Kidney donation is a reasonable choice for effective altruists and more should consider it

This ar­ti­cle was writ­ten by Thomas Kelly and Josh Mor­ri­son[1], who asked me to for­mat and post it on the Fo­rum. It makes a de­tailed case which I’d en­courage peo­ple to read—it’s made me se­ri­ously con­sider donat­ing, since I hadn’t re­al­ised the health costs were so low. Peo­ple in the UK in­ter­ested in donat­ing can do so here; peo­ple in the US can do so here.

This piece makes the ar­gu­ment that kid­ney dona­tion is a rea­son­able choice for many effec­tive al­tru­ists. For some rele­vant back­ground in­for­ma­tion, I donated my kid­ney through the Na­tional Kid­ney Registry in Septem­ber 2014. I’m also the cofounder of Waitlist Zero, a non­profit that seeks to end the kid­ney short­age by pro­mot­ing sup­port for liv­ing kid­ney donors and in­creas­ing liv­ing dona­tion rates. This is also go­ing to be more rele­vant to po­ten­tial donors within the United States as I un­der­stand more about kid­ney dona­tion in this coun­try.

I en­courage EAs who are con­sid­er­ing kid­ney dona­tion to talk with me or my co-founder Josh (also a kid­ney donor). We definitely un­der­stand it’s not a choice for ev­ery­one, and we aren’t in­ter­ested in mak­ing a hard sell to be­come a donor. But we are in­ter­ested in know­ing what mo­ti­vates peo­ple to con­sider dona­tion, and we also have ideas on how to max­i­mize the (sig­nifi­cant) pub­lic aware­ness and poli­ti­cal benefits of in­di­vi­d­ual non-di­rected dona­tions.

Table of Contents

1. Summary

2. Benefits

a. Direct Benefits of Kid­ney Donation

i. Benefits of an In­di­vi­d­ual Transplant

ii. Kid­ney Chains

b. Indi­rect Benefits

i. Is Kid­ney Dona­tion Con­ta­gious?

ii. Poli­ti­cal Effi­cacy of Donor Sup­port Movement

3. Costs

a. Sur­gi­cal Dis­com­fort, In­con­ve­nience, and Risk of Complication

b. Long-Term Risk

i. No De­crease in Life Expectancy

ii. In­creased Risk of Kid­ney Failure

iii. Minor Long-Term In­come Effect

1. Fi­nan­cial Effect of Mor­tal­ity Risk

2. Fi­nan­cial Effect of ESRD Risk

c. Im­me­di­ate Fi­nan­cial Costs of Kid­ney Donation

4. How to Eval­u­ate the Dona­tion Choice as an Effec­tive Altruist

a. How Does Donat­ing Com­pare to Other EA Choices?

b. Now vs. Later

c. EA Iden­tity and Move­ment Building

5. Conclusion

Summary

The di­rect benefits of kid­ney dona­tion are some­what difficult to calcu­late, but our best es­ti­mate is an in­crease of about four­teen qual­ity-ad­justed life-years saved with an op­ti­mistic es­ti­mate of twenty QALYs and a pes­simistic one of six. Sig­nifi­cantly higher in­di­rect gains may be pos­si­ble by in­fluenc­ing oth­ers to donate and by ad­vo­cat­ing for poli­cies that would end the trans­plant short­age, though these gains are more un­cer­tain.

Kid­ney dona­tion is a sig­nifi­cant but la­paro­scopic and broadly safe surgery with a hos­pi­tal stay of a cou­ple nights and a re­turn to work within a few weeks. It does not de­crease one’s life ex­pec­tancy and causes long-term harms in less than 1% of cases. If one does not have paid med­i­cal leave, the di­rect fi­nan­cial costs of lost wages may be sig­nifi­cant.

For a donor who doesn’t forgo wages or pay sig­nifi­cant travel ex­penses, the ex­pected benefits to re­cip­i­ents are more than 100 times the ex­pected costs to the donor (both calcu­lated in QALYs).

The de­ci­sion to donate is broadly con­sis­tent with EA prin­ci­ples. Differ­ent EAs will give differ­ent weights to the in­con­ve­nience, dis­com­fort, and health effects of dona­tion, and com­par­i­sons to effec­tive­ness of mon­e­tary dona­tions are challeng­ing. That said, de­pend­ing on sub­jec­tive val­u­a­tion of costs, many EAs may find kid­ney dona­tion’s cost-effec­tive­ness to be of a roughly similar or­der of mag­ni­tude to other EA in­ter­ven­tions such as mon­e­tary dona­tions to a GiveWell-recom­mended char­ity.

