Al the Human

Whenever I watch Finn's quest to implement Pareto-improving moves despite the incompatibility of others' wants and the downright misanthropy of some actors, I, like you, can't help but think of Al Roth.

Economists know that we could save lives if we allowed markets in human organs. Because many people who do not need organs, and some who do, find such markets repugnant, they would oppose political candidates who would change the laws to allow these markets to exist. Transplant surgeons and medical ethicists loudly oppose such moves. Because politicians wish to be elected, they also oppose policies that would save lives but that many voters oppose. And so we cannot have nice things.

Most of us spend our time yelling about how people should be different and that they should stop banning other people from doing things that don't affect them. Al Roth instead finds moves that work despite the stupid-people problem, and rightly won the Nobel for it.

Becker & Elias have updated their prior work on the number of lives that could be saved if we had market incentives encouraging organ supply. Al Roth comments on it here.

So, the arguments that they repeat have gotten stronger over time: the shortage of organs is costly in every sense, and could likely be relieved by allowing kidneys to be bought and sold by live donors, and allowing the purchase of organs from deceased potential donors, i.e. by repealing the part of the 1984 National Organ Transplant Act that makes such sales a felony in the United States. (Similar laws exist in most of the developed world: the only country that seems to have an explicitly legal market for kidneys is Iran, although many black and grey markets exist.)

So, why hasn't this argument made any headway, either in the U.S. or overseas? Is patient repetition of the argument the best way to make the case? I don't know the answers, but I think that the repugnance of organ sales is a subject worth studying, not just for science but also for those who might like to influence policy.

He further points to work with Stephen Leider looking at public opinion around organ markets. They find that a majority of the public support some forms of organ markets, and that this is consistent with prior survey evidence. They also note prior evidence that transplant specialists and physicians are far more opposed to donor compensation than are other members of the public. There's greatest support for compensation where compensation is paid by the insurance system or the government rather than by the person needing the kidney.

We find majority approval of each kidney market, though a majority supports legality only for markets with the government or insurance companies as purchaser. This suggests that monetary compensation to donors by institutional intermediaries could receive public support. Both general disapproval of body-related markets and disapproval of market encroachment on traditionally non-market spheres contribute to disapproval of kidney markets; however we find no evidence that generally negative attitudes towards markets drive this repugnance. Social conservatism and being a religiously active Christian also predict of kidney market disapproval, though largely as proxies for general disapproval for body-related markets. Furthermore, disapproval for kidney markets seems driven by concerns about repugnant transactions at least as much as sensitivity to specific policy details. Unless proposals engage these fundamental concerns, perhaps by addressing the long-term welfare of kidney providers, they will fail to address the objections of a substantial minority. 

If New Zealand voters are similar to those in the States, then the policy recommendation would be payments from the government to live donors, payments from the government to cadaveric donors, and a guarantee that live kidney or liver donors get priority queueing should they ever need a kidney or liver. It also suggests that public opposition could be far less fierce than we might have thought if we only listened to the transplantation ethicists.

Roth continues:

Judd Kessler and I have a paper forthcoming in the American Economic Review papers and proceedings (May 2014) called "Getting More Organs for Transplantation," in which we summarize the issue this way:

"Kidney sales are often the leading example of a repugnant transaction cited by those who would put stricter limits on markets in general (e.g. Sandel 2012, 2013), because of their sense that such sales arouse widespread opposition. A representative sample survey of Americans conducted by Leider and Roth (2010) suggests that disapproval of kidney sales correlates with other socially conservative attitudes, but that it does not rise to the level of disapproval of other repugnant transactions such as prostitution. In addition, there is evidence that the manner of the payment to an organ donor may mitigate some of the repugnance concerns. Niederle and Roth (forthcoming 2014) find that payments to non-directed kidney donors are deemed more acceptable when they arise as a reward for heroism and public service than when they are viewed as a payment for kidneys."

That paper closes with this thought on the presently available options: 
"While these potential donors could save thousands of additional lives, at current rates of medical need, these donors alone would not be able to supply all the demand. Consequently, we must continue working on numerous fronts to solve this growing problem. "

In summary, the issue of whether and how organ donors might be compensated is an important policy issue that also touches on an important and still poorly understood social science phenomenon. Repetition of the basic arguments may move the discussion forward as the background facts become more severe, and it's great to see the issue addressed in such a public forum as the WSJ. But it may also be that repetition of arguments is not enough. To make progress in the face of opposition, it seems likely to be useful to understand better the nature of the opposition.

 I wonder whether there's any New Zealand survey data.