Kidneys from living donors are particularly valuable because their operational longevity is greater than those from a cadaver. These fist-sized, bean-shaped organs remove waste from the blood and excess water. They balance chemicals, produce hormones that control blood pressure, and stimulate the bone marrow to produce red blood cells. They hold the key to Klotho, the protein that makes us younger. They are such a physiological marvel that even the most sophisticated dialysis machines made by humans can only recover a portion of their biological activity.
Oh... and some say they are worth a fortune.
Despite more than 112,000 kidney transplants being performed worldwide last year, the demand is so high that it has resurrected an idea that once seemed only an academic theory of ultra-liberal economists: putting a price on them and placing them in the market as if they were a retro item on Wallapop. Something that, for the first time, a lobbying group in a major Western democracy aims to achieve.
This spring, advocates for creating a kidney market will introduce a bill in the US Congress that includes tax exemptions to compensate living donors: the person who donates one of their organs would receive $50,000. This significant amount of money aims to stimulate donation by compensating for lost wages due to time spent on tests and hospital stays, as well as a "thank you" for their contribution to the community's well-being.
A future approval known as the End Kidney Deaths Act would violate international transplant agreements that explicitly state that neither the human body nor its parts can be objects of profit. "Of course, it is concerning that such an initiative could be successful," says Beatriz Domínguez-Gil, nephrologist and general director of the National Transplant Organization. "Europe is protected in that sense, but if a country like the United States, with such extraordinary influence, were to pass this law, it could have a huge impact on other countries."
The bill aims to gain traction in Washington at a time when the US healthcare system is being shaken daily with new shocks. In just a few months, Donald Trump has questioned its entire operation. He has appointed a declared anti-vaccine advocate to lead it, cut funding for major health organizations alongside Elon Musk, and weakened global public health by withdrawing from the WHO. In these circumstances, anything could happen with kidneys.
The impact of a measure like this in the US could further encourage advocates of organ markets. The most prominent is Javier Milei, president of Argentina, who openly acknowledged it during his election campaign. "It's just another market," he said. "That's an individual decision. Why can't I decide about my body?"
Currently, Argentina has not changed its transplant strategy, based on solidarity and very similar to the Spanish model. "There are some prominent figures who periodically raise this scenario," acknowledges Domínguez-Gil. "It can be disguised however one wants: some talk about tax exemptions, others about paying for students' university education or ensuring a pension. But it all boils down to the same thing: an economic incentive."
The face of kidney rewards in the US is Elaine Perlman, an activist who already has the support of various Republican and Democratic lawmakers. "The response to our project has been overwhelmingly positive," says Perlman, not hiding her optimism. "Our initiative is unique: it saves lives and reduces public spending. Over the next decade, we can prevent 100,000 unnecessary deaths in the country and save taxpayers up to $37 billion."
Perlman is the mother of a young man who, in 2017, informed her that upon reaching adulthood, he would not ask for a car or an empty house to throw a party with friends, but fulfill a wish: to donate one of his kidneys to a stranger. She was impressed and also very concerned. So she began to study the consequences and medical risks of donating a kidney. Her son eventually underwent the procedure. Elaine followed in his footsteps months later.
This is how Perlman's campaign began across the country to promote living kidney donations through talks and discussions. It is important to note that the vast majority of these acts of generosity are done to help family members or friends, and only 3% are directed towards strangers.
Nearly a decade later, Perlman leads "a solution" that promises savings for taxpayers and insurers, key players in the US healthcare system. "Dialysis is not only physically exhausting for patients, but also a financial burden on the healthcare system," she argues. "By increasing the number of transplants, this law will reduce long-term medical expenses while drastically improving quality of life."
"It can be disguised however one wants: some talk about tax exemptions, others about paying for students' university education or ensuring a pension: it's providing an economic incentive"
If successful, this woman would lead the world's most powerful country to join a peculiar and very limited club of nations that allow payments to living organ donors, a list that curiously is led by its great atavistic enemy: Iran. It also includes, with nuances, Saudi Arabia and Israel.
In the US, many doctors have opposed Perlman's proposals and believe that the system's problems would not be solved by paying. Currently, the US is the second country with the highest rate of donations per million inhabitants, second only to Spain, although its transplant organization is under intense scrutiny. So much so that even the New York Times, in an investigation published last month, described it as "chaotic." For example, it cast doubt on the functioning of transplant waiting lists, which it considers tainted by "convenience and favoritism."
