Nondirected liver donation in Canada--from the beginning

The Ottawa Citizen has the story:

The Gosling Effect: How one man (and his liver) forever changed Canadian health care. In 2005, Kevin Gosling became the first living Canadian to anonymously donate an organ to a stranger. It set a cascade of kindness into motion.  by Elizabeth Payne 

"It had been a long road for the then-46-year-old from Cornwall, Ont. For months, health officials wouldn’t take him seriously when he offered to donate the organ anonymously. We don’t do that here, he was told. Not only that, it had never been done before anywhere in Canada.

"Some top officials in Canada’s leading liver transplant program were adamantly opposed to Gosling’s proposal. They said it was unethical and immoral. They questioned his motives, even his sanity. But Gosling persisted, so far as to undergo months of physical and psychological testing and preparation.

"After more than a year and a half, everything was set to go.

...

"Gosling didn’t know much about the recipient. He only knew that it was a child.

...

"Gosling’s stubborn altruism and unwavering belief that he could make a life-changing difference to someone in desperate need almost single-handedly changed Canada’s health-care system.

"In the 19 years since that fateful day when transplant surgeons removed part of Gosling’s liver and transplanted it into the body of the very ill child, the Toronto General Hospital has completed more than 137 such operations involving people donating anonymously to strangers – more than any other hospital in the world.

...

"He was a pioneer in an area in which Canada is now a world leader – the act of anonymously donating part of a liver – a phenomenon that continues to be met with disbelief in some parts of the world.

...

"Gosling’s offer was turned down multiple times until he was eventually put in touch with the head of the multi-organ transplant program at University Health Network, one of only two hospitals in the country where living liver transplants are now routinely done. Along the way he met health officials who were adamantly opposed to the idea, even citing the Hippocratic oath. (Later, he was told by one staunch opponent that following Gosling’s case had made him change his mind.)"

HT: Colin Rowat

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See also:

Cattral, Mark S., Anand Ghanekar, and Nazia Selzner. "Anonymous living donor liver transplantation: The altruistic strangers." Gastroenterology 165, no. 6 (2023): 1315-1317.

and here are all my posts on nondirected donors: https://marketdesigner.blogspot.com/search/label/nondirected%20donor

Why High Incentives Cause Repugnance, by Robert Stüber

 Here's a nice experiment in the EJ:

Robert Stüber,Why High Incentives Cause Repugnance: a Framed Field Experiment, The Economic Journal, 2024;, ueae018, https://doi-org.stanford.idm.oclc.org/10.1093/ej/ueae018 

"Abstract: Why are high monetary payments prohibited for certain goods, thereby causing shortages in their supply? I conduct (i) a framed field experiment with a general population sample and (ii) a survey experiment with this sample and with ethics committees. In the experiment, participants can prohibit others from being offered money to register as stem-cell donors. I document that, whereas the majority of participants do not respond to changes in the incentives (63%) or become more in favour of the offer with higher incentives (20%), a minority of 17% prohibit high incentives. I show that this minority wants to protect individuals who are persuaded by high incentives. I also show that a lottery scheme reduces their objections to high incentives. Finally, I document that the public is much more supportive of high incentives than are ethics committees."

"In the experiment, participants can prohibit a transaction that involves another person signing up as a potential stem-cell or bone-marrow donor for money.1 Participants initially make a decision for two distinct amounts of compensation: one low (€10) and one high (€500). The main outcome is participants’ willingness to pay for prohibiting or permitting the offer. I find that the majority of participants (63%) do not respond to changes in the incentives or become more in favour of the offer with higher payment (20%). A clear minority (17%) reveal a stronger preference for preventing the offer when the payment is €500 rather than €10. This finding is mirrored in a second outcome, in which separate participants make simple binary decisions to prohibit the offer or not.