Benefits

Direct Benefits of Kid­ney Donation

A kid­ney donor who gives to a stranger can cause mul­ti­ple trans­plants. It is difficult to calcu­late the im­pact of each trans­plant, but it is clear they yield a sig­nifi­cant num­ber of life-years, with our best es­ti­mate as be­ing about 14 qual­ity-ad­justed life-years.

Benefits of an In­di­vi­d­ual Trans­plant: A com­monly used es­ti­mate from 2004 is that kid­ney re­cip­i­ents of a liv­ing donor can ex­pect to re­ceive an in­crease in 3.5 years of qual­ity-ad­justed life com­pared to re­main­ing on dial­y­sis.[2] While there is some definite un­cer­tainty in this figure, our es­ti­mate would be some­thing closer to ~8 QALYs/​trans­plant. The differ­ence is due largely to tech­nolog­i­cal im­prove­ment, lags in the data, sam­pling bias, and in­con­gruity with de­ceased dona­tion re­sults.

Our Es­ti­mate: The half-life of a liv­ing donor trans­plant is 14.2 years.[3] Pa­tients are gen­er­ally med­i­cally el­i­gible for trans­plant when they have a sur­vival prog­no­sis of about 5 years on dial­y­sis.[4] If we were to take the ex­pe­rience of 60-64 year old pa­tients as typ­i­cal (since their me­dian life ex­pec­tancy on dial­y­sis is 5.1 years), their av­er­age life-years gained per trans­plant though a trans­plant would be 8.9 (14.0-5.1).[5] The qual­ity ad­just­ment used in the Matas pa­per dis­counts a trans­plant year of life at 84% and a dial­y­sis year of life at 68%, though we think that es­ti­mated differ­ence might be con­ser­va­tive, since dial­y­sis is very bur­den­some.[6] Us­ing that dis­count, how­ever, im­plies a QALY gain of 8.29 years (14.0*0.84-5.1*0.68).

Given the differ­ence be­tween our calcu­la­tions and the Matas figure, we’ve tried to be con­ser­va­tive in our es­ti­mate. Nev­er­the­less, we think there are good rea­sons for op­ti­mism.

1. Tech­nolog­i­cal im­prove­ments have oc­curred in the past decade and are likely to be un­der­rep­re­sented in the data due to time lags in re­port­ing. The Matas and Sch­nit­zler 2004 figure re­lies on data from pa­tients who were wait­listed or re­ceived trans­plants be­tween 1995 and 1999,[7] when 5.7% of kid­neys were re­ported to fail within a year of trans­plant.[8] Now 3.2% do.[9] The 14.2-year graft-sur­vival figure is it­self in­com­plete be­cause it refers to kid­neys trans­planted in the late 1990s, and sur­vival rates have been in­creas­ing since then. For ex­am­ple, 2013 figures re­ported that the per­centage of trans­plants that fail within five years of trans­plan­ta­tion fell to 15.4% from 17.5% in the pre­vi­ously re­ported year.[10]

2. Method­olog­i­cal Ques­tions: The Matas figure only comes from re­cip­i­ents on Med­i­care, ex­clud­ing healthier, wealthier re­cip­i­ents with pri­vate in­surance who likely live longer. Note that the Matas figures also dis­count QALYs by 5% an­nu­ally.

3. Kid­ney Ex­change Chains: If you donate to start a chain (see be­low), your trans­plant may last longer: 3 year graft sur­vival rates are about 1.5 per­centage points higher in chains than in av­er­age liv­ing donor trans­plants,[11] which makes sense since chains are able to de­liver higher qual­ity matches.

4. De­ceased Donor Es­ti­mates: It is hard to rec­on­cile es­ti­mates of de­ceased donor im­pact with QALY es­ti­mates as low as 3.5. Liv­ing donor kid­neys last about 1.5-1.7 times as long as de­ceased donor kid­neys.[12] Es­ti­mates of de­ceased donor im­pact be­tween 1999 and 2011 have given a range of 2-10 years with an un­weighted av­er­age across stud­ies of 4.31 years gained.[13]

