast, starting at minute 39:

x

The End Kidneys Death Act has growing support

I've earlier blogged about the Coalition to Modify NOTA (the National Organ Transplant Act of 1984).

Here is a summary of their proposed legislation

The End Kidney Deaths Act Summary

It begins this way:

"The End Kidney Deaths Act is a ten year pilot program to provide a refundable tax credit of $10,000 each year for five years ($50,000 total) to living kidney donors who donate a kidney to a stranger, which will go to those who have been waiting longest on the kidney waitlist. By the 10th year after the passage of the End Kidney Deaths Act, up to 100,000 Americans who were dying on the waitlist will instead have healthy kidneys, and taxpayers will have saved $10-$37 billion. Deceased donor kidneys last half as long as living donor kidneys, the gold standard of kidney care.

"One author of the National Organ Transplant Act, Representative Al Gore, said 40 years ago in 1984 that if transplant centers conclude efforts to improve voluntary donation are unsuccessful, incentives including tax credits, should be provided to donors."  

Their list of supporters is growing, and includes many transplant professionals as well as many people who have already donated or received kidneys.

Legislative proposals to help living kidney donors

 Martha Gershun brings us up to date on various proposed pieces of legislation to help organ donors and increase access to transplants.

Legislative Efforts to Support Living Kidney Donors,  by Martha Gershun, Guest Blogger

"As a member of the Expert Advisory Panel to the Kidney Transplant Collaborative, I have been honored to provide input during the development of the organization’s priority legislation, the Living Organ Volunteer Engagement (LOVE) Act.  This legislation would help build a comprehensive national living organ donor infrastructure that would support a national donor education program, create a donor navigator system, ensure appropriate donor cost reimbursement, collect essential data, and improve all aspects of living organ donation across the country, substantially reducing barriers that limit participation today.

Key provisions of the LOVE Act would:

• Provide reimbursement for all direct and indirect costs for living donation, including lost wages up to $2,500 per week.
• Provide life and disability insurance for any necessary care directly caused by donation.
• Modify NLDAC rules so neither the recipient’s income nor the donor’s income would be considered for eligibility.
• Provide for new public education program on the importance and safety of living organ donation.
• Provide for new mechanisms to collect and analyze data about living organ donation to enable evidence-based continuous process improvement.

Numerous other federal proposals are also currently vying for support to address barriers to living donation on a national level.  They include:

Living Donor Protection Act (H.R. 2923, S. 1384)

• Prohibits insurance carriers from denying, canceling, or imposing conditions on policies for life insurance, disability insurance, or long-term care insurance based on an individual’s status as a living organ donor.
• Specifies that recovery from organ donation surgery constitutes a serious health condition that entitles eligible employees to job-protected medical leave under the Family and Medical Leave Act.

Organ Donor Clarification Act (H.R. 4343)

• Clarifies that reimbursement to living organ donation is not “valuable consideration” (I.e., payment), which is prohibited under the National Organ Transplant Act (NOTA)
• Allows pilot programs to test non-cash compensation to living organ donors.
• Modifies NLDAC rules so the recipient’s income would no longer be considered for eligibility.

Living Organ Donor Tax Credit Act (H.R. 6171)

• Provides a $5,000 federal refundable tax credit to offset living donor expenses.

Honor Our Living Donor (HOLD) Act (H.R. 6020)

• Modifies NLDAC rules so the recipient’s income would no longer be considered for eligibility.
• Requires public release of annual NLDAC report.

Helping End the Renal Organ Shortage (HEROS) Act

• Provides a $50,000 refundable federal tax credit over a period of five years for non-directed living kidney donors.

############

And here's one more, from the Coalition to Modify NOTA