Monetising organ donations

Every day three Australians die or suffer needlessly waiting for a transplant because we have poor organ donation rates. However, organ shortages are a universal problem. It has been estimated more than a million people are awaiting kidney transplants in the world. In the US, over 100,000 patients are on the kidney transplant waiting list – a steadily increasing figure, yet 3,382 patients died waiting last year. Over 22,000 are waiting for other lifesaving organ transplants in the US. The average wait for a kidney transplant is 4.5 years in the US and 3.5 years in Australia.


Demand for organs has always exceeded supply. Australia’s donation rate in particular is relatively low in the developed world; of the 146,500 people who died in 2011 only 337 became donors. The shortage is widening due to an increase in diseases common to a ‘western’ lifestyle such as diabetes and hypertension, leading to more chronic kidney disease and renal failure. As our population increases and chronic diseases become more common organ transplants will be in even greater demand.

Despite steady increases in recent years, Australian donor rates are actually lower than they were 20 years ago, at 13.8 dpm (donations per million) – interestingly, this is partly due to fewer road deaths. It is said Australia’s donation rate is also low because: (a) we do not identify every potential donor within hospitals; (b) we do not always appropriately go about seeking the consent from family members; and, (c) more families say no in Australia than in other countries. There is a need for more training of staff involved in the process.

Transplantation is highly cost effective. In Australia, to keep someone with renal failure alive it costs around $55,000-$80,000 pa for kidney dialysis where a person spends about five hours, three times a week having their blood cleaned. A kidney transplant costs around $40,000 in the first year and then up to $12,000 each year afterwards. Not only is a transplant more cost-effective but it also provides a much better quality of life. These costs do not include pensions which don’t need to be paid when, in many cases, the transplant recipient can return to work. Then there is the added value of having a fully functional individual contributing to the community.

With the Australian government having failed to increase donations over 20 years, and the developed world’s best achievement being 35dpm, it begs the question: is there a better way?

There is only one country with reportedly no waiting lists for kidney donations. How did they do it?


Renal transplants differ from most other transplants because living people are able to donate without significant adverse effects on their own health. Donated kidneys, therefore, have a potential to become a commercial asset. Living Related Donation (LRD) has become the organ source of choice and most common method. To resolve the shortage of donors, some have advocated financial payments being made. However, today, the only country with legalised organ sales is Iran. Whether talk about monetising organ donation is converted into action remains to be seen.

The first kidney transplant in Iran took place in 1967. In the following 20 years only 100 transplants were undertaken. In 1988, Iran legalised living non-related donation (LNRD) of kidneys and established an associated transplantation system. This government-organised system regulated and funded the transplantation process and compensated donors for their organs. Within the first year of this system, the number of transplants had almost doubled; nearly 80% were from living unrelated donors. In addition to payment from the government, donors also receive free health insurance and often payment from the recipient or a charity. The receiver of the ‘new’ kidney is provided with highly subsidised aftercare and charities allow those unable to pay for the transplant themselves to receive a new organ. It is illegal for the medical and surgical teams or any ‘middleman’ to receive payment. A potential donor is also not allowed to contact anyone on the waiting list.

There are no national statistics, however survival results from a major Iran hospital are similar between LNRD and LRD (living non-related donation) in Iran and other countries.

Whilst still illegal elsewhere, could the ‘Iranian model’ be used to solve the problems of kidney donor shortages? Advocates argue there are “no significant differences” in groups of donors and recipients when compared in terms of socioeconomic background (wealth and education level). Thus significant social exploitation is not occurring. Opponents dispute this, as they do the ‘no waiting lists’ claim.

Outside Iran, the issue is highly contentious but the end-stage renal failure population – and the death toll – continue to increase in most countries.

A possible compromise solution is a non-monetary reward system. Patients who have previously agreed to be donors could receive preferential health care. Governments could control the monetary aspects of the transactions rather than money passing directly between the parties. The donor would sell their organ to the state which would then allocate it according to clinical need. By making the process more medically transparent, it may partially satisfy those who accuse pro-monetary transplantation advocates of disregarding the rich exploiting the poor.

It is also likely that a reasonable price could be set to prevent those in desperate financial need from being even further exploited. Using economic cost-effectiveness analyses, a figure of approximately US$90,000 (AUD $96,000) has been proposed, compared with the estimated cost of dialysis of around US$80,000pa per patient. Government intervention would also guarantee adequate post-operative care and follow-up for the donor, something which is currently limited. More recently the Wall Street Journal proposed a starkly lower figure of US$15,000, based on the equivalent in purchasing power of an estimated payment of $4,000 in Iran for a kidney, and in their estimate being adequate to secure a plentiful supply of kidneys.

As the demand for organs increases, the idea of financial compensation for kidneys will persist. Until an alternative to human donors can be found this ethical issue will be discussed, while waiting lists and death tolls continue to rise. Whether talk about monetising organ donation is converted into action remains to be seen.