Why Don’t We Let People Sell Their Organs? | Monologue Monday

What happens when a morally well-intentioned system produces terrible results?

Chad begins with the case of Keith Lott, a 47-year-old New Jersey man whose family says they spent two days fighting an organ procurement organization over whether his organs could be recovered after his death.

But that story opens a much larger question.

America desperately needs kidneys. Living donation has remained essentially flat for decades. Dialysis costs taxpayers enormous sums. And yet federal law prohibits compensating the one person without whom a transplant cannot happen: the donor.

Why?

Chad traces the answer back to the National Organ Transplant Act of 1984, explores the strange contradictions in what Americans can legally be compensated for donating, and asks whether our moral assumptions have actually produced the outcomes we intended.

The episode examines Iran's controversial compensated kidney system, Israel's successful use of non-cash incentives, the danger of exploiting low-income donors, the economics of dialysis and transplantation, and current proposals for carefully regulated donor compensation.

The larger idea is what Chad calls “incentive morality.”

What systems actually get people to do the most good?

Because civilizations aren't built by wishing human beings behaved differently. They're built by designing institutions that work with human nature while protecting freedom, dignity and consent.

And sometimes the moral thing isn't demanding better people.

It's building a better system.

🌐 More Common Sense: ChadParkerLaw.com
📱 Call or text the show: 252-CHAD-LAW
📚 Find Chad's books, editorials and the free Common Sense Conservative Manifesto at ChadParkerLaw.com

CHAPTERS

00:00 The Case of Keith Lott
18:27 The Kidney Shortage Crisis
21:44 The Cost of a Lifetime Contract
24:02 The Origins of Organ Donation Laws
28:48 The Architecture of Organ Donation
31:22 The Moral Dilemma of Compensation
34:11 The Market for Body Parts
37:16 Legal Compensation for Living Donors
40:31 The Generosity of Paid Donations
42:38 The Kidney Conversation We Never Had
44:52 The Flatline of Living Donors
47:52 Iran's Experiment with Compensation
52:18 Incentives Over Money: The Israeli Model
54:33 The Impact of Financial Incentives on Behavior
55:37 The Cost of Kidney Disease and Dialysis
57:34 Proposed Solutions for Kidney Donation
59:54 Addressing Ethical Concerns in Organ Donation
01:01:52 Incentive Morality: Designing Better Systems
01:04:41 Revisiting the Moral Contract of Organ Donation
01:07:49 The Need for a Second Look at Organ Donation Policies
01:24:22 Practical Steps for Reforming Organ Donation

Transcript

SPEAKER_00 0:00

America, there's a clock that starts when a man dies. Most of us don't know that. Most of us think death is the end of the urgency. The worst thing already happened. Now there's just paperwork and casseroles and people you haven't seen in 11 years standing in your kitchen saying he's in a better place. But for some families, the clock starts immediately. Because in some faiths, you don't get a week. You don't get a viewing and a slideshow and a Saturday service. You get three days. You put them in the ground and you do it fast because that's what he believed, and that's what he asked for. And the last thing you can still do for a man is the thing he asked for. So there's a family in New Jersey this past May, middle of the month, four brothers, parents who've been married almost 57 years, the kind of family that keeps two barbecues and a couple of smokers going in the yard so nobody has to eat anything they're not supposed to eat. And the youngest of four brothers dies at 47 years old. He'd just finished training for a promotion. Monday was going to be his first day running it on his own. He never got to Monday. Now the family's in a hospital in Camden. The machines are doing what machines do. And the doctors have said the words that end the hoping. And the family knows about the clock. Three days. That's the window. That's the promise they made him. And then two people they have never met walk into that room and tell them, hold on, not yet. We're not done with him. And I want you to understand who we're talking about. These are not con artists, these are not grifters, these are not people who wandered in off the street. These are people from an organization that exists to do something genuinely good, something that saves lives, something you have probably signed up for yourself without thinking twice about it. They told this family the body was not theirs to bury. They told them there was a document. There was a box that had been checked. There was, and this is the phrase, this was the phrase that's been rattling around my school for two months now, a lifetime contract. Two days. That's how long the standoff lasted between the family and the collectors. Two days of a family fighting strangers over a man's organs while a clock they believe in ran out. So I started reading this story because it made me angry. And I finished reading it because it made me confused about something completely different. Something nobody in that room was even arguing about. Hang on, first this. If common sense has become part of your weekly routine, ChadParkerLaw.com is your home base. Every week you'll find something new, whether it's my latest books, a new editorial, the gaily news, the free Common Sense Conservative Manifesto, or everything else we've been building together. And if you've got a question, an idea for an episode, or you think I completely missed the mark, call or text me at 252 Chad Law. Some of the best conversations on this show start with your messages. All right, let's get to today's episode. Right after these words.

SPEAKER_01 3:00

When you need common sense, come see Chad Law. The boldest pundit you ever saw. It's true, truth it's hard, and the talk is real. Reality rules, and that's the appeal. Spread truth. You take it down the ball with the back. Come where it's real with common sense.

