How to stop losing 17,500 kidneys

System design and UNOS / OPTN performance

• Some see current U.S. organ allocation as a “regulated monopoly” rather than real central planning or a real market, and argue that such structures predictably fail users.
• Others cite transplant clinicians claiming the critique is overstated: many recovered kidneys are discarded because they are clinically unsuitable; organs are often GPS‑tracked; waiting lists are regularly updated; and prior living donors already get priority.
• These counterclaims are themselves disputed: GPS tracking is not universal; the reported 17% of offers going to deceased patients is backed by published data; and there is concern about lack of code audits and outdated crypto.
• Commenters note 17 days of OPTN downtime since 1999 and debate whether old crypto “algorithms” are inherently insecure.

Market vs central planning for organs

• Strong disagreement over introducing explicit markets:
  • Pro‑market voices argue kidneys are a textbook fit for market design; everyone has two; failure is rare; and structured markets (often with the state as monopsony buyer) could be “win‑win” and reduce deaths.
  • Opponents cite Afghanistan‑style sales as examples of exploitation: desperate poor people selling kidneys for little money and facing lifelong health risks.
• Some emphasize that economists have designed non‑cash “markets” (e.g., paired kidney exchange) that increase matches without direct payment.

Paying donors and ethical concerns

• Several people resist donating because all intermediaries are paid while donors/estates get nothing; they’d donate if families were compensated or if organs were tradable assets.
• Others argue non‑donors should be ineligible or deprioritized for receiving organs.
• Fears raised:
  • Incentivizing suicide or murder for organ money.
  • Systemic transfer of longevity from poor (sellers) to rich (buyers).
  • Growth of black markets and trafficking, analogous to prostitution or pandemic plasma markets.
• Counterarguments:
  • Living kidney donation risk is comparable to other dangerous but permitted jobs.
  • Banning compensation doesn’t remove poverty; it just removes an option.
  • Compensation could be in kind (lifetime healthcare, tax breaks, program priority), not simple cash.

Donation behavior and incentives

• Debate over opt‑out vs opt‑in: opt‑out alone may not increase donations much because hospitals still seek family consent, and refusals are common when wishes aren’t explicit.
• Some propose tax deductions or other benefits for long‑registered donors, or priority access if they ever need a transplant.

Medical practice, risk, and technology

• Clinicians’ selection behavior is criticized: some transplant teams may avoid higher‑risk organs or patients to protect their success statistics, potentially wasting usable kidneys.
• Commenters note that not all removed organs are clinically viable; rejecting marginal kidneys can be medically defensible.
• One transplant recipient urges reconsideration of “no donation” stances; others with chronic conditions stress prevention and maintaining original organs over reliance on transplants.
• New technologies like organ perfusion and xenotransplantation (e.g., pig kidneys) are highlighted as promising ways to expand usable supply, though regulatory and institutional red tape may slow adoption.