The Kidney Market of Iran: Children and the Legal Sale of Organs
Written By: Oni Schurmans
Organ transplantation is an area where governments and medical practitioners have yet to establish the optimal approach. Globally, of the 660,000 people who need a transplant, only 10% receive one. As an example to represent the global sphere, 103,223 Americans are currently on the national transplant waiting list, with 13 people dying every day in the United States from not receiving a needed organ in time. In addition, the average waiting time on the U.S. national list is three to five years. Organ transplantation is a lifesaving and life-changing technology. However, it has the problem that demand always far exceeds supply, in most cases because a donation depends on the death of the donor.
Different countries deal with these difficulties in various ways. Iran seems to have a unique solution– it claims the world’s only open kidney market, a place where kidney donations by non-relatives are legal. It is the “world’s only”, because every other country views this process as unethical for reasons expanded later in this paper. However, since 1988, Iranian citizens have been able to sell one of their two kidneys to someone in need of a transplant. The system is government funded insofar as the government provides compensation for the donors via a third party organization called the Dialysis and Transplant Patient Association (DTPA) which facilitates contact between donors and recipients. In theory, this system seems to be a good solution– Iran has no transplant waiting list, since donors always seem to be available, and therefore lives saved. However, it begs the question: who is donating their kidneys and why? And why is the kidney supply in Iran so high?
This paper examines how the kidney market in Iran functions. It argues that economic desperation is its driver, and that children are specifically vulnerable. Kidney transplantation is a serious surgery and process with the recovery taking around four to six weeks in addition to other lifelong impacts, such as an increased risk for kidney disease. Unless desperate for money, most people would not opt for this procedure. In short, the system in Iran targets the vulnerable and marginalized and enables the kidney market to flourish.
Technically it is illegal for minors to sell their organs; Iranian law only allows kidney sale from consenting adults. In practice, however, deep poverty and vulnerability places some families in a position where they sell their children’s kidneys, parents sell their own, or children themselves sell their kidneys as a way to help their family or provide themselves with financial relief. According to Iran International Newsroom, writing in 2024, with the rise of inflation and widespread poverty, more families were using kidney donation as the source of income to pay for medical bills. In addition, they also reported on a sixteen-year-old boy who sold his kidney with the consent of his family due to urgent financial problems. In other cases, traffickers get involved, both forcing people to undergo surgery for the kidneys to then be sold, but also allowing pathways for riskier organ donation across borders. Overall, while the theory of the open kidney market has some principled ideas and motives behind it, in practice it has allowed for the exploitation of the impoverished in Iran. It has enabled corruption and manipulation of the vulnerable, while also giving rise to the black-market organ trade.
This study will draw on a range of scholarship published in academic journals and via government organizations such as the U.S. National Institute of Health. It also draws on monographs and newspaper articles, in addition to The Red Market (2011), a book by the journalist and anthropologist Scott Carney.
This paper has four parts. First, it will expand upon the context of organ trade and transplantation globally, situating Iran and its unique policies within the global sphere. Next, it will briefly bring light to the effects of kidney donation on the donor. Then, it will discuss the impacts on children specifically, highlighting both familial exploitation and the emotional impact of having a family member undergo major surgery. Lastly, it will delve into the black market, looking at how kidney transplant crosses Iran’s borders into other countries, before discussing the implications of the open kidney market for the larger black market of organs worldwide.
Organ Transplantation Globally
Organ transplantation is a process that poses many significant challenges. Not only does the fact that demand outweighs supply cause a critical challenge, but organ transplantation itself is extremely complicated. In many countries, to receive an organ, one must be deemed as the most in-need person for that organ at that time. Then, a donor must die while nonetheless leaving an organ or organs undamaged. Lastly, a donor must also have a blood type compatible with the recipients. If these variables align, the organ must then be removed and transported to a hospital, where a recipient can undergo surgery to receive it. In recent years, technology has improved to allow organ-life outside of the body to increase. However, preservation still poses a significant challenge especially for transnational and transcontinental travel: keeping organs transplantable is a big logistical challenge. Part of why demand outweighs supply of organs by such a staggering amount is due to how complicated, intricate, and specific the process is.
Even in countries with well-established transplant infrastructures—such as the United States and the United Kingdom—there are still critical challenges. The biggest issue with organ transplantation is that there are simply not enough donors. Even with decades of medical progress, almost every country still faces the same issue: far more people need organs than there are organs available. Kidney transplants in particular make up the majority of global transplant procedures. Although many countries attempt to mitigate the issue through methods such as promoting donor registration or running awareness campaigns, these interventions do not come close to fixing the difference in overall supply. As a result, long waiting lists are the norm rather than the exception. This international context—persistent shortages despite varied policy strategies—is what drove Iran to its approach and what also makes it stand out so sharply.
