Putting a Price on Kidneys

Josh Barro wants to set up a marketplace for human organs. He thinks it’s a good idea, I presume, because he never saw Repo Men (a junky sci-fi movie in which the production of synthetic organs leads to a class of debtor patients who have their organs reposed once their behind on too many payments).

The “organ shortage” could be eliminated, according to Barro, through “better public policy.” He sees two barriers to fixing the shortage: 

“A 1984 law prohibits providing financial compensation to organ donors, living or dead. Price controls reduce supply, and price ceilings of $0 especially reduce supply.

Organs can only be taken for donation from the dead bodies of people who agreed, in advance, to be donors.”

Lots of people need organs, and lots more people would give them, according to Barro, if they could make some money off it. I have no doubt this would be the case.

“Allowing payment would increase the supply of organs available, just as it does now for blood plasma, which can legally be bought and sold,” he explains.

Except that blood plasma replenishes—kidneys do not.

Barro goes on to admit that people tend to be “squeamish about the idea of paying for organs,” because of the potential for exploitation. But a well-designed market he reassures us, won’t have these problems.

His solution is to introduce middlemen into the market. That is, for profit entities like insurance companies would negotiate the prices like “any other medical supply” which, when combined with universal coverage, would ensure transplanted organs would not just be for rich people.

Yes, Barro admits, most donors would be poor, but the risks are small, and people make all sorts of life choices, and we should let them literally sell parts of their body if they need the extra money to say, pay the rent, or part of their child’s tuition, or the next month’s groceries.

What is so ridiculous about Barro’s proposal isn’t it’s necessary tendency toward exploitation, but the fact that he thinks of it as a market solution despite the fact that it would require the government to run it (unless he has some other plan for instituting universal health care).

After all, I assume that instances in which one person sells a kidney because they can’t afford to pay their own hospital bills, for some other operation they just had, won’t occur because those hospital bills will already be paid by the government (either directly or indirectly through subsidies to insurance providers).

In which case the only real thing going on here is that the government is now paying people for organs—organs which will necessarily be sold by people who need the money more than the organ—and this is presumably a good thing because it gives other people a chance at a better life, which is a net good, in which case why not alleviate the impoverishment which is helping to create the supply of organs in the first place? Yes, some people might still sell a kidney so they can have their kitchen redone, or finally buy that muscle car they always dreamed of having, but one presumes that the net-good is zero when the government preys on one group of people to help out another.

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136 thoughts on “Putting a Price on Kidneys

  1. While i’m one of those people squeamish about a market for organs the recent discussions a couple weeks ago here lead me to believe a properly designed market could work. The other issue is of course getting good uni coverage. Oddly, or maybe not, some of the people for a market in organs would be opposed to any sort of realistic or proven plan for uni coverage. I’d also quintuple the NIH budget which some of the same people would be against.

    Increasing the supply of organs would be a definite good though which shouldn’t be discounted as long as the exploitation aspect is minimized.

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  2. The sale of human organs is a Pandora’s Box. Consider the snakes’ nest we’ve already created with surrogate wombs as in the Baby M case. Let’s suppose some poor man signs a contract to sell a kidney and backs out at the last minute. Is this contract enforceable?

    One we’ve monetised parts of humans, where does it stop?

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    • The vast majority of the time, remedy for breach of contract claims is monetary damages. Moreover, there can never be specific performance ordered for personal services, which courts would likely construe these contracts as. I fail to see how this is a significant concern.

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  3. We already had a huge fight on this subject a few weeks ago.

    I was part of the firm contingent that believes that you can never design a market properly for this kind of stuff. Others strongly disagreed. There was a split between “Markets yay” and market-skeptical people like me.

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  4. I guess we don’t have to worry too much. The screams against universal coverage and the proposed “government takeover of the kidney market” are sure to follow quickly and we’ll hear no more about it.

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  5. There are some really weird costs / incentives in the entire process.
    Since everyone else (doctors, hospitals, transplant centers, coordinators, etc) is getting compensated, I think having the possibility of compensating the donor (or donor’s family) should be at least discussed.

    For something like kidneys (most people could spare one), treating it more like blood donation would be a good first step. Kidney donors face real obstacles (starting with risking their own insurance pre-ACA) that could be addressed to increase the number of organs available. Pediatric liver sections is another area to look at.

    A sad personal anecdote: One of my nephews died in a car accident when he was 17. His family donated his body and organs. Due to the time constraints of the surgeries, he was kept in the hospital ICU an extra 2 days. His family was charged for the extra care. Since they didn’t have insurance, it was eventually dropped. But getting hit with an extra 5-figure bill, when they were mourning their son and struggling to pay funeral costs, was another horrible detail to an unbearable situation. In this situation, it would have been nice if the family could have received financial help to pay funeral expenses, etc.

