Incentives, kidney donation, and the myth of the Iranian waiting list

In a recent New York Times article, Tina Rosenberg argues that the United States should introduce financial incentives for living kidney donors. She writes, “In 2014, there were 17,106 kidney transplants in the United States, but more than twice that many people went on the waiting list.”

She believes that use of incentives could resolve this problem because the legal Iranian market for organs has “essentially eliminated” the waiting list for a kidney.

Such claims about the Iranian waiting list, which are commonly invoked in support of kidney markets in the United States and elsewhere, are simply false. People with end stage kidney failure living in the United States are more likely to receive a transplant than those living in Iran. Commentators debating the issue of incentives for donation have a responsibility to draw on the best available evidence in their arguments, and should not simply recycle and perpetuate myths about the success of the Iranian market.

What counts as proof that a waiting list has been eliminated?

The alleged success of the Iranian kidney market is regularly cited in public commentary and academic debate by advocates of financial incentives. References in scholarly publications can usually be traced back to a 2002 publication by Iranian nephrologist Ghods in which he declared that, “the renal transplant waiting list [in Iran] was eliminated by the end of 1999.”

What does it mean to “eliminate” a waiting list for transplantation? In many countries people in need of a kidney transplant may be unable to join a national waiting list for transplantation because

  • They cannot access healthcare services necessary for diagnosis of kidney failure, or required to prepare them for transplantation such as dialysis;
  • They cannot afford transplantation services or immunosuppression;
  • They do not meet eligibility criteria for the waiting list, where criteria such as age or comorbidities are designed to keep the list sufficiently short to match the supply of organs available for transplant;
  • There is no national waiting list for transplantation.

In a 2006 publication by Ghods and Savaj which is also cited as evidence that incentives have solved the problem of organ shortages in Iran, the authors again claim that “by 1999, the renal transplant waiting lists in the country was eliminated successfully”. In this paper, they offer an explanation which shows that the size of the waiting list in Iran is influenced by lower rates of diagnosis of end stage kidney disease:

In Iran, as in other developing countries, the prevalence of patients with ESRD is markedly lower compared with the prevalence of patients who are on renal replacement therapy in developed countries. A major cause of this is the many patients who are from villages and small towns and do not receive a diagnosis and are not referred for dialysis therapy. There also is no adopted restricting policy for accepting patients with ESRD for renal transplantation; however, the low prevalence of patients with ESRD results in fewer numbers of transplant candidates. This is the main reason that the renal transplant waiting list was eliminated quickly and successfully in Iran….”

Ghods, A. J., & Savaj, S. (2006). Iranian model of paid and regulated living-unrelated kidney donation. Clinical journal of the American Society of Nephrology, 1(6), 1136-1145. (p.1139)

The truth about the Iranian waiting list

Claims about the successful elimination of the Iranian waiting list in the early 2000s were questioned by commentators such as Griffin. However, incentive advocates have preferred to express ethical concerns about some elements of the Iranian model, arguing that better regulated incentive systems will address these, rather than to question the success of the model.

Commentators writing today ought to draw on more recent analysis of the Iranian market. A recent report by Iranian experts clearly shows that there is indeed a waiting list for kidney transplantation in Iran:

Rouchi, A. H., Ghaemi, F., & Aghighi, M. (2014). Outlook of Organ Transplantation in Iran. Iranian journal of kidney diseases, 8(3).

In this paper, the authors provide the following table summarising the disparity between the number of transplants and the number of patients waitlisted for transplantation in 2011:

Iran Waiting list

The authors note that, “the never-disappearing waiting list for kidney transplantation will be growing steadily”.

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