If it were legal, I would sell my kidney if I could get $4,000. Unfortunately, the government says we can't do this, and thousands of people die every year as a result.

Four thousand dollars is my price, I think. I’d need to talk things over with my husband, and make sure he can take care of our farm animals; manual labor is out of the question during recovery. I’d need to check with work, although I’m sure editing and writing can be done from a hospital bed. These are the preparations I’d make if I were legally able to sell my kidney.

But I can’t do any of this because the government says it’s wrong. You know what else is wrong? Having 43,000 people die annually due to the current kidney shortage in our country. I’d love to help, but I don’t currently have a huge incentive to do so. There are thousands of people, maybe more, like me who have no sob story or personal reason to help those in need of kidneys, but who would gladly participate in the vital service of giving up a kidney to a dying person if it entailed some sort of compensation.

If I were a more saintly person, I would take on this burden with no incentive whatsoever. But clearly that’s not working en masse because we have a massive kidney supply problem. Maybe it’s time to introduce what is perhaps the best incentive ever created (aside from eternal salvation): money.

Call me a bad libertarian, but I do think this practice would benefit from some amount of regulation. Plenty of other people try to garner support for outlandish or seemingly outlandish proposals by sounding a cliché call to “tax and regulate!” In many areas, I disagree with this approach—Kamala Harris, for example, and her bureaucratic busybody would-be appointees, don’t need to regulate the marijuana that I can already get pretty safely on the black market. When it comes to selling body parts, I think there’s a stronger case to be made for some amount of oversight.

Kidney-Selling Already Happens. We Can Make It Safer

We already have a massive black market for kidneys. It’s hard to get a sense of how big the problem is (the perennial problem of black markets, right?), but it’s safe to say that one exists. In Pakistan, the World Health Organization (WHO) and Sindhi Institute of Urology estimate that nearly two-thirds of all kidney transplants were done to foreigners in 2005.

Chinese data is difficult to come by, but WHO estimates that in 2004, about half of the nearly 1,000 kidney and liver transplants performed at a single medical facility went to foreigners. It’s hard to say how much organ buying and selling takes place within the United States versus how many people in need seek organs abroad.

The Atlantic uses more robust estimates for how thriving the existing black market is (note that these things are notoriously hard to corroborate):

Moreover, in the current unregulated system, the world’s poor are being exploited en masse. As of 2010, one in every five kidneys transplanted each year originated in the black market. The vast majority of people currently selling their organs are poor and live in developing nations—many do so in order pay off their debts. When one of these people sells his or her kidney, the World Health Organization estimates, it will go for about $5,000. The brokers who buy them can then turn around and sell them for as much as $150,000. Though it may seem cold and dystopian to use a market to incentivize poor people to sell their body parts, the truth is that some of them are doing it anyway.

Interestingly, in Iran, a living donor compensation model was adopted in 1988 and, by the next year, the long transplant list had been eliminated—those who needed kidneys had received them. As of the mid-aughts, “More than 78% of all renal transplants have been from living-unrelated donors.” The same journal article notes that, “To prevent transplant tourism, foreigners are not allowed to undergo renal transplantation from Iranian living-unrelated donors.”

Reason’s Ron Bailey wrote, in 2001, that we already have markets for plenty of other body parts:

What about compensating living donors? It should be noted that in the United States we already have robust markets for blood, semen, human eggs, and surrogate wombs. Extending markets to include non-vital solid organs such as kidneys and pieces of liver, which can be obtained with reasonable safety from living donors, is not such a stretch. Keep in mind that of the more the 75,000 people on the waiting list for organs, 48,639 need kidneys and 17,413 need livers.

Kidney markets already exist. Why are we so afraid to acknowledge them and attempt to make them safer?

The Problem Isn’t Being Solved By Donation Alone

The kidney shortage problem is enormous, but hard to get a sense of. Researchers Frank McCormick, Philip J. Held, and Glenn M. Chertow estimate that 43,000 people die each year in the United States because of our shortage.

Their math goes like this: about 126,000 people are diagnosed with end-stage renal disease annually (not all of those people are candidates for kidney donation, but many are). Half of those people would benefit from a donated kidney (so in the ballpark of 60,000).

About 20,000 get a donated kidney, whether from a dead or living donor, which leaves approximately 43,000 people who would benefit from a new organ but are unable to get one. Generally speaking, kidneys coming from live donors are preferable to those coming from dead donors, since live donor kidneys often last five to 10 years longer than those being donated from cadavers.