    Live-donor vs cadaver-donor situations are so different, I don’t think it helps to combine them. For cadaver-donor, switching to “opt-out” rather than “opt-in” would be a huge change.

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  6. Yeah we have been over this in detail. It never ceases to surprise me how sanguine organ payment prohibitionists are about the mountain of carcasses that are generated because they’re horrified at the prospect of both the recipient AND the donor being better off from the transaction.

    It sometimes smacks to me as being parallel with the socialcon position on women. They have to be kept unsexual pure angelic beings without agency, otherwise they’ll be deplorable sluts to be shamed and shunned. Likewise organ donors must be forced to be altruistic selfless saints; otherwise they’re either greedy money grubbing fiends or rubish naif victims of the man.

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      • I go back and forth on that, to be honest. On the one hand, I don’t want people doing it out of desperation. On the other, it doesn’t seem fair to exclude low-income people from using their kidney to better their lives. If it was the difference between it passing and not passing, well, screw the poor I guess. But mostly I’d prefer to filter out the desperate through psych-evals.

        (Multiple reasons for filtering out the desperate. Not just for their long-view benefit, but also because desperate people are more likely to lie on their application when it comes to family history and the like.)

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      • Ah, appreciate the clarification Ethan, I think perhaps I misread your tone then since I also have some very hard preconditions that my support would depend on for instance:

        -Iron clad chain of title on organs; we know exactly where every organ used comes from and how it was acquired. An absolute must both for medical safety reasons and as a wooden steak in the heart of the monstrous specter of organ theft.

        -Organs may not be considered “assets” for financial purposes. No seizure of organs in bankruptcy, no monetization of organs or the like. Too dangerous and inhumane; people can get themselves into trouble in market economies easily, having their financial lives wrecked is plenty there’s no reason that the floor should be set so low that bounty hunters would come chasing after their organs.

        Those’re my two big ones though I’m also a mushy supporter of:

        -Some form of system to insure that organs are not being sold under duress or extreme financial privation.

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    • North,

      It never ceases to surprise me how sanguine organ payment prohibitionists are about the mountain of carcasses that are generated because they’re horrified at the prospect of both the recipient AND the donor being better off from the transaction.

      This is going to sound confrontational and it’s unfair to you, because you’re always (with no exception that I’m aware of) a thoughtful commentator. But this quoted portion, especially the bolded phrases, reprise two tropes that some libertarians use that bother me a lot.

      The first bolded phrase strikes me as very much akin to the “what about the children!” approach for which some libertarians criticize (rightly, in my opinion) some liberals. There’s a “there” there, of course. The paucity of legally acquired organs is a problem and a well-regulated legal market might help to alleviate that problem, and it’s easy for me to be sanguine when I have had no personal experiences with a loved one, or myself, needing a transplant. But that phrasing seems a tinge on the emotional side.

      The second bolded phrase strikes me as a mischaracterization of those who are very skeptical of organ markets. The skeptics–be they right or wrong–are not simply aghast that someone, somewhere, might engage in a positive-sum, voluntary transaction. The skeptics are, rather, concerned about abuse and the practicalities.

      There’s a there there, too. A lot of skeptics probably adopt a form of argumentation that borders on the patronizing/paternalist, and maybe some of us skeptics lend more weight than is conscionable to our skepticism from some internal sense of an “ick and moral outrage” factor. Still, it’s not as if we’re saying, “this is good for all involved…..therefore let’s ban it!”

      I understand you’re not a libertarian (I stand to be corrected), and I realize you were responding in part to what turns out to have been an ambiguity in Ethan’s post (judging from his response to this comment and your response back). Also I don’t mean to bait all libertarians by what I just wrote. But I am noting a certain appeal to emotion that I find in libertarian-friendly positions that probably wins few converts from those who might otherwise be open to some ideas.

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  7. I think it’s perfectly logical that someone should be able to sell their organs upon their death. Everyone else, like noted above, is profititing from the organ trade, the true owners of the organs should as well. Obviously, when you’re alive, your pool of avail organs is less, but hey, your body your call.

    Besides, it’s logically consistent. A woman owns her body in terms of having an abortion but not if she wants to sell a kidney?

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  8. According to this government site:

    http://optn.transplant.hrsa.gov/data/

    the mean wait for a generic transplant is about four years.

