About 100,000 Americans need a kidney transplant right now. The median wait is 3.6 years. Thirteen die every day before they get one. In 2023 alone, 3,803 kidney patients died on the waitlist -- and more than 8,500 kidneys that were offered to transplant centers were declined. Meanwhile, one country has no kidney waitlist at all: Iran, the only place on earth where you can legally sell a kidney for cash. The question of whether other countries should follow is one of the most uncomfortable debates in medicine.

1. Just Let People Sell (Economists, including Philip Held and Frank McCormick)

The math is simple: people are dying because we refuse to let supply meet demand.

Thirteen people die every day. Philip Held, a health economist at Stanford with over 200 peer-reviewed publications, has estimated the fair-market value of a kidney at $75,000. His cost-benefit analysis found that government compensation would reduce the poverty burden on donors because regulated payments with follow-up care are better than the nothing donors currently get.

Iran proves that a legal market works. The country's system, regulated through its Ministry of Health, pays donors $2,000 to $4,000, covers all transplant costs, and provides a year of medical follow-up. About 1,400 kidneys are sold annually. The result: Iran has eliminated its kidney transplant waitlist entirely. No other country on earth can say that.

The opposition to organ markets is an emotional reflex, not a rational argument. Frank McCormick, retired VP and Director of US Economic and Financial Research at Bank of America, who now publishes in Cato and Reason, has argued that "virtually every non-economist thinks it is crazy" to allow kidney sales -- but economists across the political spectrum recognize it as the fix.

2. This Is What Exploitation Looks Like (WHO, Declaration of Istanbul Signatories)

A legal market doesn't free the poor -- it puts a price tag on their desperation.

Organ donation is amoral. The Declaration of Istanbul, endorsed by over 180 professional organizations worldwide, calls organ commercialism exploitation of the vulnerable. The WHO has called on all countries to ban organ sales. Their reasoning isn't abstract. In Pakistan, surveys of actual kidney sellers found that 70% were slaves or bonded laborers, 90% were illiterate, 88% saw no economic improvement after selling, and 98% reported health decline. That's not a market -- it's a harvest.

Iran's "success story" hides who actually sells. Forty-three percent of Iranian kidney sellers say their motivation was purely financial. The system draws from the country's poorest. The people selling organs don't strictly "want" to -- they have to.

And the black market still thrives. The free system also hasn't contained the black market -- in spring 2025, Iranian authorities uncovered a transnational organ-trafficking ring in Tehran, with Iraqi and Iranian nationals exploiting donors across the Middle East. Globally, an estimated 10,000 black-market kidney transplants happen every year -- 5 to 10% of all transplants. Organ brokers now advertise on Telegram and the Dark Web. Legalizing creates a floor price that traffickers undercut.

3. There Are Alternatives (Transplant Surgeons, including ASTS and NKF)

Donors should never go broke for saving a life -- but they shouldn't profit from it either.

Pay for everything but the organ itself. The American Society of Transplant Surgeons supports removing every financial barrier to donation -- but draws the line at paying for the organ itself. Reimburse lost wages, cover travel and housing, guarantee long-term health insurance, provide tax credits -- do everything except write a check for the kidney. The National Kidney Foundation agrees.

The End Kidney Deaths Act, a bipartisan bill introduced in Congress in August 2024, has its own solution. Sponsored by both Republicans and Democrats, it proposes a $50,000 refundable tax credit paid out over five years to living kidney donors. It's unclear whether that's a payment for costs or the organ, but maybe it doesn't matter -- it's a middle-of-the-road accommodation for a very difficult issue.

The transplant community is also betting on alternatives that could make the whole debate moot. In November 2024, NYU Langone transplanted the first gene-edited pig kidney into a living human patient. UAB researchers demonstrated life-sustaining kidney function from pig organs in humans for the first time, and the FDA approved clinical trials in 2025.

Just organize better. Spain, meanwhile, hit 46.7 organ donors per million people in 2022 -- the highest rate in the world -- not by paying anyone but by putting a trained transplant coordinator in every hospital. England copied Spain's kidney's law for the most part, but skipped the infrastructure, and got no increase in donations.

Where This Lands

Iran's kidney market is the most effective transplant policy on earth by one measure -- no one dies waiting -- and a cautionary tale by almost every other. The economists are right that 13 deaths a day represents a catastrophic policy failure. The bioethicists are right that Pakistan's bonded laborers are what a kidney "market" actually looks like in a country with mass poverty. And the surgeons are probably right that the answer is somewhere in between -- remove every cost, add every safeguard, but don't let the organ become the product. Whether the End Kidney Deaths Act's $50,000 tax credit crosses that line depends on whether you think compensation for sacrifice is the same thing as a sale. Pig kidneys and better donation systems might eventually make the question irrelevant. But for the 100,000 Americans on the waitlist right now, eventually is not soon enough.

Sources