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Last year in the United States, more than 4,000 people died while on the waiting list for a new kidney. An additional 3,600 people left the list when they became too sick for a transplant.

The kidney shortage is a global problem. The world’s need for kidneys is growing alarmingly — largely because kidney failure is one consequence of diabetes and high blood pressure. Yet the supply has barely increased. In 2014, there were 17,106 kidney transplants in the United States, but more than twice that many people went on the waiting list.

In every country that does transplants — except one — patients have two legal ways to get a new kidney. One is to have a friend or relative who is a blood and tissue match donate a kidney. The other is to get on the waiting list for a deceased donor. In America, the average time on that list varies from 3 years to 10, depending on geography, blood type and other factors. Patients can’t even get on the list until they are about to start dialysis, and the average life span of someone who starts dialysis is only 5 to 10 years. Six years ago, the list had 77,000 names. Now it has more than 100,000. Other issues: Dialysis in America costs $80,000 per year. And the longer a patient spends on dialysis before getting a transplant, the greater the chances of complications and death with a new kidney.

“If you’re looking at a country that offers dialysis that has a well-supported, sophisticated health care system, in all those countries there’s a significant wait for a kidney,” said Philip O’Connell, the president of the Transplantation Society, a global organization affiliated with the World Health Organization. “That will always be the case, unfortunately.”

It is not the case, however, in Iran. There, people wait to donate a kidney. That’s because donors are paid.

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Iran’s system has many deficiencies — not least that the very idea clashes with ethical norms observed in many other countries — and the program varies greatly from region to region. But its chief advantage is this: People who need kidneys get them rapidly, rather than die on the waiting list.

In the vast majority of cases, donors know in advance what they will be paid and receive appropriate screening and good medical care before and during the operation. And by getting patients new kidneys instead of keeping them on dialysis, the society saves a lot of money and avoids much misery.

The Iranian model suffers from insufficient funding, lack of follow-up for donors and other problems. But as waiting lists for kidneys grow around the world, Iran offers an important lesson: With good design and regulation, a system that pays donors need not be exploitative or immoral. In Iran, the legal kidney market has prevented the development of the abusive black markets and kidney tourism seen in other countries. As the kidney crisis intensifies, governments should look closely at what Iran has achieved.

For many people, the specifics of how a kidney market works are beside the point — the very idea of paying people to donate organs ends the debate before it starts.

One reason the idea of organ-selling is repugnant is that the human body has a special dignity. But if there’s an ethical barrier to selling the pieces, it was crossed long ago. We sell blood products, sperm and eggs. We pay people to do weird things to their bodies in risky clinical trials.

Perhaps kidney donation is different because kidneys do not grow back (although one healthy kidney is sufficient), and donation requires surgery. It is very safe surgery, but there is always some risk for donors. Perhaps the biggest moral issue in economically unequal societies is that a paid donor is almost always in dire straits, willing to do desperate things for money.

Yet people, especially poor people, take risks for money all the time. “We should ask ourselves why some people find accepting money to donate a kidney and save a life repugnant, but accepting money for being a policeman or miner or soldier — all of which are statistically riskier than donating a kidney — is O.K.,” said Mohammad Akbarpour, a research fellow in the Becker-Friedman Institute of the University of Chicago. “Is there a fundamental difference?”

Many people outside Iran do accept the idea of organ selling. (Societal repugnance can change. See: gay marriage.) Julio Elias, an economics professor at the Universidad de CEMA in Argentina, led a study that found that when a group of American citizens were told about the potential benefits of a regulated market for kidneys, approval went from 52 percent to 71 percent.

The conditions matter. Commercializing kidneys calls up images of a filthy, makeshift clinic, a rich traveler with a wad of cash, a desperately poor donor tricked into selling an organ, and a broker who keeps 90 percent of the money. India, Pakistan, the Philippines, South Africa and Indonesia, among other countries, are known for this type of trafficking in organs, and wealthy Americans, Israelis and Europeans are known for buying them.

But in Iran, the legal market pre-empts these abuses. To prevent kidney tourism, recipients in Iran have to share the nationality of their donors, and Iran recently banned kidneys for all foreigners except refugees in Iran from Afghanistan. “The rate of people who die in surgery is much, much lower in Iran than in other developing countries — all the transplants are under supervision,” said Farshad Fatemi, an assistant professor of economics at Sharif University of Technology in Tehran, who studies the kidney market. “If this regulated market weren’t in place, we might have organ trafficking here. We might be more like India or China and have illegal clinics, a black market where nobody looks after patients and donors.”

Iran began paying kidney donors out of necessity. The revolution of 1979 led to confiscation of the country’s assets abroad, and its treasury was further drained by the eight-year Iran-Iraq war. There was little money for dialysis and no physical or legal infrastructure for getting kidneys from deceased donors. The government began paying to send Iranians who had a match abroad, usually to Britain, to get transplants.

