Ever since organ donation became clinically feasible, there have not been enough organs to go around. Figure 1 shows the rate of change from a base value in 1995 through 2008, of three variables: (1) the number of deceased donors, (2) the number of patients with end-stage organ failure who are waiting for an organ, and (3) the number of waiting list patients who either die before an organ becomes available (ie, death on the waiting list or after removal from the waiting list as “too sick to transplant”) [1Removal reasons by year; Removed from the Waiting List: January, 1995–March 31, 2009 OPTN: Organ Procurement and Transplantation Network.http://optn.transplant.hrsa.gov/latestData/rptData.aspGoogle Scholar]. The number of potential recipients on transplant waiting lists has more than doubled, and now stands at over 100,000, whereas the number of deceased donors has increased by only half. Meanwhile, the numbers of deaths related to the organ shortage, which is now greater than 9,000 a year, has grown in parallel with the waiting list. Thus, the gap between supply and demand has grown every year for the past 15 years. Approximately two thirds of the waiting list patients suffer from end-stage renal disease. Because the kidney is a paired organ, living individuals can donate one kidney, and several thousand donate every year, mostly to relatives with whom they have an emotional bond. The problem underlying the organ gap is not a lack of medically suitable organs from patients dying from severe brain damage; if all such patients became donors, the waiting list would shrink rapidly, yet only half of potential deceased donors actually donate, and many potential living donors are medically unsuitable or are unwilling to donate, so not enough organs are donated to satisfy the need for them. How can we increase the number of donors? When a difficult or dangerous job has to be done, such as working on high-rise construction projects, we give workers an added incentive to take these jobs by offering them more benefits, such as salary supplements. Perhaps offering a financial incentive for organ donation would increase the number of willing donors. But if offering people financial incentives could increase the supply of organs, should we do it? Would it be morally appropriate? Kidneys are by far the most common transplants and can come from either a deceased donor (two kidneys) or from a living donor (one kidney). Making the case for providing financial incentives to living donors is much more difficult than for deceased donors, so if that case can be made, the arguments can cover virtually all donations, from both living and deceased donors. Although this is a cardiothoracic surgery journal, the current debate centers on living donors of kidneys. This is more appropriate than might be obvious at first, because the arguments for and against financial incentives for organ donation can be generalized easily to both living and deceased donors, and therefore these can apply to the therapies of most immediate concern to cardiothoracic surgeons (ie, heart and lung transplantations). The debate is rendered more concrete by focusing on the case of a United States senator who has a decision to make. Senator Alexis Murray is a member of the Senate's Committee on Health, Education, Labor, and Pensions, which is holding a hearing on a bill that will permit payment of up to $10,000 plus in reimbursement for expenses to living kidney, liver, or lung donors. Senator Murray listened to testimony by a few individuals and by representatives of organizations that either support or oppose the bill. He is particularly struck by the story told by George Cranford, a computer repair technician. Mr Cranford's 25-year-old daughter, Karen, has diabetic nephropathy and has suffered from end-stage renal disease for 5 years. On renal dialysis, she has had frequent bloodstream infections, several of which have been nearly fatal. She is currently hospitalized, recovering from her latest methicillin-resistant Staphylococcus aureus infection. The recurrence rate of such infections is high, and the mortality rate is between 50% and 75%. Karen is an only child; her parents and other relatives are unsuitable to donate a kidney. She is waiting for an organ from a deceased donor, but her place on the waiting list makes it likely that she will be among the 9,000 patients who die each year because of the shortage of organs for transplantation. Mr Cranford has several friends and acquaintances who have said they have considered donating a kidney for Karen, but have decided not to do so because of concerns for lost income from time away from work, the possibility of losing their jobs, possible health consequences from having only one kidney, and the stress, pain, and physical risks of the donor operation. He expresses the belief that these concerns could be outweighed by the offer of an award of some kind, such as payment for health