SPEAKER_00 3:36

I'm Chad Law, the last gay conservative, America's binary brother, the common sense extremist living in radical reality, broadcasting truth on the only rainbow that matters: the red, white, and blue rainbow. And America, this is common sense, the show where we read the fine print so you don't have to, where we bring receipts instead of outrage, where politics is really just the starting point for something much bigger. This is the shelter for the politically homeless where reality gets a vote. Results matter, truth matters, common sense matters. So welcome home, America. All right, so that man in New Jersey, his name was Keith Lott, 47 years old, he was from Swedesboro, New Jersey, youngest of four brothers, assistant director at SEPTA, that's the transit system that moves Philadelphia around every day. And he'd just finished the training for the promotion. Monday was going to be his first day flying solo in his new job. His wife's name is Brooke. They got married in 2023. And by every account in the reporting, this was a good family. His wife said it plainly. When it came to food and family, that was his love language. The yard at his parents' place in Turnsville had multiple smokers and two barbecues going, and part of the reason was so they could always accommodate his and Brooke's religious dietary restrictions. Which tells you something about that family before you know one other thing about them. Nobody eats alone. Nobody gets the well, there's a salad treatment. You build a second grill. I have relatives that won't buy a second phone charger for people who don't have iPhones. These people bought a second smoker so their son wouldn't have to sit there with a plate of ice. May 16th, he and Brooke had been over at his parents' house setting up for a gathering, a celebration actually for the promotion, and the two of them made the half-hour drive back home. And that night at home, Keith Lott had a medical emergency. Now, I'm gonna tell you how once, because it's in every version of this story, and I'm not gonna have anyone think I'm hiding the ball. He died during sex with his wife. And look, I get the impulse. There's a version of this story where that's the whole story, where everybody gets to be clever in the comments for a day and then forgets his name by Thursday. That version went everywhere. You don't need it from me. So I'll give it one line and then we're done. The man was 47, he was in his own house, and he was happy. There are worse Fridays. All right, that's the last you'll hear about it from me because the way a man dies is not the story here. What happened to him after he died is the story for me. So the paramedics came, they did CPR, they shocked his heart multiple times on the way in. They got him to Cooper University Hospital in Camden and put him on a ventilator. And what the doctors determined was that the blood had stopped circulating through his body long enough that his brain had swollen. And three days later, they declared him brain dead. So now what you've got a family standing in a hospital in Camden making the worst decision a family ever makes, which is a green to pull the plug. And here's where the clock comes in. Keith Lott had converted to Islam after he and Brooke married in 2023. And under Islamic practice, burial happens quickly, with about three days. That's the reporting. That's what the family was working against. Now I want to be careful because this is exactly the point where a lot of shows would turn this into something it isn't. I'm not going to tell you to sit here and tell you what Islam teaches about organ donation. I'm not qualified to do that. And pay attention to this part. It doesn't matter to the argument, not even a little. The Islam part is irrelevant to me. Because if you strip the religion out entirely and claim it the claim is identical. A grown man made a decision about his body. He told the state what his decision was. His family said he changed his mind, updated his license, and he was no longer a registered donor. That's not a religious argument, that's a consent argument. It's the same argument a Jehovah's Witness makes, the same argument an atheist with a living will makes, the same argument you'd make at a kitchen table tonight if somebody asked you. The family says he'd taken himself off the organ list. And the organization that showed up said otherwise. That organization is called the New Jersey Sharing Network. They're an organ procurement organization for the state of New Jersey. They're a nonprofit. Their entire stated mission is saving lives through organ and tissue donation. And I want to be very clear about something before I go one inch further. That mission is real. Those lives are real. Somewhere in this country tonight, there's a woman on dialysis three days a week who'd give anything, anything for the phone call that says we found one. That's not a rhetorical flourish. That's a person, and she is exactly as real as the Lott family. Which is what makes this so hard, folks. According to the family, the representatives insisted Keith was a donor. And according to his sister-in-law, they were told repeatedly that when you check that box at the DMV, it's a lifetime contract. His brother Alex says he stopped them right there. That his brother's faith settled the question. That when a man makes a vow like that, you respect it. The state senator who eventually got dragged into this, Paul Moriarty, said a family member called him in a panic. And his description of what was going on in that room is that people were saying they were taking the body and were going to harvest the organs, whether the family liked it or not. Two days. Two days of that, imagine. The senator made calls, and roughly two hours after the family reached out to him, the organization backed off and said they'd release the body. Two hours after two days. When NJ.com went to NJ Sharing Network, the organization responded but declined to discuss the specifics, saying they can't comment on individual patients or donor families in order to protect privacy and dignity. And I want to be fair here, actually fair, not the fake kind where you say, to be fair and then keep swinging. There are legitimate reasons an organization can't litigate a family's worst week in the press. And there's a real, unresolved factual question buried in this. Whether that change to his license was properly recorded and what the organization was actually looking at on its screen. I don't know the answer to that, neither does anyone else who was in the room. Here's what I do know. New Jersey law is not ambiguous about the principle. A donor has the right to amend or revoke that gift at any time before death. There is no such thing as a lifetime contract. That phrase does not exist in the statute. Whether whatever was on that screen, the law's position on what a man is allowed to change his mind about is not complicated. So I sat with this for a while, and my first reaction was the one you'd expect. Who the hell do these people think they are? But then I read it again and something started nagging at me, and it wasn't about consent forms. Everybody in that room was fighting like their life depended on it. Because for somebody out there it did. That's why it got that ugly. Nobody fights that hard over something there's plenty of. Nobody has a two-day standoff over a bag of ice. And that's when the question changed on me in my head. Why are we fighting this hard over one kidney? And right behind it, the one I couldn't put down? Why are there so few kidneys that grown adults are having standoffs in hospital hallways over the ones we've got? Why is it so limited? Because here's the honest part, and I need you to hold on to it. Nothing I'm about to tell you for the next hour would have saved Keith Law. Not one thing. He wasn't going to sell anybody anything. His organs were never for sale. Nothing I found in two months of digging would have changed one minute of what that family went through. It's not the point. And that's exactly what started bothering me, though. Because if the fix isn't in that room, then the problem isn't in that room either. Look at what we actually argue about in this country. Who consented, whether the box was checked, whether the family can override it, whether the procurement organization can proceed, who's next on the list, who got skipped, whether the paperwork got filed correctly at the Motor Vehicle Commission in 2024. Every one of those arguments, every single one, is an argument about what happens to a person after they die. That's the whole national conversation. 40 years of law, 40 years of hearings, 40 years of scandals and reform and congressional letters, all of it aimed at the same place. And underneath every last bit of it is something so simple it's almost stupid. There aren't enough kidneys. That's the thing generating all of it. Every fight, every rule, every phone call to state senators at 10 o'clock at night, it's all downstream of one shortage. So before I could ask whether there's another way to get more of them, and there is, and we're gonna get there, and I promise it's going to make you mad in a way you're not expecting. I had to understand the thing we're all standing around fighting over. I had to go look at the system. And what I found is that that fight the lots were having, that's not the exception. That's the whole business. The fights are constant, and they're all over the dead. So the first thing I did was try to figure out whether the lots were just unlucky. Because that's the reasonable assumption, right? Big system, thousands of cases a year, human beings under pressure in the worst hours of others' lives. Somebody's going to have a bad night. Somebody's going to have to say the wrong thing to the wrong family at the wrong moment. That's not a scandal. That's a Tuesday in America. And honestly, that's genuinely what I expected to find. Nine months before Keat Lott died, November of 2025, the House Ways and Means Committee sent a letter about New Jersey Sharing Network. Not a press release, not a tweet, a letter from a congressional committee based on what they described as accounts from nearly a dozen whistleblowers, people inside the organization. And I'm going to choose my words carefully because these are allegations. None of this has been adjudicated, and the organization disputes the characterization of its work. But the committee alleged that the organization misused documents to tell families it had the authority to remove organs even when the patient wasn't currently listed as a donor on their license, or in some cases, had withdrawn permission to donate. I read that sentence and had to go back and read it again. Because that's not a bad night. That's not one exhausted coordinator saying something clumsy at two in the morning by mistake. That's the exact thing that happened to the Lott family described in a congressional letter nine months before it happened to the Lott family. Think about that. Which means when Alex Lott said, hold up, in that hospital in Camden, he wasn't discovering something. He was walking into the second act. Okay, now I'm actually curious. That same letter alleges that that organization may have procured and then thrown out hundreds of organs. And here's the part that stopped me. Allegedly, in order to meet federal metrics, sit on that phrase for a second, because if you've ever worked anywhere with a quarterly number attached to it, your stomach just did something. There