Article Text

Prize, not price: reframing rewards for kidney donors
1. Aksel Braanen Sterri
1. Department of Philosophy, Classics, History of Art and Ideas, University of Oslo, Oslo, Norway
1. Correspondence to Aksel Braanen Sterri, Department of Philosophy, Classics, History of Art and Ideas, University of Oslo, Oslo 0316, Norway; akselbst{at}gmail.com

## Abstract

Worldwide 1.2 million people are dying from kidney failure each year, and in the USA alone, approximately 100 000 people are currently on the waiting list for a kidney transplant. One possible solution to the kidney shortage is for governments to pay donors for one of their healthy kidneys and distribute these kidneys according to need. There are, however, compelling objections to this government-monopsony model. To avoid these objections, I propose a small adjustment to the model. I suggest we reward kidney sellers with both money and a ceremony that celebrates their noble act. They should, in other words, receive a prize rather than a price.

• kidneys
• allocation of organs/tissues
• ethics
• human dignity
• transplantation

## Data availability statement

There are no data in this work.

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## Introduction

Worldwide, 1.2 million people are dying from kidney failure each year, and in the USA alone, approximately 100 000 people are currently on the waiting list for a new kidney.1 Since most of us walk around with a spare kidney, the kidney shortage is due to a lack of motivation; too few people want to donate. Another problem is that living donors who undergo an invasive and risky procedure are not compensated for their sacrifice. When donations are framed as ‘priceless gifts’, recipients may also suffer from a heavy burden of gratitude they can never repay.2

To solve these problems, philosophers and economists have proposed that kidney donors should be paid.3–14 Since money is a powerful motivator, more people with kidney failure could receive healthy kidneys if people can be paid to give one to others. Being paid could also benefit potential sellers, who presumably sell a kidney because they believe the money will be of greater benefit than their spare kidney.13 If sellers are paid a fair price, this would also relieve the recipients of a burden of gratitude. When someone provides a service at a given price, they are rarely owed anything beyond payment. The preferred model among many defenders of kidney markets is one where the government is the sole buyer of kidneys from healthy donors, it pays a fixed price, and kidneys are distributed for free to people according to need.3 4 6 10 15

Despite the many benefits of a government monopsony market in kidneys, it is vulnerable to several objections. The focus of this paper is on the degrading, demeaning and solidarity-undermining effects of introducing a market in kidneys. In what follows, I will present these objections in what I take to be their strongest form. Then I present my own proposal. I call it the kidney-reward model, and it consists in giving donors a prize delivered through a public ceremony. I go on to show how this model escapes the objections against a government monopsony market. If the kidney-reward model is to be rejected, it has to be rejected on other grounds. Since the model I am proposing is a hybrid between a market model and an altruistic model, I will sometimes use ‘donations’ to refer to the act of giving up a kidney, even though the donor receives money.

## Three objections

### The wrongful valuing objection

Sandel argues that payments may wrongly value the act of donating a kidney.16 This objection is often known as the commodification, corruption or degradation objection. The root of the concern is that the way we respond to people’s actions communicates certain attitudes and values and that some actions call for responses other than a payment.17 If we offer to pay a friend for helping us move to a new house, we risk expressing estrangement and disrespect. Sandel suggests it may similarly be wrong to value the act of donating a kidney through a payment or a monetary incentive.

### The demeaning objection

Another concern with a government monopsony market is that selling a kidney will be seen as demeaning. Within the current system, an uncompensated kidney donor is portrayed as someone who is worthy of praise for committing a great bodily sacrifice for someone in need.18 This is put in danger if donors become sellers. If people in poverty start selling their kidneys to make ends meet, selling kidneys may be seen as a mark of poverty, which might negatively impact the sellers’ self-esteem.19 20 The mere act of giving the offer may even be considered demeaning or disrespectful. To offer to buy someone’s kidneys could communicate that one treats them as spare body parts. In Iran, the only country with a monopsony model, many donors report that they see the act as demeaning.10 21

