Right now, about 7,000 people are awaiting a kidney transplant in the UK. According to NHS figures, in 2024/25 only 3,302 adult kidney transplants were performed. The charity Kidney Research UK states that “just 32% of patients receive a transplant within a year of joining the waiting list and six people die every week while waiting.”
People who experience kidney failure need either lifelong dialysis or a transplant to survive. Yet even for those lucky enough to get a transplant, that is by no means the end of the story. Kidneys from deceased donors last an average of 10 to 15 years, those from a living person 20 to 25. If (or rather, when) a transplant fails, the affected patient once again needs dialysis or a donated organ.
The UK is not unusual in having far more people who need kidneys than there are kidneys available. Every country in the world has this problem. With one exception: Iran.
What is different about Iran? It is the only state that has legalised the sale of kidneys. This began in 1988, and means the country has no waiting lists. You can expect to pay about $5,000 for a new kidney, subject to a price cap adjusted for inflation and enforced by the government. (By contrast, a kidney bought on the black market elsewhere can cost up to $120,000.) The proceeds go to the donor, who can be a friend or family relative, or just somebody who needs the money and happens to be a biological match. Indeed, in Iran most people who donate kidneys have no direct relation to the person receiving the organ. They are just doing it for the cash.
The fact something generates icky feelings is not a good reason to make it illegal
What are the lessons we might take from this? Should the UK likewise legalise the sale of kidneys? After all, if the aim is to get kidneys to people who need them, the Iranian experience proves that their system works. Currently the demand for kidneys vastly exceeds legal supply. This is because supply relies entirely on altruism, which is very limited. (Don’t believe me? Well, why haven’t you given one of yours away? After all, a healthy adult needs only one.) A straightforward way to resolve this is to increase incentives for supply. Stop appealing simply to altruism, appeal to self-interest. Don’t ask people to give their kidneys away for free – offer to pay them.
It perhaps goes without saying that this suggestion is controversial. But how justified is that? It turns out that the main arguments against legalising the sale of kidneys aren’t very robust. One common objection is that the poor will be exploited. After all, who (other than the unusually altruistic) would sell a kidney, unless they felt they needed to, because of dire financial pressures? Accordingly, a ban on the sale of kidneys might be thought necessary to protect the financially vulnerable.
There are major problems with this line of reasoning, though. It’s all well and good telling people that they are being protected from “exploitation” by market forces, but that rings hollow if we are not simultaneously doing anything to make them financially better off in other ways – as is usually the case.
There is something odd about claiming to be concerned about the plight of the poor while denying them straightforward measures to ameliorate their poverty. Similarly, if one worries that dishonest and exploitative corporate actors will not treat donors properly, that is an argument for regulation, not prohibition: ensuring the market operates in ways that protect participants – as appears to have been achieved in Iran.
Another line of objection is that there is something sacred about human bodies, which should not be traded as commodities. But sacred according to whom? Those with religious dispositions may feel this way. But why should they get to decide what those without such beliefs may do with their body parts? Especially when there are thousands suffering and dying?
More generally, there is the question of why the government should have the right to control individual choices in this matter. Given that people are allowed to give away kidneys for free, why should the state have any say in whether the same action can be performed for money?
Here, people often fall back on an appeal to feeling. Many have a strong sense that it is somehow just wrong to sell organs. And as it happens, I share this feeling. For want of a better word, the idea of people selling their organs feels icky. Yet the fact something generates icky feelings is not necessarily a good reason to make it illegal. This becomes especially clear when we consider how changeable such feelings are across times and cultures.
In the 18th century, for example, some viewed being paid to sing as akin to prostitution, and professional opera singers, particularly women, could be deemed morally suspect. At that time, therefore, it might have seemed appropriate to subject professional singing to legal strictures, just like prostitution. To us, such a proposition seems absurd. What this tells us is that such feelings very much can and do shift – indicating that they are reflective of local cultural variation, not some underlying moral truth.
What we really need to consider is whether a practice that makes us feel uncomfortable is sufficiently important that those feelings must take a back seat when it comes to legalisation. What should be given more weight: personal queasiness at the idea of kidneys being for sale, or the lives of people who desperately need kidney transplants? It is, quite literally, a life-and-death question.
But it is also a question of politics. The Iranian regime legalised the sale of kidneys in response to a domestic health crisis: with failing infrastructure more people were dying of renal failure or attempting to secure transplants overseas. Iran was able to undertake this momentous change in part because the regime was able to disregard the moral objections of Iranian citizens. Would I be comfortable if a UK government did the same?
Here I feel queasy once again. Yet this time the queasiness is well grounded: discomfort with unilateral state power is essential to a free society. If people can decide through democratic means that a market in kidneys is desirable, then so be it. But if enacting such a change is only achievable through authoritarianism, then the cost is surely too high.
Dr Paul Sagar is reader in political theory at King’s College London.
Further reading
Kidney for Sale By Owner: Human Organs, Transplantation, and the Market by Mark J Cherry (Georgetown, £19)
How Death Becomes Life: Notes from a Transplant Surgeon by Joshua Mezrich (Atlantic, £10.99)
Being Mortal: Illness, Medicine, and What Matters in the End by Atul Gawande (Profile, £8.99)
