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Paying at What Cost? - The Ethical Implications of Compensating Organ Donors

Updated: Jul 15

The United States' systems for organ donation fail countless patients who die without the life-saving transplants that they need to survive. Over one hundred thousand patients in the United States are actively waiting for a life-saving organ transplant (Donate Life America). Unfortunately, every day, seventeen people die waiting for the life-saving gift of an organ (Penn Medicine). Although this might seem like a relatively minor statistic, when you consider the daily impact on seventeen communities mourning the loss of a loved one, the devastation becomes evident. Many organizations are already educating and encouraging prospective donors to help. However, this outreach has not sufficiently increased the number of donors to save every patient in need. By reimagining the system for organ donation, the gap between the surplus of patients in need and the lack of donors could be closed, saving the lives of those dying under the current system. This paper will dive into the ethics of one option, legalizing monetary compensation for donors to encourage more people to donate, that professionals are currently considering to ease this crisis. Monetary compensation could increase the number of organ donors, but it is illegal in most countries, including the United States. Legalizing monetary compensation could save patients' lives, but it might also harmfully impact donors. The set amount of money would possess different values for various socioeconomic groups, which could lead to the unfair exploitation of lower-income individuals. Additionally, there are concerns that it is unethical for donors to be motivated by money instead of their pure altruistic interest in benefiting others. Does the immense benefit of saving thousands of lives outweigh the potential of these harmful consequences? 


Table of Contents

  • Abstract

  • Introduction

  • Historical Context

  • Organ Donation System 

  • Compensation 

  • Ethical Analysis

  • Conclusion


Introduction

The modern medical-industrial complex allowed for the tragic passing of Tonya Ingram at the early age of thirty-one, failing her and her loved ones. Tonya suffered from Lupus, an autoimmune disease that caused her immune system to attack her vital organs and destroy essential bodily processes (Mayo Clinic). She was added to the kidney transplant list in 2020, three years before her death, in an effort to save her life. However, the system for organ donation and procurement in the United States failed her, and she died waiting on the transplant list. Throughout her life, Tonya voiced her frustration with the organ donation and procurement structures in the United States that allow thousands of patients to die each year. In 2020, she spoke out alongside Senate Representative Katie Porter and various organizations to highlight the flaws of the organ donation structures in the United States and advocate for change. Tonya Ingram represents the thousands of patients who die each year from the failures of the system for organ procurement and donation. Her death, like countless others, could have been prevented by the changes she advocated for while she was living (LA Times). 


Image: Sewcream Studio
Image: Sewcream Studio

The organ demand is very high in the United States, with one hundred thousand patients actively waiting for a life-saving organ (Donate Life America). As I mentioned, the current system cannot save all of these patients by granting them the organs vital to their survival. Every day, seventeen people die waiting for the life-saving gift of an organ (Penn Medicine). Although this might seem like a minor statistic in comparison to the number of deaths each day from other conditions, when you consider the daily impact on seventeen communities mourning a loss that could have been prevented, the devastation of this number becomes evident. By reimagining the system for organ donation, the gap between the surplus of patients in need and the lack of donors could be closed, saving the lives of those dying under the current system. Many professional organizations are already working to educate communities and encourage prospective donors to help. However, this outreach has not sufficiently increased the number of donors to save every patient in need, making it clear to professionals that more action is required to attain life-saving results. 


There are various options that professionals are working diligently to bring to fruition, each with their own potential to end the shortage. However, each option comes with its own set of potential consequences, making it crucial that professionals carefully weigh the harms and benefits of each option before moving forward with it. Many of these prospective options come from the advancements in technology and medical research that professionals have been working to develop for years. One prominent technological development that continues to become more plausible as a wide-scale solution is xenotransplantation, which is the transplantation of animal organs and tissues into human recipients (U.S. Food and Drug Administration). Additionally, researchers are attempting to create replicas of human organs through emerging three-dimensional bioprinting technologies (National Library of Medicine). However, neither of these technologies is fully developed for wide-scale use yet, leaving potential changes in legislation and policy as the most promising avenue to yield results in the near future. One of these solutions, already suggested by some organizations, including the National Kidney Donation Organization, is incentivizing more living donors by providing compensation for their organ donation. 