insurance, an income tax credit, or cash payment of a few thousand dollars. If some of his friends and perhaps many others around the country could be persuaded by such incentives to donate a vital organ, thousands of lives could be saved each year. Senator Murray is impressed by the story, but is concerned about potential negative consequences of permitting a market in human organs. After the hearing, he seeks the advice of two thoughtful physician-ethicists, Benjamin Hippen, MD, and Lainie Friedman Ross, MD, PhD. The number of people with kidney failure in the United States is increasing. By 2010 it is expected to be 591,000, with more than 80,000 patients waiting for a kidney transplant [2Gilbertson D.T. Liu J. Xue J.L. Projecting the number of patients with end-stage renal disease in the United States to the year 2015.J Am Soc Nephrol. 2005; 16: 3736-3741Crossref PubMed Scopus (308) Google Scholar]. Incremental improvements in immunosuppression have rendered kidney transplantation a superior therapeutic modality for more and more patients with kidney failure. Unfortunately, despite our best efforts, the supply of transplantable kidneys has not and will not keep up with the growing demand. The current state of affairs is responsible for several unintended, but foreseeable, consequences. Longer waiting times for transplant candidates result in patients who are sicker at the time of transplantation. This factor, combined with an increased reliance on extended criteria donors (ie, marginal donors), results in inferior graft survival. Longer waiting times also serve to increase emotional pressure on any available living donor. Longer waiting times and few available options have contributed to an upsurge in international organ trafficking. This combination of factors erodes trust in the transplant community as a whole. In 2006, the federal government spent $22.7 billion dollars on end-stage renal disease, of which only $2.2 billion was spent on kidney transplantation, yet the 5-year survival with a successful kidney transplant is more than double the survival conferred by dialysis. Various solutions to this problem have either proven to be inadequate or are unlikely to succeed. The majority of people with kidney disease die from cardiovascular complications before reaching end stage; therefore, improvements in preventive strategies that increase survival after heart attacks and strokes will permit more people to live long enough for their kidneys to fail, which in turn will increase the demand for transplantable organs [3Hippen B. Preventive measures may not reduce the demand for kidney transplantation There is reason to suppose this is not the case.Kidney Int. 2006; 70: 606-607Crossref PubMed Scopus (11) Google Scholar]. Despite the aggressive efforts of the Organ Donor Collaborative to increase the number of available organs, the total number of procured organs during the last 10 years has been flat relative to the growing demand and a sizeable fraction of “new” organs, which are from extended criteria donors. These organs afford shorter graft survival, increasing the likelihood that recipients of these kidneys will return to dialysis. A policy of involuntary organ conscription is morally problematic, and countries that have such policies ensconced in law have not been able to successfully procure more organs than countries that rely on consent for donation [4Healy K. Do presumed consent laws raise organ procurement rates?.De Paul Law Rev. 2006; 55: 1017-1043Google Scholar]. The costs of this public policy failure is high, measurable in the unnecessary loss of human life, the vast expenditure of public treasure on a suboptimal therapy (dialysis), and the spread of desperation among waiting recipients and their families. This state of affairs supports arguments in favor of pilot trials of incentives to increase organ procurement from living donors. The central argument in favor of incentives is patient autonomy. Free societies typically do not interfere with competent adults making choices that affect their lives and do not significantly harm themselves or others. Free societies rely on this principle for ethically defensible uncompensated living donation and (rightly) look askance at those who would abridge this liberty. Opponents of a regulated market in organs encourage us to view this proposal through the lens of the manifest harms to vendors and recipients who participate in underground organ trafficking, without lingering on the fact that organ trafficking in developing countries would not be economically sustainable, except for the shortage of available organs in developed countries. Because organ trafficking continues unfettered by existing laws prohibiting the practice, those who are authentically committed to reducing organ trafficking can find the most straightforward solution in reducing the incentive for recipients in wealthy, developed countries to economically support trafficking. Our