"Why do some participants want to prevent high monetary incentives for signing up? I answer this question by randomly assigning participants to different treatments. In the main treatment, Reservation Price, participants again decide whether to permit an offer of €500 for becoming a stem-cell donor. However, they know that, even if they permit the offer, the offer will be made only if the individual potentially receiving the offer agrees to sign up as a donor for €10 in an independent decision made beforehand. If the individual is not willing to sign up for €10, no offer is made. Put differently, the treatment ensures that the €500 offer is made only to individuals with reservation prices of €10 or less. The offer therefore cannot attract individuals with high reservation prices. The treatment drastically reduces the resistance of individuals who prefer low incentives: the median person who was previously willing to pay €2.50 to prevent the €500 offer is now willing to pay €1.50 to permit it. "

Black market for mustard in Bogotá

 The NYT has the story:

Colombia’s Mustard Lovers Grow Desperate Amid Saucy Shortage of Dijon. Colombians are scrambling to find the beloved French condiment as a new health law removes it from shelves  by Genevieve Glatsky

"In Colombia, a new illicit product is on the rise. Desperate consumers are sneaking it in suitcases from abroad, hoarding it in their homes, paying outrageous prices online and lining up at clandestine locations to buy it.

"The contraband? Dijon mustard.

"A new health law intended to improve Colombians’ diets — which are heavy on meat and fried food — has led to the disappearance of a host of fare from market shelves, including the French delicacy of the condiment world.

...

"Inspired by a push by the Pan American Health Organization to address high rates of cardiovascular disease in the region, Colombia’s Health Ministry in 2020 imposed limits on high-sodium products, with the measure taking effect last November.

...

"Mustard must have less than 817 milligrams of sodium per 100 grams. A jar of Grey Poupon Dijon mustard has nearly three times that ratio."

New York doesn't ban Menthol cigarettes, amid controversy

 The NYT has the stories, first about the proposed ban, and then about the budget compromise that defeated it:

Black Smokers at Center of New York Fight to Ban Menthol Cigarettes. A proposal to make New York the third state to ban menthol cigarettes has created a furious and expensive lobbying war, and has divided Black leaders. By Luis Ferré-Sadurní

"A push by Gov. Kathy Hochul to ban menthol-flavored cigarettes in New York has become the focal point of a fierce and expensive lobbying fight, pitting Big Tobacco against the medical community.

"Caught in the middle are Black smokers, who smoke menthol cigarettes at higher rates than white smokers, and are the main group the ban is meant to help. Decades of aggressive marketing by tobacco companies have caused Black smokers to consume menthol cigarettes, whose cooling sensation on the throat makes them more appealing and addictive.

...

 "Well intentioned as the ban may be, it has angered some Black leaders, including a group of ministers who have rallied against Ms. Hochul’s proposal because they worry it could increase encounters between Black people and the police if menthol cigarettes were to go underground and authorities crack down on sellers.

"Other Black opponents of the ban suggest it may be discriminatory, a heavy-handed crackdown on the preferred nicotine fix of Black smokers, even if African American men have the highest rates of lung cancer, according to the Centers for Disease Control and Prevention. 

...

"Although lawmakers have signaled their support for the tax increase, the menthol ban’s prospects are far less certain, according to four officials familiar with the negotiations.

The issue has divided Black lawmakers, leaving the measure hanging by a thread in the State Capitol "and potentially forcing Ms. Hochul to weigh how much political capital she should expend on the ban, as opposed to other policy priorities."

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And here's a story saying that the governor abandoned the proposed ban in a set of budget compromises:

New York Would Change Minimum Wage and Bail in $229 Billion Budget Deal. After weeks of dissension, leaders in Albany reached a handshake agreement on a budget that saw Gov. Kathy Hochul fall short on some of her key objectives. By Luis Ferré-Sadurní and Grace Ashford

"Lawmakers managed to knock down other divisive ideas, including ... a ban on the sale of menthol cigarettes that was opposed by Big Tobacco and had divided Black leaders. Lawmakers did agree, however, to raise taxes on cigarettes to $5.35 a pack, up from $4.35."

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All posts so far on menthol

California referendum bans flavored tobacco

More midterm election news on controversial markets and repugnant transactions:

California bans flavored tobacco products, including vapes, by Nicholas Florko at Statnews

 "On Tuesday, Californians overwhelmingly voted to ban all flavored tobacco products in the state.

"The move makes California by far the largest state to ban such products, which are already illegal in a smattering of smaller states, including Rhode Island, New Jersey, and Massachusetts.

"Regulators have targeted flavored products in particular because they are overwhelmingly preferred by young people. More than 84% of young people who vape reported using flavored products, according to recently released survey data by the Centers for Disease Control and Prevention.

"California’s ban would also outlaw menthol cigarettes, which federal regulators have proposed banning nationwide because they argue such products are easier to start and harder to quit. Survey data also show that menthol cigarettes are overwhelmingly preferred by Black smokers."