Monetary compensation has immense promise for bridging the shortage gap, but it is illegal in most countries, including the United States. This precedent was set by the United States in the 1980s when the technology for transplantations was newly accessible. At this time, the World Health Organization adopted the United States' view and recommended that other countries do the same. Government officials worldwide are apprehensive about making the legislative change now to legalize compensation because of the potential harmful impacts that compensation could have on donors and the integrity of the entire process. Because of the immense influence that the United States had on the World Health Organization, it is plausible that any changes made in the United States modernly could impact the rest of the world, giving the United States a heightened responsibility when considering how to solve the organ crisis. Many experts worry that the addition of monetary rewards could lead down a slippery slope where the values of fairness and equity are no longer prioritized (National Library of Medicine). The incentives could exploit lower-income individuals to benefit wealthier individuals, who will also be given greater access to the life-saving organs they need. Additionally, there are concerns that it is unethical for donors to be motivated by money instead of their pure altruistic interest in benefiting others. This presents the core ethical dilemma I will explore in this paper through the overarching ethical question: Is it ethically permissible to compensate organ donors? 


In this paper, I will describe the historical background and modern structures that bring us to the crisis we face today. After this foundational understanding is built, I will begin to weigh the potential benefits and harms of implementing a compensation-based system in the United States by introducing other existing compensation-based systems. With these considerations in mind, the paper will transition into the ethical analysis section, which aims to provide a comprehensive analysis of the ethical considerations from all perspectives. Then finally, using these ethical considerations, I will conclude the paper by stating my ethical recommendation about how countries like the United States facing this organ shortage should proceed. 


Historical Context

Before diving directly into this ethical dilemma, it is crucial to understand the historical context of organ procurement and donation in the United States. First, we must acknowledge that the “organ shortage” is only possible because of the advanced technology that allows for organ transplants. Transplantation has been around for a long time, starting as early as the second century BC, with skin grafts. However, it was not until 1954 that the first successful organ transplant was performed. At this time, Dr. Joseph Murray transplanted a kidney from a healthy patient to an ill identical twin. This surgery was successful because the patients shared the same DNA, so the kidney was not rejected. It was not until the late 1970s and early 1980s that immunosuppressant drugs were developed to prevent rejection in patients who do not share identical genetic material. Once these drugs were developed, organ donation became a more common practice, and the government began to take an interest in it.


Image: Marc Dufresne
Image: Marc Dufresne

In the 1980s, Congress started considering national organ procurement and transplantation regulations. In 1982, about ten thousand dialysis patients were actively waiting for a kidney, but only five thousand received the life-saving procedure (The New York Times). Recognizing this demand, Dr. Barry Jacobs, who had recently lost his medical license over a mail fraud conviction in Virginia, attempted to establish a kidney broker agency (Virginia Law Review). He pointed out that if the government decided to make compensation legal, they would save fifteen thousand dollars or more on each kidney patient by paying as little as one thousand dollars for a living kidney donation. However, part of his plan was for most organ donors to be from developing countries, which made many leaders outraged. These individuals identified the clear harm of exploiting impoverished individuals for the benefit of comparatively wealthy Americans.


Following the backlash against Jacob’s compensation plan, Congress passed the National Organ Transplant Act in 1984, which prohibited people from purchasing organs with a potential fine of fifty thousand dollars and a maximum sentence of five years in jail (Federal Register). They also created the Organ Procurement and Transplantation Network, which aimed to provide national coordination to accelerate the procurement of deceased organs from deceased donors. In 1986, the United Network for Organ Sharing was given the initial contract to operate the Organ Procurement and Transplantation Network, and they remain in control of this organization today (Congress). 


Following the lead of the United States, the World Health Organization also recommended that countries ban compensation for organ donors, and most countries followed suit, leading to the massive worldwide shortage of organs that we face today. Since the United States has historically set a precedent for organ procurement and allocation systems in the rest of the world, it is plausible that any modern reforms to the United States’ system would have a global impact. Therefore, the United States might possess a greater responsibility to consider the impacts any changes made to the modern system might have on other countries and the world (Sigrid Try-Revere).  


By understanding this historical foundation that brings us to the crisis we face in the modern day, we can analyze the system more thoughtfully.


