How Much Is Your Kidney Worth?

The parenting manuals warned Elaine Perlman about the usual adolescent foibles. She had braced herself for piercings and purple hair, questionable friend choices and what she might say if she found drugs in any pockets. Not that her teenage son had raised any major concerns. Abie Rohrig was shy and kind, the sort of kid teachers describe as a delight to have in class. Abie had big ideas and the ambition to go after them.

So when Abie came home from school in 2017 and announced that he wanted to donate a kidney to a stranger, the 17-year-old’s pronouncement took his normally even-keeled mother off-guard.

“I’m donating my kidney to a stranger,” Abie told her.

While Perlman was tickled by her son’s altruism, she couldn’t stop her Mom Brain from kicking into overdrive. Wasn’t the surgery dangerous? Didn’t Abie need both kidneys? What would happen decades from now? And what could possibly motivate someone to undergo major surgery for a complete stranger?

Since 2000, the number of living organ donors in the U.S. has remained relatively stagnant at around 6,000 to 6,500 annually, even as the kidney transplant waitlist has grown to nearly 100,000 in that same time. Most of these donors give to family or friends — only around 3% of living donations are undirected and go to total strangers.

What makes kidneys from living donors especially valuable is that these organs generally last several years longer than a cadaver kidney. The shortage of available kidneys is intensified by the complexities of finding a donor with a compatible immune system profile to reduce the chances of rejection.

Although the actual surgery is generally safe and commonplace, would-be kidney donors also face a range of barriers and requirements, depending on the transplant centers. Many are medical; anything less than A+ health is disqualifying, Rosamond Rhodes, a bioethicist at Mount Sinai Hospital in New York, told me. Across the board, it’s clear: You must be in good mental and physical health. Other barriers are practical. Donors must take time off work for testing, surgery and recovery. They need transportation to and from the hospital. Then there are incidentals like food and parking. It all adds up. These hurdles may explain why only 300 to 400 Americans each year donate a kidney to a stranger, Perlman said.

Her son’s experience donating a kidney at New York City’s NYU Langone hospital in 2019 led Perlman to do the same six months later. As she learned more about America’s — and the world’s — kidney shortage, she began to champion an idea that some in the medical community find morally repugnant: compensating living kidney donors for their act.

Perlman has been the driving force behind a bill called the “End Kidney Deaths Act,” which was introduced to the House by a bipartisan group of lawmakers in late summer 2024 and would primarily provide tax breaks as a form of compensation to individuals who gave undirected living kidney donors. The amount, $50,000 over five years, is meant to not only allow donors to recoup lost wages but also as a token of appreciation for a selfless act, Perlman said. Economists arrived at the number through a series of studies that worked to balance the money saved through a transplant rather than ongoing dialysis treatment, public opinion on the value of kidneys from living donors, and a monetary amount persuasive enough to incentivize potential donors to step up to the plate.

“Donation, I recognize very clearly, is work. It’s time consuming, it’s painful, it’s stressful work. If you just compensate people for what they’ve done, you will have a far greater impact,” Perlman told me.

Economically speaking, Frank McCormick, a retired economist and former director of economic and financial research at Bank of America, told me the proposal is a slam dunk. Ethically, however, not everyone is convinced. A prohibition against selling organs has been a medical mainstay for decades. Dr. Gabriel Danovitch, the now-retired director of the University of California, Los Angeles’ Kidney and Pancreas Transplant Program, sees donor compensation as a slippery slope to back-alley surgeries and black-market organ auctions. And when so much money is on the line, will patients be as honest about their medical histories with the transplant team?

“If you’re donating a kidney to someone you care about, you’re going to tell the truth,” Danovitch said. “But if you’re doing it because you need some money, well, why would you necessarily?”

Danovitch’s revulsion at the idea of potential patient coercion and organ trafficking is shared by everyone in the transplant world. But the End Kidney Deaths Act isn’t setting up some sort of Silk Road for kidneys, McCormick told me. Instead, providing tax breaks for donors shows that society values what they do. It’s no different than paying doctors and nurses their salaries for performing the transplant.

