Direct financial compensation through organized markets has been proposed as one strategy to increase the number of potential organ donors. However, this controversial practice is legal in only one country in the world—Iran; thus, there are limited data to demonstrate how this type of system might practically function. In a new report, Moeindarbari and Feizi provide granular real-world data on the demographics of kidney vendors and recipients from 2011 to 2018 in the kidney market in Mashhad, Iran [1]. This study provides valuable insights from a direct financial compensation program for organ donation and helps contextualize the debate surrounding this controversial issue.

Most prior attempts to quantify the potential impact of direct financial compensation for donors have been limited to surveys or structured interviews about hypothetical compensation and willingness to donate, rather than the real-world data presented in this article [2–7]. These have generally found that direct financial compensation to donors would likely increase the number of people who would donate an organ. In one web-based survey of members of the Canadian general public, 54% of people who would not consider donation to a relative without any compensation would actually change to being willing to consider donation for a $10,000 payment [3]. Even among people who would already consider donation to a family member or a friend, a payment of $50,000 would make 60% of people even more likely to donate a kidney in a study from the United States [4].

The data presented by Moeindarbari and Feizi confirm that, even in a partially regulated organ sales market, donors are younger than recipients and have fewer years of education. This potentially validates previous concerns of donor exploitation and socio-economic inequalities that have been shown across many countries [8–10]. For example, the Phillipine Organ Donation Program allowed for direct financial payment to donors from 2002 to 2008, and 78% of donors did not have a single follow-up visit post-donation [10]. Importantly, Moeindarbari and Feizi point out that in addition to the market price set by the government for a kidney, the recipients are allowed to pay donors, which seems to undermine the idea of a “regulated” market and further engenders donor exploitation. The authors outlined policy recommendations and improvements moving forward to more fairly consider the market value of a kidney in Iran. However, we would suggest that we are not there yet: before we go down the road of commercial sales, there are many other methods to improve altruistic organ donation that have been underexplored and underutilized.

An increase in altruistic living and deceased donation could eliminate the need for commercial organ sales entirely. After the Israeli government criminalized organ brokering, altruistic living donation rose by 339% over 10 years [11]. Similar results were seen after the Pakistani government banned commercial transplants [12]. Iran has the opportunity to increase deceased donation efforts, given that deceased donors have only increased from 4% to 10% in 30 years [13]. Other ways to improve altruistic donation include the removal of disincentives to donate (such as expenses linked to donation, travel expenses, and lost wages) and removal of HLA, ABO, and other incompatibility barriers to living donation through paired exchange [14]. Other countries have shown these methods can substantially increase the access to living donation without commercial markets.

Even beyond simply removing disincentives to living donation, there are a number of other strategies that have been developed to increase the number of living donor kidney transplants being performed. For example, the Live Donor Champion program trains a friend, family member, or community member to advocate on behalf of a transplant candidate to identify a potential living donor and has been shown to increase the number of potential living donors who come forward to donate [15]. Other focused interventions have been developed to directly increase the number of donors who come forward for people who are racial/ethnic minorities or socioeconomically disadvantaged, although these have not been universally effective [16, 17]. In a randomized controlled trial of 145 African American kidney transplant candidates in the United States, 82% of candidates who received house calls (structured educational sessions delivered to candidates, family, and invited guests in their own home) received at least one donor inquiry compared to 47% of candidates who received traditional individual counseling in the transplant clinic [16]. In another study of 300 African American kidney transplant candidates in the United States, candidates were randomized to receive additional education from a transplant social worker (with or without living donor financial assistance) [TALKS] or to usual care [17]. The TALKS program was designed specifically to address issues precluding living donation raised by African Americans in prior studies. Although the TALKS intervention did not lead to an increase in living kidney donation, 99% of candidates who received the intervention reported a high degree of satisfaction with the intervention. Continued expansion and development of targeted interventions to increase living donation could help avoid the need for direct financial payment of living donors.

In summary, the data provided by Moeindarbari and Feizi shed both positive and negative light on how a regulated system of direct financial payment to organ donors actually functions. While such a system would likely increase the number of transplants performed, major concerns remain, and we would suggest that expanding systems designed to support and compensate donors for actual incurred expenses could substantially expand the number of donors without needing to directly provide payments for living donors. Additionally, continuing to innovate and expand the utilization of targeted interventions to increase living donation could also help avoid the need for direct financial compensation for living donors. Ultimately, we agree with the authors that careful study of this controversial topic is critical to ensuring protection of living donors.