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The kidney market in Iran is the only legal market of this sort globally. Yet, it has not been empirically studied based on real data. For the first time, we obtained data on donors and recipients from the Kidney Foundation in Mashhad, April 2011 up to March 2018, and assessed which individualistic characteristics contribute to a kidney’s price. Our findings indicate that each year of education for both donors and recipients increases the kidney price. Moreover, old patients are willing to make a higher payment to young vendors. We have also provided some policy implications to improve the efficiency of kidney allocations.
The insufficient philanthropic supply of organs has led to a significant organ shortage, mounting transplant waiting lists, and many renal patients losing their lives throughout the world. None of the new approaches to increasing the kidney donor pool in developed countries, such as developing deceased donation, introducing kidney exchange programs, and optimizing the allocation algorithms, have been successful in eliminating the drastic shortage of transplantable kidneys. Nevertheless, market-based arrangements to increase donations of human organs are broadly considered unacceptable from ethical perspectives and are therefore not relevant in almost all countries (
Since kidney markets are illegal everywhere, except Iran, there is very little known about the consequences of such a market. This paper studies the monetary market for kidneys in Mashhad, the second-largest kidney market in Iran, after the market in Tehran. Our analysis is based on a unique inclusive dataset of this market for about 7 years. For the very first time to the best of our knowledge, we assess which individualistic characteristics and institutional factors could explain a realized price of a kidney. We shed light on its several socio-economic aspects and provide evidence that gives readers a better understanding of how a monetary market for organs could work and its pros and cons.
A kidney market can considerably release patients from suffering under dialysis, increase their lifetimes, and cut healthcare costs. Nevertheless, such a market creates some ethical concerns, and our analysis should not be seen as an authorization for it. Many opponents of a market for kidneys are concerned that the two sides of the market are divided by wealth, where the majority of buyers are the rich, and most sellers are the poor who sell their kidneys because they desperately and sometimes urgently need money. That is why some opponents argue that a market for organs can be coercive (
However, we should note that as a kidney market had not made potential donors poor, it should not be blamed for that. Such a market provides a costly signal, i.e., selling one’s kidney, that make desperate poor people visible. Therefore, a kidney market could even provide a truthful mechanism to distinguish poor people and do something for them. After all, we do not expect that a wealthy individual sells his/her kidney just to get financial support from the government.
Nevertheless, a market for organs can have a crowding-out effect on intrinsic motivations for an altruistic kidney donation. Our data from the Kidney Foundation, KF hereafter, in Mashhad confirm this concern as very few kidneys have been donated altruistically. The KF is a non-profit, volunteer-run charitable organization that mediates between recipients and donors to assist both and further applies for related government and charitable benefits with no incentives for making the pairs.
Another concern about the kidney market is that low-income patients might not be able to afford live kidneys. However, as the KF in Iran is a charity in the first place, it subsides poor patients to get a kidney. Moreover, we could design a market where the government is the only authority that could legally purchase kidneys and then allocate them similar to how cadaver kidneys are allocated. Our collective responsibilities for people who suffer from kidney failure are best accomplished through a government-monopsony market in kidneys where the government is the only buyer who distributes kidneys based on need, but not ability to pay (
Notably, this is a self-financing scheme since savings from dismissing patients from dialysis and shrinking the waiting list for kidneys are much more than the costs of purchasing live kidneys. Spending even a portion of this saving on improving the living conditions of donors, e.g., post-transplant medical care, and special social services, reduces the long-term adverse effects of kidney transplantation for donors while saves many lives without irreparable damage to others.
The paper is organized as follows. In Section
Several U.S. states have legislated laws providing leave or tax benefits to organ and bone marrow donors and their employers. The passage of tax incentive legislation increased living unrelated kidney donation rates in New York (
Organ sales ban forces the organ trade underground, strengthens the role of organ brokers, and lessens organ sellers’ bargaining power, leaving them exposed to even higher levels of exploitation (
Regulated and incentivized systems that eliminate impediments to donation and remunerate donors could raise donations and reduce the unregulated markets and their harms. Working Group on Incentives for Living Donation suggest standards and guidelines for such a donation mechanism that would do more good than harm. Its critical components are protection, regulation, oversight, and transparency under the auspices of the appropriate government or government-recognized body (
There are some concerns about the long-term well-being of kidney donors. They are at increased risk of long-term risk for end-stage renal disease, ESRD hereafter, cardiovascular, and all-cause mortality compared with a control group of non-donors who were eligible for donation (
The US public is potentially amenable to compensating kidney donors (
However, not all renal patients are willing to accept an altruistic live-donor transplant since they do not perceive an opportunity for direct reciprocity. Some feel either unworthy of an altruistic live-donor transplant or responsible for the risks to an altruistic donor. Therefore, receipt of an altruistic transplant might be an even more complicated decision than a donation (
Some studies proposed a monetary incentive for living donors that would increase organs supply, discharge waiting in massive queues, raise the quality of life, and put an end to thousands of needless deaths (
Based on individual-level data from the United States and the European Union collected in 2001–2002, individuals who were familiar with the organ donation process or even had just some encounter with the health system were more likely to become organ donors, while minorities were less likely to donate (
The Iranian model of kidney transplantation, IMKT hereafter, established in 1988, is an example of a compensated and regulated living unrelated renal donation. It is an efficient and ethical model that can be employed by all other countries, which currently lack the necessary regulatory supervision (
In line with the Declaration of Istanbul, DoI hereafter, organ trafficking and transplant tourism are prohibited in the IMKT. It authorizes monetary compensation for kidney transplantation but does not tolerate transplant commercialism. Commercialism refers to the possibility within the free-market system to abuse vulnerable people to make a private profit. However, donors in the IMKT are not exploited, but they are supported by law and protected by medical insurance. Therefore, the IMKT adheres to the DoI.