    Virginia Postrel’s argument here:

    http://www.bloomberg.com/news/2012-07-16/how-much-is-your-kidney-worth-.html

    Incorporates an arithmetic error in that she states that the wait list for kidney transplants is nine years while quoting figures consistent with a mean wait time of 5.6 years. She also quotes figures to the effect that 5% of aspirant recipients of kidneys die each year waiting for them. But if you do some noodling around with the statistics quoted in this abstract for 15 year survival rates for kidney recipients:

    http://www.ncbi.nlm.nih.gov/pubmed/19711510

    you find the composite death rate is about 7% per year. There are a number of factors which affect the composite death rate such as technological improvements (these transplants having been done up to 25 years ago) as well as coarse grained and fine grained differences between the subpopulations. We might, however, begin with some skepticism that the wait times are (in context) such a severe problem.

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      • I understand that. My point was that both recipients and aspirant recipients have a certain annual death rate and that perhaps it is age or correlates of the disease manifest in both in those who receive and do not receive transplants that are largely responsible for the deaths. Alternatively (cue Ivan Ilich), iatrogenic effects of receiving a transplant generate as much risk as the wait times. The disutility would (in that case) be the disagreeableness and expense of dialysis treatment, but not much more.

        Put another way, what was age profile of the 4,700 waiting patients who died? Someone more aged than 95% of the population would be about 76 years old. The annual attrition rates for people past their 76th birthday are 3% and up. Maybe these people are just…old.

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  9. Here’s an analogy.

    Libertarians think selling your whole body into slavery or indentured servitude is unjust and should be banned.

    Well, a kidney market would be selling part of your body into slavery.

    There is a disanalogy that makes employment not like slavery. If you pay me to work, I can quit. But once I sell you my kidney, I can’t get it back. It is now enslaved to you. Kidney selling is final the way that selling yourself into slavery is final.

    This post will be attacked.

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    • This may be a relevant disanalogy between surrogacy and kidney selling. If I agree to bring your baby to term, I can always abort if I don’t want to do it anymore. You can sue me, just as if I break an employment contract, but I still have options.

      Once I sell my kidney, I haz no options.

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        • Again, fair point.

          But if you only have one kidney and you start to get sick and can get one kidney on the market, that is much worse situation (maybe I iz wrong here, cuz I iz no medicine man) medically than having two kidneys and having one of them become sick.

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          • But if you only have one kidney and you start to get sick and can get one kidney on the market, that is much worse situation….medically than having two kidneys and having one of them become sick.

            Let’s say you’re right and North is wrong (and damned if I know the truth), what shoud we do with that information? Should we say therefore that we should not allow people to take informed risks (with emphasis on informed), or that we should protect them from their own risky choices by not letting then make them?

            And if letting people sell one of their two kidneys creates too much risk, how des that information play into your advocacy of a kidney lottery in which some people are required by law to give up one of their kidneys? Is it possible that it could be a bad idea for an individual to voluntarily give up a kidney, but a good decision for the government to require her to give up that same kidney?

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    • Is blood different than a kidney? If I donate (or sell) my blood, and you receive it, is that blood still a part of my body or is it now a part of your body?

      By your analogy, I’m now your slave because some of my blood is in your body. But perhaps you’re my slave too, because you’re now obligated to keep that part of me alive.

      Or maybe it’s not so much slavery as a communitarian society where we have obligations to look out for one another’s welfare.

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    • Libertarians think selling your whole body into slavery or indentured servitude is unjust and should be banned.

      Not all; some argue that being forbidden to enter into such a contract violates self-ownership.

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      • Plus points on the “some.” I don’t think there is a standard libertarian position on this. Of course that some libertarians think you shouks be able to do so makes for a pretty sharp distinction between libertarianism and liberalism.

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    • Isn’t the recipient of your kidney now enslaved to your kidney based on this logic? They’re keeping it alive, attending it its welfare etc and all it has to do is filter blood.

      Also if we were to take this line of reasoning seriously wouldn’t organ donations in general be abominable? You’re just as enslaved if the person who hands you over does it for free as you are if they get money for it. Even libertarians think you are not allowed to irreversibly sell yourself into slavery, let along give yourself into slavery.

      Though if we’re applying the dangerous topic of pregnancy and the like here that doesn’t parse either. A woman is permitted, indeed entitled, to remove a biological mass from her body that, given time, could potentially become a separate functioning entity. She is also permitted to remove a biological mass from her body (that doesn’t have any such potential independence) and have it placed into another person so long as she isn’t financially compensated for it but she somehow looses the right to autonomy over her body if she is offered consideration for that part of herself? No I think pro-choice logic runs pretty strongly in the pro-organ selling direction.

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      • It’s a fair point.

        I’m worried about cases where a person changes their mind later on, and then curses themselves for making such an unwise choice under pressure. That can happen with donations, but I think it is more likely to happen with sales.

