Wednesday, January 5, 2011

More on the debate over kidney sales: transcript of interview

In my earlier post, Dubner interviews me about kidney sales, I promised to link to a transcript when it became available, and now it has: there's a link at the bottom of the Freakonomics post You Say Repugnant, I Say … Let’s Do It!

Dubner interviewed me for about an hour and a half, so he and his producer Chris Neary had to do lots of editing to produce the half hour or so podcast. I recall a pair of questions, one of which made it into the show and one of which was left on the cutting room floor (or wherever unused electronic files are left).  The question that made it in was about what makes many people view kidney sales as repugnant. The question that didn't make it was, if I were asked to help design a market in which kidneys could be sold, what would be my primary concerns.

Regarding what is behind the repugnance of kidney sales, here's the text of my reply included in the transcript:
"Al Roth: The late Pope John Paul wrote about this and he objects strongly to the sale of kidneys but thinks the donation of kidneys is a very good thing, though if we do it for money is a very bad thing...I think his feeling is that it turns people from ends into means which is a bad thing in itself. So that’s one nature of objection. 
Another kind of objection is that it might be OK if I offered to buy your kidney because you’d be a hard guy to exploit, you’re a successful, financially solvent person, but pretty soon we’d start seeing the desperately poor and maybe they would in some sense be acting against their self interest, they would be being exploited or coerced even, by the temptation of the money in ways that if they could use their better judgement they wouldn’t want to be.  So that’s sort of a coercion argument. 
And then there’s a slippery slope argument that says if we started allowing people to sell their kidneys, it would be primarily poor people who would sell their kidneys, and pretty soon we would start hearing political discussion that said, ‘you know, we don’t really need unemployment benefits, we don’t really need aid to families with dependent children because after all, everyone’s got two kidneys and they can take care of themselves by selling a kidney if they need to’...and that makes us a much less desirable society to live in."

I don't have a transcript to consult about what I said when they asked what I would do if asked to help design a kidney market, but as I recall, my answer went something like this.
The first thing I'd want to think about is what kind of review we would want to use to judge if the market had been a success ten years (or longer) after it had been started. The criteria we'd surely want the market to be evaluated on would include:
 How had the donor/vendors fared?: were they healthy and well treated, and respected, and did they encourage new potential donor/vendors to make the same choices they had?
How had patients with kidney disease fared?: were they receiving healthy kidneys, had the waiting list for transplants largely disappeared, were kidneys being allocated in ways that were widely seen as equitable?

To focus thoughts for future debate, we might want to think about a system in which only the federal government could legally pay for a live kidney, and would have a mandate to set the price (and associated benefits like follow-up medical care) high enough so that there would be a waiting list of donor/vendors, who could e.g. be expected to undergo regular health and suitability tests (suitability being a broad term meant to include physical and mental health, deeply informed consent, etc.)  for a year before being accepted as donor/vendors, and that the kidneys obtained in this way would be allocated anonymously through some regulated procedure that might resemble the current procedures for allocating deceased-donor organs.

In terms of how I've interpreted the ongoing debate between those in favor of sales and those against, I  think that a good deal of the coercion concern can be addressed by an appropriately designed one year waiting period, although I say that without having recently talked to someone who makes that argument with conviction.
I don't see any easy way to bridge the gap between those who think that selling kidneys is a bad thing in and of itself, not to be traded off with possible benefits of other sorts (e.g. to patients and perhaps to donor/vendors), and those who don't see it that way, or who feel that the current dire circumstances of many thousands of those with kidney disease gives legitimate counterweight to this concern.
And the slippery slope concern is the one that personally gives me the most pause. I can see how appropriate legislation would prevent e.g. your bank from asking for a kidney as collateral, but I can't see any way to be sure that making kidneys a potential financial asset wouldn't make us a less sympathetic society (even though a one year waiting period and other qualification tests would limit how much kidney sales could be used as a justification for cutting unemployment insurance in particular).

My work on kidney exchange has largely avoided being enmeshed in this debate, since the "in kind" kidney exchange doesn't seem to arouse repugnance. Thus for example Debra Satz' recent book Why Some Things Should Not Be For Sale: The Moral Limits of Markets, Oxford University Press, 2010, finds little to object to about kidney exchange, but largely disapproves of kidney sales. (I expect to meet Professor Satz for the first time this weekend, at a philosophy of economics conference in Helsinki...)


Jon Baron said...

In my book "Against bioethics" I suggest some possible answers to the coercion and slippery-slope arguments. The coercion argument assumes that people are somehow particularly irrational about money. This may be true, but we have no reason to think it is. People make irrational decisions all the time, and government does not try to protect them from most of these decisions. (It is more elaborate than this, but that is the gist.)

As for the slippery slope, it is an empirical question about whether this happens, but we have little evidence that it does. And slopes go both ways. We could just as well say that prevention of kidney sales could lead down a slope toward excessive regulation of markets.

John Hodges said...

You leave aside a critical element of your proposed evaluation metrics: What is your baseline for comparison? How do donors fare now? The majority are demonstrably healthy and well treated, and most say they would make the same choices they had for themselves. Few encourage strangers at large to donate, and potential donors are generally cautioned to become as informed as they can by donors, on the rare occasions such a conversation occurs.

Donor candidates are generally disbelieved and disrespected, with many evoking horror from loved ones, and the transplant community still fails to respect potential donors and donors by doing the research and providing the information such research would yield so that informed consent could be provided.

While it's a desirable, minimally necessary feature of any steps toward "valuable consideration" in exchange for a living donor's organ, until the transplant profession can provide this consistently and universally for donors and donor candidates, such a momentous experiment must be considered premature.

Las Vegas Foreclosures said...

a nice debate though.. just keep us posted if there's any news about this..