David R. Henderson  

Tina Rosenberg on Kidneys in Iran

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The main reason I have not posted much on Russ Roberts's excellent Econtalks is that my commute is so short (about 11 minutes) that the hassle of connecting my iPhone with my old car's system made the cost too high. But with my new car with Bluetooth, I get in, turn on the radio, and push a button to start the podcast.

I've already listened to 3 whole podcasts over the last 10 days. 11 minutes here, 11 minutes there, and pretty soon you have an hour. (With apologies to the late Everett McKinley Dirksen. By the way, the modern version you'll hear about Dirksen is that he is alleged to have said "A billion here, a billion there, and soon you're talking real money." No way does it make sense for him to have said it. For most of his years in the U.S. Senate, the federal budget was below $100 billion. So everyone then thought of a billion in government spending as "real money." It makes much more sense for him to have said "A million here, etc.")

I loved the podcast that was Russ's interview of Tina Rosenberg, who wrote a piece in the New York Times on the market for kidneys in Iran. I won't highlight a lot of things because the whole thing is worth listening to.

Instead, I want to highlight three things.

First, and most impressive, is Ms. Rosenberg's discussion of her assumptions going in and how she changed her mind in response to the evidence. Here's an excerpt from the transcript:

Roberts: Let's move to the United States. So, you talked to these folks in Iran and talked to a lot of doctors, and some patients it sounds like. And as you said a few minutes ago, it seems there's nothing really immoral about it. Did you have that feeling coming into this? And how if anything did your feelings change through these conversations?
Rosenberg: Oh, they changed a lot. I came in, I had two assumptions that I think I no longer hold. And one of them is that paying donors is necessarily exploitative. And the second one is: There are serious moral and ethical reasons not to pay donors. I no longer believe either of those things.

Then she comments on why she doesn't have the same moral/ethical views she had going in:
Roberts: Let's get to the moral issues. Why do people object to the morality of it? What is the moral objection?
Rosenberg: Several reasons. First of all there's the idea that this is your body, and we're going to pay you to sell me a part of your body. That's a big one. And the answer to that in a sense is, 'Well, we do that in some ways.' People get paid for donating plasma in the United States, and in fact because of that we provide plasma to the world. We get paid for donating sperm; we get paid for donating eggs. So, that train has left the station, in a way. And in some ways the ethical and moral issues involved with egg donation are far more fraught than this should be about a kidney, because you are not producing another human being. Then there's the issue of, well, you know, this is really dangerous work and you are exploiting the poor by taking advantage of their poverty to lure them into doing this for money. And some people go so far as to say we shouldn't allow poor people to donate kidneys. We should only allow middle class people to donate kidneys. And the response I think to that is people do dangerous things for money all the time. There's a lot of jobs that are pretty dangerous, and people wouldn't take them unless they felt the money was worth it. Donating a kidney is far less dangerous than many other jobs. So, what's wrong with that?

On her last 4 sentences, I just want to say "Brava." Also, notice that she could have done that reasoning without ever having investigated kidney sales in Iran.

I was particularly impressed with her taking on the sacredness of one's body as an argument against kidney sales:

Roberts: But anyway, going back to the kidneys, so, as you point out, these moral issues, to a large extent, at least for you are not decisive any longer. But for many people they are. It's just awful--to encourage people to cut themselves open for money is disgusting. It's bad especially for poor people. Your body is a special, holy, sacred thing. And therefore it's just off the table. And I think that's true, by the way, for people whether they are religious or not. A lot of people feel that way. Now that you feel differently, do you find yourself in conversations with doctors and medical folks--which we'll talk about from your article--but they haven't seen the world the way you see it. And how is that--what's it like for you to deal with that?
Rosenberg: Well, I just want to add one more piece of this. Which is that, yes, if your body is a sacred temple, then let's spare some thought to the thousands of people who die waiting for a kidney. I mean, yes, it might be: let's stipulate that it's okay; it's morally repugnant to pay someone for donating a kidney. It is certainly more morally repugnant to let someone die because they don't have one.

Note also by the way, although she didn't mention it, if one's body being sacred is an argument against slicing into it for a kidney for sale, it's just as strong an argument against slicing into it for a kidney to donate.

The second is her discussion with Russ about whether allowing kidney sales would make doctors better off or worse off. Russ argues (around the 48:00 point) by analogy with college sports, that allowing kidney sales would reduce incomes of nephrologists. His argument is that because college athletes are not allowed to be paid anything more than tuition and room and board, the competitive pressure shows up as higher incomes for college coaches. It is quite striking that some college coaches make 7-figure incomes, not even counting income from promoting products. So, he argues, it would make sense that because the only way for the competitive pressure to show up, when kidney sales are banned, is in the incomes of doctors and hospitals.

