Kidneys for Sale? A Commentary on Moeindarbari’s and Feizi’s Study on the Iranian Model

Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands, School of Law and Social Justice, The Liverpool Law School, University of Liverpool, Liverpool, United Kingdom, Multi-Organ Transplantation Center, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia, Clinical Hospital Zan Mitrev, University “Sts Cyril and Methodius”, Skopje, North Macedonia

Moeindarbari and Feizi recognize these concerns and state that a monopsonistic program, where the government pays a fixed sum to donors and where patients do not pay, would allow for more equality and fairness (6). Although a monopsonistic transplant program would not address the conditions of poverty that compel people to sell a kidney, it could reduce the risk of interpersonal exploitation by preventing donors and recipients from negotiating payments (17,18). While we oppose Iran's tolerance of unregulated organ payments between donors and recipients, removing criminal penalties for selling a kidney at the very least enables kidney sellers to report harm without risking prosecution (19). Previous research from Iran (13,20), and from Mashhad in particular (11,16), suggests that the degree of exploitation reported by Iranian kidney donors is less severe than those who sell their kidneys on the black market, because Iranian kidney donors are protected by law (11,16). Moeindarbari and Feizi corroborate these findings by pointing out that medical teams in Mashhad have no share of the money paid by the recipient to the donor, that prospective donors are informed about the potential health consequences of their donation and that they receive pre -and post-operative care (6). Any examination of the Iranian model should thus compare the well-being of its donors to those who sell their kidneys on the black market (16,17,21).
A growing body of empirical evidence from a number of countries reveals that while organ sales are prohibited by law, they are tolerated in practice (19,(22)(23)(24)(25)(26). In addition, research assessing the impact of prohibitive measures suggests that organ trade is being pushed further underground, increasing the role of criminal intermediaries, and exposing donors to more violent means of recruitment (19,27). Studies further indicate that transplant professionals who facilitate illegal transplants can also be complicit in the exploitation of donors and recipients by not providing (adequate) pre -and postoperative care (29)(30)(31)(32). There is however a critical lack of attention for the implications of prohibition and a lack of accountability of those who facilitate illegal transplants, including medical institutions and medical staff (19,28,29). Although complicit transplant professionals reportedly profit the most from illegal transplants (19,29,32), successful convictions of medical institutions and their staff remain virtually absent (22,29,32,33). The reluctance of organ sellers to report harm (because they risk conviction), further inhibits investigation and prosecution of criminal cases (19,29).
More empirical data is needed to develop workable solutions grounded in the empirical reality of people directly affected by the trade in organs. Dismissing evidence-based studies assessing the impact of regulatory controls in Iran, currently the only country with a semi-regulated organ market, would be counterintuitive. The implications of prohibition and the growing organ scarcity warrant a data-driven exploration of alternative models that move beyond prohibition and that may more effectively reduce the risk of exploitation of vulnerable donors and diminish patient mortality on transplant wait lists (19,28,34).
To this end, more rigorous data from Iran is needed that demonstrates how exactly its organ payment schemes reduce the risk of exploitation. It would be particularly helpful to learn more about donors' and recipients' experiences with and attitudes towards Iran's organ payment programs (11). While Moeindarbari's and Feizi's analysis is perhaps more useful for economists who study market designs, studies about Iran's organ payment programs should not be rejected exclusively on moral grounds. Rather, an honest and open dialogue is needed in which data from different countries and models is comparatively discussed. To this end, studies from Iran, even if we disagree with them, should be welcomed.

AUTHOR CONTRIBUTIONS
FA and SC wrote the article. MA and NI provided comments.

CONFLICT OF INTEREST
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.