Wednesday 22 August 2012

Coercion everywhere: organs edition

I had an awfully fun time a few weeks back guest-lecturing in an honours health ethics course in  Canterbury's Health Sciences programme. They wanted to know how an economist approached ethical issues around organ donation. It was pretty clear pretty quickly that the grad students there hadn't been exposed to economic arguments before; they were, on the whole, remarkably receptive. The lecturer, a bit less so. And so it was great fun.

I started by explaining how economists go about estimating the value of a statistical life, the importance of such estimates in drawing the appropriate balance between policies that mitigate risk and those that enhance the quality of life, and the importance of individual risk assessments in deriving those estimate. I moved then to compare the risk of workplace death in various industries with the risk of death from voluntary live kidney donation - live kidney donation is pretty safe. If we're prepared to let people accept cash for risky things like working on a fishing boat, why aren't we prepared to let people accept cash for risky things like donating organs?

The lecturer worried a lot about coercion. I yesterday noted the distinction between voluntary and euvoluntary exchanges as highlighted by Mike Munger. I noted it there too. Sales of organs seem pretty likely to fail the euvoluntary test - income pressures could drive a lot of donation decisions. But that's also true of decisions to work on a fishing boat or to take a lot of other unpleasant and risky jobs. What makes the "coercion of being poor" so much worse for the decision to sell a kidney than for the decision to take a job on a fishing boat if the risks of death or other adverse health consequence from the two decisions are roughly comparable?

The students seemed pretty happy with the notion that if we let poor people trade risk for income on fishing boats, it's a bit odd to ban them from taking roughly the same level of risk for income from selling a kidney, especially as the latter can save lives. The lecturer wasn't as keen on the idea. But I really couldn't pin down just what made the two kinds of decisions different except for that one involved organs, despite rather a bit of pressing. At one point she was backed into the (to me) clearly untenable position that workers on commercial fishing boats take the job not for the income but because they love fishing, then denying people were taking money in exchange for risk. 

I'm still puzzled about why it's obvious to many people that transactions around organs are inherently coercive but those involving very comparable levels of risk or unpleasantness that don't involve organs aren't. Bans on trade based around inarticulable squeemishness concerns do have effects. The National Business Review reports that New Zealand has imported human tissues from RTI Biologics' subsidiary Tutogen [paid link - get a subscription!]; Tutogen has gotten into a bit of trouble about how it sources its parts. Caleb Allison at NBR points to the ICIJ report that shows how pretty much everybody in the system, and especially the companies trading in tissues, are able to profit from individuals' uncompensated donation decisions. Banning trade in such things here, where we could be pretty confident that harvested tissues could be registered and traced back to source, just pushes the problem to places where the regulatory regime may well be less sound. We would have fewer problems in sourcing organs and tissues domestically were we able to compensate donors. 

I'd love to hear a comprehensible reason why we ban compensation in this area but allow it for taking risky jobs in mining, logging, and fishing.

Update: do read EuvoluntaryExchange - the pdf above-linked has the in-one-place version, but the blog is where the argument lives


  1. I'm glad you asked, especially in the context of euvoluntary exchange. It's one of Munger and my favorite topics at the Euvoluntary Exchange blog. Here's a sample of some of the thoughts we've had:

    For me, it's a matter of aesthetics. Organs are personal, cherished things. Turning them into commodities violates what J. Haidt would call sanctity. How people get from there to public policy is run-of-the-mill public choice: voting is cheap, so they'll go with the intellectually lazy mood affiliation without carefully considering the alternatives they're foisting on the poor.

  2. Awesome, thanks. I should have linked the blog instead of just the paper; the paper had the most comprehensive in-one-place discussion, but just dumb that I left the blog out. Fixing presently.

    I totally get the run of the mill rational irrationality stuff. I'm more curious whether anybody's made an argument that coherently rationalises the position to herself in a way that survives pressing.