This paper argues that, notwithstanding some recent claims by moral philosophers, the proposed Global Kidney Exchange (GKE) should be rejected as impractical and not ethical, as it does not accord with the principles of intergovernmental bodies (such as the World Health Organization) and professional societies (such as The Transplantation Society and the Declaration of Istanbul), and would violate national laws that forbid organ trafficking and that require financial neutrality in organ donation.  Under the proposal, a kidney patient in a high-income country (HIC) who is biologically incompatible with his or her donor would be matched with a prospective donor from a low/medium-income country (LMIC) who is willing to donate to a patient there who cannot get a transplant for lack of the necessary funding or facilities. The GKE would bring the LMIC pair to the HIC, coordinate the two transplant operations (LMIC donor to HIC recipient and vice versa), and fund a US$50,000 escrow account for follow-up care of the LMIC pair, including the recipient’s post-transplant immunosuppression.
A normal “kidney swap” meets ethical and legal requirements because only organs are exchanged, whereas in the GKE an LMIC patient who can supply a donor who meets the GKE’s requirements will receive not only a kidney but substantial financial benefits. Since the exchange is not financially neutral, the Council of Europe has rejected the GKE as a form of “organ trafficking” and an exploitation of financial inequality.
In response, recent defenders of the GKE have made several arguments. First among these is the claim that saving recipients’ lives outweighs all the objections raised to the program. This proves too much, as it would justify all organ sales (including from poorer to richer countries) if lives are saved. Nor can the GKE be defended on grounds of autonomy, when the terms are entirely set by the GKE; the preferences of the LMIC donor, who might prefer something else in exchange—perhaps something that might make the commercial nature of the transaction more apparent—are ignored.
Besides being unethical, the proposal is impractical. Some patients from LMICs will respond to the possibility of an organ transplant by recruiting paid donors and disguising them as an altruistic friend or relative, a ruse that experience shows transplant programs in HIC often fail to detect. Moreover, the assumption that financial inducements will yield a net increase in organs is contradicted by experience: donation rates are much higher in countries such as Spain and the US than in countries where payments occur such as Iran and Saudi Arabia.
Finally, the GKE does not provide, as the philosophers claim, “an eminently fair solution” to the inequities that face LMIC patients, who would be better served if HIC organizations helped LMICs develop appropriate programs to prevent and treat kidney failure, including deceased donor programs.