Iran is the only country in the world with an open kidney market, the system where citizens can sell their kidney to those in need. In 1967, the first kidney transplant in Iran occurred. In the aftermath of the Iran-Iraq War, Iran saw considerable organ shortage, specifically due to kidney disease. Dialysis resources were limited and expensive, and Iran did not yet have a strong deceased-donor program to rely on. Due to lack of resources in Iran to perform transplants, most people went overseas to the United Kingdom to receive one. This was not sustainable because the number of people in need of a kidney transplant in Iran only grew each year. In 1985 as an attempt to mitigate the issue, Iran opened up two kidney transplantation centers. With long waiting lists and not many alternatives, in 1988 the government officially introduced a Living Un-Related Donor (LURD) program, a regulated system that allowed citizens to receive compensation for donating a kidney. Under this model, the government would provide a set payment to donors, and the Dialysis and Transplant Patient Association (DTPA) would help to coordinate matches between donors and recipients so that the process would remain regulated. The goal of this system has been to effectively and efficiently eliminate the long transplant waiting list, allowing for there to be enough kidney donors available to meet the demand. Since humans can live if they have one functioning kidney, this method reduces reliance solely on deceased donors or in some cases volunteers, and facilitates a situation where both the donor and recipient benefit.
While this model eliminates the most challenging issue of organ transplantation seen by the rest of the world, it is also highly controversial. That is because the system in practice draws most of its kidneys from the impoverished and therefore relies on exploitation.
Impact of Kidney Donation
Iran uses various methods of minimally invasive surgery techniques to perform kidney transplants, but majority entail laparoscopic nephrectomy. During a laparoscopic nephrectomy, the surgeon makes two to three incisions on the abdominal wall, and then places a camera into the abdomen. This is for the surgeon to see the location of the kidney and remove it without needing to make a large and invasive incision. The surgery takes roughly two to four hours depending on anatomy and complications. A nephrectomy is a major inpatient procedure that requires a hospital stay from one to five days. The risks include pain, bleeding, infection, sepsis, anesthesia complications, post-operative pneumonia, blood clots, scarring, and kidney injury or failure of the one remaining kidney.
Children and The Kidney Market
While the Iranian kidney market allows for a quick waiting list and limited deaths due to kidney related issues, one should ask: who are the donors and why do they give up a kidney? The answer comes down to desperation. This system takes advantage of impoverished people in Iran, placing pressure on them to sell a body part in order to pay for certain necessities. Along with the recent growing rates of poverty in Iran, the number of children and young people selling their kidneys has also risen. In the kidney market, young donors are especially favored due to the youthfulness and robustness of their kidneys. The younger the donor and therefore the younger the kidney, the higher the price. For every year the age of the donor goes down, on average the price of the kidney increases by 100 thousand rials. This is until the age of 18, the minimum legal age for kidney donors. In addition, the sharp increase in Iran’s poverty rates and economic depression coincide with the number of desperate donors and price of the organ itself.
One key thing to mention is that in Iran, it is not legal for children to sell their kidney. Though the exact laws in Iran are not accessible, many pieces of scholarship have cited 18 as the minimum age for donation. However, some sources have also stated that with parental consent, underage donation may be legal. Despite the legal pathways not allowing it, underage kidney donation does happen in Iran as with many other places in the world. Iran’s scenario is unique, however, due to the extensive infrastructure for kidney donation and transplantation.
A study done in November 2024 looked at the behavior of the organ donors in Iran. The researcher’s methodology included on-the-ground fieldwork where they secured a sample size of 215 Iranian donors and took them through a series of 11 tests. These tests included questionnaires, intelligence tests, and behavior analytic related tests. Part of their research analyzed the income data of their sample of donors. In Iran, they found, the minimum monthly income is 11,860,273 rials while the average household income of their sample of donors was 15,205,690 rials– in other words, very close to minimum wage. In comparison, the average household income across all of Iran is 37,298,889 rials. They also reported that 5.5% of the donors owned a house compared to the population’s 64%, and 72.5% of the donors lived in a rental property compared to the general population’s 26%. In addition, only 8.7% of donors owned a car whereas 53% of the general population in Iran owns a car. As is clear, the average salary of those who are organ donors is barely above the minimum wage in Iran and far below the average household income. In addition, the study’s research showed that the organ donors in Iran do not show an above-average element of risk-taking, highlighting that the donations are done purely out of necessity, not irrational impulsivity. This underscores the relationship between the donor and the donation, suggesting that donors are economically marginalized and participate in donation as a way to receive money to pay for necessities. Seeing as kidney removal is a serious surgery with significant risks associated, it seems clear that need or desperation drive adults to kidney donation.
Children, however, are a different case. Children lack the ability to fully understand what they are doing the same way adults do. In practice, this means that, given the chance, children may sell their kidney for money without comprehending or knowing the lasting repercussions. Children may not think about the long-term consequences of kidney donation on their health, but rather the immediate financial compensation. As a comparative example, researchers have pointed to a case in 2011 in China, where a 17-year-old teenage boy sold his kidney in order to buy an iPad and iPhone. This is a prime example of why allowing a pathway for kidney donation and then subsequent compensation is a problem– and why Iranian law, in theory if not in practice, does not allow minors to do it. It may place financially unstable children in a position where all they see is the compensation at the end of the extensive process of kidney removal surgery and donation.