### The crowding out objection

The communicative effects of a government monopsony market in kidneys can also have wider spillover-effects. The concern, according to Titmuss who famously argued against a market in blood, is that some acts of altruism are particularly symbolically powerful.22 When someone is donating a kidney as a gift, we understand the act as an expression of altruism and solidarity.18 When we buy kidneys at a fixed price, we risk expressing to society that we only do something for others if we get something in return. We should not expect these effects to be the result of changes limited to the parties to the donations.7 What matters is the common knowledge that we live in a society where people altruistically donate kidneys to people in need. Although it is difficult to establish such an effect empirically, it is plausible that it may have an effect on our prosocial attitudes and behaviour.20 22

Can we design a variant of the government monopsony model that does not face the three ethical objections raised above? This may be of interest first and foremost to the extent that one finds the objections forceful. However, even if one does not find the objections forceful, it is a fact that many people do. It would, therefore, be prudent, even for the people who do not find these objections persuasive, to see if it is possible to design a system that is not vulnerable to these objections.

## The reward model

Imagine a splendid ceremony where the minister of health addresses the audience:

We are here to celebrate the brave people who have shared one of their kidneys with people in need so they can live a longer and better life. I’m sure the recipients are grateful for their generosity. But it is first and foremost we, as a collective, who ought to be grateful for these praiseworthy acts by some of our finest people. After all, it is we who bear the responsibility of providing people in need with the necessary help to live decent lives. For the great sacrifice that is made on our behalf, a reward is in place. To show our gratitude, we offer each person that has given one of their healthy kidneys a prize, which comes with US$100 000. The least we can do is to show our sincere recognition of their benevolence. The prize recipients are welcomed on stage, where they receive a diploma and a standing ovation from the crowd. The ceremony is streamed online, where one can watch and read interviews with the donors and recipients. Here they tell their stories, about what motivated the donors to give, and how a new kidney changed the lives of the recipients. A reward, or a prize, differs from other ways of responding to and motivating people to donate kidneys. We use incentives to encourage people to do something they otherwise may not do and compensation to make sure that people are not set back by their actions. When we reward, we want to publicly recognise that someone has done something extraordinary. As Walzer puts it: ‘Public honor is not a gift or a bribe but a true speech about distinction and value.’23 These categories are not mutually exclusive. Compensation works as an incentive, as it removes a barrier against acting. Similarly, when people work because they receive pay, they are incentivised and compensated for what they have to forego to be at work. Despite their commonalities, the different categories communicate something particular about the transactions they describe. They tell us something about the intention of the party that provides the money and the meaning we collectively ascribe to the transaction itself and the parties that engage in it. When we frame something as a reward, we intend to make it known to the world that someone has done something extraordinary and, therefore, deserve praise. A reward is itself a vehicle through which we give praise and a way we publicly recognise that an extraordinary act has been performed. Rewards can take many forms, such as a medal, diploma, public ceremony or statue. One can get one’s name on public buildings or scientific discoveries. A reward can also, like the proposed kidney-reward model, include a monetary aspect. In this way, it is similar to the Nobel Prize, which is accompanied with US$1 million.

We could also imagine a reward-model without a monetary element. This is the way we normally reward individuals who have done a great service to their country. We could also include a monetary element that is smaller than US$100 000. This is often the model preferred by people who seek to combine honorific elements and monetary incentives to induce more people to donate kidneys.24–26 What distinguishes my proposal from these is that it combines a generous monetary reward with an honorific element instead of downplaying the monetary aspect, either through earmarking the incentive to a charity of one’s choice or giving a small monetary incentive. In section 5, I will defend the reward model I propose against these other models. In the next section, I will examine whether the model can respond to the objections to a government monopsony market raised above. ## How reward plus money can avoid the three objections ### The wrongful valuing objection The wrongful valuing objection states that paying for kidneys is the wrong way to value the act of donating a kidney. One concern is that putting a price on something makes it into a commodity; it reduces its value to its price. However, Christians are perfectly capable of understanding that the value of a Bible is not exhausted by its price.19 The wrongful valuing objection should not, therefore, be understood as an argument against giving money to kidney donors. Rather, the concern is that paying the donor is insufficient to appropriately value parting with a kidney. There seems to be something special about providing a kidney, which calls for a recognition that exceeds a mere payment. I tentatively suggest that kidneys are unlike other goods and services we buy and sell, because they are bodily intrusive, singular acts that save lives, which demand a substantial risk to one’s health. Such acts, we think, should be met with gratitude, over and above any payment they may receive.25 When money is given through a prize, it could escape the objection that a mere price fails to express the value of donating a kidney and thus that a government monopsony market degrades kidney donations. The monetary value of a prize is clearly not meant to exhaust the value of what is rewarded. We do not take the dollar amount to reflect society’s evaluation of prize winners’ contributions, or society’s willingness to pay for them. Similarly, the reward and the ceremony express the idea that the act of giving a kidney is not an ordinary market transaction but rather a great sacrifice to help someone in need.27 It is, therefore, a better way to express society’s appreciation of the donation compared with mere payment. An objection to a generous monetary payment is that the monetary aspect of the reward will be too salient, and that it will, therefore, be understood as a mere market transaction. However, as the work of sociologists, economists and social psychologists show, there is nothing automatic in money dominating our interpretation of an act.28–31 Money that is framed in the right way can even support the moral message by giving it more weight, as when a parking ticket successfully complements a moral message against free-riding on public goods or the Nobel Prize is accompanied by US$1 million.