public policy failure merely ensures the continued health of international organ trafficking abroad. Regulated organ markets also may be safer than the current system of living donation. It is true, but trivially so, that organ donors become, in some sense, a patient. The obligations that physicians have to their patients would not change because some donors are compensated and others are not. The existing literature on donor outcomes, however incomplete, nonetheless, supports the premise that donating a kidney is safe for the long term [5Ibrahim H.N. Foley R. Tan L. Long-term consequences of kidney donation.NEJM. 2009; 360: 459-469Crossref PubMed Scopus (816) Google Scholar]. By vastly expanding the number of potential living donors, one can cherry-pick to identify people who everyone agrees would be at the lowest risk for long-term harm from donation. Incentives would also helpfully eliminate the psychological pressures brought to bear on living donors, borne of their recipient's desperate plight. Far from suppressing altruism, the authentic altruism of those who still choose to donate (uncompensated) would thereby be clarified and preserved. In itself, low socioeconomic status is an independent risk factor for the development of kidney disease over time, a fact which constitutes sufficient reason to exclude the poorest among us from participation in organ vending (or for that matter, in living organ donation). Exclusion of the very poor is justified not because poor donors and vendors are somehow incapable of autonomous judgment. For example, the poor should not be prohibited from voting in elections for political candidates who proffer the “coercive offer” of improving the economic lot of the poor. Rather, exclusion is justified because the purpose of a regulated market in organs is to increase the number of available organs without increasing harm to others. The “right to sell” does not impose an “obligation to buy,” and the interests of all involved entail an exchange that benefits recipients without harming sellers. Any system of incentives requires regulation and oversight, and it is a caricature to suppose that there is a contradiction between free exchange and the strictures of law. Law outlines the conceptual space for articulating obligations to donors and vendors, and the law explains the means whereby the legitimacy and enforcement of these obligations are possible. Among the necessary protections to be included would be the assurances of safety for both donors and recipients; transparency in regard to the risk of a living kidney donation for both the compensated and uncompensated donors; institutional integrity to protect donors, recipients, healthcare providers, and institutions who choose to participate or abstain from compensation arrangements; and the rule of law, to define how the arrangements for exchange could take place for mutual benefit [6Hippen B.E. In defense of a regulated market in kidneys from living vendors.J Med Philos. 2005; 30: 593-626Crossref PubMed Scopus (77) Google Scholar]. These protections morally distinguish a regulated system of incentives for organ procurement from the significant harms generated by organ trafficking, and they would provide a useful guide to the construction of pilot trials for incentives in this country, as well as a means of assessing the conditions in other countries. Along these lines, the United States has something to learn from Iran, which is the only country in the world with a legal pseudo-market in organs from living donors, and the 22-year legacy of that institution provides useful lessons and cautionary tales [7Hippen B. Organ sales and moral travails: lessons from the living kidney vendor program in Iran Cato Policy Analysis, No 614. 2008.http://www.cato.org/pub_display.php?pub_id=9273Google Scholar]. No evidence is perfect, but the peer-reviewed evidence we have from several sources supports the following facts: (1) for the last decade, Iran has not had a waiting list for transplantable kidneys; (2) the long-term outcomes of recipients of purchased organs is not significantly different from the outcomes of recipients of donated kidneys (a useful surrogate marker for the health of organ vendors); (3) the existence of a flourishing market has not resulted in attrition of the number of kidneys donated by biological relatives; and (4) uncompensated organ donation from the deceased has increased 10-fold since 2000, when laws recognizing brain-death as death were approved by the Iranian Parliament. On the other hand, the following is also true: (1) organ vendors are disproportionately impoverished and poorly educated; (2) the data on long-term outcomes for organ vendors is conflicting and mixed, but at any rate it is substantially incomplete. It does not follow that a system of incentives inexorably leads to bad outcomes for vendors. What does follow is that a defensible system of incentives must offer plausible