is a scoreboard. Somebody keeps score. And when there's a scoreboard, human beings, every human being in every industry in every century, start playing to the scoreboard. I ran an ad agency. I know exactly what happens when the metric becomes the mission. You start booking work you shouldn't book. You start counting things that you shouldn't count. Not because you're evil, because the numbers do on the 31st. That's it. So put that same dynamic in a room where the product is a person's kidney, and there's more. The committee said public data and whistleblower accounts show the organization allocated more than a quarter of its organs out of sequence from the national waiting list. Out of sequence. Meaning not to the person the computer said was next. And the committee's language on that was about as blunt as those letters get that the organs procured by every one of these organizations belong to the individuals on the wait list ranked and matched by medical criteria. They don't belong to the organization, and it is not the organization's rule to pick winners and losers. Winners and losers. Somewhere there's a family who got a call, and somewhere else there's a family who didn't, and who will never once in their lives find out why. And the most serious allegation in that letter, and I've read this one probably 15 times and still don't love saying it out loud, involves a case at a hospital in Camden. A patient had been pronounced dead for the purposes of organ recovery after life support was withdrawn, and according to the committee, that patient reanimated. The committee alleges the organization's CEO, who was not on site, told the staff to proceed with the recovery anyways, and that hospital staff stepped in and stopped it. Whistleblowers also alleged documentation from that case was deleted or altered, and that the organization's email servers were taken offline before emails connected to the incident were erased. Hmm. Allegations, every word of that, disputed, unadjudicated, and there's a process for exactly this reason. But I'll tell you what my honest reaction was. What kind of pressure produces a phone call like that? Because I don't think you get there by hiring bad people. I really don't. Nobody takes that job for the money and nobody takes it for the hours. You take that job because you sat in a waiting room once or because someone you loved got the call or didn't. You get there by building a system where the only way to succeed is to find more of something that there will never be enough of. Which brought me to the part I should have looked at first. How short are we actually of kidneys? Right now, according to the federal government's own numbers, there are 103,000 people on the national transplant waiting list. Seventeen of them die every day. And every eight minutes, somebody new gets added to that list. Eight minutes. Do that math with me because I did it and it wrecked me a little. By the time I'm done with this segment, two more people will have been added to that list. Before we get to the end of this episode, seven or eight more are being added right now while I'm saying this sentence. Somebody in an exam room in Ohio is hearing the word list for the first time. 17 a day is 6,000 people a year. That's a small city. That's every seat in a decent arena gone every year, waiting for something that never showed up. So now the lots make sense to me. Now the phone calls make sense. Now the two-day standoff makes a horrible kind of sense. Because you can't run a system on a shortage like that and expect it to stay polite. That's not a character flaw on anybody involved. That's just what desperation does to institutions. And it's true of any business you've ever worked for that was three weeks from missing payroll. It is. And that's the point where I thought I actually understood the story. Massive shortage, enormous pressure, terrible incentives, families caught in the middle. I actually started writing a version of this episode, and then I found the number. And this is from the Scientific Registry of Transplant Recipients, the official annual data report on kidney transplantation in this country, not an advocacy group, not a think tank, just the data. Of the kidneys recovered from deceased donors for the purpose of transplanting them, 29% were never transplanted. 29% of harvested kidneys go in the trash. They're recovered, surgically removed, packed, logged, somebody drove it somewhere, and then never put it into a human being ever. I said that out loud to an empty room. I said, that can't be right. So I went and checked it against everything else I could find because it felt like a typo. An investigation published this year found roughly one in five of all donated organs in this country goes unused. In Georgia alone, 17% of recovered organs were discarded in a single year. For kidneys specifically, it runs higher. To that same official report, the number for kidneys from donors 65 and older is 69%. 69? If you're 65 and you checked that box, the box you checked because you wanted one good thing to come out of the worst day of your family's life, the most likely outcome for your kidney is that nobody gets to use it. Now, the inconvenient half, this is not 30% of organs going into a dumpster for no reason. Researchers have looked at why that number climbed, and most of the increase comes from the donor pool broadening. We're now recovering organs from older donors, sicker donors, more complicated donors than we used to. Kidneys that 20 years ago nobody would have taken out at all. So some of that number is a system trying harder and coming up empty. And it's real. I'm not going to pretend otherwise. It doesn't matter for this argument. Some of it isn't. Because there's another thing in the reporting I can't get past. When investigators asked why so many get discarded, one of the answers from the inside the industry itself was that it's a misalignment of metrics. That transplant centers are hesitant to accept the complicated ones because a bad outcome shows up on their scorecard. So instead of trying, they let people die. So there's a scoreboard on that too. Of course there is. One scoreboard on the recovery side pushing to get more of them out, another on the transplant side making people cautious about taking the hard ones in. Two scoreboards pointed in opposite directions, and the kidney is sitting in the middle. And that's where I had to stop and go back to that hospital room in Camden with that poor family. Two days that family fought. Two days of strangers and paperwork and a phrase lifetime contract. And a burial clock running out, and a mother and a father who'd been married 57 years sitting in a hallway. Over organs that That statistically had about one in three chance of never reaching another living person ever. Nobody in that room knew that. Nobody in that hallway was doing that math. You don't run the numbers on the worst night of your life, period. You don't. And I'm not saying it makes the fight pointless. The chance isn't zero, and if it's your husband on dialysis, you'd take one and three in a heartbeat, and so would I. I'm saying we've built something extraordinarily strange. Look at the ledger when the dust settles. Actually look at it. The Lott family didn't win. They lost two days, they'll never get back. The organization didn't win. It got a congressional letter and a wave of coverage that they didn't want. The person who was next on that list, wherever they are, whoever they are, they didn't win either. Nobody got a kidney out of this, nobody. And Keith's brother Alex went home and took himself off the donor registry. Hmm. I don't blame him. That's the receipt that haunts me. Not the congressional letter. That one. Because a system this desperate for organs just spent two days fighting a family, and the actual measurable output of that entire confrontation was one fewer registered donor in the state of New Jersey. And everyone who reads that story and quietly thinks maybe I should look into taking myself off too. That's not on anybody's report either, but we're all out there. See, there's no metric for the donors you scare away. And that's the whole national conversation. Every congressional letter, every reform, every lawsuit, every hearing, every fight in a hallway in Camden, all of it happening inside that one box. And then I kept coming back to the same thing. We're having an unbelievably vicious argument about how to divide something there will never be enough of, which is actually a completely reasonable argument to have when you think about it. But why is it the only argument we're having, folks? Like, who decided this? That's the question that finally got me. Not who's right in Camden. Who decided that this is the fight? Because a system like this doesn't fall out of the sky. Somebody built it, somebody wrote it down. There are rules about who owns what and who can be paid for what and who gets to say no. And those rules did not come down off a mountain on a stone tablet. They came out of a building in Washington, DC on a specific date, and somebody's name is on them. So I went looking. I figured I'd find years of debate. Commissions, studies, competing bills, a big, serious, grinding national argument about the deepest questions you can ask. What a body is, what you own, what you're allowed to give away. That's not what I found. I found one afternoon, in 1983, there's a doctor in Virginia named H. Barry Jacobs. And I want to give you his resume in the right order because the order matters. He's a physician, or he was a physician, past tense, because five years earlier his medical license had been revoked over a conviction for Medicare fraud. So already this is a man with a track record, not somebody you'd hand your car keys to, let alone your kidney. And Dr. Jacobs, I'm gonna keep calling him doctor because that's how the papers referred to him and because it's funnier. Dr. Jacobs has an idea. He has a business. He has, God help us, a brand. He calls it the International Kidney Exchange. Here's the model. He finds people in poor countries, desperately poor countries, willing to sell one of their kidneys. He finds Americans with failing kidneys who have money, and he introduces them. The seller names a price, reporting at that time put it at about $10,000. The American pays that. And then the American pays Jacobs, two to five thousand on top for the introduction. That's the whole business. He's the middleman. He's a broker. He is functionally a real estate agent, except the property is a person, and the person is in Honduras. And in the fall of 1983, Dr. Jacobs goes to Washington and testifies about it in front of Congress. Now I have to say something, because if I don't say it, the rest of the hour doesn't work. If I'd been in that room in 1983, I would have been disgusted. I'm not being cute. I'm not setting up some clever reversal. If I, uh disbarred fraudster, walked into a hearing and told me his plan was to fly poor foreigners into American hospitals, take out their organs, hand them a check and a pocket of finder's fee, I'd have wanted him thrown out of the building as well. I might have wanted him thrown out of a window. That's not a stupid reaction. That was the correct reaction. The lawmakers in that room were not idiots and they were not cowards. They looked at a man proposing to build a commodity market in the bodies of the world's poorest people run by a guy with a fraud conviction and their stomachs turned. Mine