Organ Donation System

Image: Canva
Image: Canva

In addition to historical context, it is also necessary to understand the inner workings of current organ donation and transplantation systems to unpack the flaws and identify potential changes that could be made. Although this paper and analysis focus on living kidney donations, a foundational understanding of the donation system overall will be helpful. 


Organ donations can come from both living and deceased donors. Living donors can only donate their kidneys, part of their liver, and some other organs and tissues (Cleveland Clinic). Living donors must be eighteen years or older, maintain good physical and mental health, understand the risks of living donation, and make an informed decision to donate. After making this decision, they will undergo a physical and psychological evaluation to ensure they are a good candidate. Deceased donors can donate any viable organs or tissue. Anyone over the age of eighteen can register to be a donor upon their passing, and in some states, it is possible to register before turning eighteen (Health Resources and Services Administration). This state-determined age typically corresponds with the legal driving age because the registration process is often through the state motor vehicle commission office. However, in some states, including New Jersey, the age is younger, and individuals can designate their registration using a non-driver identification card (New Jersey Motor Vehicle Commission).  Deceased donors' organs are only viable if blood and oxygen have been continuously flowing, so patients must be ventilator-dependent at their time of death to be viable donors (Donate Life America). Although there are 170 million people registered as donors in the United States, only about 0.003% of people die in a way where their organs remain viable (Health Resources and Services Administration).


In addition to the differences between living and deceased donors, there can also be differences in the relationships between living donors. Living donations can either be directed, non-directed, or paired. In a directed donation, the donor chooses the person they are donating to, often a friend or family member. In a non-directed donation, the donor does not know who they are donating to. In a paired donation, the donor is not a compatible match to their intended recipient, so they are added to a chain of donations. In this chain, every donor gives their organ to one of the intended recipients, so every intended recipient receives a compatible organ, even if it is not from their friend or family member who wanted to help by donating (Health Resources and Services Administration). 

These distinctions in the type of organ donor and relationships between the donor and recipient show that there are many different kinds of organ donations. In this paper, I will primarily focus on living non-directed donations since this is the group that could feasibly be increased as a result of implementing a compensation-based system.


Compensation

Image: Alfexe
Image: Alfexe

As I explained above, organ donors are not compensated in most countries, including the United States. The reason for this is that the World Health Organization followed the United States' lead in the 1980s and set the precedent that the compensation of organ donors should be illegal. Most countries followed the directions of the World Health Organization, with the notable exception of Iran. The Iranian government recognized the increasing demand for treatments as the population of patients with end-stage kidney disease grew in the early 1980s. However, the demand was so overwhelming that the government struggled to provide enough resources for life-sustaining treatments like dialysis. Unfortunately, patients facing kidney failure in Iran had very limited chances of survival. If they had the financial means to do so, they could travel to another country and receive treatment, but otherwise, they would likely die under the failing healthcare system of Iran. In an attempt to ease this crisis, the government paid for some individuals to travel abroad to the United Kingdom and receive treatment. However, this service could not be provided to all patients, so many died without any support from the government. In a desperate effort to stop this crisis, the government attempted to fund transplantation teams in Iran. The government organized a system for living non-related donations in which the donors would receive compensation. The Dialysis and Transplants Patient Association was established in the late 1980s to regulate contact between donors and recipients and this organization still regulates kidney donations in Iran today (Centre for Public Impact). 


Looking solely at the numbers, Iran’s system has achieved immense success. Unlike other countries, where thousands of patients die every year due to the lack of donors, Iran has eradicated the waiting list for kidney recipients entirely. In fact, individuals are so driven to donate that there is now a waiting list of individuals waiting for the opportunity to donate (Centre for Public Impact). The implementation of a compensation-based system was undoubtedly successful in beating the crisis that Iran was facing. However, when looking at the country's realities under this compensation-based system, it is evident that this option does not come without the potential for harm. 


Although the Dialysis and Transplants Patient Association aims to maintain organization within the system, the lack of structured regulations harms both donors and recipients. When patients need a kidney, they are referred to the Dialysis and Transplants Patient Association, which acts as the broker in matching them with a donor. The government pays for both surgeries and provides healthcare coverage to the donor for a year and healthcare benefits for years, but the recipient is still responsible for paying the donor directly. Without a set price for donation, wealthier patients are given more access to organs than those of a lower socioeconomic status because they are able to pay any cost without being financially impacted. This disparity between socioeconomic groups is one of the primary reasons other countries are hesitant to implement this system even though the program successfully ended the crisis. 