"The problem is that there are countries where healthcare is structured differently from the European model, and there is not equitable access to the healthcare system and high-cost therapies, which increases the risk of these initiatives being implemented," points out Beatriz Domínguez-Gil.
The proposal to pay for kidneys is as bold as it is morally controversial.
Perlman values it at $50,000. Why $50,000 and not $5,000 or $500,000? The figure, according to her, balances the money saved from a transplant instead of ongoing dialysis treatment. Additionally, it is an amount attractive enough to incentivize potential donors to take the step.
One of the staunchest advocates in the US for ending the ban on organ sales is Frank McCormick, former director of economic studies at Bank of America, who stated in an interview that the approval of this proposal would be a success and drastically reduce the waiting list. "This shortage is killing people," he said. "Over 400,000 people suffer unnecessary dialysis and die prematurely every year."
No one doubts the economic profitability of a transplant compared to dialysis, the therapy that replaces the loss of kidney function by cleaning toxins and removing excess water from the blood. What is being questioned here is the formula to increase the number of organ exchanges. In Spain, receiving a healthy kidney is much cheaper than dialysis starting from the first year. Five years of treatment for a single transplanted patient saves the public coffers 180,000 euros compared to hemodialysis and 90,000 euros compared to peritoneal dialysis.
But who would be the organ providers in the presumed idyllic market proposed by Perlman and McCormick? Beatriz Domínguez-Gil is clear: the most vulnerable. "People who would have to sell their bodies to meet their needs," she says. "Something that, apart from being unfair, would generate a stigma in donation, as it would no longer be seen as a responsibility of society as a whole."
When presented with this argument, Elaine Perlman counters: "Americans with low incomes are three times more likely to need a kidney transplant, but only half as likely to receive one compared to higher-income individuals. So the best way to help people with fewer resources is to increase the overall kidney supply."
When poverty is discussed, Dr. Benjamín Herreros Ruiz, an expert in bioethics, suggests that payment poses a significant threat: donation ceases to be a voluntary act. "The fact that someone did it out of economic necessity could result in tainted informed consent," he points out. "Not only that, but one must also consider the hypothetical effects that selling would have on our social organization: altruistic donors could be pushed out by the market as they lose faith in the system, since they donate believing that their organ is a social good."
Benjamín Herreros, medical expert in bioethics "Charging could make donation no longer a voluntary act and informed consent would be tainted"
At the beginning of the century, a brilliant economist from Stanford University named Alvin Roth realized that the compatibility of a donor's kidney with a recipient was not only a medical issue but also an economic one. So, he designed a kidney exchange system using an algorithm aimed at regulating market design according to supply and demand. This way, the number of possible pairings could be determined, maximizing the number of transplants. By optimizing economies of scale, up to 300 potential organ donors could be connected.
It worked as follows: Imagine you want to donate your kidney to your wife, and I want to donate mine to my mother. Unfortunately, we are incompatible despite being family. Roth proposed a system where you would give your kidney to my mother, and mine would go to your wife, creating a chain of cross-compatibility.
But Roth wanted to go further with his great idea, which began to be implemented. He thought that it was not enough to implement chains of living donor transplants in the U.S., but due to high demand and compatibility difficulties, it would be most efficient to introduce incompatible donor pairs from poor countries into the American transplant program. How? In exchange for compensation. This way, the waiting list would be reduced, and the system would save a fortune on dialysis. More kidneys for Americans. Another brilliant idea. Well, it depends on how you look at it.
"For me, it's great economically, but ethically very reprehensible," says the president of the ONT, an organization that, along with its European counterparts, opposed Roth's project. The compensation, whatever it may be, is a harmful incentive that could lay the groundwork for an organ market where the wealthy would seek a kidney in Africa or the Indian subcontinent. The economist's proposal meant objectifying the human body and implying coercion for the most vulnerable to engage in organ trade. Ultimately, it was considered by many as a first step towards legalizing transplant tourism. It was not accepted.
It goes without saying that Alvin Roth has very little sympathy for the Spanish National Transplant Organization.
This scholar won the Nobel Prize in Economics in 2012 alongside Lloyd Shapley for the theory of stable allocations and market design practice.
Spain reaffirmed its global leadership in donation last year, once again surpassing its record with 6,464 organ transplants, over 4,000 of which were kidney transplants. Its donation rate more than doubles that of the European Union.
On Wallapop today, there are several "kidneys" for sale. The items that fit this definition are grilles from a car brand, some belts, and even a book written by a Michelin-starred chef and a nephrologist titled For my kidneys, I eat well today.