Kid­ney Chains: A non-di­rected kid­ney donor can usu­ally fa­cil­i­tate more than one pa­tient by fa­cil­i­tat­ing chains of paired kid­ney ex­change (ex­changes be­tween in­com­pat­i­ble donor-re­cip­i­ent pairs).[14] Th­ese chains of dona­tion in­clude a mean of 4.6 trans­plants,[15] though the longest on record led to thirty-six trans­plants.[16] That said, it is not cor­rect to think of one non-di­rected donor as be­ing the but-for cause of ev­ery trans­plant in the chain—an easy-to-match pair in the match­ing pool will likely be­come a part of some chain within a few months. Hard-to-match pairs are more difficult to calcu­late – some pa­tients can only match with less than 1% of the pop­u­la­tion. Gen­er­ally, chains al­ter­nate be­tween easy-to-match and hard-to-match pairs. Donors with O blood type start sig­nifi­cantly longer chains. Roughly guess­ing, we ex­pect par­ti­ci­pat­ing in a chain to cause 1.5-2 trans­plants that would not have oth­er­wise oc­curred.

Com­bin­ing our es­ti­mates, we’d guess that donat­ing to start a chain leads to ~14 QALYs, though there is sub­stan­tial un­cer­tainty around the right figure to use with a range of 7-20 seem­ing re­al­is­tic.

Indi­rect Benefits

Is Kid­ney Dona­tion Con­ta­gious? It’s pos­si­ble that your liv­ing dona­tion will per­suade oth­ers to donate. If I hadn’t read sto­ries about other peo­ple donat­ing, I doubt I would have. Other non-di­rected donors I know have re­ported peo­ple they know per­son­ally de­cid­ing to donate in part due to hear­ing their sto­ries.

Non-di­rected kid­ney dona­tion has grown sub­stan­tially over the last few years.[17] How­ever, a size­able frac­tion of this in­crease may be at­tributed to a co­or­di­nated effort to en­courage Ortho­dox Jews to be­come non-di­rected donors to other Ortho­dox Jews.[18]

Kid­ney Dona­tions to Strangers Per Year in US[19]

2008

179

2009

240

2010

294

2011

272

2012

354

In England, since 2009 when their trans­plant sys­tem be­gan al­low­ing non-di­rected dona­tion and a small non-profit be­gan pub­li­cly rais­ing aware­ness, such dona­tions in­creased from 0 to 10% of all liv­ing dona­tion, com­pared to 3% in the U.S.[20]

It is ob­vi­ously difficult to es­ti­mate the prob­a­bil­ity dis­tri­bu­tion, but for an effec­tive al­tru­ist who is rea­son­ably open about their dona­tion (e.g. per­haps talk­ing to friends and col­leagues about it pri­vately or writ­ing for a pub­lic venue), I think it’s fairly likely that you would even­tu­ally con­vince some­one else to donate.

Poli­ti­cal Effi­cacy of Donor Sup­port Move­ment: Non-di­rected kid­ney donors have a pow­er­ful story and unique moral au­thor­ity for ad­vo­cat­ing poli­ti­cal change for the trans­plant sys­tem. Policy mea­sures ex­ist that would end the trans­plant short­age and re­duce gov­ern­ment health­care spend­ing by pro­vid­ing sup­port to donors (such as health in­surance or an an­nu­ity) suffi­cient to clear the short­age be­tween need and availa­bil­ity. Each year about 20K more peo­ple are added to the wait­list than re­ceive a trans­plant,[21] which means end­ing the short­age through liv­ing dona­tion would save ~160K QALYs/​yr. It is difficult to quan­tify one’s poli­ti­cal im­pact, but for EAs who think this cause is worth­while, dona­tion should be more com­pel­ling.

Costs

Sur­gi­cal Dis­com­fort, In­con­ve­nience, and Risk of Com­pli­ca­tion: Kid­ney dona­tion is a la­paro­scopic surgery that typ­i­cally ne­ces­si­tates a typ­i­cal hos­pi­tal say of two nights, pre­scrip­tion painkil­ler us­age of about 5-8 days, and a re­turn to deskwork within 2-4 weeks. For donors who do not have high blood pres­sure, the chance of death dur­ing surgery is about 1.3/​10,000[22] – about the same as in child­birth. For donors taken as a whole, it’s 3.1/​10,000.[23] Short-term com­pli­ca­tions af­fect about 2-5% of donors and typ­i­cally in­volve things like wound in­fec­tions.[24]

The to­tal QALY costs of this dis­com­fort and risk are not large. The undis­counted QALY cost of a 3.1/​10,000 risk to a per­son with 60 re­main­ing years of perfect-qual­ity life is 0.019 QALYs (roughly equiv­a­lent to a week of full value life). I haven’t in­ves­ti­gated the dis­abil­ity weights that should be ap­plied, but as­sum­ing that a donor gets no value from their time in the hos­pi­tal, half value from the fol­low­ing week, and ¾ value from the fol­low­ing 4 weeks be­fore re­turn­ing to full health, the to­tal “QALY cost” of the op­er­a­tion, hos­pi­tal stay, and re­cov­ery pe­riod is <2 weeks. Com­bin­ing the risk of death and the hos­pi­tal­iza­tion and re­cov­ery pe­riod, we get costs of ~0.06 QALYs for donat­ing.