assurances that the long-term consequences for organ vendors are at least as safe as for organ donors. A broader view of what might constitute “compensation” will be instrumentally useful in beginning to provide some of these assurances. Compensations need not be limited only to cash payment. Providing a nonfungible, lifelong, comprehensive healthcare benefit for donors would intersect with the desire of the transplant community for a long-term, prospective study of outcomes after donation. Compensation might take the form of a deposit in a donor's health savings account, retirement account, favorite charity, or any number of possible permutations. The specific nature of the incentive is less important than the following: (1) a successfully functioning incentive by making more organs available, and (2) an incentive that would not give rise to further harms [8Hippen B.E. The case for kidney markets.The New Atlantis. 2006; 14 (Accessed July 31, 2009): 47-61http://www.thenewatlantis.com/archive/14/hippen.htmGoogle Scholar]. The point is that our current system brings harm to recipients who are dying by the thousands every year on a waiting list, harm to donors who (correctly) understand the dire consequences of their choice not to donate for their recipient, and harm to legions of victims of organ trafficking who silently shoulder the true costs of our ongoing public policy failure. Incentives can be structured in a way to decisively answer moral objections. Whether the transplant community and our political leaders see fit to understand this point in practice, or whether the needless suffering and economic boondoggle of the status quo will simply continue, remains an open question. We are posed with the hypothetical case of a senator who is considering a bill that will permit payment for living donors. The case may not be purely hypothetical, since the bill was introduced into the United States' Senate in 2008 [9S110, 2nd session Organ Donation Clarification and Antitrafficking Act of 2008.http://fairfoundation.org/organdonation/specter_bill.pdfGoogle Scholar]. Our hypothetical senator is particularly struck by the story told by George Cranford, a computer repair technician whose 25-year-old daughter, Karen, has end-stage renal disease and is currently doing poor on dialysis while waiting for a deceased donor organ. According to Mr Cranford, several friends and acquaintances would donate a kidney for Karen, but they have declined to do so because of concerns of lost income from time away from work, the possibility of losing their jobs, the possible health consequences from having only one kidney, and the stress, pain, and risks of the donation. Mr Cranford expresses the belief that these concerns could be outweighed by the offer of a financial reward of some kind. Karen's story is sad, but so is the story of every individual in end-stage renal disease on dialysis. In addition, there are many such cases, because the demand for solid organs for transplantation greatly exceeds the supply. Despite two decades of attempts to increase the organ donor supply, the gap is growing [10Childress J.F. Liverman C.T. Organ donation: opportunities for action Report of the Institute of Medicine Committee on Increasing Rates of Organ Donation. The National Academic Press, Washington, DC2006Google Scholar]. This gap is growing despite some real increases in the deceased donor supply due to policies, such as required request policies, first-person consent registries, the acceptance of expanded criteria donors, and donation after cardiac death [10Childress J.F. Liverman C.T. Organ donation: opportunities for action Report of the Institute of Medicine Committee on Increasing Rates of Organ Donation. The National Academic Press, Washington, DC2006Google Scholar]. For some organs, a significant increase in supply has occurred with the greater acceptance of the role of living donors. Although the number of kidneys available for transplantation has grown significantly since 1988, (ie, in 1997, there were 7,774 deceased donor kidneys and 3,929 living donors compared with 10,588 deceased donor kidneys and 6,041 living donors in 2007) [11The Organ Procurement and Transplantation Network, data reports.http://www.unos.org/data/about/viewDataReports.aspGoogle Scholar], the demand is still growing faster. Although there were 35,526 patients listed at the end of 1997, there were 66,961 at the end of 2006 [122007 OPTN/SRTR annual report: transplant data 1997–2006, chapter IV: kidney and pancreas transplantation in the United States, 1997–2006: The HRSA breakthrough collaboratives and the 58 DSA challenge.http://www.ustransplant.org/annual_Reports/current/chapter_IV_forprint.pdfGoogle Scholar]. The waiting list surpassed 100,000 in 2009 [13National Kidney FoundationOrgan shortage needs multi-faceted approach.http://www.medicalnewstoday.com/articles/137316.phpDate: January 29, 2009Google Scholar]. This growth in the waiting list