would have too. And the record's pretty clear that the disgust in that room is exactly what moved the bill. It didn't crawl through committee. It went fast. It went bipartisan. Opposition to that one man's business plan is what pushed the legislation out the door, which is where I want you to notice something, and I'll say it as gently as I can because I'm not accusing anybody of anything. We did not have a national conversation about the ethics of compensating organ donors. We had a reaction to H. Barry Jacobs. Those are not the same thing, and one of them became permanent federal law. October 19, 1984, the National Organ Transplant Act. It passed the Senate by voice vote. It passed the House by voice vote. Voice vote means nobody even bothered to record who was for it. That's how uncontroversial it was. It was written primarily by a young Tennessee congressman named Al Gore, and it was signed into law by President Ronald Reagan. Sit there one second because it matters to what this show is. There is no villain in this story, there's no party to blame, there's no cabal. Democrats wrote it, a Republican president signed it. Nobody objected loudly enough to require a headcount. This was as close as this country ever gets to unanimous. Everybody agreed. Everybody meant well, and that's exactly why nobody went back and checked this part later. Because the most dangerous laws in America aren't the ones we fight over. They're the ones everybody nodded at. I wrote a book about this. It's called The Cost of Certainty. And that's the whole idea. The beliefs that do the most damage aren't the ones we argue about. It's the ones we're so sure of that nobody ever goes back and adds up the bill. This is going to be a chapter. Anyway, back to 1984. So what did the law actually do? The law built the whole architecture we're still living in: a national network to distribute organs, a registry, funding for the procurement organizations, all the plumbing. And then there's one section that says you cannot transfer a human organ for what the law calls valuable consideration. Valuable consideration, that's the phrase. That's the whole ballgame. And it's the kind of phrase that only exists because a lawyer got paid by the syllable. In plain English, you can't get anything of value in exchange for your organ. Not cash, not a car, not a discount on your mortgage, nothing. It's actually a criminal offense on the federal books. Okay. So now I understand where the wall came from. And this is where I expected the story to end. Congress looked at a market and body parts, said, absolutely not, and slammed the door. But that's not what happened. Because in those same hearings in the House, the man from the man writing the bill, there's this. Gore spoke approvingly of incentives, specifically, and I'm quoting the record of quote, a voucher system or tax credit to a donor's estate. If, and this is the correction, efforts to improve voluntary donation turned out to be unsuccessful. Read that again with me. The man writing the ban in the room where he wrote it said out loud, this might not work. And if it doesn't, here's the door. He left us a door. Now, pre precision is important because somebody's going to clip this. That was a congressman's remark at a hearing. It's not statutory text. There's no sunset clause, there's no trigger, nobody was assigned to check. That's the whole problem. And I'm not telling you what Al Gore would say about any of this today. I have no idea, and I'm not putting words in a living man's mouth. I'm telling you what's in the record. And then the part that stopped me cold. Not the door, what the door was pointing at. A tax credit to a donor's estate. An estate? You have to be dead to have an estate. Sit with that. Just for a second. This is the absolute high water mark of imagination on this question. The most creative anyone in that building got. The escape hatch, the plan B, the one moment where somebody in power said maybe money isn't automatically evil here. And even that was aimed at dead people only. Even the way out was pointed at a corpse. That's when I started to realize this wasn't a story about a ban. This is a story about a lane and how nobody has looked out the other window in forty-two years. But hang on, because it gets stranger, and this is the part where I actually laughed out loud, which I did not expect from a federal statute. That phrase, valuable consideration, has a definition in the law, and the definition tells you what doesn't count. So here's what you're allowed to be paid for right there in the text. Removal, transportation, implantation, processing, preservation, quality control, and storage. Storage! You can get paid to put it in a refrigerator. Somebody's on the payroll for the cooler. That's a job. That's a W 2. That's somebody's whole career, and God bless them. We need them, but let's be clear about where the moral line in this country actually sits. You can be paid to move it. You can be paid to freeze it. You can be paid to inspect it, package it, fly it, thaw it, and sew it into another human being. You cannot be paid for having grown it. How backwards is that? And then there's one more item on that list, and when I got to it, I put the laptop down and went and stood in the yard for a minute, had to touch some grass. The definition also excludes, meaning it's allowed the donor's expenses for travel and housing. And lost wages. That was another one. Lost wages. Ooh. A dead man does not have lost wages. You can't miss a shift from a casket. Nobody's docking a corpse's PTO. That clause only makes sense if somebody in that room in 1984 pictured a living human being, a real person with a job taking two weeks off work to give a kidney to a stranger. They saw that person, they thought about that person specifically enough to write a clause about them. And then the only thing the United States Code had to say to that person was, you may reimburse back to zero, but not one dollar past it. That's the entire moral architecture of this country on organ donation, and it fits on one sentence. Everybody involved may profit except the one person the thing came out of. Crazy, right? Now let's follow the money because I want to be fair about where it goes. Hospitals get paid, of course they do. Surgeons get paid, and they should. That's a hard job, and you want to be the one who's good at it. Transport gets paid, labs get paid, the procurement organizations are nonprofits, but nonprofit doesn't mean nobody gets a paycheck. Those are real organizations with real employees and real salaries, as it should be. None of that is scandalous. That's a functioning medical system. But then there's tissue. Organs are one thing. Tissue is everything else. Skin, bone, tendons, corneas, cartilage, veins, valves. And when you check that box at the DMV, in most cases you're checking it for both. The tissue side operates very differently. The recovery organizations are largely nonprofits. The processors, the companies that turn what's recovered into an actual product, very often are not. They're for-profit. Routers spent years on this in a series they called the body trade, what they documented as a market, an open, legal, minimally regulated market. In one four-year stretch, brokers distributed more than 180,000 body parts from roughly 50,000 bodies with a price list: $500 for a head, more than $3,000 for a torso with legs. Routers reporter bought a cervical spine and two cadaver heads for $900 total. And not one person asked him what he wanted them for. And where does that material end up? Some of it goes exactly where you'd hope. Skin graphs for burn victims, bone for reconstruction, corneas, genuinely miraculous things that save and restore lives. And I don't want one person watching this to think otherwise. And some of it becomes cosmetics, wrinkle fillers, lip augmentation, and I'm not making this up. This is in the reporting. Penis enlargement. Somewhere in America, there's a man walking around very pleased with himself, and he has no idea he owes it to a stranger from Ohio who his cadaver fat was used to enlarge his penis. And then this year it got weirder. Because the newest thing in cosmetic medicine is injectable fillers made from donated human fat. There are brand names they advertise. One beauty writer coined a term for the category that I cannot improve on. Necrocosmetics. And demand is exploding. And here's why. All these weight loss drugs. Millions of people lost the weight. The weight came off their faces. Now they want the volume back, and there isn't enough of their own fat left to move around. So we're using dead peoples. Now careful, because this is a real medical product with real regulatory questions, and I'm not here to tell anyone what to put in their face. I love the idea. I would do it in a heartbeat. I'm just here to point at one thing. Every person in that chain gets paid. The recovery organization, the processor, the distributor, the sales rep the clinic, the doctor holding the syringe, and the family who said yes on the worst day of their life, who thought they were giving somebody a second chance at breathing, usually has no idea any of that happened and gets nothing from it. That's not a market I'm outraged by. That's a market I'm confused by. Because we've been told for 42 years that the reason we can't pay a donor is it would turn a human being into a commodity. Ladies and gentlemen, there is already a price list. Okay, so let's leave the dead alone a minute, because here's where I really lost the thread. What can a living American get paid for right now, today legally? Hair. Absolutely. Ten inches or more, there's a market. People do it every day. Nobody's ever written a congressional letter about a ponytail. Sperm, yes, there are banks, there are catalogs, there are heart height requirements. You can be turned down, which I'm told is a fun conversation to have with yourself in the parking lot. Breast milk, you can sell. Yep. A few dollars an ounce, perfectly legal. Stool! I'm serious, there are companies that pay for it. There is a man in this country right now whose side hustle is deeply humbling and extremely lucrative. Plasma, absolutely legal, wildly common. There are more plasma centers in this country than a lot of chains have stores. And college kids have been paying for textbooks that way for generations. Bone marrow. And this one's a real legal wrinkle. Not the old way where they go into the hip with a needle. But when it's collected out of your bloodstream, a federal appeals court ruled that that's not covered by the band, so compensation's permitted there. Same cells, different needle, different law. Just bizarre. Eggs. Women's eggs. And I want to slow down here because this is not a punchline and I refuse to treat it like that. Do you know what egg donation actually asks of a woman? Weeks of hormone injection she gives herself daily, monitoring appointments, early mornings, blood draws, ultrasounds, real side effects, real risks, small but real, and every donor signs paperwork acknowledging it, and then a surgical retrieval under sedation. That's not a haircut. That's a medical undertaking that reorganizes a month of your life. And she's compensated for it, eight to fifteen thousand dollars a cycle, depending on where and how many times they have to do it. Nobody protests those clinics. There's no federal criminal statute. There are ads on the radio. Then surrogacy. Nine months of pregnancy. Every single thing a pregnancy does