Since April 2000, when the Iranian parliament passed the Organ Transplantation and Brain Death Act that approved deceased organ donations, the share of transplants from deceased donors has firmly risen to more than half of transplants. Nevertheless, there are other legal barriers, e.g., the consent of all close related families for the transplantation right after the death, making the deceased organ donations not enough to eliminate the excess demand for kidneys. Even with a supply of live kidneys from the monetary market, patients in Iran should still wait for months to receive a kidney for transplantation.
The IMKT includes a compensation negotiated directly between the recipient and living donor. In Iran, the word that is used for kidney vendors is donor, though they get paid. We use the same tradition in this paper but have in mind the tautology. Additionally, the government pays a reward to donors, a fixed 10 million Rials, equal to about 1,200 USD at that time and 150 USD at present, called the gift of altruism. Every few years, the Kidney Foundation of Iran announces a new official floor price for a kidney that each of 39 branches of the KF in each province is obligated to follow. This fixed price is independent of individualistic features such as gender and health status. However, the government has allowed an additional payment above this threshold negotiated directly between the patient and living donor.
The legal kidney market in Iran is not working the same in all cities. On the one extreme, it has its remarkable function in Mashhad with transparent side payments (
Any ESRD patient with no willing related donors is referred by a physician’s letter to the corresponding KF in that province where s/he could enter the kidney waiting list. Each potential kidney donor also registers at the KF after undergoing the preliminary medical tests and bringing the notarized consent of him/herself and his/her family. There are four different matching lines for each blood type, and a donor is paired with the first renal patient in the same blood type line, based on the first-come/first-served, who is matched in terms of Human Leukocyte Antigens.
Although this matching mechanism is not the most efficient one, it raises the chance of a successful transplant. Nevertheless, this is not the only way of matching, and both sides could publicly advertise and find each other outside the KF. However, since nephrologists discourage patients from contacting random donors and transplantation centers only accept donors referred by KF, both donors and recipients have to register there and go through the required paperwork and medical tests.
Once any matched pair agrees on a price, payment is made through the KF by sending a letter to the transplantation centers located at university hospitals under the scrutiny of the
As a result of the Iranian system of compensated donation, the number of renal transplants conducted has substantively enhanced such that from about a decade afterward, the renal transplant waiting list has been almost eliminated, (
We collected 436 paired kidney donors and recipients from April 2011 (the beginning of the year 1,390 in Persian Calendar) up to March 2018 (the end of the year 1,396 in Persian Calendar) KF in Mashhad, the second most populated city in Iran. In Mashhad, the realized side payment to donors beyond the official floor price is exchanged through the KF and documented in both donors’ and recipients’ profile. This procedure makes the kidney market in Mashhad unique, while in other major markets in main cities of Iran such as Tehran, Shiraz, and Kermanshah, there is no such data.
Descriptive statistics.
Variables | Mean | S. D | Min | Max |
---|---|---|---|---|
|
134.52 | 57.29 | 50 | 450 |
|
29.91 | 4.78 | 20 | 40 |
|
37.94 | 13.46 | 8 | 68 |
|
8.04 | 3.71 | 0 | 16 |
|
9.09 | 5.07 | 0 | 22 |
A large number of the available studies suggest that most donors are female, while the majority of recipients are male (
However, kidney vending may secure low-status women in the Middle East from being forced to serve as altruistic family donors (
Donors tend to be poor young married men, who are financially motivated towards donation, but recipients are unfortunately not that wealthy, as 47% of them were unemployed. Interestingly, we had five closely related donors who sold their kidneys, albeit at much lower prices. We made a dummy variable for these cases. These descriptive statistics confirm the similar picture illustrated already in the literature that showed between 84% and 90% of living unrelated renal donors were male, 80% were married, and the majority were at the level of high school education (
We found various education levels, e.g., primary, secondary, high school, and Bachelor, for both donors and recipients. In Iran, the education system used to have 5 years of primary school, 3 years of secondary school, 3 years of high school, and 1-year of pre-college. However, we realized in our data that having any education level does not necessarily mean that one has indeed finished that level. Instead, he or she was mostly about to get to that level. We considered the average years of education at each level for those who claimed they educated up to that level. Namely, we considered three, seven, and 10 years of education for primary, secondary, high school levels of education.
