Kidneys for sale

The Gray Area with Sean Illing

This episode of 'The Gray Area' explores the ethical and economic complexities surrounding organ donation, focusing on the controversial idea of allowing kidneys to be sold.

Key takeaways

• Repugnant transactions are those people want to engage in but others oppose without direct harm, such as same-sex marriage or organ sales.

Main topics

• Ethics of organ donation and selling kidneys
• Repugnant transactions in economics

Notable quotes

'Just as markets need social support to work well, so do bans on markets.'

Conclusion

Al Roth's work demonstrates that banning certain transactions out of moral discomfort

Transcript preview

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The new Honda City, all new vibe. Speaker 4 (1:00) There are around 90,000 Americans on the kidney transplant waiting list right now, which is a horrifying number. But what's even more horrifying is that most of the people on that list won't get a kidney. And some of them will die waiting. And we probably know how to fix it. There are healthy people who would sell one of their kidneys if we let them. And there are patients who'd buy. But we don't let them. So what are we protecting when we say no? And what would it take to change our minds? I'm Brian Walsh, guest host in the Gray Area. My guest today is Al Roth. In addition to being a Nobel laureate economist, Al is one of maybe two or three people in his field whose work you can measure in Lives Saved. He designed the American Kidney Exchange, which now produces about a third of all living donor transplants in this country, and does it without anyone getting paid a cent. Speaker 4 (2:12) His new book is called Moral Economics. It's smart and it's honest, as so much of his work is. And more than anything else I've read on the subject, it explains why so many of the trades we don't allow end up costing lives that didn't have to be lost. Speaker 4 (2:47) Al Roth, welcome to The Gray Area. Thanks. So I want to start off with the title of your book, Moral Economics, which to my mind, I think a lot of people's mind kind of sounds like an oxymoron. I think people think economics strips out morality, that decisions just focuses on prices and preferences. So what does that phrase actually mean to you? It's about controversial markets and the Speaker 5 (3:09) morally contested transactions. So it's about disagreements about how people should organize themselves into markets, some of which don't use money at all. Money isn't the essential element of markets. The essential element of markets is that they aggregate information to try to get efficient and Speaker 4 (3:30) equitable outcomes. Speaker 7 (3:31) You Speaker 4 (3:31) talk in the book about what are called, I think you call repugnant transactions. And to understand that there's kind of distinction you use, we're at the top of disgust on one hand, repugnance on the other. Can you walk me through, walk us through an example of what that actually means. Like when people hear, you know, they think of something that's gross, they think of one thing, but you're, I think, talking about something else when you mean a repugnant transaction. Speaker 5 (3:52) Right. So what I mean by a repugnant transaction is a transaction that some people would like to engage in and other people who aren't directly involved in any easily measurable way think shouldn't be allowed. So... In particular, I'm ruling out all those familiar things where people object to some markets because of the negative externalities they cause, the obvious harms they cause. But when I speak about repugnant transactions, I'm speaking about transactions that the people who object to them might not even know have taken place unless someone tells them. So, for example, same-sex marriage is a repugnant transaction in that respect. Two people want to marry each other. And other people think that shouldn't be allowed. But unless someone's wearing a wedding ring, you don't know whether they're married or not. It's not something that immediately impacts third parties. Speaker 4 (4:44) What leads to that kind of repugnance? You point out that something like same-sex marriage, you can't tell even necessarily if the transaction has occurred. Is it a moral sort of qualm? Is it like a physical – is it a disgust? I mean that's what I'm trying to sort of – You talk – one example in the book is about – of all things like horse meat. California has a law banning horse meat. How does that fit in? Why do you need some cases that are banned and others that aren't, I suppose? Speaker 5 (5:11) So there's no law in California against selling cockroaches for human consumption. But there is a law against selling horse meat for human consumption precisely because some people want to buy and eat horse meat. But no one wants to buy and eat cockroaches. Also, we don't – Nobody thinks of cockroaches as a pet, so there isn't a natural feeling that maybe you're eating my pet when you eat horse meat. But the ban on horse meat in California, ban on sale of horse meat for human consumption, was a 1998 popular referendum. It was passed by direct democracy. And certainly some of the people who supported that ban did it simply because they loved horses. Other people may have supported it because, for instance, they raised beef cattle and horses are a potential competitor. So people can have different reasons for getting behind a referendum like that. But I think that what made it pass was the idea that horses are something like pets. Speaker 4 (6:14) So you have a really interesting thought experiment in the book that I wasn't really able to stop thinking about. And it's basically a question, why is it so easy? comparatively at least, to buy heroin in the U.S. and so hard to hire a hitman. Both transactions are illegal. Both transactions are banned. And yet, on one hand, over a million Americans use heroin. They obviously go through those laws. On the other hand, murder for hire almost never actually