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Liberal societies already permit people to accept bodily risk for pay in dangerous jobs, clinical research, and in some places reproductive services. If a person can altruistically donate a kidney, banning payment requires an additional justification beyond concern for surgery itself. Respect for autonomy does not settle the issue, but it creates a strong presumption in favor of permission when consent is informed and voluntary.
There is a persistent shortage of kidneys for transplant. If payment induces some additional donors who would not otherwise donate, more patients could leave dialysis earlier, avoid years of morbidity, and in some cases avoid death while waiting. This benefit is central because the status quo is not neutral: prohibition leaves existing scarcity largely in place.
When demand persists under prohibition, illicit brokers and unsafe procedures can emerge. Legal channels can require screening, independent counseling, waiting periods, registries, standardized compensation, and lifelong medical follow-up. Even if black markets do not disappear, a regulated option may reduce the share of transactions occurring under the worst conditions.
Living kidney donation imposes pain, time costs, medical risk, and possible long-term inconvenience. It is not obviously more ethical to insist that these burdens be borne only for free. Payment can be structured as compensation for assuming risk and inconvenience rather than as a pure spot-market sale.
For many eligible patients, transplantation offers better quality of life than dialysis and may reduce long-term treatment burdens. Families can benefit from restored health and reduced caregiving strain. If compensation increases transplantation materially, the aggregate gains could be substantial even after accounting for donor risk.