Organ Entrepreneurs

19 Pages Posted: 20 Mar 2017 Last revised: 29 Aug 2019

See all articles by Kieran Healy

Kieran Healy

Duke University

Kimberly D. Krawiec

University of Virginia, School of Law

Date Written: August 17, 2019


The supply of human organs for transplantation might seem an unlikely place to begin thinking about entrepreneurship. After all, there is no production market for human organs and, with the surprising exception of Iran, legal rules around the world make the sale of human organs for transplantation a criminal offense. Yet entrepreneurs have been present throughout the history of organ transplantation — a history of the active exploration, innovation, and management of a potentially very controversial exchange at the seemingly clear boundaries that separate giving from selling, life from death, and right from wrong.

This article explores the role of entrepreneurial activity in the organ transplantation industry, with the goal of showing how the specific case helps us understand the more general phenomenon of innovation in the shadow of the law, and the role of reciprocity and gift exchange in that process. We begin with a more general point about the connection between structures of exchange and their social legitimacy, illustrating it with a familiar current case from the (conventionally entrepreneurial) world of the “sharing economy”. We then describe three innovations in the world of organ transplantation, discussing the legitimation problems faced by innovators in each case, and the strategies they have drawn on. First, Kidney Paired Donation (KPD), one of the first entrepreneurial attempts to bridge the gap between kidney supply and demand, allows patients with willing, but biologically incompatible donors, to “swap” with a similarly situated pair. Second, Non-simultaneous, Extended Altruistic Donor chains (or “NEAD” chains), removed the simultaneity constraint imposed by KPD, allowing more flexibility and a greater number of transplants, but also inserting the possibility of strategic behavior by donor-recipient pairs. Finally, we consider the most recent innovation, Advanced Donation, in which a donor donates a kidney before her paired recipient has been matched to a specific donor or scheduled for surgery, creating new challenges and risks.

Keywords: entrepreneurship, sharing economy, organ transplantation, kidney exchange, gift exchange

JEL Classification: I1, L26, K00, K32

Suggested Citation

Healy, Kieran and Krawiec, Kimberly D., Organ Entrepreneurs (August 17, 2019). Duke Law School Public Law & Legal Theory Series No. 2017-26, Available at SSRN: or

Kieran Healy

Duke University ( email )

Durham, NC 27708
United States

Kimberly D. Krawiec (Contact Author)

University of Virginia, School of Law ( email )

580 Massie Road
Charlottesville, VA 22903
United States

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