In Praise of Iran's Kidney Trade
What a Pariah State Got Right About Saving Lives
Pair with: “Tina Rosenberg on the Kidney Market in Iran” (1 hr podcast with transcript)
As Iran and Israel volley missiles and narratives, it’s easy to forget our common humanity. Jewish or Muslim, we all share two lungs, one liver, and two kidneys. These gifts beneath the skin can be sliced out by skilled hands to rescue diabetics, blast victims, or the well-connected. Hundreds of thousands of souls worldwide wait on organ transplant lists,1 not for a lack of surgeons, but for government paperwork.
The most in-demand organ is one humans carry redundantly, in pairs. The kidneys filter blood of excess potassium, ibuprofen, and the like, unless chronic obesity or drug use shuts them down. At that point, patients in rich countries join the organ waitlist purgatory. For kidneys, that means four hours every other day tethered to an expensive dialysis machine that filters blood poorly, often at taxpayer expense.
After the 1979 revolution sent doctors fleeing and eight years of war with Iraq devastated the economy, Iran couldn’t afford more dialysis machines. The country also couldn’t keep sending kidney patients abroad for transplants. So in 1988, the Islamic Republic did what no other country dared. It legalized kidney sales. Though innuendo about this program abounds, the policy basically eliminated waiting lists.
Iran’s compensated kidney market has gone largely uncopied, though many countries have tried weaker approaches to increase supply. Powerful interests profit from scarcity, but the main obstacles to a regulated market remain old taboos and weak arguments that discount the lives that could be saved. As commercial bodily transactions like plasma donation become routine, the double standard is glaring.
Dare to Commodify Your Body
The 1984 National Organ Transplant Act (NOTA) banned direct payments to organ donors in the United States. States have tried workarounds like tax credits and travel reimbursement, but these policies barely move the needle.2 Never afraid to twist an arm, Israel and Singapore have found a better vein with a more coercive approach. They gave donors priority access to organs if they ever need transplants themselves.
Is organ sale prohibition actually the more coercive policy? The current system in every country except Iran allows everyone in the medical supply chain except the donor to profit from a lifesaving organ transplant. This prohibition assumes donors can’t rationally decide what's best for their own bodies and finances. Yet people are free to become coal miners or pro athletes, risking their health for a paycheck.
In this case, the health risks are overstated, since people who donate one kidney have similar health outcomes and lifespans to those with two.3 Meanwhile, the current system pressures reluctant family members into donation while excluding willing strangers. If the stranger needs a cash incentive, does this violate their “dignity”? Similar arguments were used to resist paying teachers, nurses, and opera singers.4
Today, these “meaningful work” professions are well-paid, yet it remains a permanent feature of democratic discourse that teachers and nurses are “not paid enough.” We can therefore expect that paying arbitrarily more for kidneys will never satisfy the pearl-clutchers. Critics will cite post-donation surveys (in Iran) showing one-time payments don’t eliminate poverty. They expect what lottery winnings rarely deliver.
Bioethics as Lipstick on Blood Libels
Opponents of legal kidney sales fear that poor people will be “exploited.” Under the current prohibition regime, it’s true that only relatively well-off people can take time off work, resist health misinformation, and navigate donation logistics. But among Iranian paid kidney donors (who are mostly very poor), an overwhelming 91% reported satisfaction, and more than half actively recommended the practice to others.5
If the worry is that poor donors can’t properly assess long-term risks, we’ve already solved this in “human challenge studies,” where volunteers choose to be infected with diseases to test vaccines. Participants undergo cooling-off periods, meet independent advocates, and receive follow-up care before getting jabbed for fat stacks. How is saving statistical lives easier and more legal than saving neighbors with names?6
The moral panic makes perfect sense once you recognize its prejudicial nature. Fear of bodily violation by archetypal outsiders (like vampires or body-snatchers) fuels mobs’ resistance to medical innovation. The witch brewing children into potions becomes the Jim Crow surgeon harvesting organs from living African Americans.7 Like older antisemitic stories, these murders never happened but felt emotionally true.
Today, these fears are expressed as anxieties about “organ trafficking,” reducing organ donations globally, as documented in Europe. Sometimes the phrase refers to voluntary black-market organ sales. But its most sensational form imagines criminals kidnapping people to steal their organs. These forced-donation stories are false and unrealistic, because poorly done transplants would quickly fail and be easily detected.8
Fatwas for the Free Market
How did the Islamic Republic of Iran cut through the paranoia and in-group biases that block organ donations elsewhere? The answer lies in Shia Islam, which has something Sunni Islam doesn’t: a Pope. While Sunni countries stewed in fatwa wars and WhatsApp misinformation, Iran’s top cleric simply declared kidney sales kosher.9 As with the Mormon anti-racist “revelations,” the secular tail wagged the holy dog.
The global prohibition regime centers on the Declaration of Istanbul (2008, revised 2018), basically a secular rewrite of religious notions of bodily sanctity.10 But progressive jurisdictions already price bodily tissue and womb time. Egg and sperm donors are paid in the United States and Greece, while commercial surrogacy is thriving in California, Ukraine, and parts of Mexico. Kidneys aren’t more sacred.
Defenders of bans on markets for human tissues and organs claim to protect human dignity. Ironically, their prohibitions stop new lives from beginning and cut short the lives of people already living. What exactly is dignified about dying while waiting hopelessly for a transplant? This is the fate of roughly 30 Americans every day.11 As with many harmful policies, imaginary exploitation looms larger than routine death.
