By Aksel Braanen Sterri.

Worldwide 1.2 million people are dying from kidney failure each year. The best treatment for kidney failure is a kidney transplant from a living donor, but too few people are willing to donate. In the paper, Prize, Not a Price: Reframing Rewards for Kidney Donors, I defend a way to meet the need for kidneys that escapes many pressing ethical objections.

Several philosophers and economists argue that we motivate more donors by paying them to part with a kidney. However, despite the many benefits of a market, it faces compelling ethical objections. A kidney market can be degrading, demeaning, and solidarity-undermining.

These objections all stem from the belief that there is something special about providing a kidney, which calls for a recognition that exceeds mere payment. Kidney donations are bodily intrusive, singular acts that save lives, which demands a substantial risk to one’s health. Such acts, many people think, should be met with gratitude, not a mere payment.

I argue that the demeaning, degrading, and solidarity-undermining effects of a kidney market depend on the way donors are rewarded. If we rewarded kidney donors in a way that expresses our gratitude, we could avoid these harmful effects. For that purpose, I suggest framing the reward like a prize, not a price.

Imagine the following yearly 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 100,000 pounds. The least we can do is to show our sincere recognition of their benevolence.

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. When we honor the sellers with a prize at a public ceremony, we also minimize the likelihood that selling kidneys is seen as demeaning. Moreover, it could also better express a norm of solidarity than the current system, which relies on family and friends to provide kidneys and thus, in a sense, privatizes responsibility for health needs. In the prize model, the government is taking responsibility for procuring kidneys for people who suffer from kidney failure and honoring donors for their contributions to the collective good.

An avenue for future research is to see if the model could fit for other contested goods. A promising application could be to reward participants in trials for finding a vaccination for Covid-19. Nir Eyal, Marc Lipsitch, and Peter G. Smith have argued that we should speed up the vaccination process by asking healthy, young adults to participate in a human challenge trial. They concede that “challenging volunteers with this live virus risks inducing severe disease and possibly even death,” but argue that the costs are worth it “in the circumstances of a devastating global pandemic.”

It seems appropriate to monetarily compensate people who are willing to take on such a risk for the benefit of others. The authors nevertheless resist paying the volunteers to secure “a high level of public trust.” A worry could be that a mere payment does not correctly recognize the sacrifice of the volunteers. However, a prize with a monetary component could give the participant compensation and show public recognition of the extraordinary sacrifice these people are making. The prize model could therefore secure public trust.

“Public honor is,” as Michael Walzer puts it in Spheres of Justice, “a true speech about distinction and value.” We therefore need a continuous exploration of which human activities deserve to be honored. Besides being appropriate, honoring could also be done for instrumental reasons. How to best use public honor to utilize the pursuit of recognition and status, a vital motivator, is therefore a worthwhile research project for everyone seeking to nudge human behavior towards good ends.

Paper title: Prize, Not Price: Reframing Rewards for Kidney Donors

Author: Aksel Braanen Sterri

Affiliations: PhD Candidate, University of Oslo

Competing interests: None

Social media accounts of post author: @AkselSterri