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Here's a recent (massive) report on the marketing efforts that went into making menthol flavoring popular (suggesting that we can soon expect to see menthol substitutes):

Advertising Created & Continues to Drive the Menthol Tobacco Market: Methods Used by the Industry to Target Youth, Women, & Black Americans. Jackler RK, Ramamurthi D, Willett J, Chau C, Muoneke M, Zeng A, Chang M, Chang E, Bahk JR, Ramakrishnan A. SRITA Research Paper 

Full Report: high-resolution PDF link (1.62Gb) / low-resolution PDF link (46.4Mb)
Executive Summary: high-resolution PDF link (6.2Mb)

2022 Exeter Prize to Sandro Ambuehl, Douglas Bernheim, and Axel Ockenfels

 Here's an announcement in an email from the Economic Science Association (ESA):

"We are happy to announce the winners of the 2022 Exeter Prize for the best paper published in the previous calendar year in a peer-reviewed journal in the fields of Experimental Economics, Behavioural Economics and Decision Theory.

The winners are Sandro Ambuehl (University of Zurich), Douglas Bernheim (Stanford University), and Axel Ockenfels (University of Cologne) for their paper “What motivates paternalism? An experimental study”, published in The American Economic Review. 

There is a growing interest in how “choice architects” design choices for others.  This paper provides new insights about how and why people in the role of a choice architect limit the decisions of others.  Ambuehl, Bernheim and Ockenfels use the tools of experimental economics to study how subjects help other subjects (“choosers”) to be more patient in tempting intertemporal choices (in which a small, immediate outcome is pitted against a large, delayed outcome).  A key result is that choice architects do act to restrict the choice set of choosers to help them avoid temptation.  A key strength the paper is offering insight into the motivations behind this decision.  The paper proposes and tests two possible motivations:  1) A “mistakes-projective paternalism” in which the choice architect assumes others share his/her susceptibilities to temptations and uses choice sets to minimize temptations and 2) an “ideals-projective paternalism” in which the choice architect assumes others follow his/her values and limit the choice set to those valued outcomes.  The results provide clear evidence for the latter motivation.  The paper provides evidence about additional beliefs and motivations.  Choice architects believe that they are improving the welfare of choosers and they underestimate how many people they are affecting with their restrictions.  Finally, the behavior of choice architects in the laboratory predicts support for real-world paternalistic policies (regarding, for example, taxes on alcohol and tobacco) and the motivation to make choices harder is consistent with “ideals-projective paternalism.”

The winning paper was selected by the panel of Rick Larrick (Duke University), Muriel Niederle (Stanford University), and Tomasz Strzalecki (Harvard University)."

 

Challenge trials in Britain and (not) in the U.S.

 The NY Times has an excellent piece on Covid vaccine challenge trials, and the different traditions (and repugnance) in Britain and the U.S.

Britain Infected Volunteers With Covid. Why Won’t the U.S.? By Kate Murphy

"In an age of masking, compulsive hand sanitizing and plexiglass dividers, it seems inconceivable that for more than 40 years people enthusiastically signed up — and were often put on a waiting list — to have respiratory viruses, including coronaviruses, dripped into their noses.

"They were volunteers at the Common Cold Unit, set up in 1946 by the British government’s Medical Research Council.

...

"the Common Cold Unit established and refined a model for so-called human challenge studies that paved the way for the first Covid-19 human challenge study just completed in Britain, where young, healthy and unvaccinated volunteers were infected while researchers carefully monitored how their bodies responded.

"Then, as now, there were those who decried deliberately infecting or “challenging” healthy volunteers with disease-causing pathogens. It violates the medical principle of “do no harm.” The trade-off is a unique opportunity to discover the causes, transmission and progression of an illness, as well as the ability to more rapidly test the effectiveness of proposed treatments.

...

"“The key benefit of human challenge studies is that they are controlled — everyone gets the same virus, the same amount and they are in the same environment,” said Dr. Christopher Chiu, professor of infectious diseases at Imperial College London and chief investigator in Britain’s Covid challenge study.

...

"In the United States, the regulatory hurdles to conduct challenge studies mean there are precious few, mostly for finding better treatments for malaria, cholera and influenza. Ethicists and regulators are more comfortable approving clinical trials where subjects are given a treatment, say a drug or vaccine, to see if it helps improve a condition volunteers already have, or could prevent them from developing later.

