Of all of the many objections Matas addresses, perhaps the concern that the poor will be taken advantage of is the largest stumbling block for most people. Of course, the poor would be more likely to sell their kidneys, but is it really exploitation if the individual is fully informed? Matas writes,
 

We do not prevent the poor from taking jobs with risk that the rich do not take (e.g., as miners, firefighters, police, military), and in all other areas of our society, we allow the poor to make autonomous decisions. With kidney sales, "in a surprising contravention of our usual ideas about individual liberty, we prevent adults from entering freely into contracts from which both sides expect to benefit, and with no obvious harm to anyone else." By prohibiting the poor from selling a kidney, we leave them poor and remove an opportunity for them to better their lives.

          Matas points out that it is in unregulated black markets that the poor are really exploited, and that this is no argument against a legal, regulated market with adequate safeguards. Indeed, a legal market would displace the dangerous black market. R.R. Kishore, founder of the Indian Society for Health Laws and Ethics, makes a similar point in “Human organs, scarcities, and sale: morality revisited,” published in the Journal of Medical Ethics in 2005. He writes, “The prohibition on the sale of organs has worsened the lot of the poor. Buyers quite often refuse to pay the agreed price. The vendor cannot assert his claim because of the fear of being prosecuted. Thus the strategy that was evolved for protecting the poor has been causing just the opposite effect.” As in many other areas, prohibition creates suffering.
 

Whose body is it, anyway?

          You may have thought that your body belonged to you, but clearly, as far as the law is concerned, you would have been mistaken. You may not do what you will with your body while you are alive, nor are you quite free to make provisions for its use after your death. Oddly, you may give away a kidney, even though you may not sell it. But if it is yours to give away, why is it not yours to sell?

          It is interesting that when Amit Kumar was arrested on Thursday, he denied any wrongdoing. It will be up to Indian courts – he has already been extradited – to decide the facts in the case, to determine what can be proved beyond a reasonable doubt. The principles involved, however, are clear: If Kumar did force people to give up kidneys, he should be punished. If he failed to inform them of the risks of kidney donation or failed to keep up his end of the bargain in terms of monetary compensation or post-surgical care, again, he should be punished. But if someone fully informs the donor, freely negotiates a price, and fulfills his commitments to the expected mutual benefit of all parties, by what kind of mixed-up moral code is he guilty of anything?

          If it’s wrong to force someone to give up a kidney, it is also, and for the same reason, wrong to prevent someone from selling a kidney. The issue is the initiation of force, which is never justified. It is also not practical, for by outlawing trade in kidneys, only outlaws will buy and sell kidneys, and the criminals attracted to fill in the gap will tend to be far less scrupulous than legitimate businesspeople.

          While countries like India highlight the worst of the illegal kidney trade, and countries across the rich, developed world continue to struggle with ever-lengthening waiting lists, there is one place where the story is unexpectedly different: Iran. It is ironic that the only country in the world that allows monetary compensation for kidney donors is also home to one of the world’s most repressive regimes in most every other particular. As reported in 2006 in the Clinical Journal of the American Society of Nephrology, “In 1988, a compensated and regulated living-unrelated donor renal transplant program was adopted in Iran. As a result, the number of renal transplants performed substantially increased such that in 1999, the renal transplant waiting list was completely eliminated.”

          And it is not just that paying donors has proved completely successful in providing kidneys to all who need them in Iran, though that is achievement enough, to be sure. Turning the ethical dilemma on its head, the authors of the CJASN article point out that relatives who donate kidneys are not always acting entirely of their own volition. They conclude that “it may be more ethical to perform a paid renal transplantation from a volunteer living-unrelated donor than from a living-related donor or spouse who is under some degree of family pressure or with emotional coercion.”

          Our gut feelings about the sanctity of the human body and our well-intentioned concern for the exploitation of the poor must not be allowed to trump reason and evidence. These two trustworthy guides both point to the efficiency and justice of leaving people the freedom to make their own choices. And Dr. Matas does not exaggerate when he refers to the current system of prohibition as a death sentence. With thousands dying needlessly every year, and tens of thousands languishing in the living death of dialysis for years on end, it is clear that legalizing the sale of kidneys is in fact the only ethical option.