The Donor Compact

The problem

The kidney is the one organ a healthy person can give away and live, and the one whose absence the country pays to manage at enormous cost. More than 94,000 people are on the American waiting list for a kidney; about 28,000 kidney transplants were performed in 2025, from living and deceased donors together; and about 13 people a day die waiting. Most of those on the list are on dialysis, three sessions a week, four hours each, which keeps a person alive at a cost to Medicare on the order of $90,000 to $110,000 a year and at a quality of life that most patients describe as a kind of half-death. Medicare has covered kidney failure for every American since 1972, and the programme costs the country on the order of $50 billion a year, most of it dialysis.

A transplant costs about a year of dialysis and then, for a decade or more, almost nothing by comparison. Every transplant that replaces dialysis saves the public several hundred thousand dollars and gives a person their life back. The shortage of kidneys is therefore not only a tragedy; it is one of the most expensive shortages the government maintains. It maintains it by law. The National Organ Transplant Act of 1984 makes it a federal crime to give or receive "valuable consideration" for an organ, and the result is that the supply of kidneys from living donors depends entirely on the willingness of people to undergo surgery, lose weeks of work and bear a lifetime of risk for nothing. About 6,000 a year do. It is not enough, and it has not been enough for forty years.

One country tried the alternative. Iran established a regulated programme of compensated living donation in 1988: a fixed payment from the state, plus a payment from the recipient or a charity, plus health coverage, to an unrelated donor, through a nonprofit that matched donors and recipients and permitted no brokers. By 1999 Iran's kidney waiting list had been eliminated. The programme has real problems, which the objections below take seriously: the donors are mostly poor, some report regret, and the field research is mixed on their later welfare. What is not in dispute is the list. In the only country that pays donors, nobody waits.

This catalog's rule is that a subsidy should be visible and universal. The current arrangement is a subsidy to the shortage, paid in dialysis, invisible, and borne by the 94,000.

The proposal

The Donor Compact: the federal government pays every living kidney donor a fixed sum, on the order of $50,000, spread over five years, together with lifetime coverage of any care related to the donation, disability insurance against the rare complication, and a place at the top of the waiting list should the donor ever need a kidney. The payment comes from the government and never from the recipient. Allocation of the kidney stays with the national system, by medical need. Brokers, private markets and payments by recipients remain crimes. Donors must be citizens.

How it would work

1. The state pays, the recipient never does. The donor is compensated by the federal government, from the Medicare programme that would otherwise pay for the recipient's dialysis, at a fixed sum set in statute and the same for every donor. The recipient pays nothing and has no relationship with the donor unless both choose one. The kidney goes to whoever the national allocation system places next, exactly as a deceased donor's kidney does. A donor may still direct a kidney to a relative or friend, as now, and is compensated the same.

1. Fifty thousand, over five years. The sum is set to compensate a donor fairly for the surgery, the recovery, the lost work and the lifetime of small risk, and it is paid in instalments so that it is not a lump that a desperate person takes and regrets. It is indexed and reviewed every five years against the supply of donors; if the list does not shrink, the sum is too low.

1. Care for life. Every donor receives lifetime coverage of any condition related to the donation, disability insurance that pays if the donor cannot work because of it, and priority on the waiting list should their remaining kidney fail. Under № 004 the coverage is already universal; the Compact adds the insurance and the priority.

1. Screening, cooling-off, and the right to stop. A donor is screened medically and psychologically as now, with an independent advocate who does not work for the transplant centre, a waiting period of at least 90 days between consent and surgery, and the right to withdraw at any point without penalty and without repaying anything.

1. No market. Recipients may not pay donors. No one may broker, advertise for, or match donors for a fee. Payments from anyone but the government remain the crime they are today. The Compact does not legalise a market; it creates one buyer, which is the public, at one price, which is published.

1. Citizens. Donors under the Compact are citizens, on the registry of № 001. The rule exists for the reason the catalog draws the line everywhere money moves, and for a second reason particular to this case: a paid donation programme open to the world's poor would become the thing its opponents fear.