At face value, this may seem sur­pris­ingly low – donat­ing a kid­ney is only as bad as giv­ing up 3 weeks of life? Upon re­flec­tion, though, this makes sense – donors are able to re­turn to work and most ev­ery­day ac­tivi­ties within 4 weeks, and run only a very small risk of death.

Note that the above as­sumes in­cur­ring zero util­ity from donat­ing, but that’s un­likely. Donors may have many pos­i­tive ex­pe­riences (e.g. read­ing, spend­ing time with friends or fam­ily, de­vel­op­ing in­ter­est­ing sto­ries) dur­ing those 4 weeks and should ex­pect a feel­ing of pride in the tan­gible and pub­lic ac­com­plish­ment of dona­tion even above what might be likely from a more ab­stractly-ex­pe­rienced fi­nan­cial gift.

Most of the costs that pre­vent peo­ple from donat­ing in prac­tice seem to be psy­cholog­i­cal ones (i.e. fear) rather than these literal in­ca­pac­i­ta­tion costs. Of course, these will vary across po­ten­tial donors, and effec­tive al­tru­ists may be par­tic­u­larly well-dis­posed to take them on.

Long-Term Risk

No cred­ible stud­ies have demon­strated that kid­ney dona­tion de­creases life ex­pec­tancy. How­ever, it does in­crease the risk of kid­ney failure. The best data cur­rently in­di­cates that long-term med­i­cal harms af­fect less than 1% of donors.

No De­crease in Life Ex­pec­tancy: Kid­ney dona­tion has not been shown to mea­surably de­crease long-term life ex­pec­tancy.[25] Donors live longer than the gen­eral pop­u­la­tion be­cause they are healthier to start with.[26] The re­main­ing kid­ney grows af­ter surgery to ac­com­mo­date the func­tion of the pre­vi­ous kid­ney, and chronic kid­ney dis­ease tends to im­pact both kid­neys equally. A study of World War II sol­diers who suffered a trau­matic in­jury that de­stroyed one kid­ney found them to have similar health out­comes to two-kid­ney’d sol­dier con­trols.[27]

In­creased Risk of Kid­ney Failure: The av­er­age Amer­i­can has a life­time risk of kid­ney failure of 3.2%. Kid­ney donors must have very good kid­ney func­tion pre-surgery, so their life­time risk (if they do not donate) is about 0.14%. A 2014 study in­di­cates that peo­ple who donate have a 0.9% life­time chance of de­vel­op­ing kid­ney failure.[28]

The risk of kid­ney failure mounts over time and the risk of de­vel­op­ing ESRD dur­ing one’s work­ing years are much lower. At age 50, only 0.28% of liv­ing donors had ex­pe­rience kid­ney failure.[29] As such the ex­pected loss of in­come due to ESRD is very low. Kid­ney failure is typ­i­cally the out­come of decades of de­gen­er­a­tive kid­ney dis­ease (in about half of cases this is caused by obe­sity and/​or di­a­betes, so about half the risk is con­trol­lable by diet and ex­er­cise). Donat­ing one’s kid­ney likely does not in­crease the chance of that chronic kid­ney dis­ease; in­stead, donat­ing re­duces one’s to­tal kid­ney func­tion to about 70% of where it was be­fore. Only donors with ex­cel­lent kid­ney func­tion are al­lowed to donate, so this does not typ­i­cally have any health im­pacts. How­ever, for those who de­velop chronic kid­ney dis­ease in the fu­ture (a small num­ber), donat­ing re­duces some­what the buffer of ex­cess func­tion be­fore chronic kid­ney dis­ease leads to kid­ney failure.[30]

There are sev­eral challenges to calcu­lat­ing long-term risk of liv­ing kid­ney dona­tion. The first is that ESRD takes so long to de­velop. Given the med­i­cal ad­vances in kid­ney dona­tion, such as the switch to a la­paro­scopic pro­ce­dure, it’s pos­si­ble that long-term risks of dona­tion have diminished for cur­rent donors but have not yet showed up in the data. That said, the long pro­gres­sion of kid­ney dis­ease may also im­ply that stud­ies will tend to un­der­es­ti­mate the failure effect due to limi­ta­tions in fol­low-up du­ra­tion,[31] and there may be sig­nifi­cant un­cer­tainty about health im­pact (try­ing to ex­trap­o­late to health effects thirty to fifty years in the fu­ture is very difficult). Fi­nally, the sig­nifi­cant ma­jor­ity of donors give to rel­a­tives mak­ing it pos­si­ble that these re­lated donors are ac­tu­ally at greater risk than un­re­lated donors[32] (and be­cause of trans­plant cen­ter se­lec­tion crite­ria, non-di­rected donors are likely to be healthier to start with than the av­er­age donor).