...

"Dr. Fauci’s office said the institute has no plans to fund Covid-19 human challenge trials in the future. Many bioethicists support that decision. “We don’t ask people to sacrifice themselves for the good of society,” said Jeffrey Kahn, director of the Johns Hopkins Berman Institute of Bioethics. “In the U.S., we are very much about protecting individual rights and individual life and health and liberty, while in more communal societies it’s about the greater good.”

"But Josh Morrison, a co-founder of 1Day Sooner, which advocates on behalf of more than 40,000 would-be human challenge volunteers, argues it should be his and other people’s right to take risks for the greater good. “Most people aren’t going to want to be in a Covid challenge study, and that’s totally fine, but they shouldn’t project their own choices on other people,” he said."

HT: Axel Ockenfels

Repugnance as paternalism: bans on flavored tobacco products

 The NY Times has the story on the recent FDA policy:

Biden Administration Plans to Propose Banning Menthol Cigarettes. The move has been long sought by public health and civil rights groups, after decades of marketing aimed at Black smokers.  By Sheila Kaplan

"The Biden administration is planning to propose a ban on menthol cigarettes, a long-sought public health goal of civil rights and anti-tobacco groups that has been beaten back by the tobacco industry for years, according to a federal health official.

"For decades, menthol cigarettes have been marketed aggressively to Black people in the United States. About 85 percent of Black smokers use menthol brands, including Newport and Kool, according to the Food and Drug Administration. Research shows menthol cigarettes are easier to become addicted to and harder to quit than plain tobacco products.

"The F.D.A. is being forced to act by a court deadline — a federal district judge in Northern California had ordered the agency to respond by April 29 to a citizens’ petition to ban menthol. But the odds are unlikely that a ban would take effect anytime soon, because any proposal is likely to wind up in a protracted court battle. The proposal would also include a ban on all mass-produced flavored cigars, including cigarillos, which have become popular with teenagers.

...

"Delmonte Jefferson, executive director of the Center for Black Health and Equity, one of the organizations behind the petition, called the decision a victory for African Americans and all people of color.

“This has been a long time coming,” said Mr. Jefferson. “We’ve been fighting this fight, since back in the 1980s. We told the industry then, we didn’t want those cigarettes in our communities.”

...

"Menthol is a substance found in mint plants, and it can also be synthesized in a lab. It creates a cooling sensation in tobacco products and masks the harshness of the smoke, making it more tolerable." 

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Here's the announcement from the Food and Drug Administration:

FDA Commits to Evidence-Based Actions Aimed at Saving Lives and Preventing Future Generations of Smokers  Efforts to ban menthol cigarettes, ban flavored cigars build on previous flavor ban and mark significant steps to reduce addiction and youth experimentation, improve quitting, and address health disparities

"April 29, 2021: Today, the U.S. Food and Drug Administration announced it is committing to advancing two tobacco product standards to significantly reduce disease and death from using combusted tobacco products, the leading cause of preventable death in the U.S. The FDA is working toward issuing proposed product standards within the next year to ban menthol as a characterizing flavor in cigarettes and ban all characterizing flavors (including menthol) in cigars; the authority to adopt product standards is one of the most powerful tobacco regulatory tools Congress gave the agency. This decision is based on clear science and evidence establishing the addictiveness and harm of these products and builds on important, previous actions that banned other flavored cigarettes in 2009.

“Banning menthol—the last allowable flavor—in cigarettes and banning all flavors in cigars will help save lives, particularly among those disproportionately affected by these deadly products. With these actions, the FDA will help significantly reduce youth initiation, increase the chances of smoking cessation among current smokers, and address health disparities experienced by communities of color, low-income populations, and LGBTQ+ individuals, all of whom are far more likely to use these tobacco products,” said Acting FDA Commissioner Janet Woodcock, M.D. “Together, these actions represent powerful, science-based approaches that will have an extraordinary public health impact. Armed with strong scientific evidence, and with full support from the Administration, we believe these actions will launch us on a trajectory toward ending tobacco-related disease and death in the U.S.

...

"If implemented, the FDA’s enforcement of any ban on menthol cigarettes and all flavored cigars will only address manufacturers, distributors, wholesalers, importers and retailers. The FDA cannot and will not enforce against individual consumer possession or use of menthol cigarettes or any tobacco product. The FDA will work to make sure that any unlawful tobacco products do not make their way onto the market.