to a body, and if you've been in the room for one, you know that it list is very long and it doesn't end at delivery. Bed rest sometimes, a C-section sometimes, tons of genuine medical risk because pregnancy is genuinely risky. That's just true. For somebody else's child. Base compensation in this country generally runs $45,000 to $75,000, and total packages go higher. And it's so accepted here that America's become the destination. People fly in from countries that outlawed paying a surrogate specifically because we didn't. Now picture the other family on the end of that, because I've known some of them. The couple that spent six years and everything they had, the woman who beat cancer and lost the ability to carry two men who wanted to be dads. And there's a kid. There's an actual kid, nine years old in a school picture on somebody's refrigerator right now who exists, full stop, exists because a woman was compensated to make it possible. Tell me the money made that child less real. Tell me the check made that surrogate's nine months less generous. Tell me it made the egg donors' needles less brave. Look at that photograph on the refrigerator and tell me the transaction contaminated it. You can't. Nobody can. We know better. We watch those reunion videos and we cry like everybody else. We already believe, as a country, in practice, in law, on the radio, that somebody can be paid and it can still be one of the most generous things a human being ever does. We just believe it about everything except one organ. So I made a list. I actually sat down and made a list because I wanted to see it in one place. Hair, sperm, milk, stool, plasma, eggs, a pregnancy, bone marrow as long as it's in your arm and not a hip. And then a line. And then a kidney, which equals prison. I stared at that list a long time trying to find the principle. What's the rule? Renewability? No, a woman doesn't grow new eggs. Risk? Carrying a pregnancy for someone else is not a low risk undertaking, and everybody who's done it knows that. Intimacy, come on, we let a woman carry a stranger's child for money and we're worried a kidney's too personal? I couldn't find the principle. I still can't. If you find it, text me 252 Chad Law because I have looked. But somewhere in the middle of staring at this stupid list, I noticed something else, and it wasn't about a line at all. Every single item on it, hair, sperm, milk, stool, plasma, egg, surrogacy, marrow, every one of those is a living person. Walking around, making a choice, signing a form, going home afterward. And I went back through everything I'd read for two months. The law, the hearings, the escape hatch aimed at an estate, the congressional letters, the scoreboards, the discard numbers, that hospital hallway in Camden, New Jersey. Every argument this country has had for 42 years is about the dead, the dead, the dead, and the dead. Every biological thing we've decided a person can be paid for involves somebody with a pulse. And the one thing we're most desperate for, a kidney, the one where 17 people a day run out of time and die is the only place we've never once had that conversation? There are a few hundred million Americans walking around with a spare kidney and no plan for it. So where the hell was that conversation? How did that never come up in 1983 and no one's questioned it since? You can donate a kidney while you're alive. Duh, everybody knows that. People do it for family all the time. Why don't we let people sell them? That's the reveal. You have two. You only need one. Now, not me, obviously, let's be honest about where I sit in all this. Nobody's fighting over these organs. Nobody's calling a state senator at 10 o'clock at night to get a piece of this. I've got German heritage, which means my body is basically a 1966 Chevy pickup. Beat all the hell, 500,000 miles on it, 10-year-old oil, something rattling under the hood that nobody has ever successfully identified. And on both sides of my family, people die late into their 90s. Not health nuts, not one of them. Nobody was doing yoga, nobody was tracking their macros. They just would not die. That's how I am. Nobody wants these fat, unhealthy organs. So no. You don't want my parts. But I'll tell you, that truck is going to outlast every brand new vehicle in the lot, and there is not a mechanic alive who can tell you why. And I'll say the real thing underneath that joke, because there is one. That's luck. That's all that is. I didn't earn a day of it. I didn't build the Chevy truck. There are millions of people who did not win that draw, whose kidneys quit at 31, and no one can give them a reason. And we mostly don't think about them because they aren't doing anything dramatic. They're sitting in a chair three days a week while the rest of us get to walk around feeling healthy and calling it a lifestyle. So when I show you the next number, keep that in mind. Those aren't statistics, those are their odds. I just happen to pull the genetics lottery. Not everyone does. For the rest of you, healthy people, give one away and walk out of the hospital and go back to their lives. And this is not experimental. It's not new. It's not frontier medicine. The first successful kidney transplant in the history of the world, 1954, was a living donation. A man gave one to his twin brother. 1954. That's before the interstate highway system. Thirty years before the law we've been talking about. We have known how to do this the entire time. So obviously, obviously, as that list climbed past 100,000 and hospital hallways turned into standoffs, the number of living donors must have gone up, right? That's the pressure valve. That's the one place the supply isn't capped by how many people happen to die the right way on the right day. Here's the number. About 6,000 living kidney donors a year. And it has not moved in 25 years. Not one inch. Not gone down either. That'd be a story. Not gone up, that'd also be a story. Flat. A quarter century. Straight through the entire crisis, through every awareness campaign, every ribbon, every celebrity PSA, every DMV clerk asking if you'd still like to be a donor. 6,000, 6,000 a year. Meanwhile, and this is from the sponsors of legislation we're going to get to, between 2010 and 2021, 100,000 people on that waiting list either died or got too sick to transplant and then died on dialysis. 100,000 people on one side of the ledger, a flat line on the other, 6,000. I've spent my career in marketing. I've run campaigns for things nobody wanted. And when a number sits perfectly flat for 25 years while demand explodes, that is not a supply problem. That's a nobody tried problem. Something has to be actively not happening for 25 years to produce a line not boring. And then I found the second thing, and the second thing is worse. Because if we're ignoring a lousy option, fine. If living donor kidneys were the spare tire, gets you home, don't take it on the highway, I'd understand the shrug. They're better. That's in the official annual data report. Across every racial and ethnic group they've measured, patients who got a kidney from a living donor survived at a higher rate than patients who got one from a deceased donor. Higher survival. So the option with a hard ceiling, where a third of what we recover never gets used, where families end up in standoffs and hallways, that's the one we built an entire national apparatus around. And the option with no ceiling that produces better outcomes, that doesn't require anybody to die first. That one's been sitting at 6,000 since Bill Clinton was president, and the entire national apparatus we built, the law, the network, the organizations, the metrics, all of it, is pointed at the other lane. If I ran a company that way, I'd be fired, then sued, then honestly, probably studied. So I went looking for one very specific thing. Has anybody, anywhere on this planet, ever tried changing the incentive for living donors? Not the ads, not the awareness, the actual incentive. Has anyone run the experiment? And I'm typing this into a search bar, fully expecting the answer to be no. Because if somebody had run it, surely they'd I've heard about it. That'd be famous, right? Huge. One country. One. And it's Iran. Go figure. And I know, believe me, I know. And I want to be extremely clear before I say another word because this is the part that gets clipped and posted with a caption I didn't write. I'm not praising the Iranian government. I'm not telling you Iran is a model society. I'm not telling you Iran does healthcare better than we do, or medicine better than we do, or anything else better than we do. I checked this three separate times over about two weeks specifically because I did not want to be the guy on the internet saying Iran figured something out. But the fact is the fact. Since 1988, Iran has run the only legal government regulated program in the world that compensates living kidney donors. Here's roughly how it works. A patient with kidney failure gets checked for a relative who matches. If there's no relative, they go on the deceased donor list and wait about six months. If nothing comes, then and only then the search moves to living unrelated donors. The matching doesn't happen through a broker in a strip mall. It runs through a charitable association. There's a screening panel of doctors deciding whether a person is medically eligible to donate at all. Donors have to be healthy adults with spousal or parental consent. And the donor receives a fixed payment from the government, plus an additional amount from the recipient or from a charity. And the government deliberately framed it. This is a marketing decision, and I notice these, not as a purchase, as a reward for the act of donation. And here's what happened to supply. Transplants climbed steeply. And the published research, including the papers everyone on every side of this argument cites, reports that by 1999, roughly a decade in Iran's kidney transplant rating list was eliminated. No more waiting list because of a private kidney market. Hmm. Now, deep breath, here comes the other half. That eliminated claim is disputed, not by activists, by transplant researchers and the literature. There's a review in the journal Transplantation arguing flatly that brokers do exist in Iran, a black market exists, transplant tourism exists, and waiting lists was never actually eliminated at all. All the things that would happen just with drugs and every other product, including shampoo. I don't think that makes it necessarily worse, but it also points out that one city in Iran called Shiraz went the other direction, phased out, paid donation, built up deceased donation instead, and by 2011, the vast majority of its transplants came from deceased donors. So I guess it's semi-contested. Interesting nonetheless, because researchers went and asked the donors. And the record is genuinely mixed because fast forward, a separate multi-center study of nearly 500 Iranian donors a few years later documented coercion in only one case, found 91% said they were satisfied, and about half said they'd recommend it. It also found 62% were living below the poverty line. So two studies, two eras, very different pictures, both real. So what do I take from Iran? Because I sat with this for a long time. The supply result is real. Nobody seriously disputes transplants went up, way up. That's the one thing everybody agrees on. Change the incentive, more kidneys, more people alive. That happened. To me, that's what's most