American and Israeli bombs may soon topple a government well practiced at resisting international pressure. That pressure, a contingent combination of war, sanctions, and religious decree, created a libertarian diamond in Iran’s kidney market. For however much suffering the Ayatollahs wrought on women and gays, they also gave the world a rare glimpse of life without waiting lists. Don’t bury a good idea with a bad regime.
According to the Global Observatory on Donation and Transplantation (GODT), an estimated 157,494 organ transplants were performed worldwide in 2022. In the U.S. alone, over 103,000 people are currently on the transplant waiting list, with only 48,149 transplants performed in 2024. U.S. data is used to show the vast gap between organ supply and demand, since global waiting list data is not comprehensively tracked.
Lacetera, Nicola, et al. “Removing Financial Barriers to Organ and Bone Marrow Donation: The Effect of Leave and Tax Legislation in the U.S.” Journal of Health Economics, vol. 33, 2014, pp. 43-56. The authors analyzed legislation from 31 states offering leave for state employees, 16 states providing tax deductions up to $10,000, and various other incentive schemes implemented between 1989-2009. Tracking donation rates across states over 20 years, comparing outcomes before and after policy implementation, they found “no statistically significant impact on the quantity of organs donated” while confirming positive effects for bone marrow donation, which are less invasive than organ donation.
Park et al.’s meta-analysis, “Long-Term End-Stage Renal Disease Risks After Living Kidney Donation,” notes “similar or much better survival” among kidney donors compared to the general population, as donors are healthy individuals carefully screened beforehand. See also “Kidney Donors Live Longer” in Transplantation, which found better 20-year survival rates (85%) among donors compared to matched Swedish non-donors (66%).
Reese, Alexander, and Ingo Pies. “The Morality of Kidney Sales: When Caring for the Seller's Dignity Has Moral Costs.” Bioethical Inquiry, vol. 20, no. 1, 2023, pp. 139-152. Reese and Pies argue that implementing market-based kidney procurement in the United States would prevent 5,000 to 10,000 deaths annually while reducing suffering for 100,000 more dialysis patients. The economic benefits are also large, as kidney markets would more than triple the yearly net welfare gain for society from $20 billion to $66 billion, since “dialysis is almost four times as expensive per quality-adjusted life year as a kidney transplant” (143).
Malakoutian, Tahereh, et al. “Socioeconomic Status of Iranian Living Unrelated Kidney Donors: A Multicenter Study.” Transplantation Proceedings, vol. 39, no. 4, 2007, pp. 824-825. Beyond government compensation, nearly two-thirds of donors received additional payments from recipients through direct negotiation. For the overwhelming majority, these payments provided meaningful economic relief, most commonly to settle personal debts. Despite widespread poverty, documented coercion remained virtually nonexistent.
For a snapshot of group-bound altruism, see Rod Richardson, “Blacks Often Suspicious About Organ Transplants: Many African-Americans Refuse to Donate, Fearing That Only Anglos Would Benefit. Some Recipients Try to Dispel the Myths and Lessen the Shortage.” Los Angeles Times, 28 Mar. 1993. The article quotes relatives who refused donation because “their organs would only be used to save the life of some rich, Anglo person,” and notes that in South Florida (1991) Latinos were 37% of recipients but 13% of donors, Blacks 30% of recipients yet 10% of donors, while Anglos were 33% of recipients and 77% of donors.
Although medical schools sourced cadavers from graveyards, contra ethnocentric folklore, “There are no recorded cases in the United States of an actual murder of an African American for medical dissection.” See Colin Dickey’s “Night Doctors” in The Paris Review. These beliefs persist in pockets of Africa, like Malawi, where in 2017 vigilante groups attacked doctors they believed were vampires using stethoscopes to suck blood.
Matesanz, Rafael. “Tráfico de órganos: hechos, ficciones y rumores.” Nefrología, vol. XIV, no. 6, 1994, pp. 633-645. Rafael Matesanz is founder and director of Spain’s National Transplant Organization (ONT), and pioneer of the world-renowned “Spanish Model” of transplant coordination. In his words: “Nunca, en ningún lugar…” (“Never, anywhere in the world, has a single concrete instance [of criminal organ trafficking] been proven. Not one.”)
Siraj, Md. Sanwar. “How a Compensated Kidney Donation Program Facilitates the Sale of Human Organs in a Regulated Market: The Implications of Islam on Organ Donation and Sale.” Philosophy, Ethics and Humanities in Medicine, vol. 17, no. 10, 2022, pp. 1-18. Siraj documents how “contentious fatwas banning organ donation are often posted on social media, while those advocating for the biomedical practice are not,” for example: “wrong-doers who alter the Creator’s design will be punished in the ākhirah [hereafter].”
The International Society of Nephrology still lists the Declaration of Istanbul (DoI) as its central ethical framework, bragging that “180 national and international professional organizations and local governments have publicly endorsed the principles of the DoI” have endorsed it and many have written its language into declaration. Although the American Society of Transplant Surgeons “vigorously endorsed each of the principles” of the DoI in 2009, it immediately carved out U.S. exceptions, arguing that rigid bans on incentives or mandatory donor insurance clash with federal law and practical reality.
While commonly cited statistics report 17 American deaths daily on organ waiting lists, this figure excludes patients removed for being “too sick to transplant” who subsequently die. The more comprehensive count of 30 daily deaths includes both waiting list deaths (5758 in 2021) and those removed for being too sick to undergo surgery (5371 in 2021). See National Academies of Sciences, Engineering, and Medicine. Realizing the Promise of Equity in the Organ Transplantation System. The National Academies Press, 2022.
I checked into this, and it's too bad donors are only compensated the equivalent of a few thousand dollars - if you're a foreigner looking to make easy money you'd barely come out ahead after travel costs.