We adjusted the kidney price with the Iranian Central bank’s monthly consumer price index to make data from different years comparable in a pooled setting and takes its logarithm as the dependent variable. Our regressions in
OLS regressions on the logarithm of inflation-adjusted kidney price.
Variables | Model I | Model II | Model III | Model IV |
---|---|---|---|---|
Constant | 4.19*** (0.025) | 4.089*** (0.038) | 4.074*** (0.039) | 4.078*** (0.039) |
2012 | 0.024 (0.035) | 0.023 (0.035) | 0.03 (0.035) | 0.034 (0.035) |
2013 | −0.045 (0.038) | −0.045 (0.038) | −0.044 (0.038) | −0.04 (0.038) |
2014 | 0.077** (0.036) | 0.075** (0.036) | 0.077** (0.036) | 0.084** (0.036) |
2015 | 0.084** (0.035) | 0.077** (0.034) | 0.081** (0.034) | 0.085** (0.034) |
2016 | 0.095** (0.039) | 0.101*** (0.038) | 0.103*** (0.038) | 0.103*** (0.038) |
2017 | 0.117** (0.045) | 0.099** (0.045) | 0.1** (0.045) | 0.1** (0.044) |
Donor Education | 0.007*** (0.002) | 0.008*** (0.002) | 0.008*** (0.002) | |
Recipient Education | 0.004** (0.002) | 0.004** (0.002) | 0.004* (0.002) | |
Age Difference | 0.001** (0.000) | 0.001** (0.000) | ||
Relative Donor | −0.265*** (0.096) | |||
N | 432 | 432 | 431 | 431 |
R_squared | 0.052 | 0.079 | 0.087 | 0.104 |
Adjusted R-squared | 0.039 | 0.062 | 0.068 | 0.082 |
Prob (F-statistic) | 0.000 | 0.000 | 0.000 | 0.000 |
However, as it is distinct from
Moreover, donors compared to recipients tend to be relatively younger, about 8 years on average. However, patients have wider variations in their age, as it is not restricted, and after all, the disease could emerge at any age, and it is more probable for elders, while donors’ age has much less variance since it is restricted by law to be between 18 and 40 years old. There are different views on the effect of age on graft survival and, consequently, the kidney’s price. While kidney allocation mechanisms do not consider factors other than blood type and tissue compatibility, the market mechanism itself considers each pair’s age difference.
According to the estimation results, a family relationship between the donor and the patient reduces the kidney price. A related donor, who decides not to donate his or her organ for free, vends it to his or her relative for about 26.5 million Rials (about 867.15 USD) less than non-related donors. The dummy variables of all years, except 2012 and 2013, raise kidney prices in all models. This robust and positive effect could be because, compared to the official price in 2011, in these 2 years, the official prices increased a little, from 60 million Rials (almost 1963.35 USD) to 70 million Rials (almost 2,290.5 USD) and 90 million Rials (almost 2,945 USD) respectively, while afterward, it increases to 140 million Rials (almost 4,581.15 USD).
A market for organs is a typical example of market failure where the market equilibrium does not maximize social welfare. Iran is the only country in the world where it is not illegal to exchange an organ, e.g., a kidney, for money. The only government intervention so far in Iran’s kidney market has been setting a minimum price for the whole country. While there is a scoring system for patients with renal disease in Iran that prioritize them getting a kidney from a deceased donor, Iran’s kidney market does not prioritize patients and works simply on the first-come-first-serve basis. This paper is the very first attempt to provide a cornerstone to regulate the kidney market more efficiently.
We tried to explain variations in kidney price based on individualistic characteristics such as age and education level. Our findings indicate that related donors, who need to be compensated, vend their kidneys to close relatives for significantly less monetary compensation. We could interpret this impact as the crowding-out effect. Moreover, each year of education for both donors and recipients increases the kidney price. While kidney allocation mechanisms do not consider factors other than blood type and tissue compatibility, the market mechanism itself considers age difference and allows a higher price for assigning a kidney from a young donor to an old patient. These findings call for a revised mechanism for the Iranian kidney market that should not be merely based on the similarity of blood types, but also it is supposed to consider individual characteristics of donors and recipients such as age.
The datasets presented in this article are not readily available because access to data is restricted to protect proprietary information. It can be made available upon request with permission of the kidney foundation in Mashhad. Requests to access the datasets should be directed to
TM collected data, analyzed it, wrote the first draft of the manuscript, and proofread it. MF was the initiator who defined the research question, analyzed the data, and finalized the manuscript.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
DoI, Declaration of Istanbul; ESRD, End Stage Renal Disease; IMKT, Iranian Model of Kidney Transplantation; KF, Kidney Foundation.