        What is important is that we protect people from neing pressured into making the choice to sell or donate.

        A weird analogy: in a way, marriage is donating yourself into a kind of slavery, so is having or adopting kids. The is a difference between that and selling yourself into marriage, which I am against, too.

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        • Nearly all live donations are directed donations, I believe. I would imagine that knowing a loved one or close friend needs a kidney that you can provide, and which they’re highly unlikely to get (or at least get soon) unless you donate could leaving you feeling quite a lot of pressure.

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        • I’m worried about cases where a person changes their mind later on, and then curses themselves for making such an unwise choice under pressure

          I think it may not be a great idea to start banning sales that may result in consumer regret.

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          • I think this is true, though with organ donation there is an intertemporal choice issue (and temporal discounting issue in particular) that is somewhat unique to organ donation. If I give a kidney, and then 10 years from now my remaining kidney turns out to be a lemon, I’m in a bit of trouble that exceeds, say, not being able to get the latest smart phone because I unwisely bought the last generation right at the end of its relevancy. Unfortunately, this is not the sort of calculation humans are particularly good at making in the present moment, which complicates the moral issue.

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    • Libertarians think selling your whole body into slavery or indentured servitude is unjust and should be banned.

      I’m confused. Just yesterday CK McLeod linked approvingly to an article that extrapolated from a libertarian who argued that you can sell yourself into slavery to conclude that libertarianism is feudalism.

      So which is it, liberals? You guys are all experts on libertarianism, I believe, so please help me out here.

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    • Shaz,

      How does this differ than any other private property? If I sell you my car, I can’t get it back, unless you agree to give it back. Presumably the kidney could be returned to the one who made the donation by reversing the procedure. It’d just be highly unlikely to happen; just like you selling me back my car.

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      • Yeah, but if I sell my kidney and then suffer health problems and lose the remaining one (I call him lefty), even if I can buy one kidney back, I’m a lot worse off than if I had kept both.

        What worries me is that once you’re a uni-kideny, you can’t go back, and selling yourself into uni-kidney status is therefore like selling yourself into slavery in that sense.

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        • Nah, but the price you’d be willing to sell the kidney for would probably include the present value of any future expected costs related to “complications” of only having one kidney or such. Since there isn’t a real open market for this type of thing, no one really knows.

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        • Shaz,

          I’m on record as saying that any market I’d endorse would need to have A) post-operative care in perpetuity and B) priority status for donors who need a donation themselves. I think this goes a long way towards addressing your objections.

          But the analogy still holds. If I sell you my car and then crash my other one, I’m in a pickle.

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    • a kidney market would be selling part of your body into slavery

      But if you give someone your kidney free of charge, it’s no less enslaved by the recipient. And since you presumably don’t believe it’s any more legitimate to give yourself into slavery than to sell yourself into slavery, am I wrong in thinking you inadvertently created an argument against organ donations by living donors?

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  10. Last time, we came up with a perfectly good answer: pay people to become organ donors upon their death. I see no reason to open the Pandora’s box of a market in organs extracted fro the living.

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        • You joke, but I know a couple of people who refuse to be donors for reasons along those lines. Basically, fear that their life on the ER operating table is suddenly beingbalanced against another life or lives.

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              • “…they…” being the people you know who refuse to give?

                My plan would involve some separation between the ER doctor and the transplant doctor. The ER doctor would be prevented from knowing the donor status of the patient.

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                • There already are safeguards like that in place. (Although it’s more like no one knows the donor status before the patient dies, because, uh, why would that be relevant?)

                  The idea that doctors would behave that way is actually rather absurd. Doctors are judged by how many of their patients _don’t die_. The idea that they would let some of their own patients die so some other guy would do a surgery so the organs could be used for some random patient…that’s paranoia ravings totally separate from how doctors actually work.

                  Doctors barely have time to actually do their job, they can barely keep track of their _own_ patients. They don’t have time to figure out which of them should die so that some other patient of some other doctor can live.

                  It’s sorta like worrying that firefighters might own stock in home insurance companies, and then direct fires _away_ from those properties and towards properties insured by other companies. That…is not a plausible failure mode of firefighters, which generally attempt to stop _all_ fires that they are fighting, and scarcely have time to even _know_ any of that stuff.

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    • Yeah, I’m pretty sure we settled this. Pay people $1000 or whatever to sign up to be organ donors. Everyone would do it in college.

      And while some people asset that still wouldn’t be enough donations for kidneys, I have to ask…so?

      Let’s do the thing without possible dangerous repercussion now, before we do the dangerous thing that might backfire horrible. Until we’ve actually _done_ the safe thing, and it has _failed_, we’ve got no business debating the dangerous thing.

