The sourceS: “Compensated Kidney Donation: An Ethical Review of the Iranian Model” by Alireza Bagheri, in Kennedy Institute of Ethics Journal, Sept. 2006; and “Payment for Kidneys: A Government-Regulated System Is Not Ethically Achievable” by William Harmon and Francis Delmonico, and “Kidney Vending: The ‘Trojan Horse’ of Organ Transplantation” by Gabriel M. Danovitch and Alan B. Leichtman, in Clinical Journal of the American Society of Nephrology, Oct. 4, 2006.

In the United States last year, roughly 18 people died every day while waiting for an organ transplant, leaving more than 93,000 remaining on waiting lists. Most of them needed a kidney, but only one was donated for every four eligible ­patients.

Nobody dies on a waiting list for a kidney transplant in Iran. An “Iranian model” of “compensated donations” has achieved unique success in eliminating any waiting list for kidney transplants, writes Alireza Bagheri, a research associate in the Graduate School of Law at Kyoto University. The Iranian system, which disregards the taboo on compensation, has attracted international attention as kidney disease has become more wide­spread throughout the ­world.

The sale of kidneys is prohibited in the United States, but Bagheri argues that the ban is ethically backward. Depriving donors of legitimate compensation for giving up one of their two kidneys is unjustifiable. Everyone participating in organ procurement is paid except the donor, and the donor’s sacrifices should be recognized. Further, compensating a kidney donor is not the same as buying an organ. It is the “recognition that somebody who comes forward to donate an organ should receive appreciation and some level of reimbursement for time taken from work, travel, and loss of earnings incurred, and even perhaps to be incurred in the future,” the author ­writes.

The Iranian system allows transplant candidates to apply to a charitable organization for help in finding a donor. The Charity Foundation for Special Diseases, a ­non­governmental organization, com­pen­sates donors with a flat sum of $1,090, a little more than a third of the annual per capita Iranian income at the time of Bagheri’s research. Donors and recipients sign pledges that they will not ask for or pay more than the flat amount. Transplants between citizens of different nationalities are prohibited to prevent “transplant tourism.”

About 80 percent of all donors are poor, and slightly more than 50 percent of kidney recipients are also poor. Iran has had no waiting list since 1999. Nearly 20,000 kidney transplants have been performed since the program ­began.

Harvard Medical School doctors William Harmon and Francis Delmonico say that although the Iranians should be commended for providing health care to the kidney donor and for prohibiting trans­plant tourism, the Iranian model fails to meet ethical standards. “It is the poor person who bears the burden of being the kidney source for transplantation,” they write. This person is “coerced to make this donation decision” out of financial ­desperation.

Moreover, kidney markets cannot truly be regulated. Once there is a market for kidneys, Harmon and Delmonico argue, what is to stop donors from seeking the highest possible price by soliciting ­under-­the-table ­payments?

Drs. Gabriel M. Danovitch and Alan B. Leichtman of UCLA and the University of Michigan, respectively, say that the open discussion of kidney “vending” threatens the core values that have permitted organ transplantation to flourish in the past half-century. The altruism that has motivated donors and the families of deceased donors to contribute kidneys is at ­stake.

Safe donation, they write, requires honesty and openness about health, family history, and past ­high-­risk behavior. When altruism motivates the donation, the donor has no incentive to knowingly give a potentially defective kidney. When the motive is money, that safeguard is ­gone.

Kidney vending might seem like a tempting solution to the organ shortage, according to Danovitch and Leichtman, “but like the Trojan horse of old, once we permit it within our gates, we may find that it brings destruction and not relief.”