While kid­ney failure for liv­ing donors re­mains tragic, liv­ing donors re­ceive sig­nifi­cant pri­or­ity on the or­gan wait­list and are thus much more likely to re­ceive a kid­ney trans­plant of their own.[33]

More­over, it seems ap­pro­pri­ate to be­lieve tech­nolog­i­cal in­no­va­tions like ar­tifi­cial or­gans are likely on a multi-decade timescale,[34] sig­nifi­cantly re­duc­ing the ex­pected costs of risk­ing ESRD in mid­dle or old age. Based on this con­sid­er­a­tion (along with fact that liv­ing donors re­ceive pri­or­ity on the wait­list), I’m in­clined to sig­nifi­cantly dis­count the po­ten­tial long-term nega­tive health effects for donors who are young and healthy to­day.

A 1% risk of de­vel­op­ing kid­ney failure in 30 years has a rel­a­tively limited QALY im­pact even if not dis­counted for tech­nolog­i­cal im­prove­ment. If the av­er­age pa­tient de­vel­ops kid­ney failure at 65, and the av­er­age donor re­ceives a trans­plant, they should ex­pect to live about 11 years with a dis­abil­ity weight of 0.84, com­pared to about 15.5 for Amer­i­cans with­out ESRD, yield­ing a to­tal es­ti­mated QALY cost of 0.063[35] or about three weeks. Nearly any pos­i­tive dis­count rate would re­duce that cost (30 years in the fu­ture) sub­stan­tially.

Minor Long-Term In­come Effects: One ar­gu­ment that’s been made is that kid­ney dona­tion could be on some level self-defeat­ing from an EA stand­point be­cause it re­duces your long-term giv­ing by an amount with greater im­pact than your dona­tion. We dis­agree strongly with this po­si­tion, and think the best es­ti­mate of long-term in­come loss is some­thing less than ~$150.

· Fi­nan­cial Effect of Mor­tal­ity Risk: If you donate $10K per year and have 40 years of re­main­ing work­ing life, the risk of death in surgery would re­duce your dona­tions by only an ex­pected $120. Risks to in­come from po­ten­tial kid­ney failure are un­likely be­cause of evolv­ing tech­nol­ogy, but even if they oc­curred, they’re likely to be­come an is­sue near re­tire­ment.

· Fi­nan­cial Effect of ESRD Risk: Long-term in­come effects of ESRD risk are likely neg­ligible. Here’s a quick back-of-the-en­velop calcu­la­tion to demon­strate. Say there is a 1% risk of kid­ney failure, and 50% chances each of re­tire­ment, tech­nolog­i­cal im­prove­ment, abil­ity to re­ceive a trans­plant, and defec­tion from the EA cause (each con­ser­va­tive es­ti­mates). Say that if none of those con­di­tions holds one would lose $250K in char­i­ta­ble dona­tions thirty years from now. This means that the ex­pected loss will be $156.25 (250,000*.01*.5*.5*.5*.5) in 2044, but this figure needs to be dis­counted to net pre­sent value to be com­pared to a choice to­day. If you in­vest a dol­lar to­day at 5% an­nual com­pound­ing in­ter­est, in thirty years, it would be worth $4.32. Thus, the long-term in­come loss ex­pected from kid­ney dona­tion would be equiv­a­lent to pay­ing $36.17 (156.25/​4.32) to­day.