important. And when you look at where the harm is concentrated, it's not in the fact that money existed. It's in the parts nobody designed, the direct bargaining between a sick person and a poor person with nobody else in the room, the brokers, the no follow-up care, the donor going home to nothing and no one, never hearing another word about the other human being walking around with his kidney. So it's not proof that compensation can't work. It can. That's proof that whatever Iran did in the parts they didn't regulate, don't do that. That's it. I mean, they may not be the blueprint, but they are the receipt. The only country on earth that ever ran the experiment, and the reason it's the only receipt available isn't that Iranians are more comfortable with money. It's that nobody else ever looked. Forty countries have very strong opinions about a test, exactly one of them bothered to take. All right. Now I've got a problem with my own argument. Because if the story stops there, the takeaway is pay people and they'll do anything, and that's a genuinely dangerous idea, and it's not what I believe. So Israel. Israel had one of the lowest organ donation rates in the developed world for decades. Not for lack of trying. They had ad campaigns, appeals, the whole thing. So in 2008, they passed a law. Here's what it did. If you're a registered organ donor and you ever need a transplant yourself, you get priority on the waiting list. Same if a first degree relative donated. That's the incentive. That's all of it. If you're a donor, you're first on the list. Not one dollar, no payment, nobody sells anything, nobody buys anything. The only thing that changes hands is a place in line. And when the public actually found out about it, because it took a while and a big campaign to publicize, family authorization for donation went from 45% to 55% and hit an all-time high just over 60. The donation rate went from about 8 per million people to 11 and a half. And Israelis going overseas for kidney transplants, which is a polite phrase for buying one in a country where nobody's asking questions, collapsed. 155 in 2006, 35 by 2011. Look at what that proves, because it's not what people assume. It doesn't prove money works, it proves people respond to incentives. Money's just one incentive, and honestly, it's not even the most interesting one. Fairness works, reciprocity works, you showed up for the system, the system shows up for you, that works, and it works well enough to move a national number. Decades of moral appeals couldn't budge. Turns out the phrase that changes human behavior isn't you should. It's and here's what's in it for you. Even what's in it for you is nothing but your rightful place in line. Okay. Now let me break my own argument again, on purpose. Two economists ran an experiment at daycare centers in Israel. The problem's the one everyday care on Earth has. Parents show up late. Teachers stuck there at six o'clock with somebody's kid, mom's in traffic. So they introduced a fine. You're late, you pay. Now what happens? Obviously, fewer late parents, that's the whole point of a fine. That's the entire theory of every parking ticket ever written. Late pickups still went up, significantly up. And the part that should genuinely bother you, when they took the fine away, the lateness stayed up. It never went back. They'd broken something and they couldn't unbreak it. Why? Because before the fine, being late meant I'm doing something rude to a woman who has her own family to get home to. That's guilt. Guilt is free and guilt is powerful, asked my mother. After the fine, being late meant this costs eleven bucks. And a whole lot of parents did the math and thought, you know what? Eleven bucks is fine. I'll take the eleven bucks and take my time. They didn't buy their way out of the fine, they bought their way out of the guilt. And once you've sold somebody an indulgence, you can't take it back. You've told them there's a price. They're never going to unhear that. So no, incentives are not magic. A badly designed one doesn't add to your conscience, it replaces it. Which is exactly why this is not a question of whether money is good or bad. It's a question of design every single time. All right, let's talk about what we're spending right now today on the system we've got, because this is where I got genuinely worked up. If your kidney fails in this country, you go on dialysis, and Medicare covers it for basically everyone, regardless of age, which is its own strange piece of history. What does dialysis cost, you might ask? Per patient per year, the average Medicare payment for dialysis runs somewhere between $87,000 and $99,000. $90,000 a year, every year until they die. And a transplant patient? About $36,000 a year. But it's not just the annual number, because that's not how you'd look at this if this was your business. The economists who've run this estimate every single kidney transplant saves taxpayers roughly $146,000 in present value. And zoom all the way out, kidney disease costs Medicare in the neighborhood of $140 billion a year, about a fifth of the entire Medicare budget with one organ. We're not allowed to sell even though we have extras of them. So here's where we are. We spend $90,000 a year forever hooking a man up to a machine three days a week to keep him from dying. And the thing we cannot morally stomach, the thing that is a federal crime, is writing a check to the woman who'd make him well. We already put a price on that kidney decades ago. We just made absolutely certain it never reaches the person it came from. Period. And I want to be careful because I'm not making a budget argument. Don't anyone watching this think my case is transplants are cheaper? If the numbers ran the other way, I'd still be standing here because a man on dialysis three days a week is not living the same life as a man with a working kidney, and money isn't the point. The money is just how you can see the moral line, because the money proves we were never squeamish about spending on this. We were only ever squeamish about who gets it and who gets to sell it. Now, another part I didn't expect to find. Because at this point in my reading, I'm sitting there thinking, great, so my options are the system that produced a hallway standoff in Camden or Iran. Those can't be the options. Well, in April of 2025, a bill gets introduced in the House of Representatives. Nicole Malatakis, a Republican from New York, and Josh Harder, a Democrat from California, a Republican from Staten Island and a Democrat from the Central Valley. If those two agree on lunch, it's a miracle. Something got their attention. It's called the End Kidney Deaths Act. Here's what it does. If you donate a kidney to a stranger, you get a refundable tax credit. $10,000 a year for five years, $50,000 total. And now listen to the design because the design is the whole thing. It has to be non-directed. You don't know who's getting it. Written into the bill, at the moment that kidney comes out, you do not know the identity of the person it's going into. So there is no buyer. There's nobody to negotiate with. The government pays it, not the patient. It's a tax credit. It comes from all of us, which is exactly what it is. Society saying thank you. And the kidney goes to whoever's waiting the longest, not the wealthiest, not the most connected, medical allocation unchanged. The line is still the line. No brokers, no bidding, no auction, no Craigslist. A designed incentive. The projections, and these are the sponsors' numbers, so weigh them accordingly. Up to a hundred thousand American lives over the first decade and ten to thirty seven billion dollars in taxpayer savings. So where is the bill right now? Sitting in committee. Wah w it's always sitting in committee. It's a piece of paper in a building in Washington with two names on it and a number not moving, and almost nobody in this country has ever even heard of it. Would it work? I don't know. Genuinely, I don't know. Nobody does. It's never been tried here. But my God, isn't would it work a more interesting question than the one we've been asking for forty two years? Money immoral conversation over? Stupid. Stupid. Now let me make the strongest punch because there's one and it deserves a straight answer and I can already hear you typing. If you pay for kidneys, poor people will end up supplying rich people. You'll turn desperation into a harvest. That's not a stupid objection. That's the best objection there is, and I'll tell you why I take it seriously. Because Iran's own data supports part of it. Sixty-two percent of those donors were below the poverty line. That's not a talking point, that's a finding. But that objection is devastating against one specific thing. A market where a sick person with money negotiates directly with a poor person who needs rent. A broker in the middle, a price that moves, no advocate, no follow-up. That's H. Berry Jacobs. That's 1983. And you know what? That should be illegal. It is illegal. Keep it illegal. I'm not asking anyone to reopen that door. But that's not what's sitting in committee. You can't be exploited by a buyer who doesn't exist. You can't be underpaid by a bidder when the amount's fixed in statute and identical for everyone. And I'm not going to sit here and tell you every problem solved because it isn't. You'd need serious screening. You'd need an independent advocate for the donor whose only job is the donor. You'd need lifetime follow-up care, which Iran did not have and which where a lot of damage came from. You'd need honesty about the medical risk, which is small, major complications under 3%, risk of dying from the surgery somewhere around two or three in 10,000. But which is not zero, and anyone who tells you it's zero is lying to you. Those are hard problems. They are not, however, unanswerable problems. They're design problems. And this country has solved harder ones on a deadline. What we should not do, what I think we've actually been doing since 1980 before, is declare the entire conversation morally settled because money makes us uncomfortable. Because look at what the pure version bought us. 6,000 donors a year flat for 25 years. That's it. There's a name for the question I've been asking this whole hour, and I didn't have it until about three weeks ago. It's called incentive morality. Not what should people do, but what systems actually get people to do the most good. Because should is not an operating system. Should doesn't staff anything, should doesn't fund anything, should has been the entire American kidney policy for forty-two years and should produce a flat line. Civilizations aren't built by wishing people were different. They're built by creating institutions that work with human nature instead of against it. Period. And that's when I finally understood what had been bothering me about that hospital in Camden, New Jersey. Look at the question I started with two months ago, sitting there furious about a family in New Jersey. Who gets Keith Lott's organs? Then it became why aren't there enough organs? Then, why can't a living person get paid to donate their kidney? And now it's something else entirely. What if the most moral system isn't the one with the purest motive? But the one that actually saves the most people while protecting their freedom and their dignity. Keep going back to that hallway. Two days. A man's parents married fifty-seven years standing there, a wife three days into being a widow, a brother