I confess that I always thought the way Russ thinks about the effect of the ban on paying college athletes, but I think Rosenberg schooled both him and me in economics.

Rosenberg (at about the 49:20 point): You think their salaries would go down if there were more kidney transplants. (emphasis hers)
Russ immediately sees her point: with more kidney transplants, there would be more demand for doctors. He hedges, but she actually convinced me that doctors would do better with more demand for their services. Now I've got to reconsider my views about college coaches.

The third is Rosenberg's hilarious point about fighting over estates. She recalls (at about the 54:00 point) a discussion with someone whose objection to selling the kidneys of dead family members was that the family would fight over the money. She says:

Yeah, this would be the first time that a family has fought over who gets the money from a deceased person. We have a time-honored tradition of that in the United States.

Postscript:
Notice the comment by Sigrid Fry-Revere.
Also, co-blogger Scott Sumner has a piece in the Washington Post arguing for legalizing kidney sales.




COMMENTS (17 to date)
LD Bottorff writes:

My wife was watching the Ken Burns piece on Prohibition last night. Thinking of Prohibition, the War on Drugs, and the policy on organ sales reminds me of this shortcoming of democracy: When large numbers of people have no real, immediate stake in a policy, it's easy for them to support a position that sounds good. There were many people whose lives were devastated by alcohol. It sounded good to outlaw its manufacture and sale. Some people are seduced by drugs. It sounds good to outlaw their sale. Some people may be exploited by opening up the sale of kidneys. It sounds good to make it illegal and it's easy to ignore the cost in lives lost and dialysis paid for by everyone.

This is why it is important for economists to keep talking about these issues.

Toby writes:
I confess that I always thought the way Russ thinks about the effect of the ban on paying college athletes, but I think Rosenberg schooled both him and me in economics.

Rosenberg (at about the 49:20 point): You think their salaries would go down if there were more kidney transplants. (emphasis hers)

Russ immediately sees her point: with more kidney transplants, there would be more demand for doctors. He hedges, but she actually convinced me that doctors would do better with more demand for their services. Now I've got to reconsider my views about college coaches.

Reading your post the first time around I was actually on Rosenberg's side of the issue: more kidney transplants result in more demand for doctor service.

However, it is not more demand for doctor service, it's more demand for kidney transplant services and less demand for dialysis provided by doctors.

It's comparable to the situation where your local hairdresser in addition to offering to cut your hair offers to shave all of your hair. Some of the demand for having your hair cut will be reduced as the demand for having all of your hair shaved will increase. The net effect is unclear without additional assumptions I'd guess.

For the hairdresser we have the assumption of profit maximization to tell us which direction the effect will go if the hairdresser chose to offer this additional service. Though, it might very well be that if all hairdressers offer this service that their income will drop.

Conscience of a Citizen writes:

Basically, I am in favor of organ sales.

But many people who oppose it have a solid logical basis you should consider, even if you weigh the tradeoffs differently than they do. They may not always articulate their rationale clearly but it gives them good reason to call organ sales "immoral" and want them banned.

As I shall explain in a moment, no one can be confident that voluntary organ sales won't lead to involuntary organ sales. No one can be confident he or she will never go bankrupt with body parts their last remaining assets with immediate cash value. So people who want to legalize organ sales basically want to subject other people to the risk of having their organs removed against their will. To a fearful person that seems awfully immoral, or even if they concede it is moral in the abstract, it still frightens the hell out of them-- and so they call it immoral.

Essentially everyone is jealous of his/her bodily integrity. It could hardly be otherwise; we are evolved to avoid injury. There is a natural distribution of fearfulness. Most people are somewhat fearful and squeamish but can override their emotions enough to accept injuries in medical treatment (such as injections, wound care, surgery). Some people are less fearful and will accept injuries for cosmetic reasons, as when they get piercings and tattoos. Some people are more fearful and can't even sit still for dental cleanings.

Organ removal is a big, deep, horrible-to-contemplate injury, whether or not it is justified. A noticeable fraction of the population are innately too fearful to volunteer to donate an organ. Some people are so squeamish that they don't even want their organs harvested after death. They hardly care if you tell them about how much good it will do the recipient or society, because you're trying to override an emotional reaction with logic and that is never easy. Furthermore, since all normal people project their emotions onto others, fearful people assume that other people are fearful too and those who aren't are crazy. Dangerous crazy, since they promote scary injuries to people's bodies!