Im­me­di­ate Fi­nan­cial Costs of Kid­ney Donation

The costs of surgery and of any com­pli­ca­tions from surgery are cov­ered by the re­cip­i­ent’s in­surance (usu­ally Med­i­care). How­ever, fi­nan­cial costs you in­cur in donat­ing (such as lost wages if you don’t have paid med­i­cal leave) are typ­i­cally borne by the donor. In the United States, there is no fed­eral law re­quiring paid leave for or­gan donors. How­ever, fed­eral em­ploy­ees re­ceive paid leave, as do em­ploy­ees in many states and em­ploy­ees of com­pa­nies with gen­er­ous benefits in other states.[36] The cost of dona­tion for donors who do not re­ceive paid leave is of course sub­stan­tial. The other ma­jor cost of dona­tion is travel, which is re­im­bursed by the Na­tional Liv­ing Donor As­sis­tance Cen­ter for any donor whose re­cip­i­ent makes un­der 300% of the US poverty line, and is also un­der 300% of the poverty line.[37] The Na­tional Kid­ney Registry also re­im­burses all costs for donors who donate to start chains.

There are mean­ingful costs that are not re­im­bursed in the United States. Homemak­ers who donate do not re­ceive any money to pay for child­care, el­der­care, or chores they can­not com­plete. In ad­di­tion, there is no com­pen­sa­tion for the pain or dis­com­fort of the pro­cess.

For full-time em­ploy­ees with paid leave, the fi­nan­cial costs of liv­ing dona­tion are greatly ame­lio­rated.

How to Eval­u­ate the Dona­tion Choice as an Effec­tive Altruist

The choice to donate a kid­ney to a stranger clearly has a pow­er­ful pos­i­tive health effect to the re­cip­i­ents that is at least an or­der of mag­ni­tude larger than the cost to the donor. It fits effec­tive al­tru­ist prin­ci­ples by be­ing a gift that is sig­nifi­cant to the donor and has a mea­surable and highly pos­i­tive im­pact. This does not by any means im­ply that donat­ing is the right de­ci­sion for all (or even most) effec­tive al­tru­ists since differ­ent peo­ple will value the costs of hav­ing surgery differ­ently.

How Does Donat­ing Com­pare to Other EA Choices? Donat­ing a kid­ney is similar in di­rect im­pact to, but on the lower end of, other EA choices like giv­ing money to a GiveWell recom­mended char­ity. Donat­ing a kid­ney gets ~14 QALYs at a cost of some­thing on the or­der of ~0.1 QALYs. If you can give a month of your life to ex­tend some­one else’s by 14 years, that seems to be a good de­ci­sion and one where a small sac­ri­fice yields a sig­nifi­cant gain for oth­ers. Believ­ing that donat­ing will en­courage oth­ers to do so or that the re­turns to poli­ti­cal ad­vo­cacy are high could eas­ily dou­ble these ex­pected re­turns.

GiveWell es­ti­mates the cost-per life saved for their top char­i­ties as ~$3-5K.[38] As­sum­ing a healthy 50 year lifes­pan for those who are saved, this works out to $60-$100/​DALY. GiveWell cau­tions not to take these cost-es­ti­mates liter­ally, due to sig­nifi­cant un­cer­tainty around them.[39]

A pos­si­ble EA cri­tique to kid­ney dona­tion is to say that, “If donat­ing a kid­ney will save ~14 QALYs and a de­vel­op­ing world DALY only costs ~$100 to save, then donat­ing a kid­ney is only worth $1,400 in dona­tions.” We think there is some­thing true and im­por­tant in this ar­gu­ment, and we wouldn’t en­courage some­one to donate a kid­ney if it meant they would forego sig­nifi­cant dona­tions to GiveWell’s top char­i­ties. But we don’t see why that should be the case, since giv­ing a kid­ney is a com­ple­ment to and not a re­place­ment for mon­e­tary dona­tion.

Put some­what differ­ently, “donat­ing a kid­ney is only worth $1,400 in dona­tions” takes our failure to donate the max­i­mum we could and uses it to avoid or­thog­o­nal ac­tions that would be ex­tremely net benefi­cial but don’t nec­es­sar­ily quite reach the benefit-cost thresh­old we’ve set for our fi­nan­cial dona­tions.[40] This would also im­ply an in­cor­rect fun­gi­bil­ity be­tween moral choices and is a prin­ci­ple that could lead to worse be­hav­ior in the long-run (i.e. con­stantly for­go­ing pos­i­tive-util­ity ac­tions whose gains are not the same as char­i­ta­ble dona­tions with the best ex­pected value).

Dona­tion may also have benefits per­sonal to the donor, in­di­rect to other trans­plant re­cip­i­ents, and sup­port­ive to the EA cause that are not ac­counted for in its di­rect QALY figure, and giv­ing through non-fi­nan­cial dona­tion may also be a use­ful di­ver­sifi­ca­tion strat­egy for one’s al­tru­ism.