What sum and what framing would be acceptable is difficult to know in advance. However, there are several experiments that can be performed to get an idea of how people will view the different models. One could, for instance, design survey experiments where people are showed the description of the reward model, where different aspects including the size of the monetary component of the prize are varied. There may or may not be a threshold where money dominates the interpretation of the act.

When kidney donations are framed as heroic and highly moral acts, and the prize is set at a sufficiently generous level, it could also protect the sellers against the loss in their social status that could result from a government monopsony market. Through the ceremony and the generous monetary reward, the donors are marked as people who are elevated above the crowd for doing an extraordinary sacrifice. The generous monetary reward and public recognition are together expected to motivate people from a broad set of backgrounds, thus avoiding that selling a kidney is seen as something only poor people do. In a recent study, 31.3% of people living in Philadelphia, USA, with an annual household income above US$100 000 said they were willing to sell a kidney for US$100 000. 47.9% of people with an annual household income below US$20 000 were willing to sell a kidney at the same price.32 We should expect even more people on higher incomes to be willing to provide a kidney if they can receive public recognition. A forceful challenge to any proposal that includes paying donors has recently been raised by Rippon.33 34 He believes that everyone has a right to ‘fully autonomous veto power over any physical incursions on the most intimate parts of our bodies by other people,’33 and that offering to buy someone’s kidney if they are too poor to reject the offer is to violate this right. In his most recent paper, he frames this concern as one of disrespectful demands. Rippon asks us to imagine a case where someone is drowning and rescuing is supererogatory. The only person in a position to rescue offers to help under the condition that the person about to drown give away one of their kidneys. Although the offer may be mutually beneficial and the drowning person agrees to the deal, the offer would be both wrong and disrespectful. It is no better, Rippon argues, to offer to buy a kidney off someone who lives in poverty and is without decent options. One response would be to exclude such people from the pool of potential donors. If honour and money can reinforce each other, sufficient number of people with decent options would be willing to donate. However, a problem with this strategy is that the very people we are trying to help by excluding them from the donor pool may end up worse off. Even if the offer is disrespectful, people with no decent options may nevertheless prefer having the option of selling a kidney open to them so they can make their situation somewhat better. Disrespect is only a pro tanto reason against offering to pay donors, which can be outweighed by other concerns, such as improving the material well-being of the prospective donors. Neither is it clear that offering to reward someone for their kidney is disrespectful if they lack decent options. Consider a modified version of the drowning case. A shipwrecked person will drown in the coming storm if he is not helped. The storm is so dangerous that rescue is supererogatory and no one among the hundreds of people in the village are willing to embark on a rescue mission. However, they know of a mother who is desperate to help her son who is in need of a kidney. The people in the village work as intermediaries between the mother and the person about to drown and they ask the drowning person if he would be willing to donate a kidney if the mother is willing to risk her life by coming to rescue. Although both parties are offered disrespectful offers on Rippon’s account, it does not seem plausible that the offers are disrespectful in a way that makes it wrong to make them. We should, therefore, not assume that offering to buy a kidney from someone without decent options is necessarily wrong. The amended drowning case also challenges Rippon’s favored explanation of why it is wrong to offer someone help under the condition that they donate a kidney: that it violates someone’s autonomous veto control over physical incursion on their bodies. Whether an offer is disrespectful or not seems to depend on other factors, such as whether the reward is proportional to what is asked of the seller and whether the recipient and seller are equals. Currently, people are dying or living miserable lives without access to kidneys. If the collective is asking people to help and offers to reward them for their benevolence, people who are desperately poor may feel pressured to agree. However, if this is our only chance to help people in need and the donors are compensated fairly and honoured for their benevolence, the offer can arguably be made without expressing disrespect. They are therefore not made worse off by having the option open to them. ### The crowding out objection By expressing that a great sacrifice is done, the reward model may also increase solidarity rather than crowd it out. Remember, Titmuss’s worry was that a market would replace a system of altruism that communicates that ‘I do good deeds for other citizens I do not know’ with a system that communicates ‘I will only do something for others if I am paid.’ The claim is not that kidneys are always donated for altruistic reasons within the current scheme. Rarely is altruism the only reason why people donate: family pressure and self-interest also play a role.35 Neither is the claim that one cannot sell a kidney out of altruism. If one sells a kidney to pay for life-saving medical treatment for one’s children, this is certainly an act of altruism.12 The concern lies, again, with the communicative effects of a market. And in that respect, the reward model is arguably better than the current model. Currently, very few live donors give kidneys to strangers. To the extent that people donate during their lives, they donate to their friends and relatives. It is therefore more likely to communicate parochial values, not solidarity among citizens. The kidney-reward model, on the other hand, will motivate strangers to donate a kidney and thus demonstrate that strangers are willing to make a substantial sacrifice for their fellow citizens and that the community is willing to generously reward people who do so. ## Why a generous reward? Why prefer a kidney-reward model with a generous monetary component instead of a smaller monetary incentive or a purely honorific model, as is more commonly proposed? The reason is that a generous reward is more likely to satisfy the reasons for considering a government monopsony market in the first place: that we compensate the donors fairly, relieve the recipient of a burden of gratitude, and motivate a sufficient number of donors. If the government takes on responsibility for people’s basic healthcare and asks citizens to make a substantial sacrifice to meet that goal, it seems appropriate that the donors receive adequate compensation. When someone is donating a kidney, they create a surplus by saving money on dialysis and enabling the recipient to go back to work. According to one recent estimate, a donated kidney reduces healthcare costs by US$1.3 million.36 The donors who make this important contribution should receive a fair share of the surplus.