“This is a shortage that is killing people,” McCormick said. “More than 40,000 people each year are suffering on dialysis unnecessarily and dying prematurely.”

Whether the bill will pass under the new administration remains to be seen, but if it became law, the U.S. would join the ranks of only a few other countries — Iran, Saudi Arabia and Israel — that permit payments to living donors. It’s a bold step, as well as one fraught with ethical complications. 

Anatomy Of A Transplant

Ever since Dr. Joseph Murray removed Ronald Herrick’s kidney and placed it into the abdomen of his 23-year-old identical twin brother, Richard, in 1954, organ transplants have been saving lives. The development of immunosuppressant medications such as cyclosporine and tacrolimus opened the world of transplant to others, beyond identical twins. This lifesaving achievement had limitations, however, as the number of individuals needing a transplant has always outstripped the number of organs available.

What makes kidney transplants different, Perlman told me, is that living people can donate with no long-term ill effects. Our kidneys filter toxins from our blood, yes, but they also ensure the correct balance of water, electrolytes, salts and essential minerals in our bodies. They’re so vital that our kidneys have far more capacity than we really need. Many of those born with unilateral renal agenesis — a rare condition where a person only develops a single kidney — never even know they have it. A single kidney, then, is generally adequate for normal physical functioning.  It’s not until kidney function drops dangerously low to about 15% that individuals develop serious symptoms of kidney failure. 

But just because someone has excess kidney capacity doesn’t mean they’re a candidate to relinquish their spare parts. Common conditions such as diabetes and hypertension are a leading cause of kidney failure, which rules out many would-be donors. Heart disease, cancer and obesity can all exclude donors. Even high risk of developing these conditions in the future is enough to keep someone from donating. If the rules sound stringent, that’s because they are, Dr. Arthur Matas, a transplant surgeon at the University of Minnesota Medical School, told me.

“In order to be a kidney donor, you need to essentially be perfectly healthy with no chronic diseases, except maybe something like acne or asthma,” he said.

Physicians like Matas helped craft these rules over the decades to protect donors from unforeseen health consequences down the road. Should an unforeseen health crisis occur, these donors are typically placed at the top of the transplant list.

“You’re taking somebody to the operating room who doesn’t need an operation for their own physical benefit, so you want to do absolutely everything to minimize risk,” Matas said. Long-term studies show that living kidney donors show minimal increased risk for future disease even decades after their kidney was removed. Donor screening was rigorous enough to ensure that the donors were unlikely to develop conditions that would have a detrimental impact on their remaining kidney function.

The other challenge for physicians is ensuring the new kidney isn’t rejected by the recipient’s immune system. All our cells are studded with sugary proteins called human leukocyte antigens that act as molecular “Hello My Name is” stickers that our immune system reads to determine if the cell it encounters is from our own body or a pathogen. Our name tags are controlled by genetics, which means that a parent, child or sibling is much more likely to have a cell signature similar to our own (only identical twins would have virtually the same molecular name tags on their cells). If patrolling immune cells stumble upon a name tag that isn’t ours, they will attack the intruder.

Immunosuppressant medications can dampen this response, but they can’t eliminate it. A donor kidney with a more familiar name tag is crucial for the organ to last long term. Without an adequate match, even a kidney from an exceptionally healthy and willing donor isn’t of much use.

In the early 2000s, Stanford economist Alvin Roth realized that matching a donor kidney to its recipient wasn’t just a medical question, it was an economic one. Instead of sending a donor-recipient pair away because of an immunological mismatch, Roth helped develop a system of kidney exchanges. This allows recipients with incompatible donors to swap kidneys to create the ultimate win-win scenario. It goes something like this: say Wife A wants to donate to Husband B, and Father C wants to donate to Daughter D, but neither is a good match. Instead, Wife A donates to Daughter D and Father C donates to Husband B — both better matches here — and everyone wins.

“You’re looking for combinations that yield lots of good transplants,” Roth said.