Additionally, many individuals are so driven to receive this monetary reward in Iran that they will post flyers in public spaces describing their blood type and other genetic markers and offering to donate for a set price (The Guardian). This overwhelming desire to donate makes many professionals question whether these individuals are being coerced into donating out of a need for money. The compensation that donors receive is substantial enough, with an average amount equivalent to four thousand five hundred US dollars (STAT), to impact an impoverished individual's ability to support themselves financially. However, the average amount of compensation would likely be viewed as relatively small by a wealthy individual and would not provide the same motivation to them. Compensation disproportionately motivates individuals of lower socioeconomic status in comparison to individuals of higher socioeconomic status, which only furthers inequalities among classes.


Although organ donors are not paid in the United States, egg and sperm donors are compensated. These functional systems of compensation in the United States could act as a guide to implementing compensation for organ donors. Egg and sperm donors must undergo careful psychological screening to ensure that they have the mental capacity to choose to donate. Once they are deemed to have mental capacity, they are able to donate and receive compensation. Egg donors are typically compensated around twelve thousand dollars for each donation (Weill Cornell Medicine), and sperm donors are typically compensated between forty and one hundred dollars for each donation (Stanford). 


The broad difference in compensation between egg donors and sperm donors raises the question of whether they are being compensated for the service of donation or the goods themselves. The donation process for egg donors is significantly more invasive–egg retrieval requires a thirty-minute procedure while sperm donation only requires an ejaculation–so it makes sense that they would be compensated more if the compensation is based on the service. Additionally, eggs are much rarer than sperm–only ten to twenty eggs are retrieved from each procedure (The World Egg and Sperm Bank), while between 200 to 300 million sperm are produced in a single ejaculation (WebMD)–which could be one reason that they are more expensive if they were considered goods. However, considering the utility of the goods, the drastic difference in the amount of compensation does not make sense since eggs and sperm are equally valuable to creating life. Additionally, the process of determining how much egg and sperm donors supports that this donation is regarded as an exchange of goods. The amount of compensation is often based on factors like age, health, and how desirable a donor’s qualities are. These factors all impact the perceived value of the good, changing the amount of money a donor is given to provide that good. 


Surrogacy is another example of a compensated practice in the United States. Surrogates in the United States are paid between forty-five thousand dollars and seventy thousand dollars (CBS). The amount of compensation depends on various factors, including the surrogate's experience, location, and income. Surrogates are compensated for the service of acting as a gestational carrier for individuals who are either unable or unwilling to do so.


In conclusion, the inconsistencies of structures in the United States lead to the consideration of whether donors are compensated for the donation's service or the donation's end result, whether that is an organ, tissue, or child. themselves. Organ donation encompasses both elements because the donor serves by having surgery to harvest the organ but also gives the physical organ to the recipient.


 If organ donation was acknowledged as a service, the compensation should be equal for all individuals because all donors must endure the same surgery and potentially risky process to donate. However, if organ donation is seen as the transaction of a good, the amount of money given to each donor could vary because each organ could possess a different value. If the amount of money differs, it is possible that the system would be inequitable because patients of a higher socioeconomic status would have better access to the organs they need. This consideration illuminates the different types of compensation that could be implemented if it becomes legal, setting the foundation to unpack which system is most ethically permissible. 


These considerations of goods versus service would be important if compensation is deemed an ethically permissible option and made legal. They would help to guide the way that professionals structure the system of compensation to implement it in a way that promotes as much benefit as possible and minimizes harm. 


Ethical Analysis

The foundational knowledge that has been presented thus far allows us to ponder this situation further through an ethical lens. As mentioned, legalizing monetary compensation could save patients' lives, but it might also harmfully impact donors. If the amount of money were set, it would possess different values for various socioeconomic groups, which could lead to an unfair disparity between socioeconomic classes. Additionally, the introduction of a monetary reward could compromise the intentions of the donor. In this section, I will dig further into these considerations using ethical frameworks to come to a conclusion on my overarching ethical question: is it an ethical practice to compensate organ donors? Through the frameworks of virtue ethics and consequentialism, which each highlighted various aspects of the ethical dilemma, I have come to the conclusion that compensation is an ethical practice because of its immense potential to save the lives of thousands of patients like Tonya Ingram, who would otherwise die while waiting on the transplant list.