This proved unsustainable, so Iran began allowing donors to be paid — first in a private system, and then, in the mid-1990s, in a state-regulated system in which the government paid donors the equivalent of about $3,500 in Iranian currency, labeling the sum a gift for their altruism. By 1999, the waiting list for a kidney was essentially eliminated.

With time, inflation eroded the comparative value of the government’s payment. The number of rials paid has not risen and now the payment is worth only about $350. So private payments from recipients are now sought, to encourage donors.

It works this way: People who want to donate a kidney go first to the regional office of the Dialysis and Transplant Patients Association, a charity run by patient volunteers. The patients association arranges for medical and psychological testing.

Patients who need kidneys also go the patients association. Unlike in America, they can request a transplant as soon as they know they will eventually need one —another reason few people die while waiting for a kidney.

Once a patient is registered, the association introduces him or her to a potential donor who is a blood-type match. For most patients there is no wait, since donors are waiting for patients. Once a match is made, it still takes time to do tissue and other testing and negotiate payment. Often, these further steps rule out the match and the process starts again — and again.

The government-set price for a kidney is now just over $5,000 in total, with all but $350 coming from the recipient. The recipient’s payment is held in escrow by the patients association until after the transplant. The patients association does not take a cut — in fact, if the patient is too poor to pay for the kidney, it is the association’s job to do so. Male donors are also exempted from military service. (In the days before health insurance applied to all Iranians, donors received it as an additional benefit.)



Related More From Fixes Read previous contributions to this series.

Transplants normally take place in a university-affiliated hospital, but there are reports that private hospitals also perform them. Medical costs are covered.

The system works, for the most part, because it is closely regulated and a charitable group serves as a middleman. But there are problems — most of them because of a lack of money.

Paid kidney donors, of course, tend to be very poor, but at least they know what they will receive in advance, and get legal protections and good care through the transplant (not afterward, however). What if a poor person needs a kidney? Some patients associations have sufficient charity, but in at least a few regions, there isn’t enough. Sigrid Fry-Revere, an American bio-ethicist who explored the kidney market in various regions in 2008 and 2009 (her book, “The Kidney Sellers,” is fascinating) said that in Kermanshah, the association ran out of money halfway through the year.

A poor patient does have the alternative of going to Shiraz, a city that has a different system. Rather than use paid donors, it gets kidneys from deceased donors, a practice legalized in 2000. The waiting list is short in part because so many patients in Iran use live donors.

Another issue is a lack of follow-up medical care for donors. This is in part a geography problem: Transplant centers are in major cities, and many rural donors don’t make the trip back for checkups.

But it is also because of a stigma that kidney donors sometimes suffer because people assume they are drug addicts desperate for money. (In fact, the patients association uses drug tests to screen out users). Nevertheless, many donors simply want to be done with the process after the transplant, and deliberately leave an incorrect phone number.

The lack of follow-up is a major failing. Poor people are sicker people, and it is wrong that Iran hasn’t done more to help donors, or even track how they are doing.

Fry-Revere said that patients associations in Isfahan and Mashhad try to overcome the stigma. Donors get more than money; they also get social support: job training, small business loans, dental care. “They are treated as equals to the recipient — people who are helping each other,” she said. “They do whatever it takes to make people feel like the heroes they are, and not like society is abandoning them.”

The other issue is that the system leaks. There have been news reports of private brokers in Tehran working for donors or recipients whom the patients association won’t accept for medical reasons. It’s unclear how widespread this is. Also, in at least one case a foreigner was able to buy a kidney. The hospital that did the operation lost its transplant privileges as a result.

The deficiencies in Iran’s kidney market need to be put in context. America’s system is also unfair to the poor. The only way to get off the waiting list is to have a friend or relative donate, and that’s expensive. A donor must shoulder the cost of traveling to the transplant site, although there is some travel assistance for low-income donors from the National Living Donor Assistance Center. Donors must also be able to take a month or more off work to recover from surgery, and no system of compensation exists for that.

Who has these kinds of friends and relatives? Not the poor, who as a class have much higher rates of kidney disease. And that disparity also creates a racial disparity. Largely because of diabetes and high blood pressure, African-Americans make up a third of all Americans with kidney failure. Yet an African-American patient who needs a kidney has half the chance a white patient has of getting a living-donor transplant.

“There are many markets that people don’t like, but we have to talk about costs and benefits,” said Fatemi. “We have to try to improve the system — make it as humane as possible. But what would be happening in Iran if we didn’t have this? How many people would die on the waiting list?”

Next week: I will look at how the debate about compensating kidney donors is shifting around the world, and what the United States might do.

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Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and the author, most recently, of “Join the Club: How Peer Pressure Can Transform the World” and the World War II spy story e-book “D for Deception.” She is a co-founder of the Solutions Journalism Network, which supports rigorous reporting about responses to social problems.