      You guys are leaping to crossing the streams before you tried to trap the ghost like normal. You’re trying to break down the door before you checked if it was locked.

      Let’s try the ‘Pay people to agree to donate upon their death’ plan before we get to the ‘Pay people to donate while still alive’ scheme.

      And, as an added bonus, this _doesn’t require any changes in Federal law_. A state could do this right now. Some states, already, technically do this, although my state has decided that my hypothetical saving of multiple people’s life upon my death is worth a grand total of $7 off my driver’s license….oh, no, wait, I checked that since last time I talked about this and they actually _stopped_ that back in 2005.

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      • I’d be perfectly cool with holding off on compensated live donations and seeing where we can get with cadaver donations, if after five or ten years and we haven’t plugged the gap, we can try compensated live donations. If we’ve plugged the gap, then the issue is solved.

        (I assume that, under your plan, if they change their mind about kidney donation, they basically just pay the $1k back?)

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        • (I assume that, under your plan, if they change their mind about kidney donation, they basically just pay the $1k back?)

          We can either do that, or we can do something like offering people $100 for each year.

          Or, frankly, I think if we just offer people $1000 dollars for a single year’s promise to donate them, and that stayed as ‘donate’ afterward unless they went and changed it, no one would bother changing it.

          Of course, what we _actually_ should do is simply make it opt-out. Someone suggested that the government should just take them, and I don’t actually see why not. We actually _forbid_ people from keeping bodies and body parts. They are something you are required by law to either bury them in the ground or incinerate. They are _literally_ trash. They have no value to the ‘owner’ at all. And the owner is dead anyway.(1)

          Take them automatically, let people opt out if they’ve got some religious or moral objection, and problem solved.

          The problem is, no one would actually do that.

          1) An argument can be made that you do not actually own your body anyway after you die. You did not create it, so it’s like any other naturally occurring object. If you pick up a stick on public land, you ‘own’ that stick if you _keep_ it, but if you leave it laying somewhere in public and someone else picks it up, you can’t come back and assert ownership over it. Well…the same thing applies to your body if you just leave it laying around. It’s only _your_ body while you’re in possession of it. Especially since, unlike a stick, you can’t have _any_ expectation of returning to pick it back up, because the government actually pays people to wander around and pick up stray bodies for disposal.

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          • I think $1000 a year a person would get expensive pretty quickly. Maybe $1000 up front and then $100 a year after? I’d need to do math.

            I totally support opt-out rather than opt-in donations. That’s not remotely close to being remotely close to being a close call.

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            • I don’t think I was very clear. The premise is $100 a year, _or_, alternately, we offer them $1000 once, for the first year they’re signed up, with no more payments ever, and then _leave their choice in place_ unless they went and changed it after that first year…which almost no one would do. (Especially if you have to go do it in person.)

              Basically, there’s almost no resistance to being an organ donor by ~80% of the population. There’s just no _incentive_ to it either. Pay them to sign up for a single year, leave that choice in place by default, and even with the ability to remove themselves after the year they were paid for, almost no one would. (1)

              But the sanest method is, of course, to simply sign everyone up and they can opt-out if they want…and for some reason, the public is horrified at this idea, despite generally being in favor of organ donation. I can’t quite figure out why.

              (Also, $1000 a year a person isn’t that much, but that’s beside the point, because we don’t need to pay that much.)

              1) Mainly because it is patently immoral to remove yourself. It is possible to justify not signing up in the first place via conspiracy theories or some sort of vague religious objection. But it’s not really possible to be okay with it _for money_ but not for free, or they have to conclude they just did something immoral for money, or something very dangerous for money, which people don’t want to do. Once people have decided to do it, they’re mostly morally trapped unless they can invent some _new_ justification.

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  11. Let’s be honest… people trade “their body” for money all the time. We give up blood, sweat, and tears every time we go to work and in exchange we receive a paycheck.

    No one would say that people shouldn’t be allowed to toil for money or use their muscles via hauling rocks for money.

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  12. I wasn’t in the last organ donation fights. Has there been any examination of how the donor does after giving up the kidney? The data is suggestive of caution, and the paucity of data is even more frightening. That second kidney ought not be considered a “spare.” Heisenberg’s point above distinguishing between blood and kidneys along “renewable resource” lines applies well to this issue. And considering that there is an increased likelihood of medical complications and maybe diminished lifespan for a donor (maybe–as I say, there is little tracking of the fates of kidney donors) it seems like it would be unconscionable to sell a kidney on the cheap.

    If there is to be a market for live donation of organs, I’d want it to be regulated sufficiently to ensure that donors are made very well aware of what could happen to them.