The strategy seemed like such an obvious solution, Roth told me, but it took an act of Congress to make the idea legal. The 1984 National Organ Transplant Act (NOTA) established the framework of the modern American transplant system. It also included a provision that prohibited any exchange of “valuable consideration” for a human organ for transplantation. This terminology made it illegal to buy or sell human organs. What no one could answer with any certainty was whether a kidney donation chain counted as valuable consideration, since the organs were exchanged outside of strict donor-recipient pairs. It wasn’t until 2007 that Congress officially amended NOTA to allow for donation chains. The longest of these chains at a single site started in 2013 and currently spans over 100 people at the University of Alabama at Birmingham.

Even the Nobel Prize committee agreed with the importance of donation chains, awarding Roth and Lloyd Shapley the 2012 Nobel Prize in Economic Sciences “for the theory of stable allocations and the practice of market design.” But Roth’s idea hasn’t made much of a dent in the transplant waitlist.

“We do more than 1,000 kidney exchange transplants a year in the United States now. That’s a good thing, but it’s not enough to end the shortage of kidneys,” Roth said.

Some in the transplant community saw the ongoing problem as one of economics, in which demand far outstripped supply. To people like McCormick, the solution was simple: pay people to donate their kidneys.

As someone who has browsed both eBay and Facebook Marketplace, I have seen people put a price tag on pretty much everything. Everything from dusty yearbooks and Beanie Babies to antique vases and endangered turtles (despite prohibitive rules) can be bought and sold with the click of a button. The prices of such items are often governed by the elusive laws of supply and demand. A high-demand, low-supply item, such as an original Picasso, commands staggering prices. The inverse — a low-demand and high-supply item— causes the value to plummet (as evidenced by the job offers received by myself and other freelance writers).

McCormick learned these rules in Econ 101 and taught them to subsequent generations as a guest lecturer. The law of supply and demand, however, comes with a caveat: it only applies to an open market. Since the government forbids the sale of kidneys for transplant, it’s not an open market. As an economist for the Bank of America, he didn’t think much about how supply and demand applied to kidneys. McCormick didn’t even think they should be bought and sold. But as he prepared his lecture notes on price ceilings for an introductory economics lecture at the University of California, Berkeley, he asked a friend for examples that might be more relevant to younger students than 1970s price controls on gasoline. His friend asked, “What about kidneys?” 

Banning the sale of an item, be it a can of kidney beans or an entire functional kidney, imposes a price ceiling of $0. Everything fell into place in McCormick’s head with a sudden thunk. Kidneys were scarce because there was no market to buy and sell them. Create a market and you could reduce that deficit. 

“There’s a market for kidneys, just like there’s a market for everything else,” McCormick said. “Supply and demand apply to kidneys as well as everything else. And if you fool around and hold the price down, you’re asking for trouble, and trouble is what we have in spades.”

According to the rules of economics, then, McCormick reasoned, the most efficient way to increase kidney transplants is by simply paying donors. But to others in the transplant community, the issue was moral and medical, not economic. The world needs more organ donors, yes, but they argue that the solution isn’t to put a price tag on kidneys.

Navigating Potential Pitfalls

From an engineering standpoint, the kidneys are a physiological marvel. Even the world’s most advanced dialysis machines only recapture a portion of the kidney’s biological activity. The complexity of the fist-sized organs — along with the life-threatening complications when they fail — never ceases to amaze Danovitch. As a UCLA nephrologist, he helped hundreds of patients receive new kidneys and watched hundreds more die while waiting for a transplant. But Danovitch draws the line at compensating donors.

“It’s payment. It’s money,” he told me. “And it’s a disaster.”

Danovitch cites a laundry list of reasons why paying organ donors is fraught with moral hazard. In addition to incentivizing aspiring donors to conceal important and potentially disqualifying information, compensating donations solely to strangers could effectively strangle the far more common process of donating to a loved one. Why go through a painful surgery if you could just wait for someone else to donate for the $50k tax break? Most of all, the promise of payment is likely to be coercive; a person in desperate straits might do something they wouldn’t otherwise, just because they need the money. Danovitch cites news reports from around the world about impoverished people who sold a kidney to feed their families, keep a roof over their heads or pay for school. These potential downsides, paired with the urgent need for more donors, mean that physicians are constantly debating whether to compensate living donors.