happens outside the movies. So what's actually different about those two markets and what does it show about what you're talking about when it comes to this kind of market economics? Speaker 5 (6:48) Okay, so the point I'm trying to make in that discussion is that just as markets need social support to work well, so do bans on markets. And the thing that buying heroin and hiring a hitman have in common is that they're both banned, but we support those bans differently as a society. And the way I talk about that in the book is I say, supposing I asked you where I could buy heroin, you'd be surprised, and maybe you don't know, or even if you know, maybe you wouldn't tell me. But that would be the end of it. But if I asked you where I could hire a hitman, because there was someone in particular I had in mind who I wanted to have murdered, you'd be even more surprised. And you might call the police. And when you call the police, they would respond. They would say to you, why don't you call Al back and tell him that if he comes to a certain bar with enough money and ask for Joe, Joe will take care of him. And I'd find myself. trying to hire an undercover policeman to be a hitman for me, which, of course, is a crime in itself. But the ban on heroin and on hitmen is very similar. When we catch drug dealers or hitmen, we put them in jail for as long as we can. Yet, if you had called the police and told them I wanted to buy heroin, they would have told you they were very busy. So the ban on hitmen has a lot more social support than... than the ban on heroin. Speaker 4 (8:15) One difference, of course, if you think of a hitman and, you know, murder for hire as a transaction, there is a person in that transaction who very much does not want it to happen, which is the person who would be targeted for killing. Whereas in, uh, with, with legal drugs, with heroin, um, there is damage done of course, but that person who's buying the drugs is presumably entering it willingly. And is that, that distinction seems to matter as well. When Speaker 5 (8:38) I talk about controversial markets, I don't confine myself to repugnant transactions. There are other controversies going on. But there's nothing controversial about murder for hire. It has a victim. What makes the two things useful to look at together is that they have similar bands. Both of them lead to long prison sentences. But our prisons are full of drug dealers, but hardly any hitmen. Speaker 4 (9:05) Right. I think a major challenge we face is how do we deal with situations where there is a market for it essentially. It could be sex work as an example you use as well, drugs as another. But I want to sort of focus on something that you spent the longest time on, which is kidneys and kidney donation. So just before we get into the actual market questions and donation questions around this, can you just give me a shape of the problem here? Like how many Americans are dying because of a shortage of kidneys? And for people who, you know, maybe they think just you can put someone on dialysis, they'll just be fine. What doesn't dialysis actually solve? What is that experience like? Okay. Speaker 4 (9:44) Kidney failure is Speaker 5 (9:45) one of the top 10 causes of death in the U.S. and in most of the world. In the U.S., we have about 130,000 new cases of kidney failure each year, but we do fewer than 30,000 transplants each year, and transplants are the treatment of choice. So it's tragically scarce. Most people whose lives could be improved and lengthened by having a transplant will die without receiving one. Now, dialysis keeps people alive for quite a while when they have kidney failure. But the average, but half the people who go on dialysis die within five years. So it's not nearly as good as a transplant. And it's also a very hard, in some cases, almost brutal treatment. You know, you're going three times a week for four hours at a time, and it leaves you really fatigued. So many people can't maintain. a work life, for instance, when they're on dialysis. So transplants are the treatment of choice. And those, when I say we do fewer than 30,000 transplants a year, we do something like 22,000 transplants from deceased donors of kidneys. And we do another not quite 7,000 transplants from living donors of kidneys. And the reason living donation is possible with kidneys is that healthy people have two kidneys and can remain healthy with one. And one of the things that is legally repugnant in most countries in the world is paying... Speaker 5 (11:18) living donor for a kidney or paying the family of a deceased donor for allowing their loved one, their next of kin, to become a donor. So when economists and many other people look at the shortage of kidneys, one of the things they talk about is maybe we should reconsider the question of whether it might be legal to be more generous to donors and to the families of deceased donors. You Speaker 4 (11:48) know, even though no money is exchanged hands, this is not a market that has any monetary value whatsoever. And yet there's still a sense among a lot of people in the health world that this is still, there's something repugnant about this. And what, what is behind that? Speaker 5 (12:05) So it's complicated. And there are many concerns that are expressed. The one that I can identify best with and have the most sympathy for is the idea that donors may be vulnerable and that we have to be very, very careful to avoid exploiting vulnerable donors and to take very good care of the donors. And so I think part of the idea that countries should be self-sufficient in transplant came from around the same time that the World Health Organization and the International Red Cross urged countries to be self-sufficient in their blood supply. There was this concern that maybe the global north would suck the blood out of the global south. Rich countries would import lots of blood from poor countries, which of course hasn't happened. I mean, the U.S. is the big exporter of blood plasma