    OTOH, I’m in a business where people put price tags on years of human life as a routine and innate function of the work. It’s not always easy or palatable to do, but diminished lifespan can be quantified in dollars. Perhaps that process, and a survey of other transactions, would illuminate the potential organ donor’s willingness to sell and if so, what price she would demand.

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    • In the original conversation, I noted that assuring all necessary post-operative care (even if this is ongoing) for the donor AND giving them priority status if/when they need an organ themselves (especially in the case of having given a “spare” kidney) were necessary components of any system.

      To your second point, we all do that everyday. Perhaps not actively or consciously, but we do it. “I’m going to eat this cheeseburger because it gives me X value of enjoyment value, even if it risks costing me Y days on earth.”

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    • Here is a good rundown of donorship from the University of Maryland.

      Here’s the National Kidney Foundation’s rundown. Worthy of note, the largest concern among donors is “negative financial consequences of donation.”

      Studies suggest that there is not a decreased life expectancy among kidney donors as compared to the rest of the population. Granted, to qualify as a kidney donor, you have to be in reasonably good health to begin with.

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      • OTOH, I’m in a business where people put price tags on years of human life as a routine and innate function of the work. It’s not always easy or palatable to do

        So in a market we could keep that regulation or we could just let the health status affect the market price. And by the time liberals and libertarians wear themselves out on that battle, we’ll probably have perfected growing new organs from stem cells!

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    • OTOH, I’m in a business where people put price tags on years of human life as a routine and innate function of the work. It’s not always easy or palatable to do

      There are many things we’re uncomfortable putting a price on, but given that every decision/choice/action has an opportunity cost, everything does in fact have a price. We avoid confronting this by refusing to translate those costs into dollars, but our avoidance does not mean the cost isn’t still there, and it doesn’t mean the translation–the dollar equivalency of our choice–doesn’t still exist.

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  13. Here is my worry.

    It is true that we as a society have a duty to provide organs for those who will die without them, especially when donating them will not result in more than a small amount of death.

    However, as we see in places like Iran where there is an organ market, the poor end up being the ones who give up their kidneys in a more open, unregulated market. It isn’t fair or just if the poor and the desperate end up being more likely to give up a kidney than the rest of society.

    There may be ways to structure a market (or a lottery system, that could be bought out of, even though you all think I am crzay) that would minimize that burden on the poor and the desperate. But I am extremely skeptical and would want to see empirical evidence in a small test case (I’m looking at you Vermont kidneys) that the designed system worked as planned.

    And I wouldn’t even bother with that test until I had checked to see whether organ donation card incentives (or tax penalties for not signing them) worked to solve the kidney shortage for all but the oldest and sickest of patients, who probably don’t get much out of the donation anyway, yet get listed as “needing a kidney.”

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    • This raises a very interesting question that I think gets at something implicit in libertarianism, or even in much of the way that modern liberal society looks at the subject of choice, which is the notion that choice is always an unadulterated positive and is never a burden. I.e., that if you live with the burden of being poor, say, that if you are given an option, such as to legally sell an organ, that you have definitionally at worst only been made no worse off. Whereas before you didn’t have the option to sell a kidney to alleviate your poverty somewhat, now you do, but you absolutely don’t have to. You simply have an option available to you that you did not before. It would seem to follow that you’re in at least a slightly better position than you were before, with that additional option added.

      But do we believe that’s always true? Isn’t it at least possible that people experience some choices as a net burden, and that the option and possible spreading trend of the idea of selling a kidney represents a worsening of someone’s overall situation, for example in a case where a person does not want to sell a kidney and in fact is simply not going to do it in exchange for money (though perhaps this person would do it for an ailing relative), but now has to devote some amount of mental and emotional energy to rationalizing and/or examining that decision that he wouldn’t have before?

      Is that concern just a nonstarter based in a misconception of the nature of choice, or is it a legitimate way to look at the potential value of an additional option? If it’s the latter, what might be the larger philosophical and policy implications of that?

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      • It seems to me to be a nonstarter. I mean, I guess having choices taken away from you can make life easier in some ways, but it also makes it harder if you have a real preference for the choice that was taken away over the choice that remains. I think that in general the latter outweighs the former.

        It also strikes me as an argument likely to be employed very selectively, based largely on esthetic preferences. You could make the same argument about abortion, for example. That’s a really tough decision for some women to make—maybe we should just spare them the stress and decide for them.

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        • I didn’t argue it should govern policy entirey; obviously the loss of choice is a real loss in lots, probably the large majority, of instances. I just questioned whether it’s the case that people always experience an additional choice as at worst not negative, or whether they sometimes experience it as a burden.

