Save a Stranger and Get Paid: A New Bill Says Yes

Want $50,000? All you need is to donate your kidney. 

Around 35.5 million Americans are estimated to have chronic kidney disease (CKD), a condition where the kidneys slowly lose their ability to function. Another 815,000 suffer from kidney failure, the final stage of CKD, in which the kidneys can no longer function enough to sustain the body. Nearly 550,000 are on dialysis, a costly medical treatment that cleanses the body as functional kidneys do. Almost 90,000 are waiting for a kidney.

The only cure for CKD is a transplant. Kidneys are often sourced from deceased donors—who consent for their organs to be posthumously given to those in need. However, transplanted kidneys from deceased donors are not nearly as successful as kidneys from living donors. The National Kidney Donation Organization reports that kidneys from living donors are matched more accurately to their recipients, transplanted at more optimal times for both donor and recipient, and last around twice as long as kidneys from deceased donors. Thus, as the number of Americans waiting for a kidney increases—with nearly 50,000 joining the waitlist in 2023—the number of living donors must increase as well.

Kidney disease is a quiet, expensive killer. What better way to counteract it than with bold action? 

Earlier this year, New York’s own Rep. Malliotakis introduced the End Kidney Deaths Act (EKDA) to address the kidney crisis. The EKDA includes a 10-year pilot program that offers nondirected kidney donors a refundable tax credit of $10,000 per year over five years. By implementing this government-regulated system in which nondirected kidney donation is compensated with a significant tax credit, we can simultaneously subvert ethical fears around compensation while preventing more American deaths.

This legislation would be the first of its kind. Since the National Organ Transplant Act (NOTA) passed in 1984, the current organ sharing system has not been significantly modified to increase the number of living donors. Under NOTA, donations must undergo a six-step process: donor identification and screening, consent, matching the donor to a recipient based on biological compatibility, arranging the transplant, recovering organs, and transplantation. 

The specific issue with our current system is clear—it simply does not produce enough donors. In the context of living donation, there are many factors that could obstruct someone’s willingness to donate. For instance, only a few states require employers to offer organ-donor-leave to their employees. This means that employees who donate their kidneys often have to take unpaid leave: a privilege many do not have. By providing compensation, the EKDA seeks to reduce financial disincentives, and consequently, increase the number of living donors to save lives. 

Since NOTA, some scholars and healthcare professionals have been staunchly opposed to the idea of incentivizing living donation. Their claims mainly revolve around three ideas, that 1) offering money commercializes organ donation and produces ethical violations, 2) people of a lower socioeconomic status will be more incentivized to donate, and 3) people will be pushed to endanger their health for financial gain through donation. 

The commercialization of organs has been a hot topic for decades, with debates over whether placing a financial value on a body part reduces human dignity. The EKDA claims that the four principles of clinical ethics—beneficence (the concept of doing good and helping others achieve their best health), non-maleficence (doing no harm to patients), autonomy (a patient’s right to choose to donate), and justice—are upheld. Justice, arguably, could even be augmented by the EKDA. As of today, people of lower socioeconomic status and marginalized communities are disproportionately affected by the kidney crisis. Increasing the number of kidneys available would help alleviate the disparity. Thus, the EKDA counters the concern that the bill would undermine the moral integrity of organ donation and demonstrates that the bill follows an ethical code of professional conduct.

The aforementioned coercion of the poor is crucial to evaluating the benefits of the EKDA. To address this concern, it first must be clarified that the EKDA only incentivizes non-directed donation—the donation of a kidney to a stranger. This, in itself, removes the possibility of directly buying a kidney from someone, as the government-regulated organ matching system chooses the recipient based on compatibility and need. 

Many still question if more people of lower socioeconomic status will be pushed to donate their kidneys for the financial benefit. To this end, the EKDA offers a simple argument that criticizes our fixation on coercion at large:  People are compensated for dangerous, but necessary, occupations: firefighters, police officers, construction workers, soldiers, and oil riggers, to name a few. Moreover, we frame many of these jobs as heroic. 

Why should we not see kidney donation—which undeniably saves a life—in the same light? 

The EKDA states that anyone should have the opportunity to donate their kidneys and receive compensation, just as anyone should have the opportunity to join the police force and receive pay.

The last opposing standpoint and one of the most common fears about living donation—whether kidney donation endangers donors—is easily countered. In 2010, a study reported that the long-term risk of death for living donors was not significantly higher than that of the sample comparison group of non-donors. At the time, the perioperative (measured within 90 days post-surgery) mortality rate measured 3.1 per 10,000 surgeries. Over the past decade, though, living donation has become even safer through the widespread adoption of laparoscopic nephrectomy, a less-invasive alternative to open donor nephrectomy. With these new advancements in scientific technology, the mortality rate for live donors is now around 0.9 per 10,000 surgeries. This is lower than the maternal mortality rate for childbirth, which, as of 2023, is 1.86 per 10,000. 

Statistics, however, only matter because of the lives behind them. 

I first learned about the kidney crisis two years ago. My friend revealed that her pastor had passed away from CKD, describing the donation process as “a toss of the dice.” At around the same time, her uncle had been lucky enough to receive a transplant. His life was saved. 

Yet, on a fundamental level, her uncle was just that: lucky. Every day, 12 people are not so lucky, passing away while waiting for their transplant. All on the toss of a dice? 

It stands to reason that we must change our current organ sharing system. The kidney crisis reflects deeper flaws in how we structure care, allocate resources, and balance risk in reward. Every death from CKD is a consequence of a system constrained by outdated regulations. It’s true: the EKDA is not perfect, nor does it completely subvert ethical concerns. The debate over compensation, coercion, and commercialization is real and paramount, but must be weighed against the human cost of inaction as well. Although familiar preemptive policies such as targeted, educational outreach lead to higher rates of donation and should be implemented simultaneously, they can take years to enact change. That time is a privilege that kidney disease patients do not have.

Answering one fundamental question will make our choice clear: do we as a society have a moral obligation to save lives wherever possible? If our answer to this is ‘yes,’ then incentivizing kidney donation is not only permissible, but an obligatory step toward a more responsive healthcare system. 

Grace Zhou (CC’29) is a staff writer for CPR from New York City, studying Economics and Political Science. She can be reached at gz2370@columbia.edu.