Virtue Ethics

Virtue ethics is one ethical framework that is central to this dilemma. Virtue ethics determines whether an action is ethically permissible by considering whether it promotes virtuous traits essential to human flourishing (Britannica). In this case, it is crucial to consider donors' various intentions and determine whether specific intentions are more ethically permissible than others. 


Under the current system, where donors are not compensated, there is no physical extrinsic reward that a donor receives for the act of donating. Therefore, under the current system, many donors hold purely altruistic intentions, meaning that they act purely in the best interest of patients in need, with no intention of gaining anything from the experience. However, even without a measurable extrinsic reward, there could still be motivations that benefit the donor. For example, a donor might choose to donate to feel good about themselves for helping to save the life of another or to receive attention from their peers for performing this good deed. It is important to acknowledge that the donor could intend to gain something from the experience, even when there isn’t a physical prize. From the perspective of virtue ethics, these extrinsic motivations would be regarded as less virtuous because they promote the benefit of the individual instead of selflessly helping those around them. Selfless acts are often regarded as more virtuous than actions that an individual personally benefits from because they show a unique care for others. 


If compensation is legalized, these extrinsic motivations will likely take over because more donors will be driven to donate by the extrinsic reward of money. Some donors could still maintain altruistic motivations, and the money would only be a bonus to them. However, donors could also be motivated by the incentive rather than their sole interest in helping others, which would be viewed as a less ethical intent through the lens of virtue ethics.  

Therefore, through the lens of virtue ethics, one could argue that it is ethically impermissible to legalize the compensation of organ donors in an effort to maintain the altruistic intentions of donors under the current system, which are the most virtuous. However, others might argue that the donors' intentions do not matter when the consequence of their actions is saving a life, leading to the next ethical framework of consequentialism. 


Consequentialism

Consequentialism judges whether an action is ethically permissible based on the consequences the action creates rather than the action itself. This framework can be used to identify positive and negative consequences, which can be compared through the framework of utilitarianism, which states that actions are right if they create the most benefit. 

Through a consequentialist lens, compensation is ethically permissible because it creates the positive consequence of saving patients by increasing the number of donors. In Iran, compensation has proved to eliminate the shortage of organ donors and instead create a surplus of people willing to donate. Compensation would save the lives of the thousands of patients who die on the transplant list. 


However, compensation could also be considered unethical from a consequentialist perspective because of the potential harm to lower-income individuals who could be coerced into donating because of the incentive. The standard amount of compensation would possess different values for various socioeconomic groups. For higher socioeconomic individuals, the amount of money might be very small and, therefore, not incentivize them to donate. However, the amount could significantly impact another person of lower socioeconomic status’s ability to support themselves financially. This disparity could lead to the unintended consequence of exploiting people of lower socioeconomic status for the benefit of sick patients. 


Additionally, there could be a slippery slope in incentivizing donors because of the potential harm to their own safety. Organ donors undergo major surgeries in order to harvest their organs, posing a risk to their own safety. This leads to the question of whether it is ethically permissible for individuals to be put in potentially dangerous situations to help others. Organ donors undergo thorough psychological evaluations before they donate, in part to ensure that they have the capacity to make an autonomous decision to donate and put themselves in a potentially dangerous position for the benefit of another. These evaluations ensure that autonomy is maintained for the donors, and they are choosing to make this sacrifice with a clear understanding of the potential for harm. Because these evaluations ensure informed consent, the potential consequences are not as important. 


Finally, there could be a slippery slope in moving away from the inherent altruistic nature of the system and toward extrinsic rewards that would promote self-centered motivations. Non-directed organ donations are considered virtuous because they prioritize another person's needs over the donor themselves and provide very little potential gain for the donor. In a society where we tend to think about ourselves over the people around us, the act of donating an organ to a stranger for no payment in return is incredibly selfless and admirable. By offering monetary compensation to motivate more donors to help, the selfless motivations inherent in the current system would no longer be consistent and could not serve as a model of virtuous behavior. However, when the consequence of the donation, regardless of the donor's intentions, is as positive as saving the recipient's life, this potential shift in the system seems rather insignificant. 