can be explained by: (1) the success of modern medicine to keep people alive long enough for their kidneys to fail; (2) an inadequate supply of deceased donor organs; (3) an expanded criteria for eligibility onto the organ waiting list; (4) our aging population; and (5) very significantly, some of our lifestyle choices (the obesity epidemic has contributed to a dramatic rise in diabetes and hypertension, which are the two main risk factors for renal failure). Although the National Organ Transplant Act made it illegal to buy or sell organs in the United States in 1984 [14National Organ Transplant Act Public Law 98-507. October 19, 1984Google Scholar], and the World Health Organization recommended a similar ban in 1991 [15World Health Organization (WHO)WHO Guiding principles on human organ transplantation.Lancet. 1991; 337: 1470-1471Abstract PubMed Scopus (64) Google Scholar] (that was reaffirmed in 2008) [16World Health Organization (WHO)WHO Guiding principles on human organ transplantation.http://www.searo.who.int/LinkFiles/BCT_WHO_guidingprinciples_organ_transplantation.pdfDate: May 26, 2008Google Scholar], support for a kidney market has blossomed in the past decade [17Cherry M.J. Kidney for sale by owner: human organs, transplantation and the market. Georgetown University Press, Washington, DC2005Google Scholar, 18Taylor J.S. Stakes and kidneys: why markets in human body parts are morally imperative. Ashgate Publishing Lmtd, Hampshire, England2005Google Scholar, 19Goodwin M. Black markets: the supply and demand of body parts. Cambridge University Press, New York, NY2006Google Scholar, 20Richards J.R. Nephrarious goings on Kidney sales and moral arguments.J Med Philos. 1996; 21: 357-373Crossref PubMed Scopus (98) Google Scholar, 21Matas A.J. The case for living kidney sales: rationale, objections and concerns.Am J Transplant. 2004; 4: 2007-2017Crossref PubMed Scopus (91) Google Scholar, 22Gill M.B. Sade R.M. Paying for kidneys: the case against prohibition.Kennedy Inst Ethics J. 2002; 12: 17-45Crossref PubMed Scopus (65) Google Scholar, 23Hippen B.E. In defense of a regulated market in kidneys from living vendors.J Med Philos. 2005; 30: 593-626Crossref PubMed Scopus (30) Google Scholar]. In this article, I argue that the market is not an ethical solution to the organ shortage. I argue this position using the bioethical framework developed by Beauchamp and Childress [24Beauchamp T.L. Childress J.F. Principles of biomedical ethics.5th ed. Oxford University Press, New York, NY2001Google Scholar]. Although Matas [21Matas A.J. The case for living kidney sales: rationale, objections and concerns.Am J Transplant. 2004; 4: 2007-2017Crossref PubMed Scopus (91) Google Scholar] has used these principles to argue why a market is ethical, I show why he and other pro-marketers have misrepresented these principles. In the book titled the Principles of Bioethics, Beauchamp and Childress [24Beauchamp T.L. Childress J.F. Principles of biomedical ethics.5th ed. Oxford University Press, New York, NY2001Google Scholar] explicate four fundamental principles of bioethics: (1) autonomy, (2) beneficence, (3) nonmaleficence, and (4) justice. The principle of autonomy (or more accurately, the principle of respect for autonomy) refers to the right of self-determination. In medical ethics, we say that the competent patient (an individual who has decision-making capacity) has the right to accept or refuse medical care, even lifesaving medical care. The principle of beneficence addresses the obligation of physicians to act in their patient's best interest, whereas the principle of nonmaleficence states that physicians should avoid, when possible, harming a patient. Neither of these principles is absolute in that we often cause some harm with our treatments, with chemotherapy for cancer being a case in point. Rather, these principles are understood to mean that the benefits should outweigh the risks of harm. The fourth principle, the principle of justice, is the most complicated one, because it refers to obligations beyond the doctor–patient relationship. Jonsen and colleagues [25Jonsen A. Siegler M. Winslade W. Clinical ethics a practical approach to ethical decisions in clinical medicine.6th ed. McGraw-Hill Companies Inc, New York2006Google Scholar] discuss the importance of justice in policy decisions, but that it should not be used to make distribution decisions at the bedside. There are two main competing conceptions of justice in medical ethics: (1) utilitarian justice and (2) deontological or principle-based justice [24Beauchamp T.L. Childress J.F. Principles of biomedical ethics.5th ed. Oxford University Press, New York, NY2001Google Scholar, 26Veatch R.M. Transplantation Ethics. Georgetown University Press, Washington DC2000Google Scholar]. Utilitarian justice focuses on utility or efficiency. A distribution scheme of organs is just if it maximizes the number of lives or the number of life-years gained. That