Washington Post Opinion 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 Today 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.