Now vs. Later: If one in­tends to donate a kid­ney, donat­ing now is sig­nifi­cantly more effec­tive than donat­ing much later. Cur­rently, the trans­plant short­age is se­ri­ous, but fu­ture policy or tech­nolog­i­cal change could greatly de­crease the marginal benefit of kid­ney dona­tion. That same change could cause a dona­tion to­day to be a bridge for the re­cip­i­ent into a pe­riod with sig­nifi­cantly de­creased mor­tal­ity for kid­ney failure that they would not oth­er­wise have sur­vived to. Op­por­tu­nity to in­fluence fu­ture donors and the poli­ti­cal sys­tem are likely also higher now than later.

From a risk per­spec­tive, donat­ing when young is in­fe­rior to donat­ing when old, be­cause younger donors do not have as much in­for­ma­tion on fu­ture health con­di­tions as older donors (i.e. a 50 year-old with­out chronic kid­ney dis­ease will al­most cer­tainly never de­velop it, but a 25 year-old still could). For ei­ther group, the ab­solute risk of kid­ney failure is still small and less than that of the gen­eral pop­u­la­tion. How­ever, we note that donors who are cur­rently young are more likely to benefit from fu­ture ad­vances in tech­nol­ogy (such as ar­tifi­cial or­gans) that re­duce the ex­pected costs of dona­tion.

EA Iden­tity and Move­ment Build­ing: One con­cern that has been ex­pressed is that, since kid­ney dona­tion is an un­usual and se­ri­ous choice, dona­tion can marginally pull the EA move­ment away from the main­stream. This con­cern comes from a model of suc­cess­ful so­cial move­ments as in­cre­men­tal and mod­er­ate.

A differ­ent model finds move­ments do bet­ter when they are dra­matic, salient, and com­pel­ling. Kid­ney dona­tion is a very ad­mired choice with clear and iden­ti­fi­able benefi­cia­ries. It is a visi­ble choice and at­trac­tive nar­ra­tive that demon­strates sig­nifi­cantly stronger com­mit­ment than a non-bind­ing pledge to donate money in the fu­ture. It also may open op­por­tu­ni­ties for a broader dis­cus­sion of EA prin­ci­ples. The more EAs save the lives of iden­ti­fi­able strangers, the more no­tice the move­ment gets and the bet­ter it looks.

Ad­di­tion­ally, much of the EA move­ment to date— GiveWell, Giv­ing What We Can, and the earn­ing to give dis­cus­sion at 80,000 Hours—has fo­cused on money as the core re­source we have to al­lo­cate. We don’t dis­agree that de­ci­sions about money are im­por­tant, but we think that the EA move­ment will be stronger and more com­pel­ling to new­com­ers if it can offer a broader va­ri­ety of ways to make the world a bet­ter place. Kid­ney dona­tion should very much be con­sid­ered as one of those ac­tivi­ties.

Conclusion

Kid­ney dona­tion con­fers di­rect benefits to re­cip­i­ents that clearly ex­ceed the cost to the donor by a large fac­tor (more than a hun­dred, ac­cord­ing to our es­ti­mate). It is a tan­gible choice to sig­nifi­cantly and pub­li­cly af­firm one’s com­mit­ment as an effec­tive al­tru­ist. For many effec­tive al­tru­ists, kid­ney dona­tion is a good choice, and as some­one who iden­ti­fies as an Effec­tive Altru­ist, I’m glad I donated.



[1] Thanks to Josh Mor­ri­son for helping write this and to Ryan Carey, Howie Lem­pel, and Alexan­der Berger for re­view­ing it. All mis­takes are Josh and my own.

[2] Matas and Sch­nit­zler (AJT). See also The Prob­lem. See gen­er­ally Na­tional Kid­ney Registry, Liv­ing Donors

[3] 2012 OPTN An­nual Re­port, figure 6.7. See 2012 Kid­ney Data for the ex­act figure. If you re­move from con­sid­er­a­tion pa­tients who died for rea­sons un­re­lated to graft failure, the half-life of a liv­ing donor graft that sur­vives past the first year post-surgery is 26.6 years. OPTN An­nual Re­port 2010

[4] See Schold, AJT.

[5] 2013 USRDS, p. 266. For com­par­i­son, the differ­ence in life ex­pec­tancy be­tween 45-49 year olds on dial­y­sis (8.3 years) and re­ceiv­ing a trans­plant (22.8 years) is 14.5 years. Id. Th­ese figures in­clude liv­ing and de­ceased trans­plants and are thus likely to un­der­count the im­pact of a liv­ing donor.

