Would you ever donate a spare organ to someone else while you’re still alive? Probably not, given how few living organ donations happen these days.
Kidneys, and more recently livers, are some of the only body parts that can be donated by someone living. Our bodies can function perfectly fine with one kidney, whereas the liver can grow back (doctors only take out a piece for transplantation).
While there are some short-term risks—as with any surgery—and potential rare complications, studies have shown that the average kidney donor lives as long as they normally would have and likely with few, if any, long-term health effects (some studies have suggested a possible higher risk of conditions like hypertension or diabetes). Living kidneys also tend to survive longer in their new recipients than those from a deceased donor, lasting over 20 years in some cases.
Though living kidney donations have been increasing over time, they still aren’t very commonplace, however. Only about 6,500 people in the U.S. donate a living kidney every year, out of roughly 25,000 kidney transplants performed in total.
Last December, authors Mario Macis andElizabeth Plummer published an article in JAMA Internal Medicine aiming to change that reality. Plummer is a professor specializing in health care policy and taxation at Texas Christian University, while Macis is an applied economist at the Johns Hopkins Carey Business School. Their paper is both a personal essay, detailing Plummer’s relatively easy experience donating a kidney to her cousin in January 2024, and a research-led exploration of the factors that discourage others from doing the same.
We spoke to the pair about the myths and barriers surrounding living kidney donation, as well as how to ethically convince more people to follow in Plummer’s footsteps. The following conversation has been lightly edited for clarity and grammar.
Gizmodo: What compelled you to team up for this unique blend of an article?
Plummer: I had never given thought to donating a kidney, and the entire donation experience was eye opening—from start to finish. It was like seeing into a world that most of us don’t even know exists. But there are so many people who are on dialysis just to stay alive, and there is a tremendous need for living kidney donors. This was an opportunity to increase awareness and understanding. And Mario’s knowledge of the donation process and system is outstanding. It seemed like a great partnership.
Macis: As an economist, I have always been very interested in understanding markets where persistent shortages exist. This is the case for blood donations in many countries and organ donations around the world. One key reason for these shortages is that in these contexts, the price mechanism is not allowed to operate due to ethical considerations. While prohibiting financial transactions in these markets is meant to uphold moral values and prevent exploitation, it also comes with significant costs—both in terms of human lives and economic inefficiencies.
In the case of kidney donation, the prohibition on compensation means that the number of available organs depends entirely on altruism, which is not sufficient to meet demand. As a result, tens of thousands of patients remain on waiting lists, many of whom will either die or become too sick for a transplant before receiving one. From a public finance perspective, this shortage also imposes a substantial burden on taxpayers. The alternative to transplantation—dialysis—is not only physically taxing for patients but also extraordinarily expensive, with Medicare covering a significant portion of these costs. Each kidney transplant saves the healthcare system about 150,000 dollars, yet policies that fail to address financial disincentives for donors limit the number of transplants performed.
Removing financial disincentives to donation, while stopping short of direct payments for organs, could increase supply while respecting ethical concerns. My interest lies in exploring these tradeoffs—how ethical constraints shape markets, what consequences they have, and how policies can be designed to better balance moral concerns with the urgent need to save lives.
Gizmodo: What are some of the biggest misconceptions that people have about living kidney donation, in your opinion?
Plummer: Most people remember the old days when surgery was “worse for the donor than the recipient.” But now, donor surgery is laparoscopic, and most donors are discharged after 2 to 3 nights in the hospital. While everyone’s experience is different, I had little pain and returned to work a week later. People who have physically-demanding jobs will of course need to be off work longer.
Another misconception is that you need to know someone who needs a kidney and you must be a match for that person. But that’s not the case at all. Transplant centers now allow for a kidney donor chain, which is a series of transplants where multiple donors and recipients participate. For example, if my kidney had not matched with my cousin, I could still have donated to a stranger who did match, and my cousin would receive a kidney from a stranger who matched with her. Donor chains can be between different transplant centers and can involve any number of donors and recipients. You can also be a completely altruistic donor—that is, you don’t know anyone who needs a kidney. You just want to donate. Transplant centers will find someone who you match with—and there will definitely be someone.
Another misconception is that you have to be young. Healthy people over 60 can be excellent donor candidates. In fact, some things are even more in their favor. Many are retired and don’t have children to care for. Their lifetime odds of kidney disease can be lower than that of a younger person. The donor medical teams do extensive workups to evaluate whether you are medically qualified to donate, but age is not necessarily a deterrent.
Last, the medical teams who assess donor candidates work independently from the teams who assess recipients. This helps prevent any pressure being applied to the donor or the donor’s medical team. Several times, the medical team assured me that I could withdraw from the donation process at any time and for any reason, and they were legally bound not to tell anyone the reason I withdrew.
Gizmodo: What are some practical steps that U.S. policymakers or transplant-related organizations like the National Living Donor Assistance Center could take to make these sorts of donations become more commonplace?
Macis: Removing all financial disincentives to living kidney donation is essential to increasing the number of transplants and reducing the persistent shortage.
While organ recipients’ insurance covers medical and surgical costs, donors often face substantial out-of-pocket expenses, including lost wages, travel costs, and dependent care. These financial burdens can amount to tens of thousands of dollars and discourage many willing donors from proceeding. A more comprehensive system that eliminates all these disincentives would make living kidney donation a truly financially neutral act, ensuring that no donor is made worse off by their decision to save a life.
A key reform is to expand reimbursement to cover all direct and indirect costs of donation, regardless of the donor’s or recipient’s income level. We should provide full compensation for lost earnings, dependent care, and travel expenses without means-testing restrictions (but excluding donors with very high income). Although direct payments for organs remain ethically controversial, reimbursing donors for all costs enjoys broad support from the transplant community and the public. Additionally, donors should receive long-term health insurance coverage for any future complications related to kidney donation, protecting them from uncertainty about potential medical costs [some lawmakers in the U.S. have been pushing for donors to receive free healthcare for life].
Beyond direct cost reimbursement, additional protections are necessary to eliminate financial and non-financial risks for donors. For example, recognizing the non-financial burdens of donation, such as pain, anxiety, and inconvenience, a refundable tax credit should be introduced to acknowledge the personal sacrifice involved.
Estimates indicate that each additional kidney transplant saves American taxpayers about $150,000. Increasing the number of living kidney transplants would significantly reduce the number of patients on dialysis, potentially leading to billions in Medicare savings while improving health outcomes. A bold policy that eliminates all financial disincentives would not only improve the lives of thousands of patients in need of a transplant but also save taxpayers’ money and strengthen the overall efficiency of the healthcare system.
Given the widespread agreement that donors should not bear financial costs, implementing these changes would align with both ethical and practical considerations.
Gizmodo: How’s Elizabeth doing these days? And her cousin?
Plummer: I’m doing great. The whole donation process seems like a lifetime ago. You pretty much forget about it, and my lifestyle hasn’t changed at all—except that I can no longer take NSAIDs (e.g., ibuprofen and Aleve). I used to love those!
My cousin is doing very well—or at least her kidney is. She no longer needs dialysis, which used to take 12 hours every night and required her husband’s help. She feels better and stronger. But people who are ill enough to need a new kidney often have other medical issues, so it’s a balancing act. She has to take several medications for the rest of her life (anti-rejection drugs and antibiotics), and has frequent doctor appointments for testing. But so far, her body seems to love its new kidney. We are both happy we did it.
