It is hard not to feel a certain sadness reading arguments for legalising the sale of kidneys that rely more on provocation than on engagement with how healthcare systems actually work in the UK (The big idea: Should we sell our kidneys?, 25 January).
Kidney failure is devastating, and the shortage of donor organs costs lives. About 7,000 people in the UK are currently waiting for a kidney transplant, and six people die every week while waiting. It is therefore concerning to read an argument that implicitly accepts continued late diagnosis of kidney disease and progression to kidney failure as an inevitability, rather than recognising the urgent need to raise awareness of kidney disease and prioritise its prevention before lives reach crisis point.
Furthermore, the notion that altruism in the UK has reached its limits, justifying a legal market for human organs, is not supported by public attitudes, social evidence or ethics.
Kidney disease, and access to care, are already shaped by inequality. Dr Paul Sagar may recognise concerns about exploitation, but he does not answer the central ethical question. How can a system be just if it starts to depend on people under financial pressure selling their organs and allowing economic vulnerability to become the engine of organ supply, while the causes of kidney failure and unequal access to care remain unaddressed?
Altruism is yet to have its day. Research by the Robert Dangoor Partnership for Living Kidney Donation has shown that more than half of UK adults would consider donating a kidney to a family member, nearly a third to a friend, and one in seven to a stranger. More than two-thirds of people say they want to make a positive impact on the world, even when it comes at a personal cost.
The issue is not the absence of altruism, but how effectively we inform and enable people to act on their existing willingness to help others by raising awareness and providing support for living kidney donation. Our work is making an active difference in this space, with support available through donateakidney.co.uk.
Saving lives doesn’t mean monetising our organs. It demands investment in prevention, research, fair access to transplantation, and sustained support for ethical, voluntary donation.
Sandra Currie
Chief executive, Kidney Research UK
“It turns out that the main arguments against legalising the sale of kidneys aren’t very robust,” writes Dr Paul Sagar. There are many arguments for and against the use of financial incentives for organ donation. Coherent debate, however, requires engagement with reliable empirical evidence. Unfortunately, in advocating for the introduction of markets in the UK, Dr Sagar’s case appears to rest on the assumption that payment for kidneys will inevitably ensure sufficient supply to meet the demands of people in need of kidney transplant. He bases this assumption on historical and unfounded claims that the Iranian market in kidneys eliminated the waiting list.
Eliminating a waiting list is easy; one need only restrict the eligibility criteria for wait-listing. A recent study by Ali Nobakht Haghighi and colleagues reported 32,000 patients undergoing dialysis in Iran, with only 2,500 receiving a transplant each year; only 40% of those transplants were obtained from living donors. They also highlighted some of the concerns about the Iranian organ market, noting the limitations of market regulation in prevention of exploitation.
The Iranian waiting list continues to grow, as Alireza Heidary Rouchi and colleagues noted more than a decade ago, in part due to better identification and referral of patients who would benefit from transplantation, but also to the rising burden of kidney disease. Around the world, the most effective way to reduce the gap between supply and demand for kidneys for transplant remains investment in prevention and management of kidney disease.
Dominique E Martin
Professor in health ethics and professionalism, Deakin University
The figures from the NHS in Paul Sagar’s article, that although 7,000 people in the UK require a kidney transplant, only 3,302 adult transplants took place in 2024/25, really angered me. Why? Because a few years ago I applied to be an altruistic living kidney donor, and the process was such a shambles and so disheartening that I gave up on the application, and they didn’t even bother to follow up. Almost two years ago I met someone who needed a kidney and she put me forward as her donor. Since then the NHS has been incompetent with her case and to this day continues to cause huge delays. This is without even vetting me to confirm I’m a suitable match, or if I’m even eligible to donate at all. It’s been an impossible battle. If the whole NHS donor system matches our experiences with it, I’m not surprised there’s so much need outweighing availability.
Name and address supplied
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