Is it okay to compensate a kidney donor?

Numerous comments have been made about ethical aspects of kidney transplantation practice in Iran, generally referred to the “Iran model of kidney transplantation programme” (1). The compensated programme for using living unrelated donation (LURD) has fired strong opposition as well as support since its introduction in 1988. However, common to most of the attributed comments are the terms used for addressing the experience: “organ selling” or “a market for organ transplant”. The major question in most of the papers is whether selling body organs is acceptable. No distinction is made between a “compensated kidney donation” and “selling kidneys”. For example, in Indian Journal of Medical Ethics, in an editorial, the authors ask: “Is it okay to sell a kidney?” (2). Julian Savulescu in a debate in the Journal of Medical Ethics claims, “If we should be allowed to risk damaging our body for pleasure (by smoking or skiing), why not for money which we will use to realize other goods in life?” (3).

Such arguments from those opposed to kidney transplantation from living unrelated donors, and even from supporters of the practice, views what is being done in Iran as of a purely financial nature. However, as a nephrologist deeply involved in kidney transplantation in Iran, I strongly disagree with the terms used for explaining the condition. In a fair number of situations I have asked my (donor) patients: “Would you donate your kidney just for money considering that you cannot do anything else to resolve your monetary problems?” The answer I commonly receive is: “This is not just for money. I am saving a human life and this will not be disregarded by God.” Some of them come up with other ways that might resolve their financial problems as well. They claim that they want to do something good for their “eternal life after death”; they look at donation as an endeavour that could concomitantly resolve their monetary problems and make God happy.

Some fear that altruistic living donation may decline in the face of payment for organ transplants. But what exactly is an altruistic donation? In the general understanding, an altruistic donation is a non-paid donation. However, even a pure altruistic donation has its own associated expenses. For example, donors will be out of work during kidney transplantation, they may also lose their job. This is a barrier to altruistic donations by people of lower socio-economic classes who have altruistic intentions. On the other hand, if we tighten the criteria for altruistic donation, there will rarely be available altruistic donations. Just consider a mother who donates her kidney to her child. Even in this case, the mother gets a reward — saving her child’s life, which is a matter of extreme concern to her. Or when a friend donates a kidney, it might be a reimbursement for help earlier given by the recipient. Even in living related donation, some have claimed that because of hidden coercion there could be more ethical problems compared to what exists in LURD. The problem will be greater when we consider suggestions for expanding the living donor pool, like gifting the donor a medal or medical insurance, or priority for public services.

In my understanding, giving gifts to LURD donors does not reduce altruistic living donation; it could even promote it in some way. I do agree that we need to continue improving our donors’ conditions and to use cadavers as the most ethical source for organ transplantation in the country.