The American system of kidney donation is badly broken. Every year, 4,500 people die waiting for a transplant (that’s 30 a day), even though donating a kidney carries few negative health consequences. The tragedy of this situation has been widely remarked-upon, yet for decades it has persisted. Despite a number of proposed fixes, the number of unfortunate souls awaiting transplants now tops 100,000. Yet there may be one route out of the quandary that serves both kidney patients and justice alike: a universal mandatory nationwide lottery.
In fact, the Harvard economist N. Gregory Mankiw has unintentionally proposed just such a system. As part of his defense of inequality, Mankiw uses the example of kidney donation in an attempt to show how abstract principles of justice are subordinate to real-life practices:
A person in the original position would surely sign an insurance contract that guarantees him at least one working kidney. That is, he would be willing to risk being a kidney donor if he is lucky, in exchange for the assurance of being a transplant recipient if he is unlucky. Thus, the same logic of social insurance that justifies income redistribution similarly justifies government-mandated kidney donation. No doubt, if such a policy were ever seriously considered, most people would oppose it. A person has a right to his own organs, they would argue, and a thought experiment about an original position behind a veil of ignorance does not vitiate that right.
Mankiw believes this unusual argument can undermine the case against inequality; but the idea of mandatory kidney donation is not the self-proving absurdity that Mankiw takes it for. In fact, it may be the fairest way out of our present dilemma.
The system would be roughly as follows: kidney duty would operate like jury duty, a responsibility of citizenship. Individual citizens would be selected at random to be kidney donors, though exemptions could be offered based on age and health. Each person would have an equal likelihood of becoming a donor, with every person on the waitlist being matched with a random mandatory donor. In this way, four thousand lives per year would be instantly be saved.
It may appear illegitimate to jeopardize one person’s health to secure the life of another. But the risks in this case are small; a kidney transplant is a simple operation that leaves the patient with all of their faculties intact. Asking citizens to donate a kidney is therefore no greater a burden than asking them to serve on a jury. (In some cases it may even be less so; trials can drag on for months while transplant operations have a short recovery time.) Furthermore, Americans are already willing to impose health risks on some for the well-being of others; this is the reasoning behind the military draft. If the country can reserve the right to take citizens’ lives in order to serve a vague “national interest,” surely it can perform a minor surgery in order to prevent thousands of very real deaths.
Admittedly, this solution is out-of-step with the present policy orthodoxy. Many economists, including the Nobel Prize winner Gary Becker, have suggested that in order to solve the problem of the kidney waiting list, people should be allowed to sell their organs. This practice is currently banned, but the economic argument is that by opening up a market, the problem would solve itself. Those in need would get kidneys, those who donated would get compensated. The argument is simple, and has been repeated over and over.
Yet objections to the market proposal are powerful. Certainly, it would save lives. But in practice, the wealthy would almost certainly be less likely to auction their kidneys than the poor. The result would be that those who sold their organs would often be driven to it by economic necessity. A situation in which laid-off breadwinners must sell their organs to support their children strikes many as an unpalatable Dickensian nightmare.
By contrast, a kidney donation lottery does not disproportionately burden the poor. Each American is extremely unlikely to be called up, but those selected would be an equitable cross-section of the general public. The burden is trivial and the outcome miraculous.
Greg Mankiw suggests that a person’s “self-ownership” stands in the way of the practice. But in order accept this, we must allow a purely abstract, fictitious interest to triumph over thousands of actual human lives. Mankiw is asking us to prioritize the imagined self-ownership of some over the very real self-preservation of others. Anyone who argues this believes that people ought to die in order to preserve her own personal convenience.
At the personal level, it is almost certainly morally indefensible for an individual not to donate his or her kidney. After all, a life is saved at relatively little cost to one’s self. But the gross selfishness of withholding one’s organs does not seem a sufficient motivator for people to voluntarily close the transplant gap. (I have not donated a kidney myself, despite knowing full well that not doing so is killing someone.) More vigorous measures must therefore be taken.
Every year, America’s kidney crisis results in a number of deaths equal to more than one-and-a-half 9/11s. It is far past time to end this moral horror, by establishing a universal national kidney lottery.