Providing the donor with fair compensation will also relieve the recipient of a burden of gratitude. A concern with the current system and any other system that relies on family members and friends to donate out of their good will, is that the recipient may perceive the kidney to be a ‘priceless gift’ they will never be in a position to return. A public ceremony can alleviate the burden of gratitude by communicating that the collective takes responsibility by honouring the donors. However, without a substantial monetary component it may be insufficient to clear the deck. The reward needs to be sufficiently substantial to relieve the recipient of ‘the tyranny of the gift’.

A final concern is that a reward-model with no or a small monetary incentive may not be able to motivate a sufficient number of donors. Admittedly, given that people seek honour, a reward should be able to motivate more people to donate than the current system. However, the reward is likely to be more motivating if it is accompanied with a generous monetary prize, although the appropriate value of the monetary reward is partly an empirical question.

## Conclusion

I have argued that several compelling ethical objections against government monopsony markets have to do with the communicative effects of a market. By using the fact that rewards express very different things depending on how they are given, I have proposed a model for how a government-monopsony market can meet these objections.

When we consider the ethics of markets, the interesting thing is not whether there are bad ways of doing something, but whether any good ways exist. I do not claim to know what exact features a kidney-reward model, such as the one I have proposed, should have. However, I am confident that a prize with a monetary component is a promising way to show our gratitude to kidney donors.

## Data availability statement

There are no data in this work.

## Acknowledgments

I am grateful for the thorough and very constructive feedback from two anonymous reviewers. I have benefited from feedback on earlier versions of this paper by colleagues at the University of Oslo, the Oxford Uehiro Centre for Practical Ethics, and Harvard’s Government Department. I would especially like to thank Sadie Regmi, Ole Martin Moen, Alejandra Mancilla, Becky Brown, Michael Sandel, Robert Huseby, James Stacey Taylor and Alexander R. Cohen for their many helpful comments during the development of the article.