In Iran, it is shown that a large percentage of donors are people who are unemployed with families to financially support. An estimated 85-90% of donors are male and 80% of donors are married. This suggests that also a high percentage of donors have a family. Barring the impacts on children due to their own kidney donation through illegal pathways, this system may negatively affect children whose parents undergo the major internal surgery that donation entails. Not only does this cause the absence of a parent while they go through and recover from surgery, but it also places a mental weight on the child, possibly heightening anxiety or other mental disorders. In addition, once returned from the hospital the parent must recover and heal for up to many weeks, experiencing discomfort and pain that may add to the stress of children who observe it.
While so far this study has mainly discussed the implications of the legal market in Iran, it is also important to highlight the pipeline of illegal kidney selling in Iran. The organ black market exists all over the world. But due to the extensive infrastructure in Iran for unrelated organ donation, surgery, and profit-based donation, the black market for organs is not only prevalent in Iran, but also flourishes there.
Iran and the Kidney Black Market
Black markets, meaning the illegal trade of scarce items, exist across the world. For everything, when demand outweighs supply of something, a black market will appear. A black market of organs takes the form of organ trafficking, which involves the use of coercion and force to obtain an organ from someone and then transport said organ for profit. Organ trafficking is less common inside Iran due to the organized system of legal kidney donation; however, the illicit selling of kidneys across Iran’s borders is quite common. It is estimated that roughly 10% of all transplants use organs obtained from the black market, however, this figure is outdated and is also hard to measure due to the illegal nature of the activity with the percentage likely being higher. The organ black market operates through a highly organized system with myriad facilitators including transporters, organizers, and healthcare providers themselves. The majority of the black market for organs in Iran consists of Iranian citizens selling their kidneys to international recipients.
As a result of the steep economic recession in Iran, many people look to sell their kidneys outside of Iran’s borders to other countries. There, people can get a higher price for kidneys rather than the set market price in Iran. Countries that buy black-market Iranian organs include the United Arab Emirates, Iraq, and Turkey especially. Since this is an illegal type of organ transplantation, richer clients in neighboring countries are willing to pay a premium price for a kidney in order to save their or a family member’s life. This attracts many Iranians because the entire process of kidney donation is about compensation and financial gain. In neighboring countries, Iranians can sell their kidneys from about $7,000 to $15,000 contrasting with the much lower $2,000-$5,000 subsidization coming from the Iranian government for internal donations. This pathway for the illegal selling of organs outside of Iran’s borders, not to mention involuntary organ trafficking, only further exacerbates harm to Iranian citizens including parents and their children.
The organ black market operates due to a series of different people working together. This includes the patients, sellers, organ brokers, police, traffickers, and surgeons. The black-market surgeons conducting the kidney removal are corrupt and willing to break their code as a surgeon and the law. This is relevant because the extensive infrastructure for kidney removal surgery in place in Iran enables corrupt surgeons to get by, as in to move through the channels of the system in place. For these illegal transplants to occur, limited and coveted actors are the surgeons themselves, as their skills are hard to obtain.
The kidney black market is a system that allows for the illegal distribution and selling of kidneys, most commonly from citizens in Iran to buyers across the borders. This expands the industry of kidney transplantation, and also expands its impacts, giving rise to dangerous circumstances with no government regulation to monitor the risk of surgery. In addition, while real surgeons perform the nephrectomies, the risks associated with the surgery are naturally increased in black-market efforts as the environment is much less controlled and regulated. These factors heighten the risks of kidney donation, also heightening the negative impact on donors in Iran and their children.
Conclusion
The Iranian kidney market is a unique system that initially aspired to solve the unfortunate reality of kidney shortage seen by the rest of the world. It has successfully eliminated the transplant waiting list so that supply is comparable with demand. The negative aspects of it, however, are that the open kidney market preys on the country’s most vulnerable population– the extreme poor. Families find themselves in situations where a parent feels pressured to sell a kidney in order to pay their bills. This system allows for exploitation of people and situations, and can cause immense harm to the vulnerable.
Kidney removal surgery is a serious surgery that requires days of hospital time and weeks of healing time afterwards. Most donors in Iran are parents, meaning that children regularly see their parent go through an extensive operation. In some cases, with parental consent, the children are the ones themselves going through the surgery. This is not only physically harmful but also emotionally– it places a large mental strain and stress on the children, possibly causing disorders such as anxiety.
In addition, the environment of selling a body part for cash compensation is potentially damaging as it normalizes harmful values. It raises questions surrounding bodily autonomy and what it means to have control over oneself. Yes, all legal donations are in theory consensual. But how truly consensual can it be in practice when people donate out of a sense of need, driven by a desperation for cash? The black market is riskier still– potentially offering donors more money, but coming with greater risk. The open kidney market is especially problematic for children in Iran, causing a harmful environment along with anxiety, stress, and pressure. In sum, a system meant to be noble in theory– by helping those who need a healthy kidney get the organ they need– turns out to function off of corruption and exploitation in practice, while raising profound questions of medical ethics.
Written By: Oni Schurmans
Edited By: Theodoros Charalampous