“We’re always asking, ‘should we or shouldn’t we, should we or shouldn’t we,’ and the last thing we want is to say no because, after all, they’re going to be able to go to college now, or they’re going to make $50,000,” he said.

Our culture celebrates organ donors as heroes, Danovitch said, recalling a flight attendant’s look of joy when she told Danovitch of her own experience donating a kidney to a friend. When fellow passengers overheard what the flight attendant had done, they treated her to a round of applause.

“It’s like a halo effect,” Danovitch told me. Selling kidneys would change that.

All of which might be true. But many of us might prefer the $50k. Haloes, after all, don’t put gas in the car or food on the table. The fact that Danovitch got paid to perform transplant surgeries doesn’t make his efforts any less lifesaving, nor does it mean you can’t get the warm fuzzies inside from doing a worthwhile job, Matas, the transplant surgeon, noted.

Matas also argues that seemingly altruistic decisions such as donating a kidney to a friend or family member nonetheless have value to the donor. They might be able to enjoy more years with a spouse, child or friend. Just because the benefit isn’t monetary doesn’t mean it doesn’t exist, he said.

Nor is it any of our concern how a potential paid donor might choose to spend their funds, Rhodes said. Maybe they want money for college or to pay for a cancer drug, or maybe to start a business or travel the world. 

“People’s motivations are their own business,” Rhodes said. “I shouldn’t be the one to judge their acceptability.”

For Andreas Brøgger Albertsen, a philosopher and political scientist at Aarhus University in Denmark, the moral dilemma is more subtle. Why, he asked me, have we created a culture in which people feel that selling a kidney is the best economic option? This doesn’t mean that the U.S. shouldn’t modify NOTA, nor that it’s a bad idea. However, he said, there’s a danger in turning “donate a kidney” into a “get out of poverty” scheme.

“This proposal will interact with existing inequalities. Even though those inequalities might not preclude people from making an informed choice about whether they want to be organ donors, it could reflect sadly on the society, that this is what we do for people who don’t have means,” Albertsen said.

It’s hard to overcome the initial gut reaction that paying for a kidney somehow sullies the moral waters and taints an otherwise “pure” gift, Rhodes told me. The attitude lingers in the 2007 NOTA modification that officially okayed donation chains but not reimbursement for would-be donors. To Perlman and other activists, this attitude is a moral relic that claims as many as 4,500 American lives on the transplant waiting list each year.

The Price Of Altruism

That someone would volunteer for an invasive procedure they didn’t need, to part ways with a perfectly healthy organ, to donate to a stranger, wasn’t always seen as altruistic. Just a few decades ago, many thought it unhinged, Rhodes pointed out. Several years ago, Rhodes chaired a meeting of the Mount Sinai Hospital ethics board about non-directed kidney donation, she recalled. At the time, the hospital didn’t allow it because of concerns about the psychiatric health of potential donors. Nearly everyone agreed that the hospital shouldn’t allow these surgeries to proceed. Out of the corner, however, a committee member spoke up.

“There is that forest in Israel,” the physician began.

Mount Sinai’s long Jewish tradition meant that everyone in the room knew what he was referring to: the trees surrounding the Yad Vashem Holocaust museum that were planted in honor of those who risked their lives to help Jews during World War II. 

“We honor them and think they are heroes. They were also seen as crazy people, and it was certainly more life-threatening than being a kidney donor,” Rhodes told me. 

The comment hit home. When it came time to vote on Mount Sinai’s non-directed donation program, everyone in the room raised their hand, Rhodes recalled.

Once Perlman’s son, Abie, realized that he was walking around with an item that he didn’t technically need that could save another person’s life, he couldn’t be dissuaded from donating a kidney. Perlman was somewhat less-than-enthusiastic about her son’s choice.

