From Scarcity to Abundance: What the End Kidney Deaths Act Teaches Us About Spending at Scale
The kidney shortage is a design failure hiding in plain sight.
Every year, roughly 10,000 Americans die while waiting for a kidney transplant. They are not dying because we lack medical knowledge, and they are not dying because we lack money. They are dying because we have built a system that produces kidney scarcity and then treats that scarcity as inevitable.
It is not inevitable.
That matters far beyond kidney policy. Effective altruism is increasingly asking what happens in a world with dramatically more capital. That is an important question. But the kidney shortage reveals something equally important: sometimes money is already abundant, and people still die because institutions fail to design systems that convert resources into outcomes. The End Kidney Deaths Act forces that failure into the open.
A Solvable Problem That Continues to Kill People
Nearly 90,000 Americans are currently waiting for a kidney transplant, and around 10,000 die each year waiting. We know how to stop most of those deaths: transplant more kidneys. This is not a technological challenge. We already know how to perform kidney transplants, and living kidney donors routinely save lives while going on to live healthy lives themselves. The problem is supply.
The alternative to transplant is often described in sterile policy language. It should not be. People frequently begin dialysis by walking into the clinic. Then they arrive in wheelchairs. Eventually, many arrive on gurneys. Roughly 60 percent of dialysis patients die within five years, while dialysis consumes roughly one percent of the federal budget. We are spending enormous sums of money to keep people alive in a system that often delivers suffering first and death later.
For decades, policymakers have pursued reforms that are now available to the majority of donors: reimbursing travel costs, covering lost wages, and paying for dependent care. These reforms are humane and worth supporting. But they have not solved the problem. Living kidney donation has remained largely stagnant for 25 years. This is not a failure of compassion. It is a failure of imagination and institutional design.
The Taboo We Refuse to Question
The End Kidney Deaths Act (HR 2687) proposes a ten-year federally regulated pilot program that would provide nondirected kidney donors with $10,000 annually for five years. It is a carefully structured pilot designed to generate evidence. It is also bipartisan, with 48 House sponsors.
And yet opponents often treat it as morally radioactive. Not because they have proven it will fail. Not because they have shown that it will harm donors. They object because it violates a cultural norm that many people refuse to interrogate: the belief that certain forms of life-saving altruism must remain unpaid.
That principle is not applied consistently. We compensate plasma donors. We compensate surrogates. We compensate participants in clinical trials. A frequent plasma donor can earn roughly $50,000 over five years. Surrogates often earn far more. Yet compensating someone who undergoes surgery to save another person’s life remains taboo. Kidneys are treated as morally exceptional and their work not worthy of payment. The price has been needless suffering and the death for 10,000 waitlisted Americans every year.
What the Current System Actually Does
Defenders of the status quo often speak as though they are preventing harm. They are not preventing harm. They are reallocating it.
The burden falls on patients who deteriorate while waiting. It falls on families burying loved ones who should still be alive. It falls disproportionately on low-income Americans, who are three times more likely to die from kidney failure. It falls on taxpayers who continue funding dialysis indefinitely. It also helps sustain black markets abroad, a human rights violation that is maintained due to scarcity.
The current system is not morally clean. It simply hides the suffering more effectively.
EKDA Is a Mechanism
What makes the End Kidney Deaths Act so compelling is that it does not rely on vague awareness campaigns or hope that people will simply become more altruistic. It creates a direct mechanism: more donors means more transplants, and more transplants mean fewer deaths.
That mechanism may largely pay for itself. Each kidney transplant saves hundreds of thousands of dollars compared with long-term dialysis. If EKDA works as expected, it could save up to 10,000 American lives annually while saving taxpayers roughly $4 billion each year. Right now, we are spending more money preserving the shortage than it would cost to end it.
The Real Constraint
Effective altruism often focuses on funding constraints, and that makes sense. But at scale, money is often not the real bottleneck. Judgment, coordination, institutional courage and mechanism design can become intransigent bottlenecks.
The most important philanthropic question may not be how much more money we can raise. It may be what systems can reliably convert resources into measurable human flourishing. The End Kidney Deaths Act offers one answer.
Scarcity Is a Policy Choice
There is nothing natural about kidney scarcity. It is a policy choice.
Many people say they would consider donating a kidney, and roughly 95 percent of living donors report that they would donate again. Yet only about two percent of willing donors ultimately donate. That gap is about structure.
We ask people to undergo six to twelve months of testing, major surgery, weeks or months of recovery, and lifelong medical follow-up to save someone they may never meet. When firefighters run into burning buildings to save strangers, we call that heroic work and compensate them. Kidney donors are doing something similarly heroic. Their heroism simply unfolds over months instead of minutes.
What Happens If This Works
If EKDA succeeds, it will do more than save lives in the United States. It could inspire thousands of people to become healthy enough to donate and provide a blueprint for countries around the world seeking to end their own kidney shortages.