          As to abortion, some women may experience that as a burdensome choice, but then we already have a very vocal contingent of people arguing against choice as it is. Of people wanted to make that argument – that choice itself was a burden on women; I’d be fine with people making the argument. I suspect the extent to which we’d hear it would be limited. What matters for me is context. My argument above isn’t that choice is bad, but just that choice might not be unquestionably good in all instances. It’s not a conversation-ender. It seems to me that being pregnant and having two kidneys are not directly comparable states of being. One doesn’t amount to anything more than just an ongoing status quo in life all else being equal, while the other implies an impending profound change in one’s life absent a change to that state of being (from within or without). It doesn’t seem to me that the value of choice will obviously be the same in either situation. We can call responses to that selectivity or inconsistency in the use of an argument, or we can just call it having different human reactions to different kinds of situations.

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          • …Or to more directly respond to your concern: I would hope it would be used selectively. The whole of the observation is that the value of an additional choice will vary with the choice on offer, and with the situation into which it is introduced. The good thing about arguments, though, is that we get to assess them before acting on them (that’s why we even bother with them). So unless something went very wrong in a way that would imply problems much larger than the scope of this particular discussion, we actually would get to examine the merits of any particular selective use of this observation before it came to govern policy.

            I guess generally I’m in favor of selectivity in the application of principles to public policy debates. Including that principle, I suppose (i.e. there are certain principles we don’t place any emphasis on applying only selectively, but by no means is that true of principles generally).

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          • I just questioned whether it’s the case that people always experience an additional choice as at worst not negative, or whether they sometimes experience it as a burden.

            I think that’s a tough question. It harks back to the discussion from a few months ago about whether a person’s action necessarily reveals their true preference or not (the context was a anti-gay marriage Christian politician who had an affair). If it does, then the new choice opportunity presumably must always be an improvement, else they wouldn’t take it. If not, then the new choice opportunity could be a net negative for some people.

            If the latter, the question becomes whether we should deny some people the opportunity to improve their lives through the choice because some others don’t want to have to face, and potentially make it. (Or to turn that phrasing around, the question becomes should we allow a situation that will make some people worse off just because it will make some others better off?)

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            • Right. It certainly isn’t a reason to suddenly drastically lower our estimation of the value of choice. It’s just maybe a reason to qualify it slightly and look at the question a bit more situationally/empirically than we might have done before (i.e., is this a choice that seems like a particularly valuable one to people, or one they’re not even really concerned about – possibly to the point of not really being very aware of or at least very concerned about the fact that they don’t currently have it, which I think is the case for kidney sales for an awful lot of people).

              In the case of kidney sales, I think the con side of the ledger is pretty slight, so I wouldn’t see this as something that would tip the scale. (OTOH, I think the pro side is pretty slight too, so you never know.)

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              • …Actually, to clarify a bit more (I think I suggested this above, but maybe it wasn’t clear), I don’t think this concern is something, in almost any case, that would actually end up on the actual con side of the ledger for making a particular choice available. I.e., it’s not properly a harm that would result, but rather a potential qualification on the measurement of the expected benefit.

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          • What kind of slavery are you thinking of? In such a system a contract would be required, so presumably any rational person* selling themselves into slavery would require conditions that make it satisfactory to them. Someone selling themselves into true chattel slavery would be a pretty rare case, and if we want to ensure that it doesn’t happen even rarely (since it is likely to happen with those who already are the worst off), we could put some basic restrictions on that without banning the whole concept and limiting those who might benefit from it.

            To be sure, this isn’t a major issue for me, and I’ll never spend effort lobbying my congressperson to legalize slavery contracts. I just want to make some distinctions that are relevant to a theoretical discussion.
            _________________
            *The irrational can be protected by extant rules mitigating enforcement of contracts with those mentally incapable of making competent decisions.

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            • James,

              *The irrational can be protected by extant rules mitigating enforcement of contracts with those mentally incapable of making competent decisions.

              I’m jumping into a fray here that I’m not sure I’d want to jump into, but I agree with this only partially. I think some contracts might be so bad for the weaker party that they should be presumptively invalid. To put it another way, the principal way to protect an irrational person in such contracts would be to forbid the contracts outright.

              I’m not sure how far I’d want to take this. If it were limited to banning voluntary self-sales into chattel slavery,then I think I’m solid ground or at least on ground I’m willing to defend.

              There are a lot of other situations where I’m at least willing to consider legalization, such as prostitution or in the thread, potentially organ sales.