The study’s authors are clear that the shortage is a dire problem, albeit an unsexy one: “To put this in perspective, this is the same death toll as from 85 fully loaded 747s crashing each year.” (For an easily-readable version of these numbers, Vox’s Dylan Matthews has more.)

There’s also a financial cost of our kidney shortage problem. Per the study’s authors:

Moreover, under the current system in which compensation of kidney donors is prohibited, each transplant saves taxpayers about $146,000, because the total lifetime cost for treating a transplant patient is far less than the lifetime cost for a patient receiving dialysis therapy, and the government accounts for most of the spending on both. Thus, the government could afford to compensate a kidney donor up to $146,000 and still save money for taxpayers.

It’s terrible visualizing that number of people withering away in hospital beds, waiting for a kidney transplant that may never come. They’re unable to work, contribute to their communities, spend time with their families, and generally improve the world around them.

It’s a terrible fate, but one that far too many people have to suffer, which is odd given that we’re all typically born with a superfluous kidney. If only we could figure this out!

Bodily Autonomy Arguments Ought to Apply to Kidneys

The pro-choice crowd is wrong when they screech about “my body, my choice,” oversimplifying their opponents’ arguments, thinking abortion is a debate of mere bodily autonomy (it’s not). But all those quibbles aside, if they do authentically believe their own rallying cries, presumably every pro-choice person would be in favor of consensual kidney-selling.

If it is, in fact, a person’s body (I believe there’s a much better argument to be made for a kidney being a part of a person’s body than a developing fetus with its own distinct DNA), then it follows that kidney-selling should be a person’s choice to make. Why wouldn’t that be a choice reserved for a woman and her doctor to make?

So there’s an important theoretical autonomy point to be made here. But, the naysayer might argue, isn’t autonomy undermined by desperation? Can consent truly take place if someone is debating between a set of imperfect options—selling an organ and profiting handsomely versus starving to death?

That would be more compelling if we didn’t already allow poor people to work in horribly dangerous industries for money. The Volokh Conspiracy’s Ilya Somin writes:

[M]any people oppose legalizing organ markets because they believe it would lead to exploitation of the poor. But most of them have no objection to letting poor people perform much more dangerous work, such as becoming lumberjacks or NFL players. If it is wrong to allow poor people to assume the risk of selling a kidney for money, surely it is even more wrong to allow them to take much greater risks in order to increase their income.

He continues:

If you believe that organ markets must be banned because they exploit the poor, you must also argue that the poor should be forbidden to take jobs as lumberjacks and football players. If you believe that such considerations justify banning participation in organ markets even by the non-poor, than we must also categorically forbid monetary compensation for football players. Indeed, the case for banning the payment of football players is actually much stronger than that for banning organ markets. Unlike the ban on organ markets, a ban on professional football would not lead to the deaths of thousands of innocent people.

These aren’t the only examples of risky jobs that poorer people do. Commercial fishing has a very high mortality rate and relatively low median wages. Roofers, garbage collectors (and recyclables collectors), construction workers, iron and steel workers, electricians, and truck drivers all have high mortality rates as well. Government does not intervene to protect these people from working in these industries, so clearly their interest is selective. Either desperation undermines autonomy and invalidates consent or it doesn’t, but we should be more consistent.

Donations Aren’t Instantly Corrupted By Adding Profit

This is a common fallacy that people on the left make. Money isn’t inherently bad, and otherwise-acceptable actions aren’t immediately corrupted when a profit motive is introduced.

We saw this a little bit with the Operation Varsity Blues pay-for-play scandal. People were disgusted by the fact that stars were buying college admissions for their kids in such an overt way. But as many a smart writer pointed out, we’ve been “buying” admissions for the children of the elite for many years. We just get especially outraged when it’s so blatant.

There’s not a huge difference between technically legal elite bribery and technically illegal elite bribery—the outcomes are the same, since a child who hasn’t truly earned entry to an elite institution gets to cut in line, taking a spot from a more deserving candidate—but we feel very differently about it.

Then, oddly enough, we look at social entrepreneurship companies (B Corps and the like) as valuable precisely because they marry profit with creating some form of social good, or at least reducing the negative impact a company has. We think of companies as extra worthy of our money when they do feel-good charitable work.

