“Two major, interconnected problems afflict organ transplantation today: the widening gap between the demand for organs and their supply and the illegal, exploitative organ trade. [..]
Organ trade profits from this gap by preying upon both patients waiting for and willing to buy an organ and potential donors living in poverty and willing to sell one.
In particular, the principle of financial neutrality has been questioned. This principle states that a donor or their related family should not lose, but also not gain, monetarily as a result of donation, implying that the organ does not become a commodity and money not the motivation for donation. In contrast, financial incentives have been proposed by some who believe this will increase organ donation. The most recent proposal, the End Kidney Deaths Act (HR 9275), would offer a refundable tax credit of $10 000 annually for 5 years to nondirected living kidney donors (ie, people who donate to a stranger). Donors who do not owe enough to use the tax credit would receive the balance as cash over 5 years. The passage of this act would fundamentally change the US National Organ Transplant Act (NOTA) by allowing some donors to sell a kidney.
Although the intention of the proponents of HR 9275 to increase legal donation may be laudable, we question the assumption that organ donation will increase if this act is passed, and warn against the potential harms for transplant medicine globally and the exploitation of vulnerable donors. Such a fundamental change in NOTA would legalize organs as commodities for the first time, put a price on donor organs, and open the door to the commercialization of donation. [..]
The proponents of the End Kidney Deaths Act suggest a 10-year trial of this practice because of the uncertainty regarding the relative benefits and harms. However, such a fundamental change in the ethical framework of the law will be difficult to reverse, and the unintended harms to altruism and transplantation as a noncommercial process built on solidarity and trust are likely to be irreversible: the Rubicon will have been crossed.
As global advocates for ethical donation and transplant, we are concerned and warn against the potential harmful effects that may follow the fundamental legal and ethical change in transplant medicine proposed in this bill. We strongly endorse the statements of the major US transplant societies and our colleagues.
The fact that such a bill has been proposed highlights the urgent need to develop effective measures to address organ shortage. This aligns with the goals of the DICG [Declaration of Istanbul Custodian Group] to combat organ trafficking in various ways, including support for activities targeting the gap between demand and supply.
First, the most obvious strategy to increase organ availability would be to reduce discard rates of donated organs by increasing acceptance of organs from older and comorbid donors, which are known to provide acceptable function and quality of life for selected recipients. Decisions about organ acceptability may be subjective, highlighted by Aubert and colleagues, who found that approximately 1700 kidneys discarded in the US in 2019 would have been used in France, likely without negatively impacting patient outcomes. Despite such findings, the discard rates in the US increased in 2022 to approximately 25% of kidneys recovered for transplant.
Second, the effective removal of financial disincentives to living donation (eg, reimbursement in costs and lost earnings) and ensuring long-term follow-up and insurance coverage related to the donation have still not been achieved, which may support more donations without raising ethical controversies.
Third, reducing the demand for organs could be achieved through prevention and early treatment of kidney disease in general, and improving long-term survival of transplanted organs. Approximately 11% of people on the waiting list need repeat transplants.
Fourth, the End Kidney Deaths Act stresses the urgency to increase organ donation as a means to reduce deaths on the waiting list. Although this is a laudable goal, these deaths could also be reduced by improvements in dialysis quality and care.
Therefore, addressing organ discard rates, disincentives, transplant survival, and dialysis quality are more effective, ethical, and realistic strategies to narrow the gap between demand and supply than introducing financial incentives for nondirected living donors.
The US trains the world in transplant medicine and leads scientifically in almost all cutting-edge areas in transplantation. Extending commercialization, in particular by commodifying donor organs in the US, may set a global precedent with far-reaching implications. It seems particularly unwise to risk further unanticipated harms, in addition to those predicted here, entailed in the End Kidney Deaths Act, when necessary and achievable alternative measures are not yet fully utilized.”
Full editorial, TF Mueller, MA Matamoros, GM Danovitch and S Nagral, Journal of American Medical Association, 2025.3.26