1. Deceased donation too. Alongside the Compact, the country moves to presumed consent for deceased donation, on the Spanish model, in which every adult is a donor unless they have registered otherwise. Spain has the highest deceased donation rate in the world. The two together are the supply.

The numbers

The list. 94,000 waiting; 13 deaths a day; about 28,000 transplants a year, of which about 6,000 from living donors.

The cost of waiting. Dialysis at about $100,000 a year for each of the roughly 90,000 on the list who are on it is on the order of $9 billion a year for the list alone, and far more across the whole dialysis population.

The arithmetic of a donor. A transplant that replaces five years of dialysis saves about $400,000 net of the transplant's own cost. A donor paid $50,000 plus perhaps $20,000 in insurance and care is a saving to the public of several hundred thousand dollars per donation, before counting the life.

What the list would take. If the Compact drew 15,000 additional living donors a year, the list would fall by more than half within five years and the deaths with it. Iran's experience suggests the number is reachable. The proposal does not promise it; it promises that the sum will rise until it is.

The honest objections

"This is buying organs from the poor." The strongest objection, and Iran's experience is its evidence: Iranian donors are overwhelmingly poor, and some regret it. The Compact's design differs at each point where Iran's has been criticised: the payer is the state, not the recipient, so no rich patient buys from a poor donor; the sum is fixed, paid over years, and accompanied by lifetime care and insurance; there is a cooling-off period, an independent advocate and a right to withdraw; brokers are criminals. The honest reply to the objection is that the current system also takes from the poor. The 94,000 on the list are disproportionately poor and Black, and the people who die each day are the ones who could not find a relative to give for free. A regulated payment from the public is more just than a shortage borne by the people with the fewest options.

"Paying donors will crowd out the altruistic ones." It may reduce the number who give for nothing, and it will be a net gain if it adds more than it displaces. Paid plasma donation, which the United States permits and most countries forbid, supplies most of the world's plasma; the countries that forbid payment import it from America. The evidence from blood, plasma and Iran is that payment expands supply, and item 2 sets the sum by watching the list.

"Repugnance is a legitimate basis for law." It is, and the Compact is written for people who find the idea distasteful and the alternative worse. Thirteen deaths a day, paid for at $100,000 a year each, is also repugnant, and it has the disadvantage of being the current policy.

"Iran's programme is not the success it is presented as." Its waiting list is gone and its donors' welfare is mixed; both are true. The Compact takes the first as the goal and the second as the design problem, and it says so in items 2 through 5. A programme that eliminated the list and left donors worse off would be a failure. The proposal's bet is that the state as sole payer, paying over time with care attached, can have the first without the second, and the review in item 2 is where the country checks.

"Presumed consent for the dead is a violation of conscience." It is a default with a register, as it is in Spain, Austria and most of Europe: anyone who objects records the objection and is honoured. The default changes what happens to the people who never thought about it, who are most people, and the evidence is that it roughly doubles the supply.

Sources

• Organ Procurement and Transplantation Network, waiting list and transplant data, 2025, optn.transplant.hrsa.gov; United Network for Organ Sharing, on waitlist deaths
• Centers for Medicare and Medicaid Services, Calendar Year 2025 End-Stage Renal Disease Prospective Payment System final rule; United States Renal Data System, Annual Data Report, Medicare spending on end-stage renal disease
• Ghods and Savaj, "Iranian Model of Paid and Regulated Living-Unrelated Kidney Donation," Clinical Journal of the American Society of Nephrology (2006); Kidney International Reports (2025), "20 Years Iranian Experience of Organ Donation"
• Moeindarbari and Feizi, "A field study of donor behaviour in the Iranian kidney market," European Economic Review (2024)
• National Organ Transplant Act of 1984, 42 U.S.C. § 274e
• Held, McCormick, Ojo and Roberts, "A Cost-Benefit Analysis of Government Compensation of Kidney Donors," American Journal of Transplantation (2016)
• Organización Nacional de Trasplantes (Spain), deceased donation rates
• Proposals № 004 (CitizenCare); № 021 (The Caregiver's Wage); № 043 (The Formulary)