But Abie’s well-researched response to his mom was worthy of a debate team. Humans are perfectly healthy with a single kidney, and the donation surgery is safer than everyday procedures like appendectomies and knee replacements. Long-term outcome studies show that kidney donors are just as healthy as their non-donating counterparts. What’s more, 90,092 Americans are currently waiting for a kidney and 17 people die every day waiting for a transplant. His logic came down to this: donating a kidney will save a life and cause me no harm. “Why wouldn’t I donate a kidney?”

Perlman’s rebuttal — because it’s completely bonkers, that’s why — did little to sway Abie from his quest. At 18, the minimum age for organ donation, Abie Rohrig began the lengthy, rigorous process of medical testing.

But as Perlman continued researching the idea, she gradually became intrigued, then convinced. By the time Rohrig had cleared the medical hurdles, the surgery itself seemed a breeze. When Rohrig arrived home from the hospital a few days after the donation, Perlman had made up her mind. She, too, would donate her kidney to a stranger.

“We’ve got nearly 5,000 people a year dying on the waitlist. To me, that’s not ethical when it’s preventable,” Perlman said.

After Perlman joined the One Kidney Club (her nickname for living kidney donors that she bestowed upon an online support group), she began to meet others who had donated a kidney to strangers. All shared the same experience as she and her son: a relatively minor inconvenience for them that saved the life of another. 

Perlman began to devote her efforts to enabling more people to donate to strangers. The barriers, she discovered, were surprisingly banal. Giving someone the ability to take time off work and pay for issues associated with the transplant surgery and its aftermath would clear problematic hurdles for many people, but what potential donors needed was cash.

Economists like McCormick had been contemplating this issue as well. While many researchers may have shied away from connecting a dollar figure with a functional kidney, McCormick has not. Part of McCormick’s challenge was a lack of precedent. Iran pays living kidney donors a small fixed sum of 10 million rials (about $240) as a reward, according to a 2022 study, although would-be donors can also negotiate an additional, supplementary payment from recipients. Saudi Arabia also compensates kidney donors, providing 50,000 rials (just over $13,000) to donors, while Israel provides reimbursement for expenses and lost wages that vary by patient and are based on income. Cultural and economic differences between these countries, as well as the different methods used to compensate donors, limit comparisons. 

A multitude of studies have shown that kidney transplants in the U.S. save both money and lives. Current estimates place that per person dollar amount at $1.3 million in value for the recipient’s improved quality of life and lifespan, plus the $1.45 million in savings on medical care for the no longer necessary thrice-weekly dialysis appointments. A 2022 paper placed the market value for a healthy kidney from a living donor between $10,000 and $25,000.

In a series of studies, McCormick and colleagues closed in on a figure between $50,000 to $100,000, which would remove the financial disincentives of kidney donation (as measured in lost wages and other variables), account for the value of the kidney itself, and also be large enough to spur an adequate number of donors. A system of tax breaks spread over five years would provide additional value to donors while also helping to prevent unscrupulous individuals from taking advantage of the poor and desperate. Rather than simply cutting a check, the activists working to modify NOTA proposed tax breaks at $10,000 per year for five years. If someone didn’t pay $10,000 in federal taxes, they would receive the remainder of the funds as cash. The program would start as a 10-year pilot project, and Perlman said that, if successful, it could be made permanent.

The idea has had bipartisan support, but it has also remained in legislative limbo for the past six months, waiting to be shepherded through the process that introduces a bill and transforms it into a law. With a new Congress taking office, the process will need to begin again. While no one has yet proposed reintroducing it, supporters remain hopeful.

“This is a proposal that just says donors are really generous,” Roth said, “maybe we can be generous to them in return.”

Corrections: On Feb. 14, 2025, this story was corrected to reflect the fact that Iran is not the only country that allows payment for living donors — Saudi Arabia and Israel do as well. The story was also corrected to note that Dr. Gabriel Danovitch is a nephrologist, not a transplant surgeon.