[6] Dial­y­sis in­volves sev­eral, un­com­fortable treat­ments sev­eral times per week and leaves 80% of pa­tients un­able to work, whereas trans­plant pa­tients can live a fairly nor­mal life. It also has a very high rate of com­pli­ca­tion com­pared to trans­plant. “Ad­justed rates of all-cause mor­tal­ity are 6.5–7.9 times greater for dial­y­sis pa­tients than for in­di­vi­d­u­als in the gen­eral pop­u­la­tion. For re­nal trans­plant pa­tients, rates ap­proach those of the gen­eral pop­u­la­tion, yet re­main 1.0–1.5 times higher.” Id. To use a spe­cific ex­am­ple, “fe­male dial­y­sis pa­tients in their 30s, 40s, and 50s … are ex­pected to live just one-fourth as long as their coun­ter­parts with­out ESRD. Trans­plant pa­tients fare bet­ter, with ex­pected re­main­ing life­times 75–80 per­cent as long as those in the gen­eral pop­ula­tion.” Id.

[7] Sur­vival rates are pro­jected for­ward from mor­tal­ity rates in early years.

[8] Matas and Sch­nit­zler (AJT), pg 218.

[9] 2013 USRDS, p. 284

[10] 2013 USRDS, p. 284

[11] http://​​www.kid­neyreg­istry.org/​​pages/​​p308/​​NKRQuar­ter­lyRe­port3rdQuar­ter.php

[12] See OPTN An­nual Re­port 2010;

[13] See The Prob­lem for a list of these stud­ies.

[14] Rees, NEJM.

[15] NKR Quar­terly Re­port 2014Q3. The NKR is the largest kid­ney ex­change net­work.

[16] A Record Chain of Kid­ney Trans­plants, NY Times

[17] OPTN An­nual Re­port 2012

[18] Re­newal website

[19] OPTN An­nual Re­port 2012

[20] Kid­ney Activity

[21] See Or­gan Trans­plan­ta­tion and Pro­cure­ment Net­work, Na­tional Data

[22] Segev, JAMA (2010).

[23] Id.

[24] 2012 OPTN An­nual Data Report

[25] Id. See also Ibrahim, NEJM and gen­er­ally Muzaale, JAMA (2014). Note that a 2014 study in­di­cated more se­ri­ous health risks (Mjoen, 2013). But this piece had se­ri­ous method­olog­i­cal prob­lems—for ex­am­ple, the mean age of the con­trol group was 37.6 com­pared to 46.0 for the donors, and the study did not have BMI data for much of the con­trol group. See Boudville, Kid­ney In­ter­na­tional and Ka­plan, AJT for some of the limi­ta­tions with the Mjoen piece.

[26] Kid­ney Donors Live Longer

[27] Narkun-Burgess, Kid­ney International

[28] Muzaale, JAMA (2014). See Gill, JAMA (2014), Ka­siske, AJKD, and Alle­gretti, AJT for cri­tiques and com­men­tary of the Muzaale piece. Kid­ney dona­tion also in­creases the risk of preeclamp­sia (a di­s­or­der of preg­nancy char­ac­ter­ized by high blood pres­sure and large amounts of pro­tein in the urine.) by 5-6%. Ibrahim, AJT, 2009. See also Po­ten­tial Risks for Kid­ney Dona­tion for a gen­eral overview on risk of dona­tion.

[29] Muzaale, JAMA (2014)

[30] Steiner, AJT

[31] Id.

[32] The 2014 Muzaale study found the risk of re­lated donors de­vel­op­ing ESRD within 15 years was 34.1/​10,000 as com­pared to 15.1/​10,000 in un­re­lated donors, but this re­sult was not statis­ti­cally sig­nifi­cant.

[33] OPTN FAQ

[34] Dis­cussed in Lav­ine, Science, Foun­tain, NY Times, and Krassen­stein, 3D Print­ing News. UCSF is also try­ing to de­velop an im­plantable mi­ni­a­tur­ized dial­y­sis ma­chine. UCSF, 2013 and Kleff­man, San Jose Mer­cury News.

[35] (15.5-11*0.84)*0.01

[36] Na­tional Kid­ney Foun­da­tion Tax Deductions

[37] NLDAC Eligi­bil­ity Guidelines

[38] See, e.g. Bed­nets; Bed­nets vs. De­worm­ing vs. Cash Trans­fers. See also De­worm­ing Up­date.

[39] Can’t Take EV Es­ti­mates Literally

[40] See Alexan­der B on Altru­is­tic Kid­ney Donation