And if this ten year pilot program fails, we will still learn something enormously valuable: we will have real evidence. That is far better than preserving a deadly status quo because testing new ideas makes us uncomfortable.
The Question We Keep Avoiding
If a policy could save thousands of lives every year, reduce public spending, and be implemented as a limited, reversible pilot, what exactly justifies refusing to test it?
Discomfort is not an answer.
One American dies every hour waiting for a kidney transplant. How many more deaths are required before we are willing to test something better?
What This Means for Effective Altruism
We are entering a world where far more money may be available for doing good. That will matter. But money alone does not solve problems.
The End Kidney Deaths Act offers a model where money predictably saves lives, not through vague aspiration, but through design.
If effective altruism is serious about deploying much larger sums of money wisely, it should prioritize mechanisms that solve root shortages rather than endlessly managing downstream suffering. We have seen versions of this logic before: when New York City experimented under Michael Bloomberg with paying families to improve school attendance and educational outcomes, the central idea was that incentives can shape behavior faster than moral appeals alone, even if the specific program design required refinement. The same principle applies here. Effective altruism should fund incentive structures tied to measurable outcomes, support organizations willing to challenge outdated norms, and cultivate greater tolerance for policy experimentation when the status quo is clearly failing. The goal should not simply be to spend more. It should be to build systems that create abundance, generate evidence, and reduce the need for perpetual philanthropy.
For effective altruism, the future will not be shaped by how much money we accumulate. It will be shaped by what we are willing to build.
Note: To help pass the End Kidney Deaths Act, sign our petition: https://forms.gle/rVmseMDioZmazLQXA
I realise I am arguing with ChatGPT here, but you are equivocating between EA and the US government. We (EA) are preparing for having more money, and this doesn’t in any way contradict the fact that we (USG) already have a lot and we (USG) have chosen absurd kidney market restrictions.
That’s a fair critique, and I agree that EA and the U.S. government are obviously distinct actors.
My argument wasn’t meant to conflate them. It was meant to highlight a broader lesson that I think is relevant to both.
The U.S. kidney system is an example of a domain where enormous resources already exist, Medicare spends billions on dialysis annually, yet poor institutional design prevents those resources from translating into optimal outcomes.
My broader point is that EA may face analogous problems if funding grows dramatically. The central constraint may increasingly shift from, “How do we raise more money?” to “How do we build mechanisms that reliably convert money into public good?”
The kidney shortage feels like a useful case study because it demonstrates that abundance of capital alone doesn’t solve coordination failures, incentive failures, or policy failures.
In other words: the government example is illustrative, not identical.
And I’d argue that this lesson becomes even more important in a world where EA capital scales rapidly.
Please consider signing our petition to help get the End Kidney Deaths Act to the finish line. 100,000 Americans (the total number that will be saved over the ten year pilot program) are relying on us to save their lives. https://forms.gle/rVmseMDioZmazLQXA
I have mixed feelings on this post:
On the one hand, the case for compensating donors is compelling and seems well supported.
However, the AI style of the prose makes the arguments sound weaker, because we are developing antibodies to this kind of text after having been exposed to AI slop in other parts.
Also, I think “effective altruism is preparing for a world with far more money” is a non sequitur. There are problems in the world that we know how to solve with money, that doesn’t mean the prevalent opinion is that money is the only constraint. People talk frequently about talent and coordination as bottlenecks.
Thanks for the fair critiques.
On the writing style: I did use ChatGPT as an editorial tool for structure and phrasing.
On the second point: I agree that EA absolutely talks about talent, coordination, and institutional bottlenecks not just money. My argument was narrower than perhaps the opening suggests.
I was responding explicitly about navigating a potential influx of capital, and trying to argue that even in a world with much more funding, mechanism design may matter more than additional grant-making in some domains.
The kidney shortage (that we are working hard to end) presents a case study because it’s a place where enormous resources already exist (billions spent on dialysis), but poor institutional design prevents those resources from producing better outcomes.
So I agree the opening could have been more precise. The stronger version of the claim is probably:
“Even when funding is abundant, poorly designed systems can still produce scarcity.”
This is relevant both to kidney policy and to EA more broadly.
Please consider signing our petition to help get the End Kidney Deaths Act to the finish line. 100,000 Americans (the total number that will be saved over the ten year pilot program) are relying on us to save their lives. https://forms.gle/rVmseMDioZmazLQXA
I like your point
“Even when funding is abundant, poorly designed systems can still produce scarcity.”
This is a real concern, even more if EA funding grows faster than the infrastructure to spend the money wisely.
But.
I think you used too much chatGPT to the point where it’s not an editorial tool and it compromised the intelligibility of the post.
Afaiu, you have 2 main points in your post:
Kidney deaths as a case study on how money is not the only bottleneck.
CTA: please support our petition.
Both reasonable and interesting. But hard to parse from the AI aesthetic fillers.
And also, the Manifund post explicitly asks for how to / what systems we need to navigate having more money. I think you are preaching to the choir when you say that systems can be more important than sheer amounts of money.