The kidney shortage is a design failure hiding in plain sight.

Every year, we allow 10,000 waitlisted Americans to die from kidney failure not because we lack money or knowledge, but because we have chosen not to design a system that would save them.

Effective altruism is preparing for a world with far more money.

That framing is comforting. It suggests progress. It suggests we are winning.

It is also misleading.

Because in at least one domain, we already have more than enough money to solve a large, ongoing, fully understood problem. And we have chosen not to.

The End Kidney Deaths Act makes that choice visible.

A Solved Problem That Still Kills People

In the United States, roughly 90,000 people are waiting for a kidney transplant. Around 10,000 die each year.

We know exactly how to prevent most of these deaths: transplant more kidneys.

We have the money. We have the knowledge.

We do not yet have the kidneys.

We also know the alternative to transplant. Dialysis is not just costly. It is a long, grinding decline. People often begin dialysis by walking into the clinic. Then a wheelchair. Then a gurney.

Dialysis consumes roughly one percent of federal spending while delivering death to roughly 60 percent of patients by year five.

For decades, policymakers have tried to close the gap between kidney demand and kidney supply by removing friction. Reimburse donors for lost wages. Cover travel. Pay for dependent care.

These reforms are humane and already widely implemented for the majority of living donors.

They have not worked.

Living kidney donation has remained essentially flat for 25 years.

This is not a failure of compassion.

It is a failure of design.

The Taboo

The End Kidney Deaths Act proposes a ten-year, federally regulated pilot that would provide meaningful compensation to nondirected kidney donors through a $10,000 annual payment for five years.

It is limited, testable, and reversible.

It is also bipartisan, with 48 sponsors in the U.S. House of Representatives.

And yet by its opponents it  is treated as dangerous.

Not because the mechanism is unclear.

Not because the problem is misunderstood.

But because it violates a cultural norm: that certain forms of altruism must remain unpaid.

This norm is not applied consistently.

We compensate people to donate plasma. A frequent plasma donor can earn roughly $50,000 over five years.

We compensate surrogates between $50,000 and $110,000.

We compensate participants in clinical trials.

Kidneys are treated as exceptional, but that exception has never been rigorously justified.

What We Are Actually Doing

The current system does not avoid harm.

It redistributes it.

It shifts the burden onto patients who wait, deteriorate, and die.

Low-income Americans are three times more likely to die from kidney failure.

It shifts costs onto taxpayers who fund dialysis indefinitely. The average American taxpayer spends roughly $330 annually on dialysis-related costs.

It contributes to illicit global organ markets by maintaining artificial scarcity.

We have built a system that tolerates predictable, preventable deaths in order to preserve a costly and deadly status quo.

EKDA as Mechanism, Not Idealism

What makes EKDA important is not just its ethics or its politics.

It is its structure.

It ties funding directly to outcomes.

More donors → more transplants → fewer deaths.

There is no complex theory of change.

No reliance on awareness campaigns.

No dependence on institutional goodwill.

Just a mechanism, one that converts funding directly into measurable increases in life-saving supply.

And because dialysis is so expensive, the mechanism pay for itself. Each transplant reduces long-term public spending by hundreds of thousands of dollars. With the passage of the End Kidney Deaths Act, we will save up to 10,000 American lives and $4 billion in taxes. 

Until then, we will continue to spend more to maintain the shortage than it would cost to end it.

The Real Funding Problem

Effective altruism often treats funding as the primary constraint.

But in a world where capital increases dramatically, the constraint shifts.

Judgment does not scale well.

Committees do not scale.

Grantmaking does not scale cleanly.

Mechanisms do.

The most scalable philanthropy may not be philanthropy at all. It may be designing systems where compensation reliably produce public good.

The question is not where to allocate money.

It is whether we can build systems where money predictably produces outcomes.

The End Kidney Deaths Act is one such system.

Scarcity as a Choice

There is no natural law that says kidneys must be scarce.

There is only a system that fails to produce them.

Surveys suggest many people would consider donating a kidney.

Historically, roughly 95 percent of living kidney donors report that they would donate again.

Yet only a small fraction, only two percent, of willing donors ultimately donate.

The gap is not moral.

It is structural.

We have asked people to undergo six to twelve months of medical testing, major surgery, weeks or months of recovery, and lifelong medical follow-up, all to save the life of someone they have never met.

When a firefighter runs into a burning building to save a stranger, we call it heroic work and compensate them for it.

Kidney donation is similarly heroic. It simply unfolds more slowly.

One takes minutes.

The other takes months.

And if that is true here, it may be true elsewhere.

What Happens Once This Works

When the End Kidney Deaths Act succeeds, it will do more than increase kidney supply.

It will demonstrate that we can replace moral exhortation with institutional design in at least one domain.

That we can align incentives with outcomes in ways that are both ethical and effective.

If it fails, it will still generate something rare in public policy: clear evidence.

Either outcome is better than repeating a system that produces the same preventable deaths every year.

The Question We Are Avoiding

If a policy could save thousands of lives annually, reduce public spending, and be implemented as a controlled, reversible pilot, what exactly justifies refusing to test it?

The answer cannot simply be discomfort.

Because discomfort is not neutral.

It has deadly consequences. One waitlisted American dies every hour waiting for a kidney. 

Implications

We are entering a world where money may be abundant, but good outcomes will still require design.

Most charitable spending remains diffuse, indirect, and difficult to evaluate.

The highest-leverage interventions may not be additional grants.

They may be mechanisms.

The End Kidney Deaths Act offers one: a system where money predictably saves lives, not through aspiration, but through design.

Because we are serious about doing the most good, we should pay close attention.

Because the future of effective altruism will not be determined by how much we give.

It will be determined by what we build.

Note: To help pass the End Kidney Deaths Act, sign our petition: https://forms.gle/rVmseMDioZmazLQXA