Justice Everywhere

a blog about philosophy in public affairs

We have a duty to pay for kidneys

In this post, Aksel Sterri discusses their recent article in Journal of Applied Philosophy on the ethics of a government-monopsony market in kidneys.


Two million people suffer from kidney failure worldwide. They either die or live difficult lives on dialysis while waiting for kidneys to become available for transplant, from dead or living donors. Our failure to meet the need for kidney transplants is a moral failure that calls for a change in how we procure kidneys. In a recent paper, I argue members of nation states have a collective duty to pay kidney donors to ensure that people in need receive a new kidney.

In most states, the system for procuring kidneys from live donors is highly regulated. It is nevertheless fundamentally privatized. We burden the person in need of an organ with the responsibility of finding a donor while prohibiting them from compensating the donor monetarily. The result of this is to decrease the number of willing donors, leaving many without hope for a new kidney. In the United States alone, 100,000 people are waiting to get a kidney, and the list is growing.

The system also perpetuates inequalities. A recent report from the US government reveals that ‘65.9% of transplant recipients were white, though they made up only 36.2% of the waiting list’. In contrast, only 12.5% of the transplant recipients were Black, although they made up 33% of the waiting list.

This state of affairs is not only unfortunate, it is also unjust. We arguably have a collective responsibility to meet the health care needs of the sick. You are not normally forced to go to family and friends to get them to pay your dialysis bill. People in need direct their claims to the government, and individual duty bearers support the system by paying their fair share in taxes. In the United States alone, taxpayers spend $34 billion on dialysis.

Unfortunately, dialysis is a highly suboptimal treatment compared to a transplant. Only 35 percent of people on dialysis survive the next five years, while the same is true for 80 percent of people who receive a transplant. The collective has a duty to provide the best available treatment at reasonable cost. Since the best available treatment is kidney transplants, the collective must provide kidneys if that can be done without imposing excessive burdens on anyone in the process.

A market in kidneys where the government is the sole buyer and where the sick can claim kidneys for free is a way for the collective to fulfill its duties to the sick without imposing excessive burdens on anyone. The primary function of paying donors is of course to give people an incentive to part with a kidney. However, it also serves to distribute the burdens more fairly among the duty bearers compared to the current scheme, where family and friends must step up with no claim to compensation.

Despite this model’s ability to provide everyone in need with kidneys, several objections have been raised against it. Here I want to address one principled objection from Cécile Fabre. Fabre argues we have individual obligations to donate kidneys to people in need but believes it is wrong to pay donors. The reason is that it is wrong to pay someone to fulfill their duties. If you come across someone drowning in a shallow pond, you have an unconditional duty to save the person. It would be wrong to make your help conditional on being paid.

Although I believe we have unconditional duties to help in emergencies, the argument does not easily generalize. We are, as a community, permitted to pay someone to work as a lifeguard in the local swimming pool even though we pay them to do what would otherwise be their duty.

I argue the difference between the two cases is that, in the case of the shallow pond, we have a dyadic obligation. You owe it to the person in question to rescue them. In the case of the lifeguard at the local swimming pool, however, the moral relationship is triadic. It is the community that is the primary duty bearer. The community has a primary duty to the swimmers to keep them safe and hires a lifeguard to fulfill that duty. It also has a secondary duty to the lifeguard to satisfactory compensate them for their time.

The same logic applies in the case of kidney transplants. Since we have a collective duty to people who suffer from kidney failure, it is not wrong for an individual donor to be paid. On the contrary, it is a requirement of justice. The collective does not only have duties to people in need but secondary duties to the individual duty bearers to distribute the burdens fairly among them. The best way to do that is to reward the donors generously for the responsibility they accept on behalf of the rest of us.

Rewarding donors could be done through setting a high price on kidneys, but also, as I argue elsewhere, through a public ceremony, where donors are recognized with a monetary prize, not merely a payment. Whichever form of reward we choose, monetarily compensating donors is the way to fulfil our duties to those in need.

The Journal of Applied Philosophy is a unique forum for philosophical research that seeks to make a constructive contribution to problems of practical concern. Open to the expression of diverse viewpoints, it brings the identification, justification, and discussion of values to bear on a broad spectrum of issues in environment, medicine, science, policy, law, politics, economics and education. The journal publishes in all areas of applied philosophy, and posts accessible summaries of its recent articles on Justice Everywhere.

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1 Comment

  1. Note: Always review your references and make any necessary corrections before using. Pay attention to names, capitalization, and dates. Ethical theories normally make room both for global duties to human beings everywhere and special duties to those we are attached to in some way. Such a split-level view requires us to specify the kind of attachment that can ground special duties, and to explain the comparative force of the two kinds of duties in cases of conflict. Special duties are generated within groups that are intrinsically valuable and not inherently unjust, where the duties can be shown to be integral to relationships within the group. Since nations can be shown to meet these conditions, acknowledging special obligations towards compatriots is justified. However for such partiality to be reasonable, it must be balanced against recognition of duties of global justice. These duties include duties to respect human rights and duties of fairness towards non-nationals. Weighing such duties against domestic duties of social justice is not a simple task, and the outcome should depend on the precise specification of the duty at stake. In particular, the duty to respect human rights fragments into four sub-duties whose force when set against local duties is markedly different.

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