But why do we feel like we need to silo profit from doing good? Why can’t we create more systems where you can do both at once, or where you have more of a reason to help others? Do we just feel like altruism is corrupted when monetary incentives are involved? An icky and inexplicable feeling about money’s corrupting power is a bad reason to deny people the ability to receive life-saving kidneys.

Again, Reason’s Bailey has more here:

In the long run, the organ shortage may be solved with biotech miracles like transplantable animal organs genetically tailored to match individual human immune systems, or by repairing damaged organs using human stem cells. But in the short run, monetary incentives will matter. As one transplant physician pointed out to me years ago, everybody else in the transplant business—from doctors to hospitals to pharmaceutical companies—gets paid. And, of course, the recipient gets something far more valuable than money. Given all that, it seemed reasonable to him that the bereaved families of brain-dead donors should be paid something, too.

Bailey goes on to talk about compensating live donors as well.

Some Tamer Arguments and Ideas

If outright kidney-selling is too wild a proposition to entertain, consider this: hospitals, individuals, or insurance companies could, as Vox’s Dylan Matthews and the National Kidney Foundation suggest, focus on “compensating donors for our lost wages, child care, and travel expenses incurred due to donation.” That’s a roundabout way of paying someone, and it reduces the barriers that make donation an unattractive option.

I’m personally less in favor of it because I think strings-attached money is condescending and silly, making little real difference in the end. But if that spoonful of sugar helps the medicine go down, so be it.

Alternatively, an incremental program that allows kidney-selling could be rolled out, providing modest financial incentives, administered under the supervision of a few hospitals across the country. We could test the theory—that giving people a financial incentive makes them more keen to give organs to those in need—without opening up the organ-selling floodgates.

Perhaps the most palatable argument is that selling a kidney is really not too different than donating one. You’re still providing for someone in need, you’re still undergoing a medical procedure and sacrificing some of your own health and comfort in order to elongate another human being’s life. If we care about the pro-life cause, and the value of our fellow human beings, there’s a clear case to be made that we have a moral obligation to help the sick recover. Societally, we’re failing at that, but adding a financial incentive could make that just a bit better.

Why do we look at kidney-selling as so drastically different than blood donation or signing up for marrow registries? Unlike marrow and blood, kidneys don’t regenerate after donation (livers do, which puts them in an even more interesting category). But we still have surplus.

Many people fear that if people sell or donate their kidneys, their remaining one will fail to work and they’ll be out of luck. It’s worth noting that, while kidney disease kills many people each year, the risk of dying from it is significantly lower than the risk of dying from heart disease, cancer, stroke, diabetes, flu/pneumonia, or random accidents. And in a world with more robust kidney markets, selling one of your kidneys would take on less risk because, if you ended up needing one later down the line, you’d have a brilliant sales pitch as to why you should be given one.

There’d also be significantly less of a shortage (this is one of the very, very, very rare situations where we can look to Iran as an example).

Not All Organ Markets!

With the parts of our bodies where we have surplus, and other people rely on these parts in order to stay alive, I don’t see good arguments for restricting the consensual exchange of an organ for money. This isn’t to say organ markets should all be legal. Kidneys make the most sense right now given that we’re born with two of them yet typically only need one. The argument could also be credibly replicated for livers, for reasons stated above.

And it isn’t to say there’s no potential harm for abuse or exploitation. There certainly is, but the benefits to thousands of people surely outweigh the costs. We use much smaller crises, by death count, to justify drastic action in myriad other areas. Why isn’t the obvious solution to kidney shortages being explored? And why are we okay with kidneys killing so many people in our country annually, instead of feeling some sort of exigency?

We’re so deferential to the status quo, and the fear of the unknown is powerful. Politicians probably don’t want to be tarred as libertarian nuts. That’s unfortunate; this is an area where, if we adopted slightly more libertarian thinking, we could save thousands of lives, and make other people money while doing so.

Child-selling, vote-selling, heart-selling, and lung-selling all strike fear in the hearts of most sane people. For good reason (though the libertarian case could be made for all of those things, and we’ll perhaps have those discussions in our weekly meetings where we smoke peyote and read through Justin Amash’s delightful vote explanations while draft-dodging on our seasteading houses)! But kidney-selling should not be lumped in with the others at all because it’s markedly less risky and less ripe for exploitation than we assume.

Since we’re failing at pure altruism, maybe it’s time we turn to cold, hard cash as a better way to save lives.