"These actions are an important opportunity to achieve significant, meaningful public health gains and advance health equity. The FDA is working expeditiously on the two issues, and the next step will be for the agency to publish proposed rules in the Federal Register allowing an opportunity for public comment. "

What Motivates Paternalism? By Ambuehl, ,Bernheim and Ockenfels in the AER

 I have long been interested in repugnant transactions, which some people would like to engage in and others, not themselves involved in the transaction ('third parties') think should be forbidden.  That's a big class of phenomena (even when we exclude transactions that third parties object to because they might suffer negative externalities). In some cases (e.g. opposition to same sex marriage) there seems to be a lack of empathy with those who want or need to transact in ways that third parties object to. In other cases (e.g. opposition to surrogacy) there often seems to be a desire to protect vulnerable parties  (e.g. potential surrogate mothers) from entering into a transaction that the objecting third parties believe would harm the surrogates.  This latter kind of objection often falls under the label "paternalism."

Here's a paper in the latest AER that explores and finds paternalism in the lab.

What Motivates Paternalism? An Experimental Study By Sandro Ambuehl, B. Douglas Bernheim, and Axel Ockenfels, American Economic Review  March 2021, 111(3): 787–830, https://doi.org/10.1257/aer.20191039

Abstract: "We study experimentally when, why, and how people intervene in others' choices. Choice Architects (CAs) construct opportunity sets containing bundles of time-indexed payments for Choosers. CAs frequently prevent impatient choices despite opportunities to provide advice, believing Choosers benefit. They violate common behavioral welfare criteria by removing impatient options even when all pay-offs are delayed. CAs intervene not by removing options they wish they could resist when choosing for themselves (mistakes-projective paternalism), but rather as if they seek to align others' choices with their own aspirations (ideals-projective paternalism). Laboratory choices predict subjects' support for actual paternalistic policies. "

Paternalism as a motivation for repugnance: Ambuehl, Bernheim and Ockenfels

When I talk about repugnant transactions, I mean transactions that some people would like to engage in, but others don't think they should be allowed to, even if those others don't suffer themselves when the transactions take place.  In this recent NBER working paper, Sandro Ambuehl (one of the leaders in the study of these things) teams up with Doug Bernheim and Axel Ockenfels to study paternalism, which is closely related and often a primary cause of a transaction being repugnant (e.g. you might not think I should chew tobacco, because you think it would be bad for me...)

PROJECTIVE PATERNALISM
by Sandro Ambuehl, B.Douglas Bernheim, and Axel Ockenfels
NBER Working Paper 26119 http://www.nber.org/papers/w26119

Abstract: "We study experimentally when, why, and how people intervene in others' choices. Choice Architects (CAs) construct opportunity sets containing bundles of time-indexed payments for Choosers. CAs frequently prevent impatient choices despite opportunities to provide advice, believing Choosers benefit. We consider several hypotheses concerning CAs' motives. A conventional behavioral welfarist acts as a correctly informed social planner; a mistakes-projective paternalist removes options she wishes she could reject when choosing for herself; an ideals-projective paternalist seeks to align others' choices with her own aspirations. Ideals-projective paternalism provides the best explanation for interventions in the laboratory and rationalizes support for actual paternalistic policies."

From the conclusion:

"This  paper  examines  when,  why,  and  how  people  intervene  in  others’  choices.   In  a  setting  involvingintertemporal tradeoffs, we find that Choice Architects frequently remove options that are attractive toimpatient decision makers.  Choice Architects believe their interventions benefit the Chooser, and are thusacting paternalistically.  How do Choice Architects judge what is good for others?  This is a difficult taskbecause, by definition, paternalists are hesitant to rely on the judgments implicit in Choosers’ decisions,and indeed may even question whether Choosers are aware of their own best interests.  Ideals-projectivepaternalism  emerges  from  our  empirical  analysis  as  the  key  organizing  principle.   An  ideals-projectivepaternalist acts as if she believes other share, or ought to share, the ideals to which she aspires for herself."
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I think of paternalism as being one cause of a lot of repugnance to certain transactions, but certainly not the only cause. For example, I don't think that repugnance to same-sex marriage was intended to help those who wanted to marry...