“Why Can’t I Buy a Kidney?” Lesson Plan

Altruism 

Acting in the best interest of others, sometimes superseding one’s own interests. 

• People who volunteer to undergo surgery to donate one of their kidneys to a stranger often describe their motivation as wanting to be altruistic. 

Commodification 

The act of turning something into an item that can be bought or sold.

Compensation/Reimbursement 

A payment to someone for service or to address someone’s loss, damage, or injury by providing an appropriate benefit. In this Episode, compensation and reimbursement are used interchangeably. 

Disincentives 

Factors that prevent or discourage an action or effort, such as the fear of punishment. 

Exploitation 

To take unfair advantage of someone, or to use another person’s vulnerability for one’s own benefit.

Incentives 

Factors that induce action or motivate effort, such as expectation of reward.

Polarized 

Divided into two sharply distinct opposites.

Additional Terms Adapted from the OPTN’s Ethical Principles in the Allocation of Human Organs 

For use in the Sample Activity: Rating Donation Models 

The Organ Procurement & Transplantation Network (OPTN) is an organization that oversees and connects all organ donation and transplantation efforts in the United States. It is a partnership between the US Department of Health and Human Services Health Resources and Services Administration (HRSA) and a private non-profit organization, United Network for Organ Sharing (UNOS). The OPTN has adopted ethics principles to inform their work and UNOS’ work. 

Justice 

Fairness in the distribution of benefits and associated risks or actual burdens or harms. 

Respect for Persons 

In healthcare, honoring patients’ rights to control their own lives, bodies, and health. 

Utility 

Providing the maximum benefit and minimizing harms for the maximum number of people (sometimes written as “the greatest good for the greatest number”).

(sample answers provided in italics) 

• What are the different ways to get a kidney for transplant that were mentioned in the Episode?
  • Waiting for a kidney from a deceased donor
  • Waiting for a kidney from an anonymous living donor 
  • Finding a family member or friend to be a living donor
  • Finding a living donor on a matching website
  • Daisy Chain donations – a network of exchanges within a group of donors and recipients that results in everyone in the group receiving a matched kidney from a donor in the group, allowing for more transplants to be performed than single donor-recipient pairs
  • Compensating or reimbursing donors for kidneys (this is a proposal for how to increase the supply of kidneys, which has not yet been adopted)
  • Buying a kidney illegally on the black market 

• Why don’t we pay people for kidneys?
  • Kidneys are solid organs, and a law passed by Congress in 1984 (the National Organ Transplantation Act) prohibits exchanging anything of value, including money, for solid organs 
  • It might be exploitative 
  • It commodifies the human body 
  • It might make altruistic donors less likely to donate and end up resulting in fewer kidneys overall available for transplant  

• What are the different models we might use to incentivize more people to donate their kidneys? Can you think of any that weren’t mentioned in the Episode? 
  • Reimbursing people for the costs of donating
  • Compensating people by reimbursing for costs plus a cash payment
  • Compensation in the form of a voucher that would get a loved one to the top of the waitlist
  • Compensation in the form of tax credits
  • Compensation in the form of contributions to a retirement fund or college fund 

• Which of the above incentives do you think are ethically acceptable to use to encourage more people to donate their kidneys? Which are unacceptable? Why?  

• What would constitute exploitation in kidney donation? Do any of the above incentives raise concerns of exploitation for you? 

• Is the commodification of kidneys wrong? What if it increases the kidney supply?
  • What if it increases supply by 10%? What if it increases by 50%? 200%? 

• Currently, living kidney donors and families of deceased donors have no say in who gets their kidneys unless it is a directed living donation. Patients who need a kidney transplant are placed on a waitlist and given a score that determines their spot in line. How would a free market for buying and selling kidneys change who receives a kidney? 

• Can you think of other ways we might increase the supply of kidneys for transplantation that don’t involve incentives for living donors? What ethics concerns are raised by them?  
  • Examples provided by students might include xenotransplantation – for example, pig kidneys; lab-grown kidneys/ 3D printed kidneys; and, novel incentives to increase donation after death. 

Description: 

Students assess three different kidney donation models. Students can draw from the ethics tensions highlighted in the Episode and raise additional issues that they believe are important. Rating how those donation models fare in light of particular value statements shows the ethics trade-offs present within and across different organ donation policies. This exercise can be done individually or together as a class, or both! 

Note: Directed kidney donations from living donors are legal. Someone can donate their kidney to a family member or friend if they are a match. Directed donations cannot be compensated. This exercise does not address directed donations, instead focusing on situations like Sally Satel’s, who could not find someone to donate a kidney to her. This exercise also does not address organ donation after death. Most donated kidneys come from deceased donors, but not nearly enough to meet demand.  

Instructions: 

Before the Activity: 

• Students should listen to the Podcast Episode. They should be familiar with the terms provided in the Vocabulary. 

