The Ethics of Compensated Living Kidney Donation

Abstract

Kidney waiting lists continue to grow in nearly every country, and living donors remain the intervention that best relieves them, yet paying donors beyond reimbursement of direct costs is prohibited almost everywhere. This policy analysis examines the case for and against regulated compensation for living kidney donors, drawing on cost-benefit assessments, empirical donor-welfare data from Iran's decades-old compensation program, and survey evidence on public attitudes toward payment. It weighs the leading objections -- commodification of the body, coercion of financially vulnerable donors, and the risk that any legal payment scheme undermines the global fight against organ trafficking -- against the mortality and cost burden of the current altruism-only regime. We argue that the empirical record from Iran demonstrates both the supply-side promise and the donor-protection failures of a poorly scaffolded compensation model, and that recent proposals for publicly administered, fixed, non-negotiable payment paired with independent donor advocacy represent the most defensible way to test compensation without repeating those failures. We conclude that neither an unregulated organ market nor an indefinite continuation of the status quo is ethically or empirically satisfactory, and that policy attention should shift toward the specific safeguards a compensation system would need.