In conclusion, by looking at the consequences of compensating and not compensating organ donors, we can attempt to minimize the harm imposed on society as a whole and maximize the benefit to society. Looking at these consequences through the framework of utilitarianism, which states that actions are right if they benefit the majority, I believe that the most benefit would be created by legalizing compensation and saving the lives of thousands of patients, like Tonya Ingram, who would otherwise die while waiting on the transplant list. The potential harms of less altruistic intentions and inequalities among socioeconomic groups are outweighed by the lives that would be saved.


Conclusion

Based on the ethical analysis above, I believe it is most ethically permissible to legalize compensation because saving thousands of lives each year outweighs the negative consequences of a shift towards less altruistic motives for living non-related donors and potential inequalities among socioeconomic groups. 


This leads to the consideration of the most ethical compensation system for the United States to embrace. As I mentioned above, the system could recognize organ donation as a service and set a standard amount of compensation for this service. If this were the case, each donor would receive the same amount, given that they all provide the same service.

However, if the donation is regarded as the transaction of a good, the value of each organ could differ. Various factors make an organ more or less desirable and warrant a difference in the price of organs. For example, organs from a donor with a rarer blood type might be viewed as more valuable than organs from a donor of a more common blood type. If the system acknowledges a difference in the value of each organ, like the system in Iran does, many inequalities could arise. Higher-income patients in need would likely be given more access to a life-saving organ because they could afford all of the organs on the market. Unfortunately, the payment to the donor could serve as a barrier for patients of lower socioeconomic status and limit them to fewer options of viable organs. Since a compensation system based on the value of the good itself could lead to further inequalities among social classes, it is best to view the donation as a service and keep the patient price consistent to promote equal access to treatment.


However, making the compensation a standard amount opens a whole other discussion of how much this amount should be. Professionals identify the importance of finding the delicate balance between encouraging individuals to donate and coercing people of lower socioeconomic status who need money to donate, exploiting this need to benefit comparatively wealthy patients. By establishing this incentive thoughtfully, we can aim to limit harm to the stakeholders of people of lower socioeconomic status, therefore implementing the system in the most ethically permissible way. 


Ned Brooks, the founder of the National Kidney Donation Organization, has been working with his team to modify the National Organ Transplant Act and legalize compensation for organ donors. He has developed a thoughtful suggestion for compensation that aims to limit harm to donors and maximize the benefits for the recipients in need. He suggests that the standard should be one hundred thousand dollars over ten years in the form of tax deductibles. He believes that this amount finds the delicate balance between encouraging individuals to donate and not coercing people in challenging financial situations because the reward is given over a more extended period of time and not in the form of cash (National Kidney Donation Organization). Brooks's suggestion only serves as one possibility for the ethical implementation of a compensation-based system, but it shows the creative ways that we can aim to limit harm.


There are various other options for framing the monetary reward. The money could be paid directly to the donor in the form of cash upfront after the donation. However, there are concerns that an upfront payment would offer more potential for the exploitation of lower-income individuals. By either offering the money in a form other than straight-up cash, like the tax-deductible that Brooks mentioned, or breaking the amount up over a period of time so that each payment impacts an individual's ability to support themselves financially in a less substantial manner than if they were to receive the entire payment upfront. If legislation is passed that legalizes compensation in the United States, these considerations will all be essential to establishing an organized system that promotes fairness and equality among donors and recipients. 


In conclusion, the option of compensating recipients provides immense benefits for the stakeholders of patients like Tonya Ingram, who would otherwise die waiting on the transplant list. This benefit of saving thousands of lives outweighs the potential harm to lower-income individuals and the consequence of shifting away from the nature of altruism inherent in the current system. However, if compensation is legalized in the United States, the system for compensation must be set up carefully to avoid these harmful ramifications and, therefore, maximize the positive consequences created as a result of the compensation system. As this option becomes more feasible, the potential consequences must be considered in order to implement the system as ethically as possible. 


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Sheikh, Zilpah, et al. “Sperm: How Long Sperm Live, Sperm Count, and More.” WebMD, 22

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Walsh, Dylan. “Would You Sell Your Extra Kidney?” WIRED, 5 January 2023,

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