saying, Hold up, a burial clock, strangers with a form and a phrase, and a person somewhere else in this country on dialysis waiting for a phone call that never came out of that fight either. Nobody won. And here's the thing that will not leave me alone. While all of that was happening, every hour of those two days, there was someone out there, somewhere, a healthy person with two kidneys, who would have just said yes. Who has never once been asked. Let me tell you what I think that family was actually told. Not the words. The words were lifetime contract, and the other words were wrong, and we've been over that. I mean the thing underneath the words, because whoever said it believed it. That's the part I can't shake. Somebody stood in a hospital room in Camden and said a sentence they were sure was true because that's the sentence they've been handed, and nobody in the building had any reason to go check it. And it turns out this whole country has been living under a lifetime contract. Ours got signed in nineteen eighty four. Nobody read it to us either. The terms were simple. We don't pay organ donors. And I understand why we signed it. I told you I'd have signed it too in that room that year, looking at the man and his brochure. It was not a stupid decision, it was a decent instinct and an indecent moment. But a decision made in one bad afternoon quietly turned into something else. It turned into a permanent moral rule, and if permanent moral rules don't get reviewed, that's what makes them permanent. So here's the question the title of this show asked, and after two months I think I've earned the right to answer it. Why don't we let people sell their organs? Not because we tried it and it failed. We have never tried it. Not because there's no other model in the world. There are other models, and one of them's been running 38 years, and there are people alive today because of it. Whatever else you want to say about it, it saved lives. And definitely not because money is absent from any of this. There's a price on storage, there's a price on transport, there's a price on a head, and it's $500. We don't do it because 42 years ago we drew a line in a moment of understandable disgust, and we have never seriously gone back and looked at that particular line again. That's the whole answer, folks. Now let me quickly tell you what I'm not saying because someone's gonna clip 40 seconds of this and put a caption on it. I'm not telling you to sell your kidney. I'm not even telling you the tax credit's right. Maybe it's the tax credit, maybe it's fixed compensation, maybe it's lifetime health coverage for anyone who donates, which honestly might be the most conservative idea in the bunch. You took a risk for a stranger, this country's got your back for the rest of your life. Your life. Maybe it's priority on the list, the Israeli way, and not a dollar changes hands at all. Maybe we test one and it goes badly and we stop and try something else. Wow, that's allowed. That's called learning. Folks, the mechanism isn't the lesson. Smarter people than me are fighting about that right now, and good, let them. The lesson is that your moral discomfort is not substitute for measuring the results. We already know this. We know it everywhere else in our lives. A surgeon gets paid and she still saves the kid. A teacher gets paid and he still changed that kid's life. A firefighter gets paid and he still ran into the building. A woman got paid to carry somebody else's baby for nine months, and there's a nine-year-old in a school photo on a refrigerator who's not one ounce less loved because of it. Money doesn't make an act moral. Nobody's arguing that. A man can get rich doing something rotten. But money doesn't make an act immoral either. And somewhere along the way, we started acting like it did, but only here. Only in this one place, only for the one person in the whole chain who actually gave something up. Money and morality are not mutually exclusive, they never were. And the test of a system can't only be does this sound virtuous. It has to include what did it actually produce? Because I'll tell you what ours produced. 6,000 living donors a year every year for 25 years, 103,000 people on a list right now, 17 a day, a third of the kidneys were recovered from the dead people, never reached a body, and a family in New Jersey losing two days of their grief in a hallway. That's the yield on 42 years of moral purity. I'm not telling you to sell your kidney. I'm telling you that we don't pay for organs was never a moral position. It was a mood. And a mood that costs this many lives owes us a second meeting, don't you think? And the man who signed that law in 1984 was Ronald Reagan, my personal hero. October 19th, 1984. And that's not an indictment. He signed a bill Congress passed by voice vote, written by a Democrat, supported by the transplant surgeons, aimed at stopping a con man from building a market in poor people's kidneys. If I'd been at that desk, I'd have signed the same bill. But here's why I'm bringing it up. Two and a half years later, March of nineteen eighty seven, Reagan sat at that same desk and did the hardest thing a person in that job ever does. He told the country he had not traded arms for hostages. He believed it. And then the facts came in. And this is what he said. A few months ago, I told the American people I did not trade arms for hostages. My heart and my best intentions still tell me that is true, but the facts and the evidence tell me it is not. My heart tells me one thing, the evidence tells me another. And the evidence wins. He went on to say what should happen when you make a mistake. You take your knocks, you learn your lesson, and then you move on. That is not a weak man talking. That's the strongest thing in that entire presidency, and I'd argue it's the whole job description of self government. A free country isn't one that never gets anything wrong. That country doesn't exist and never has. A free country is one willing to go back and check its own work. A law isn't scared because a president I admire signed it. A law is scared because it works, and if it doesn't, the honorable thing, the conservative thing, is to say so out loud. So here's the question I'd put to that bill 42 years later in the plainest English I've got. Did it work? And you don't need a party to answer that. The bill sitting in that committee right now has a Republican from New York and a Democrat from California on it. That's not left versus right. That's not capitalism versus socialism. That's we've got a problem, we've got 42 years of results, and it might be time to check our work. I keep coming back to three groups of people. A family in New Jersey trying to bury someone they loved on the schedule he had asked for. An organization full of people that took that job because they wanted to save someone's life staring at a scoreboard that never stops. And a woman on dialysis three days a week in a chair watching a clock of her own and hoping. Not one of those three is a villain in this story. Not one of them got what they needed either. And that's exactly why the answer can't be everyone should just behave better. They already are. They're all behaving as well as the system lets them. Sometimes the moral thing isn't to demand better people. Sometimes, most of the time, the moral thing is to build a better system. We haven't checked that line in 42 years. I think it's time we did. I'm Chad Law, and this has been common sense. Stick around for the after hours while I answer all the questions that came into 252 Chad Law during the show. Alright! We're still here. You guys know the drill 252 Chad Law. You text me, I read them. Some of them I regret reading. Let's go. Rachel, 3308. Okay, what was the single weirdest thing you found out you can legally sell? You clearly cut something. You guys are always asking what I cut. I cut a lot, Rachel. Um, but the one that broke me are companies in this country that will pay you for your stool. And I don't mean 40 bucks for a science project. I mean it's a real screened competitive program. Because it turns out a very small percentage of people have the right bacteria in there to actually treat certain infections. And if you're one of them, you are sitting on, and I want you to hear how carefully I chose that phrase, you are sitting on a genuinely valuable medical asset. Some of these programs are more selective than the sperm banks, which is a sentence I've now so said out loud on television. Lovely. So somewhere in America, there's a guy who got rejected by a fertility clinic and then got a letter that said, Congratulations, your poop is elite. And honestly, take the win. But here's why it's stuck with me, and it's not just a bit. That's legal, that's regulated, screening process, payment, contract, follow-up, the whole apparatus. We built an infrastructure for it. Nobody in Congress has written a letter about it. Nobody thinks it degrades human dignity. And a kidney is a federal crime. That's the show and one deeply undignified example. Let's go to the next question. Marcus 7742. So you spent an hour tearing apart American policy, and your big example is Iran? Come on, Chad. Are we talking healthcare advice from the Ayatollahs now? Listen, Marcus, I love you, and I knew this was coming before I finished writing the episode. And I think I said your name out loud while I was working on it and I've never met you. But you're always asked these great questions. No. We're not taking healthcare advice from Iran. If Iran came to me with advice on anything, foreign policy, women's rights, elections, what to have for lunch, I'd probably pass. But look at what you just did there, because it's the one thing I want people to catch. You didn't tell me the data was wrong. You told me you don't like where it came from. Hmm. Those are two completely different objections. One of them's an argument, the other one's a feeling. If a country I can't stand runs an experiment I'd never run, and the results are documented in peer-reviewed journals everybody in the field cites, that information doesn't become false because the flag over the building offends me. Reality doesn't care about my foreign policy positions. Reality's rude that way. And honestly, Marcus, the reason Iran's my only example is the whole point of the episode. It's not that Iranians are morally looser than we are. It's that they're the only ones who ever ran the test. Everybody else, us included, had spent forty years having very strong opinions about an experiment nobody actually bothered to conduct. That's not Iran's fault. That one's on us. Great question. Denise 1195. I have a real problem with the egg donation comparison. I donated my eggs in my twenties. I still have both my kidneys, and I have children. It is not the same thing, and it felt like a cheap comparison. Um, I guess that's fair, Denise, genuinely, and I'll take it seriously because you're one of the few people texting me about this who's actually done one of the two things. Um, you're right that they're not the same. They're not close in the way that matters most to you. You can give eggs up and still build a family, you give a kidney and it does not grow back ever. The risk profiles are different. The permanence is different, the recovery is different. Anyone telling you that a nephrectomy and an egg retrieval are equivalent procedures is lying or hasn't read anything. So let me be clear about what I was doing with that comparison because