• The exercise also refers to a 2024 Congressional proposal called the End Kidney Deaths Act. More information about this bill can be found in Additional Resources. 

• Print the Lesson 1.4 Handout, one for each student.  

• If you plan to do the exercise together, as a class, prepare a whiteboard or shareable screen with three rows of twelve lines, representing a scale: Definitely No, Probably No, Unsure, Probably Yes, Definitely Yes. See the Handout for an example of the scale.   

Review Donation Models: 

It may be helpful to review the three donation models as a group. Connect each donation model back to the Episode to remind students of the ethics questions that accompany each model. Key facts and ethics considerations for each model are listed here.

Model 1: Altruistic donation to the existing waitlist  

Key Facts & Ethics Considerations 

• This is the current model.  

• Although it is rare, sometimes a living person will decide to donate one of their kidneys to a stranger. Donors are not compensated and they are responsible for their own costs, such as medical costs, transportation, time off of work, etc. When someone donates a kidney, neither the donor nor their family can choose who gets it. 

• Patients who need a kidney are placed on a waitlist and are given a score based on the likelihood of survival of the patient after transplant, the estimated longevity of survival of the kidney, and other factors including age, other diseases, and time on the waiting list.    

• Donation without compensation ensures that donors are not pressured into donating by a financial  incentive, and are making the decision freely without any pressure. However, this model has resulted in too few kidneys being available– there are not enough for everyone on the waiting list.  

Model 2: Reimbursed donation to the existing waitlist  

Key Facts & Ethics Considerations 

• This model is based on a 2024 bill introduced in the US Congress called the End Kidney Deaths Act.  

• The bill proposes compensating people who decide to become living kidney donors. To be compensated, a donor must donate their kidney to the waitlist, and the donor cannot select who receives it. The compensation is $10,000 a year for five years in the form of a tax credit.  

• The waitlist and allocation decisions remain the same as Model 1 under the bill.  

• The bill aims to use financial incentives to increase the supply of kidneys available for donation. It does not affect the allocation of kidneys to those who need them. This incentive might make people feel pressured to donate their kidneys when they otherwise would not. While this model doesn’t directly turn kidneys into commodities, it does in a way “put a price” on a human body part.  

Model 3: Free market exchange 

Key Facts & Ethics Considerations 

• This model was first attempted in the early 1980s, and led to the passage of the National Organ Transplant Act (NOTA) in 1984 by which Congress banned the sale of solid organs, making this model illegal–you cannot exchange anything of value for a kidney or other solid organ like heart, liver, lungs.  

• This model is essentially an open marketplace for kidneys, like eBay. For example, donors could look for someone who would pay them the most money or could choose a recipient based on other criteria they decide are important to them, even including gender, education, political or religious affiliation, financial status, or race. Patients needing a kidney would have to compete against each other to offer the best deal to donors, with wealthier patients likely benefiting the most.  

• This model could lead to exploitation. Offering a lot of money to donors might pressure them into making unwanted choices. It also risks turning kidneys into commodities, just like any other product that can be bought or sold. 

Rate Donation Models: 

Students can rate each donation model on each scale, according to the numbered statements on the Lesson 1.4 Handout. Students can do this on their own and can volunteer to share their reasoning behind each rating with the class. The class can also work together to come up with their own ratings.  

Debrief & Discuss: 

• How did the three models differ across the three ethics considerations: utility, justice, and respect for persons? 

• Which model do you think is best? Why?
  • Are there any amendments you would make to the model to make it more ethical? 

• Would you sign up to be an organ donor under any of these models? Why or why not?
  • Would you arrive at a different answer if you or your family member needed a kidney?

1. ELA writing assignment: Choose one of the methods for distributing kidneys for donation: directed donations to known recipients, daisy chain donations, a voucher system, or a reimbursement model. Review how this method of distribution reflects ethics considerations of respect for persons, utility, and justice (fairness).

The Organ Procurement & Transplantation Network (OPTN) is an organization that oversees and connects all organ donation and transplantation efforts in the United States. It is a partnership between the US Department of Health and Human Services Health Resources and Services Administration (HRSA) and a private non-profit organization, United Network for Organ Sharing (UNOS). The OPTN has adopted ethics principles to inform their work and UNOS’ work. 

S.2048 – National Organ Transplant Act, 98th Congress, 1983-1984.

Ethical Principles in the Allocation of Human Organs, OPTN, 2015. 

United Network for Organ Sharing 

How we develop policy, United Network for Organ Sharing (UNOS). 

In the Group Activity: Rating Donation Models, Model #2 is based on a bill that was introduced in Congress in 2024, called the End Kidney Deaths Act. 

End Kidney Deaths Act, introduced by Nicole Malliotakis (NY-11), 2024. 

There’s a severe kidney shortage. Should donors be compensated? NPR, 2024. 

For up-to-date statistics about organ donation in the United States, check out the UNOS data dashboard: https://unos.org/data/.