              I’m not saying this as a gotcha. I realize you’ve just said you’re not necessarily going to agitate for legalized chattel slavery. But this is part of what I’m getting at in my comment below (at June 14, 9:31am) where I suggest we don’t always know how to protect people or how to fashion the rules that govern the market. And I think some of the confidence that we can do so well is misplaced. So if we’re going to liberalize people’s options in areas where traditionally those options have been foreclosed (albeit to much suffering and “mountains of carcasses,” as a comment above noted), we have to consider the incidental costs of doing so.

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      • (though perhaps this person would do it for an ailing relative)

        Why is this better? That is, how is “Donate a kidney or your brother will be stuck on dialysis for years and maybe die, and your family will hold you responsible” preferable to “Donate a kidney and we’ll give you some money?”

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        • Do you deny that this is in fact many people’s attitude? It;s their kidney; I think we should respect someone’s prerogative to have exactly that attitude.

          One doesn’t ever wish to be put in the situation where one’s spare-ish kidney is potentially more valuable to a loved family member than it is to oneself. We are discussing whether we would wish to afford ourselves the legal choice whether to avail ourselves of a monetary translation (h/t JH) of the difference in between the value of our kidney to ourselves and its value to an unknown person who is willing to pay us for it. Given that we don’t ever wish for the former situation but just have to deal with it when or if it arises, why would it follow that we wish to have the latter choice? Maybe we do, maybe we don’t; I don’t think the two sentiments inform each other. I was just noting that the attitude of willingness to donate a kidney (or bone marrow, or etc.) to a family member in need is something that’s out there, and that it doesn’t imply or always coincide with an interest in selling or having the option to sell those items, and that that’s just a sentiment that’s a real thing we have to acknowledge. Are you prepared to say it’s just objectively misconceived or mistaken?

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          • I dunno MD, I find your arguement that having the choice opened up does add a certain burden (the burden of having to choose, the burden of others expectations); but I just don’t see how that added burden could possibly outweight the burden of wanting the choice and having it forbidden by law.
            In sum even if we allowed that there’s some measurable harm in allowing people to have this choice it’s outweighed by the benefits of having the choice avaialable.

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            • As I said, I wasn’t arguing that suddenly there should be a presumption against choice. At most, I’m saying this intuition might complicate policy assessment rather than settle it. Policy analysis is about balancing various values, ends, benefits, harms etc. that result from a policy. The value of added choice is one of those values; all I’m asking is whether there might be an unexamined assumption that it’s more unambiguously positive for people in all circumstances (which is not to say everyone assumes it’s always the most important value to maximize, though some people assume that) than is in fact the case in people’s experience in practice.

              For example, I’ve been reading that the abortion rights movement has been re-examining their rhetorical emphasis on choice of late, and I think it’s noticeable that the frame of access to a full complement of health services for women has been more prominent since I’d say at least the outset of the 2012 elections campaign.

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      • I think the same question relates to the topic of gender roles that came up recently — there are plenty of people in traditional societies, women and men, who take comfort in the idea that their roles have been chosen for them and are hostile to the idea that they should be free to choose.

        This isn’t a new question, of course — see the “Grand Inquisitor” story in The Brothers Karamazov…

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    • “It is true that we as a society have a duty to provide organs for those who will die without them, especially when donating them will not result in more than a small amount of death.”

      No we don’t. No one has any obligation to do anything for any other individual unless they so choose to do so. If I pull you from your burning house, it’s because I choose to do so, not because “society” tells me to do so. And anything “society” chooses to do can be ended anytime it so chooses because it’s members decided it’s no longer in their interest to continue this program.

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  14. I have some objections to legalized selling of kidneys from live persons. Some of those objections, I must admit, arise from the such a policy’s relative newness and my personal discomfort that others might opt to do something that I consider unwise, even if they choose to do so with full knowledge of the risks, etc. Perhaps that’s the nanny-statist in me, and I don’t expect the pro-legalized selling side to be particularly impressed with those objections.

    But I also have more pragmatic objections. This is one area where we must consider the unintended consequences of a liberalized kidney (or other organ donor) market. In this thread, most of the comments of which I’ve read, there’s seems much discussion about how “a properly structured” market, combined with lifelong health coverage, etc., will ensure that such a market will be “fair.”

    I remain skeptical. That talk reminds me of the same confidence we see from some liberals who endorse some versions of centralized economic planning with the promise that “the experts will know what to do.” Only now, it’s a promise that “the experts” (or those who structure the market……at any rate, those who have the power to make the rules of the game) will be wise enough and disinterested enough to fashion rules that will actually not result in some very bad, unintended consequences or perverse incentives.

    What those consequences and incentives might be, I can only speculate. And I’ve thought too little about this to offer any well-informed speculation that anyone ought to take seriously. But I think we should keep in mind that we don’t know all.

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