Now consider the slippery-slope problem with organ sales. Authorizing organ sales means granting nearly everyone a new property right, the right to sell a spare kidney or whatever for cash. Furthermore, if organ sales are recognized as legal and moral, that property right is like any other, potentially subject to involuntary as well as voluntary transfer.

If organ sales are allowed, possessing a spare kidney will be like owning a motorcycle. You could sell it for cash. If you lose a lawsuit or fall behind on your child-support payments, a court might compel you to sell a kidney to raise cash. Logically the subjective value you put on your kidney won't matter, only its market value-- after all, a court will make you sell your motorcycle even if it's your only legacy from your father or something.

Imagine you are so afraid of bodily injury that you would never donate a kidney voluntarily. Logically you should oppose organ sales, even call them immoral, because once organ sales are normalized, creditors will push relentlessly to make them obligatory for people whose other assets are exhausted.

The history of child-support enslavement is instructive. Courts routinely jail child-support defendants who owe just a few thousand dollars, not for refusing to share their income with their plaintiffs, but for failing to come up with as much money as the judge thinks they ought to earn. A judge willing to throw a man in jail for a year for owing a few thousand dollars will not likely scruple to order one of his kidneys removed.

I don't think it is a good answer to fearful people that you propose to legalize only voluntary organ sales. Laws are not static and the judges who interpret them are often willing to construe them in ways their drafters did not intend. Some judges are extremely callous and would be perfectly willing to decree, for example, that pledging some broadly-worded security interest in personal assets in a promissory note included consent to an organ sale. How long did it take from decriminalizing homosexual relations to fining cake-bakers $135,000 for refusing to celebrate them?

People who oppose non-voluntary organ sales have good reason to oppose all organ sales. The further down the slipperly slope you go, the harder it is to stop. And it's easier to run a simple campaign against all organ-selling than a nuanced one against only some sales. As soon as you concede any sales are okay, you have to deal with nitpicking over the boundary between good organ sales and bad ones.

John writes:

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Don Boudreaux writes:

On the question of the effect of legalization of market sales of kidneys on surgeons' salaries:

There are two principal effects, and I'm not sure just how to model the way(s) that each plays out in reality.

One effect is that which Ms. Rosenberg correctly identifies. With more transplantable kidneys, the demand for the services of transplant surgeons rises and, thus, pushes their salaries upward.

But a second effect is the dissipation of currently existing artificial rents that are now paid to some parties in the supply chain other than to the organ donors themselves. This effect works in a direction opposite from the first.

The ban on payments to donors keeps the quantity supplied of transplantable kidneys artificially low. Because each kidney transplant requires a kidney (real or artificial), the ban on payments to donors keeps the quantity supplied of kidney-transplant surgeries lower than it would be were payments to donors allowed. One consequence of this artificial reduction in the quantity supplied of transplant surgeries is an artificially high marginal value for each of the transplant surgeries that are supplied. Thus, the price that donors are willing to pay for each such surgery is higher than it would be were the number of transplant surgeries performed each year larger.

Because organ donors are prohibited from being paid for the inputs that they supply to transplant surgeries, the portion of payments that would (absent the payment ban) go to donors can then be captured by some other input suppliers - such as transplant surgeons.

The buyers of transplant surgeries don't care how the prices they pay are divided among the input suppliers. If I'm willing to pay $100K for a kidney transplant, and if the kidney donor is effectively prevented from receiving any of this payment price, I'm still willing to pay the $100K. And I will pay this amount - meaning that some surgery-input suppliers receive higher payments than they would receive absent the ban on payments to organ donors.

Before pondering Tina Rosenberg's point, I assumed that this second effect is the dominant one (largely because I carelessly failed even to consider the first effect). The effect that she believes is dominant might, in fact, be dominant in reality. It's puzzling, at least to me, to attempt a priori to determine which effect is the dominant one. In fact, this puzzle strikes me as being a classic empirical question.

ThaomasH writes:

Worrying about physicians' incomes is monumentally irrelevant to the issue if organ sales. It like worrying about the increased value of sunny locations if we taxes CO2 emissions.

More generally however, I do like the way this argument is being made, basically looking at the costs and benefits or organ sales and making the case that benefits out weigh costs.

This is very much unlike the minimum wage arguments that are made here, which is basically to argue that if there is any cost (in loss of employment) that settles the issue in the negative, rather than weigh the costs to those that loose or do not gain employment with the befits of the larger incomes of those that do.

It is better to address the real arguments rather than straw man arguments in order to actually be persuasive.