is, the focus is on maximizing the well-being of the greatest number. In contrast, egalitarian justice focuses on equity and a fair distribution of resources, even at the expense of efficiency. In general, in the realm of organ transplantation, the practice has been to use policies and practices that balance equity and efficiency [26Veatch R.M. Transplantation Ethics. Georgetown University Press, Washington DC2000Google Scholar]. For example, the current deceased donor allocation system focuses on ABO blood type matching (efficiency) and on waiting time (equity). Consider then how the supporters of a market for kidneys would use the four principles to justify the position that Mr Cranford's colleagues should receive a $10,000 incentive to serve as Amy's kidney donor. First, they would argue that the principle of autonomy means that individuals have the right to do as they please with their own bodies. As long as a vendor sells his kidneys voluntarily, without coercion, he should be free to do so [27Friedman E.A. Friedman A.L. Payment for donor kidneys: pros and cons.Kidney Int. 2006; 69: 960-962Crossref PubMed Scopus (70) Google Scholar, 28Friedlaender M.M. The role of commercial non-related living kidney transplants.J Nephrology. 2003; 16: S10-S15PubMed Google Scholar]. Beneficence also supports a market because thousands of individuals die each year on the kidney transplant waiting list so physicians are acting in their patient's best interest by allowing the sale of kidneys [29Satel S. Organs for sale The American.http://american.com/archive/2006/november/organs-for-saleDate: October 14, 2006Google Scholar]. Although the principle of nonmaleficence may argue against kidney sales, the supporters of a market note that we allow emotionally-related living donors to donate their kidneys. If the risks to kidney donors are considered acceptable when given voluntarily, then the risks do not change when money is involved [21Matas A.J. The case for living kidney sales: rationale, objections and concerns.Am J Transplant. 2004; 4: 2007-2017Crossref PubMed Scopus (91) Google Scholar]. Finally, they point out that a utilitarian conception of justice would support any means to increase organ procurement and save lives. Therefore, if the market will reduce the organ shortage and there are good reasons to believe it will [30Adams A.F. Barnett A.H. Kaserman D.L. Markets of organs: the question of supply.Contemp Econ Policy. 1999; 17: 147-155Crossref Scopus (30) Google Scholar, 31Ghods A.J. Savaj S. Iranian model of paid and regulated living-unrelated kidney donation.Clin J Am Soc Nephrol. 2006; 1: 1136-1145Crossref PubMed Scopus (188) Google Scholar], then a market is moral. They do not deny that inequalities exist, but argue that the market will allow individuals with fewer resources to try to improve their situation by vending their kidneys through a voluntary market [29Satel S. Organs for sale The American.http://american.com/archive/2006/november/organs-for-saleDate: October 14, 2006Google Scholar, 32Radcliffe-Richards J. Daar A.S. Guttmann R.D. et al.The case for allowing kidney sales International forum for transplant ethics.Lancet. 1988; 351: 1950-1952Abstract Full Text Full Text PDF Scopus (239) Google Scholar]. So where is the fallacy in their arguments? First, let us look at the principle of autonomy. The principle of autonomy is not absolute, as with all guiding bioethics principles [24Beauchamp T.L. Childress J.F. Principles of biomedical ethics.5th ed. Oxford University Press, New York, NY2001Google Scholar, 33Levine D.Z. Kidney vending: “Yes!” or “No!”.Am J Kidney Dis. 2000; 35: 1002-1018Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar]. There are moral constraints on autonomy. As Oliver Wendell Holmes remarked, “The right to swing my fist ends where the other man's nose begins [34Holmes Jr, O.W. http://thinkexist.com/quotation/the_right_to_swing_my_fist_ends_where_the_other/217369.htmlGoogle Scholar].” That is, one moral constraint on autonomy is harm to others. But the harm to the organ vendor is to himself, not to others, except insofar as one believes that we as a society are worse off if we allow vulnerable individuals to sell their body parts on the grounds of commodification [35Sandel M.J. What money can't buy: the moral limits of markets. The Tanner lectures on human values delivered at Brasenose College, Oxford, May 11–12, 1998.http://www.tannerlectures.utah.edu/lectures/documents/sandel00.pdfGoogle Scholar]. The argument from commodification holds that market valuation has a degrading effect on certain goods and practices if they are bought and sold, even if fair bargaining positions exist (a most unlikely position). But we do place limits on autonomy to protect individuals from themselves. For example, we do not allow individuals to sell themselves into slavery. Part of the argument is the moral dignity of the individual [36Lawler P.A. Is the body property? The New Atlanti