Letter to the Editor of WSJ
Edited version ran Sat. Jan 2014

The Rest of the Story

I read with great interest Gary S. Becker and Julio Elias article “Cash for Kidneys: The Case for a Market for Organs” in Saturday’s WSJ.  Like so many others who have written on this subject, their article misrepresents the Iranian system of compensated donation.

Usually not much is said about Iran, because not much is known, but I went to Iran and spent nearly two months interviewing paid kidney donors for a documentary film I was planning. I visited six different regions and returned with over 200 transplant stories.  There are too many misconceptions about what is going on in Iran to explain in one letter, but the most important thing I would like to point out is that paid kidney donors are people, not commodities, and no matter what the economics of the situation, there is a human element that can’t be ignored.

You might think I’m going to say we should not pay kidney donors, or that I’m going to rage about how exploitive kidney selling is. Not so. I learned many things on my trip to Iran, but the most important was sometimes money is what makes helping others possible.

The issue isn’t how much a kidney is worth, but how to make helping economically feasible and how best to show appreciation. I disagree with economists who say you can put value on someone giving up part of their body to save another person’s life. A conscious, informed decision, to risk oneself for another is an invaluable gift both to the person and to society.

Iran is the only country in the world that has solved its kidney shortage, and it has done so by legalizing and regulating compensated donation.  In the rest of the world there are two options:  Altruistic donation and the black market. The third option only exists in Iran where the rule of law protects donors and recipients alike. Paid donors are not treated like criminals, as is the case when the underprivileged are exploited for their kidneys on the black market. 

The Iranian system has developed over 30 years and continues to improve.  Today, paid donors are secure in their knowledge that the system works to protect their rights as much as the rights of recipients. Their money is put in escrow, the middlemen who arrange kidney matches are NGO volunteers, not black market profiteers, and they are treated on the same medical wards and in the same post-operative clinics as kidney recipients.  

How much are Iranian kidney donors paid for their service to humanity? Much more than the thank you, travel expenses, and occasional lost wages, paid altruistic donors in the United States. Iranian kidney donors receive the equivalent to six month’s salary for a registered nurse in Iran, or approximately $32,000 in the United States. But in addition to monetary compensation, they receive many goods and services that are hard to quantify in dollars.  All receive at least one year of health insurance, not just care related to their nephrectomy, as is the case in the United States. They also receive automatic exemption from Iran’s two-year mandatory military service.

Furthermore, Kidney donors often receive extra health insurance, sometimes for their whole family and often under terms where it can be renewed annually. They receive dental care at the NGO dental clinics that serve diabetes patients and kidney recipients. They receive job services, small business loans, and household goods.  I estimate the total average package paid donors receive in Iran is close to $45,000 in value. 

Most importantly, these paid donors know the government supports them for having done something honorable, like a paid firefighter or a paid emergency medical professional. They have saved a life -- and their contribution to society is invaluable.  Mohaghegh Damad, the ethicist for the Iranian Academy of Medical Sciences told me no payment could ever be enough. But, the payment Iranian kidney donors get, makes doing the right thing easier. 

In the United States 20-30 people die every day because they can’t get a kidney. Iran is the only country in the world where almost everyone who medically qualifies to get a kidney gets one, and in many regions of the country there is a waiting list for people who want to donate.  Maybe its time we learn something from their experience.

Sigrid Fry-Revere, J.D., PhD, is a bioethicist and founder and president of the non-profit organization Stop Organ Trafficking Now and author of The Kidney Sellers (Carolina Academic Press, 2014).

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