David R. Henderson writes:

@ThaomasH,
Worrying about physicians' incomes is monumentally irrelevant to the issue if [sic] organ sales. It [sic] like worrying about the increased value of sunny locations if we taxes [sic] CO2 emissions.
You might want to listen to the interview. Neither Roberts nor Rosenberg was worried about physicians’ incomes.

Michael writes:

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David R. Henderson writes:

@Conscience of a Citizen,
Well-argued. I think it’s a worthwhile risk as, I gather, you do too, but you’re right that it’s a risk.

Dan Jennings writes:

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Tom West writes:

a judge ordering someone to sell their kidney, finger, or skin will be headline news.

I don't know. Framed the right way, I can see the public rallying behind this.

Having bilked the elderly widow out of her retirement savings leaving her penniless and then spent it all on a year of hard partying, the villain smirks, "Sure, go ahead, seize all my assets, what do I care? Maybe she can buy herself a hamburger on them."

"Indeed, all your assets sounds about right," replies the public.

Tom West writes:

Like Conscience, I support selling organs, but am leery about the consequences in a different manner.

I worry more about the subtle long-term shift in public perception of the worth of human lives in face the clear, specific monetization of body parts.

Why shouldn't murderers monetarily compensate their victim's families?

Why should murder (especially manslaughter) be treated any differently from any other property crime?

Now, I don't worry a whole lot for those of us valued by society because we're pretty close to the mean, and thus are seen as real people. But I do worry for those who are different enough that they're mostly protected by the idea that human life is sacred rather than any actual care on our part.

Remove the magical sacredness part and make them simply another item of property with a market value, and have this accepted by the bulk of society, and things can get very bleak very quickly.

All that said, I think the benefits of organ selling to many people today fairly heavily outweigh a small step towards a very bleak future.

I am curious though. How many people here feel that a person of sound mind should have the right to sell *all* their body parts if they so chose? The idea horrifies me, even as I'd defend the right to doctor-assisted suicide...

John Hayes writes:

Tom West, a few years back I attended a talk by Kenneth Arrow on the details of the kidney donation system. He did an audience survey on body parts including eyes (one or two), lungs, heart.

A single lung lost majority of the audience, a single eye lost about 95% of the audience and no one was willing to allow selling both eyes or a heart. I think there's a lot of barriers to suicide via organ donation. People won't want to do it, doctors will refuse to do it, courts won't honor contracts. Private law leaves almost no chance of it happening with or without legislation. If a primary home can't be collected through bankruptcy (and student loans aren't absolved) making a rule for organs seems like a very easy thing.

The current kidney donation regime requires simultaneous transplant. They do two and three way matches (that's an operating theatre with 6 operations at once) so no one can back out at the surgical team effectively acts as broker. This only works when kidney transplants are highly successful, the practical side of the ranked recipient list. The other side of the recipient list is managed within the medical establishment, which is too opaque for my personal taste.

In the future, selling organs will become less bleak thanks to progress of synthetics or cultured organs. While livers are a long shot, eyes, lungs, kidneys and hearts are plausible. Eventually the battle to deregulate will come and hopefully with more allies.

George writes:

I didn't realize Iran didn't ban kidney sales. But can't we answer conscious' objections by looking at what the Iranians are doing when it comes to bankruptcy and organs?

Furthermore why isn't the organ sales camp looking at Iran as their poster child? I know Iran isn't pretty but facts are powerful. I feel like there should be a research paper on this.

Nathan W writes:

On the matter of demand for doctors.

I don't know the actual answer, but I imagine that a lot more doctor services are used in caring for people who need transplants than would be used if these patients could swiftly access a transplant when needed.

I think paid donors should be allowed, but a) these people should get bumped up to number 1 spot if they later need a transplant for their remaining kidney and b) the donor fee should include insurance where a fairly high additional payout (for the estate) occurs if the donor eventually dies because their single remaining kidney fails before an alternative can be found.

Conscience - I'm pretty sure that there's a fairly strong right to refuse medical procedures that you don't want. No harm in pointing out where the slippery slope lies, but I don't think any politician or judge would have the guts to cross the line in the way you suggest. I think Tom West frames the concern in a more realistic way, where harvesting organs from undesirables could be accepted, followed by an expansion of who is sufficiently undesirable. But again, the right to refuse a medical procedure still holds quite strongly.

Khodge writes:

The crucial step in removing the ban on the sales of organs is passing laws that allow those sales (remove those laws which forbid it).

Simple. Let's appeal to the morality of the lawyers and politicians who are the gatekeepers of our laws.

Kevin writes:

Listen to the podcasts as 1.5 or 2x speed.

Nephrologists don't do transplant, transplant urologists do. More transplants is a transfer of pts from one to the other. How those incentives would shake out is up to debate.

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