Is the seller of a kidney being exploited? To focus on the difficult issues, let’s assume that the seller is of good mind and fully informed about all the risks of donating a kidney. Even in this situation, many people argue that someone selling a kidney is being exploited. Dr. Francis Delmonico, a transplant surgeon and prominent opponent of kidney sales, argues that “payments eventually result in the exploitation of the individual. It’s the poor person who sells.”2

Delmonico is correct that a poor person is more likely to sell a kidney than a rich person. But does this mean that the poor person who sells a kidney is being exploited? Let’s consider three cases.

Case 1: Alex buys a kidney from Ajay.

Case 2: Alex pays Ajay to clean his house.

Case 3: George Mason University pays Alex to grade exams.

In all three cases, the seller would not sell if he were wealthier. So are the sellers (Ajay in the first two cases and Alex in the third) being exploited? We may feel that there is something different about selling a kidney, but it’s difficult to see the dividing line that separates exploitation from exchange. Many people in rich and poor countries alike take jobs that involve significant risks. The yearly mortality rate for commercial fishermen in Alaska, for example, is seven times higher than the mortality rate for donating a kidney—so why is donating a kidney different from fishing in Alaska?3

One response is that for a poor person the money is exploitative because the circumstances of poor people give them little choice but to sell things they would rather keep. But consider which of the three following cases is most exploitive:

Case 1: Someone asks you to donate a kidney but offers you nothing in return.

Case 2: Someone offers you $5,000 to donate a kidney.

Case 3: Someone offers you $500,000 to donate a kidney.

Few people would say that case 1 involves exploitation. But what about case 2 and case 3? If case 2 is exploitative, then case 3 must be even more exploitative—after all, the temptation to sell is many times greater. In fact, many more people, including a great many people in rich countries, would accept an offer of $500,000 to sell one of their kidneys. But it seems odd to say that case 3 is the most exploitative case. The usual story is that buyers exploit sellers by offering them too little, not too much! But if bigger offers are less exploitive, then case 2 can’t be exploitative either because case 2 is case 1 plus some money and how can offering someone more be a way to exploit them?

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If someone offered you $500,000 to sell your kidney, would you feel exploited? Probably not. After all, you could always say no. But if case 3 doesn’t exploit you, it’s hard to see how case 2 exploits Ajay. Maybe Ajay needs the money more than you but imagine, for example, that 10% of the people in India would accept $5,000 for a kidney and 12% of people in the United States would accept $500,000 for a kidney. Does this make the larger offer more exploitive?

Keep in mind that everyone agrees that abject poverty is itself a problem. Overall, it would be better if people had access to clean water, good health care, and more wealth. The issue is whether it’s wrong to offer to buy things from the poor just because they are poor. We will be returning to the issue of poverty and the distribution of income later in the chapter.

One more point: we assumed for the sake of argument that the seller of the kidney was of good mind and understood all the risks. One possible response is to say that no one ever understands the risks well enough to make trades like this. If that is the case, however, then we ought to ban gifts of kidneys as well as sales. In fact, thousands of people voluntarily give one of their kidneys away every year and we generally regard such people as heroes. But we don’t allow anyone to buy or sell a kidney, despite the fact that doing so could save many thousands of lives.