LAUSR

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 *Correspondence: Dorry L. Segev [email protected]