Tina Rosenberg on the Kidney Market in Iran

Episode Summary

Executive Summary: Russ Roberts and Tina Rosenberg examine Iran’s legal kidney compensation system, why it emerged, how it works, and whether it should influence reform elsewhere. Rosenberg explains that a regulated paid-donor model largely eliminated kidney waiting lists in Iran, while Roberts and she debate exploitation, morality, and whether compensating donors could expand supply without abuse in the U.S.

Main Topics: The kidney shortage crisis (Priority: 5/5): The conversation opens with the severe mismatch between kidney demand and supply in the U.S., including long waits, dialysis dependence, deaths on the list, and rising need from diabetes and obesity. How Iran’s paid kidney system works (Priority: 5/5): Rosenberg describes Iran’s state-regulated donor compensation system, its origins after the revolution, the role of NGOs, screening, and how it largely removed the kidney waiting list. Costs, incentives, and donor compensation (Priority: 4/5): They discuss how medical costs are covered, how payment moved from government-funded stipends to mostly patient-funded compensation, and how charity helps but is uneven across regions. Ethics, exploitation, and commodification (Priority: 5/5): A major segment weighs objections that paying for organs exploits the poor or violates moral norms against selling body parts, versus the argument that saving lives and regulating payments is better than black markets. Civil society and nonprofit middlemen (Priority: 4/5): They emphasize that Iran’s regional nonprofit associations coordinate matching and funding, and that a nonprofit intermediary may help avoid predatory broker behavior seen in black markets. Policy lessons for the United States (Priority: 5/5): The discussion turns to U.S. reform, including compensating donors for lost wages and expenses, possible pilot programs, and whether a legal market could reduce deaths and dialysis costs. Selection, safety, and follow-up (Priority: 3/5): They note that live donation is generally safe, but follow-up is imperfect, donor stigma can discourage return visits, and deceased-donor transplants and dialysis differ substantially in outcomes.

Key Arguments: The U.S. kidney shortage causes major preventable suffering and death; long waits and dialysis are not sustainable for many patients. Iran’s regulated compensation system is not the same as an abusive black market; legal payment can reduce exploitation by eliminating brokers and secret deals. Paying donors is not necessarily immoral or exploitative if it is regulated, medically screened, and transparent. The biggest practical problems in Iran are financial and regional, not proof that compensation itself cannot work. A nonprofit or civil-society intermediary is preferable to a for-profit broker in a vulnerable-body-parts market because it reduces incentives for abuse. U.S. reform could begin by reimbursing donors for lost wages, travel, childcare, and insurance, but those measures alone will not solve the shortage. Opposition to paid donation often reflects moral intuitions and institutional inertia, but those concerns may be outweighed by the harm of allowing patients to die waiting. Better-organized compensation schemes could expand the donor pool, improve access for poorer patients, and reduce the need for costly dialysis.

Data Points: U.S. kidney waiting list: ~101,000 - Number of people waiting for kidney transplants in the U.S. (April 2015). Total U.S. transplant waiting list: ~123,000 - People waiting for transplants of any kind in the U.S. U.S. transplants in 2014: 17,000 - Total transplants performed in the U.S. in 2014. Living-donor transplants in 2014: ~5,000 - Kidney transplants from living donors in the U.S. in 2014. Deceased-donor transplants in 2014: ~10,000 - Kidney transplants from deceased donors in the U.S. in 2014. New kidney patients added monthly: 3,000+ - Number of new patients added to the kidney waiting list each month. Deaths while waiting (daily): 12 per day - Estimated deaths each day among people waiting for a kidney transplant. Deaths while waiting (2014): 4,270 - People who died in 2014 while waiting for a kidney transplant. Too sick to transplant (2014): 3,617 - Patients who became too sick to receive a transplant while waiting in 2014. Dialysis cost: about $80,000/year - Approximate annual cost of dialysis in the U.S. Medicare dialysis coverage: 100% regardless of age - Roberts notes Medicare covers dialysis for kidney failure patients irrespective of age. Iran government donor payment (early system): about $3,500 - Initial regulated payment to kidney donors in Iran, described as a 'gift for altruism.' Current regulated kidney price in Iran: over $5,000 - Approximate government-set price, with the government paying only a small portion now. Government share of current Iranian payment: $350 - Amount the Iranian government still contributes toward donor compensation. Anti-rejection medicine coverage (Medicare): 3 years - Medicare covers only three years of anti-rejection drugs after transplant, which Rosenberg calls a false economy. Estimated kidney-value study: $15,000 - Economists’ estimate of a kidney’s value based on pain, risk, and suffering. Dialysis effectiveness: ~15% as well as natural kidneys - Rosenberg says dialysis cleans blood far less effectively than a healthy kidney. Live-donor kidney survival estimate: up to 20 years - Rosenberg cites an upper-end survival estimate for a transplanted live-donor kidney. Kidney failure deaths annually: ~87,000 - Rosenberg cites annual deaths from kidney failure, many of which involve patients who might have been transplant candidates. Regional charity shortfall in Iran: mid-year / around July - In poorer regions like Kermanshah, charity funds can run out halfway through the fiscal year.

Pivotal Quotes: "there's only one country in the world where it's legal to buy and sell kidneys, that country being Iran." — Russ Roberts: Introduces the episode’s central topic and the Iranian kidney market. "I came in, I had two assumptions that I think I no longer hold. And one of them is that paying donors is necessarily exploitative. And the second one is there are serious moral and ethical reasons not to pay donors. I no longer believe either of those things." — Tina Rosenberg: Rosenberg explains how her reporting changed her views on organ compensation. "If your body is a sacred temple, then let's spare some thought to the thousands of people who die waiting for a kidney." — Tina Rosenberg: Her moral counterargument to objections against compensation.

Implications: The episode suggests kidney compensation could be a practical reform if tightly regulated, especially via donor reimbursement and pilot programs. It also warns that policy design, nonprofit mediation, and follow-up care matter more than the simple question of whether payment is allowed.