if it landed as these are the same, I wrote it badly. The comparison isn't between the procedures. It's between the arguments. Because the reason we're told we can't pay kidney donors isn't surgery's too permanent. Nobody makes that argument. The argument we're given is that money would corrupt something sacred, that paying a person for a piece of their body turns them into merchandise. And that argument, that exact argument, word for word, was made about egg donation and about surrogacy, and it lost. It lost because millions of Americans looked at the actual outcome, looked at the actual families, and decided a woman can be compensated for something enormous, and it's still one of the most generous things a person can do. You proved that you did it. There's something out there because you did. So no. The procedures aren't comparable, and I should have said it plainer. Thank you for calling me out. The principle, however, is comparis comparable. That's the part I want back. Great question. Tony ending in 61 sorry, Tony ending in 6019, devil's advocate. Couldn't paying people actually make things worse? Right now people donate because it's a beautiful thing to do. Start writing checks and it stops being beautiful and now it's a job nobody wants. Uh, Tony, this is a great question. And it's the same one that kept me up. Yes, it could. That's a real risk, and I'm not pretending it anyway. Uh, but you remember the daycare thing. They added a fine and the lateness went up because the price replaced the conscious. Economists call it crowding out. If you design and if you design this badly, you could absolutely take a small, beautiful, genuine thing and turn it into a transaction fewer people want any part of. But here's what I keep bumping into, though. Something has to actually be crowded out. There has to be a robust thing they're getting displaced. 6,000 donors a year for 25 years against 100,000 people on a list? I'm not saying that's not beautiful. It's incredibly beautiful. I read stories during this research about people who gave a kidney to a total stranger and never met them, and I'm not built like that. There's that's a better human being than I am. But there's a version of your question that be is that's basically careful. You might disturb the flat line. And here's the thing nobody tells you, which is what I think is the actual answer. Altruism does work when we bother to design around it. There is a system called kidney exchange. You want to give your husband a kidney, you don't match, so you swap with another couple in the same spot. And it chains. One person who gives to a stranger can kick off a chain that ends with a dozen transplants. An economist won a Nobel Prize for building it. It now accounts for something like 35% of living donor transplants in this country. Nobody got paid a dime in that system, not one dollar. It works because someone sat down and designed it around how people actually behave, including the fact that in those chains, people almost never back out, even when the model predicted they would. People keep their word way more than economists expect. So my honest answer, Tony, is you might be right. Which is exactly why you'd start small, you'd measure it, and if donations went down, you'd stop. The thing I refuse to accept is we won't check because we might not like the answer. That's not a reason. All right, Priya, ending in 4470. She says, I work with low income patients. I have watched people make terrible decisions for $500. You're talking about $50,000. Be honest, you are describing a system where poor people's bodies keep rich people alive. How is that not exactly what you're against? Priya, that's the strongest thing anyone can say to me on this, and I'm not gonna dance around it. Let me give you what I've got, and then let me tell you where I still don't have an answer. First, you're not wrong about who shows up in Iran. In one study, sixty-two percent of donors were below the poverty line. That's their own research. I'm not gonna pretend the volunteers would be tech executives. But here's the distinction I'd asked you to hold, because I think it's the whole difference. The thing you're describing, where a person's body keeps a rich person alive, requires the rich person to be in the transaction. It requires a buyer. Somebody with money on one end, somebody with rent due on the other, with a broker in between, working both of them. That's not what the bill in Congress does. Under that bill, you don't know who's getting your kidney. It's written in the text. There's no buyer to be exploited by because there's no buyer at all. The government pays the same amount to everyone, and the kidney goes to whoever's waited the longest, which, by the way, is disproportionately going to be poor in working class patients because that's who waits the longest under the system we have now. So one version of this makes poor people the suppliers, the other version makes them the recipients. Now, where I don't have an answer, you're still right that fifty grand means something completely different to a woman working two jobs than it does to me. That asymmetry doesn't disappear because the paperwork's clean. It's true of the military, it's true of every dangerous job in this country. We haven't solved it there either. We've just decided it's tolerable when the risk is a roof and not a kidney. I don't have a clean answer to that, Priya. I have a process. Screen hard, give the donor their own advocate whose only job is the donor, cover their health care for life, watch the demographics obsessively, and if it turns into what you're describing, kill it. And honestly, you should be one of the people watching. I mean that. People like you are the reason it either gets built right or doesn't get built at all. Great question. Wesley 8853. Simple question. Would you sell one of your kidneys for $50,000? Be honest? No. $50,000 tax credit or cash? No. And I want to manage expectations here. Nobody's asking. We covered the 66 Chevy situation. There's no bidding war for this. But let me actually answer it because the honest answer isn't flattering to me. Not because it's beneath me, not on principle. I'm sitting here telling you it should be legal, so I'd be a hell of a hypocrite to act like I'd be above taking it. The reason is I don't need 50 grand. That's the whole reason. I'm at a point in my life where 50 grand doesn't change anything. So I'd get to feel very principled, and it would cost me absolutely nothing to feel that way. But ask me at 26, broke, really broke, and someone says $50,000, you're screened by doctors, you're covered for life, and a stranger gets to stop going to dialysis three days a week? I don't know, Wesley. I'd like to tell you I'd have said yes for noble reasons. I think the truth is I'd have thought about the money for about a week, then found the noble reasons. That's the part I want people to sit with. My no isn't virtue. My no is a bank balance. Now, what's my number? Because I know that's the follow-up question. I don't have one, and I'll tell you why that answer annoys me. Because if I say a number, I've priced it. And if I say there's no number, I'm lying because everyone's got a number for something. What I do know is my dog wouldn't give up a thing. Ronald Reagan, the Frenchie, has never given up anything to anyone in his life. That animal takes. He'd absolutely accept a kidney and he would not write a thank you note either. All right. Curtis, 2231. So basically your argument is people are selfish, and that's why socialism doesn't work. Just say it. Uh no, and I want to push back on the premise, Curtis, because I think the people are selfish framing is lazy, and I don't believe that either. You know me, I'm an optimist. People aren't selfish. People are complicated. The same guy who won't pick up a shift for free will run into a burning building for a stranger. People give to churches, people adopt kids, people sit with dying parents for months. Six thousand Americans a year cut themselves open for somebody else and get nothing but a scar. That's not selfishness, that's people. Here's the actual argument, and it's smaller and more boring than the one you're assigning me. Every system fails when it requires one specific version of a human being to show up every single day, forever, without exception. Design something that only works if everyone's a saint, it breaks. Design something that works if everyone's a shark, that breaks too, and faster. People have interests. People want to say in their own lives. People respond to what the system rewards. That's not a slur, that's a spec sheet. Period. And notice this isn't a left or right thing, Curtis, which is why I'm not taking your bait. The system I spent an hour criticizing tonight isn't socialism. It's a purely altruistic system a Republican president signed into law and a Democrat wrote. Both teams built this thing. Both teams have left it alone for forty two years. Nice try nonetheless, Curtis. Try again next time. Amanda five five six seven. Fine, you've got the pen. What do you actually do tomorrow morning? I love questions like this. Uh okay, three things, and the first one's going to surprise you because it has nothing to do with paying anybody. One, stop punishing people who already do it. I didn't have room for this one in the show, and it made me angrier than almost anything else I found. Right now in this country, people who donate a kidney to a stranger can run into trouble afterwards getting life insurance, getting health coverage, being treated like they've got a pre-existing condition because they gave away a body part to save somebody else. There's legislation on that too. Also stuck in committee. So before we argue about whether to give donors 50 grand, could we possibly stop fining them? We're currently running a system where the punishment for extraordinary generosity is a higher premium. Fix that Tuesday. That should be unanimous. Two, run the experiment. The tax credit, non-directed, fixed amount, government pays, longest wait gets the kidney. Ten year pilot with hard reporting requirements, who's donating, what happened to them at once. Five years later, ten, publish all of it, including the bad numbers, especially the bad numbers. And lastly, three, build a real off-ramp into it, written into law. If donations from people below a certain income spike disproportionately, if outcomes get worse, if we see anything that looks like Iran's problems, the program ends automatically, not a debate trigger. Period. And Amanda, if we run that and it goes badly, I'll do that episode too. I'll come back here and say I was wrong on camera. That's the deal. Because here's what I actually learned doing this one. Congress amended this exact law once already back in 07. They had to clarify that kidney exchange, the swap system, wasn't illegal. It passed unanimously, both chambers, nobody objected. So it's not that we can't touch this law. We've touched it. We just did the one part that didn't cost anybody anything. All right, that's the show tonight, ladies and gentlemen. If you see us, share us. And go find out where your license actually says you stand. Whatever you decide, decided on purpose. Good night. We'll see you back. And God bless you, President Reagan, and may God save America.

SPEAKER_02 1:26:06

Yes, you've made my life so glamorous. You can't blame me for failing. It's so marvelous that you should get for me. It's one the boots. Marvel Dance Glory as it's glad.