Directed and semi-directed living donation of kidneys: a current debate in Israel and elsewhere

 Israel leads the world in per capita living kidney donation. A good part of that comes from the work of Matnat Chaim (gift of life), an organization of religious Jews, who donate kidneys to people they don't know.  They are "semi-directed" rather than non-directed donors, in that the organization allows them to indicate some criteria they would like their recipients to have.  Sometimes they want their recipients to be fellow Jews, and this has generated some controversy in Israel.

Below is a study of this phenomenon, and in an accompanying editorial, a criticism of it.

Nesher, Eviatar, Rachel Michowiz, and Hagai Boas. "Semidirected Living Donors in Israel: Sociodemographic Profile, Religiosity, and Social Tolerance." American Journal of Transplantation (in press).

Abstract: Living kidney donations in Israel come from 2 sources: family members and individuals who volunteer to donate their kidney to patients with whom they do not have personal acquaintance. We refer to the first group as directed living donors (DLDs) and the second as semidirected living donors (SDLDs). The incidence of SDLD in Israel is ∼60%, the highest in the world. We introduce results of a survey among 749 living donors (349 SDLDs and 400 DLDs). Our data illustrate the sociodemographic profile of the 2 groups and their answers to a series of questions regarding spirituality and social tolerance. We find SDLDs to be sectorial: they are mainly married middle-class religious men who reside in small communities. However, we found no significant difference between SDLDs and DLDs in their social tolerance. Both groups ranked high and expressed tolerance toward different social groups. Semidirected living donation enables donors to express general preferences as to the sociodemographic features of their respected recipients. This stirs a heated debate on the ethics of semidirected living donation. Our study discloses a comprehensive picture of the profile and attitudes of SDLDs in Israel, which adds valuable data to the ongoing debate on the legitimacy of semidirected living donation.

Danovitch, Gabriel. "Living organ donation in polarized societies." American Journal of Transplantation, (Editorial, in press).

"Nesher et al are to be congratulated for reporting on a unique, effective, yet ethically problematic manifestation of living kidney donation in Israel. To summarize, living kidney donation has become “de riguer,” a “mitzvah” (a religiously motivated good deed) among a population of mainly orthodox Jewish men living in religiously homogenous settlements. According to the authors, the donors view themselves as donating altruistically within a larger family. The donations, over 1300 of them, 60% of all living donations in the country, have changed the face of Israeli transplantation, reduced the waiting time for all transplant candidates on the deceased donor waiting list,2 and minimized the temptation of Israeli transplant candidates to engage in “transplant tourism,” a phenomenon that was an unfortunate feature of Israeli transplantation before the passage of the Israeli Transplant Act of 2008 that criminalized organ trading.3

So, what’s the problem? Matnat Chaim (“life-giving”), the organization that facilitates the donations, permits the donors to pick and choose among a list of potential recipients using criteria that according to its own website,4 and as Nesher et al note,1 are not transparent. ... frequently the donors elect to donate to other Jews.  ... " Israel is a country with an 80% Jewish majority; a decision to only donate to other Jews, thereby excluding non-Jews, is a practice that, were it reversed in a Jewish minority country, would likely be labeled antisemitic. Concern that the process encourages racist and nationalistic ideation has been raised in the past6 and only emphasized by the public pronouncement of some media-savvy kidney donors.7

"What lessons does the Israeli experience hold for the US and other countries, faced as all are, with a shortage of organs for transplant? Conditional living donation exists to a limited extent in the US: DOVE is an organization that works to direct living kidney donation to US army veterans9; Renewal is an organization that encourages and facilitates living donation from Jews to other Jews but also to non-Jews10; in the 1990s an organization called “Jesus Christians” made organ donation one of its precepts.11 But in each of these cases, it is a minority group whose interests are being promoted.

...

"What now for Matnat Chaim? Given its prominent impact on Israeli transplantation, its allocation policies must be transparent and subject to public comment. Criteria must be medical in nature and religious or political considerations excluded. Fears that as a result living kidney donation rates will plummet are likely exaggerated. "

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I can't help reading this discussion while being very aware that Dr. Danovitch is an ardent opponent of compensating kidney donors, for fear that inappropriate transplants would take place if that were allowed.  In much of that discussion, inappropriateness of transplants focuses on possible harm to the (paid) donors, but the donors in the Israeli case are unpaid. Here his concern is that donor autonomy about to whom to give a kidney comes at the expense of physician autonomy in choosing who should receive a transplant, by "medical" criteria. But frequently those criteria have a big component based on waiting time, rather than any special medical considerations. So maybe in general he thinks that privileging the physician's role in this way is worth having fewer organs and consequently more deaths.

Still, I think he has a point about how we perceive what is repugnant. Having minority donors donate to fellow minority recipients seems much less repugnant than having majority donors specify that they aren't interested in donating to minority recipients.

But, speaking of donor autonomy, I'm not sure that there are practical ways around it, since semi-directed donors could always present as fully directed donors to a particular person that some organization had helped them find. So, we may just have to live with the increase in donations and lives saved that donor autonomy can support.

########

Earlier posts:

Thursday, July 27, 2023

Kidney brouhaha in Israel: is a good deed still good when performed by a shmuck?

I ended that post with this:

"I'll give the last word to a Haaretz op-ed, also in English:

 Is It Kosher to Donate Kidneys Only to Other Jews?  A well-known religious journalist in Israel declared the " -only" donation of his kidney. His act is imperfect, but not immoral by Robby Berman"

Monday, July 31, 2023

Altruistic kidney donors in Israel

...

and, here in the U.S.:

Friday, March 12, 2021

Kidneys for Communities

" A new organization, Kidneys for Communities, plans to advocate for living kidney donation by seeking donors who identify with a particular community.  Their come-on is "Put your kidney where your heart is.  Share your spare with someone in your community"

Directed deceased donation of organs for transplant. (Legal in U.S. but not yet in Europe.)

 It is legal in the U.S. for a deceased donor organ for transplant to be directed to a particular recipient, if the recipient is compatible (and otherwise the organs are allocated as in the usual way for nondirected deceased donation.)  Because compatibility is tricky, directed deceased donation (DDD) is rare (but deceased donor kidneys can potentially be used to start a deceased donor initiated chain of kidney exchange).

But in most of Europe, it turns out, DDD isn't legal. (!) Here's a paper by the European Society of Transplantation's European Platform on Ethical, Legal and Psychosocial Aspects of Organ Transplantation. It cautiously argues that maybe this ban is "one thought too many," and that the ban should be lifted so that carefully regulated DDD would be allowed to increase organ donation in Europe and save more lives.

"When is directed deceased donation justified? Practical, ethical, and legal issues," by David Shaw1,2 , Dale Gardiner3, Rutger Ploeg4, Anne Floden5,6, Jessie Cooper7, Alicia Pérez-Blanco8, Tineke Wind9, Lydia Dijkhuizen10, Nichon Jansen10 and Bernadette Haase-Kromwijk10; on behalf of the ESOT ELPAT Working Group on Deceased Donation, Journal of the Intensive Care Society, 2024.

Abstract: This paper explores whether directed deceased organ donation should be permitted, and if so under which conditions. While organ donation and allocation systems must be fair and transparent, might it be “one thought too many” to prevent directed donation within families? We proceed by providing a description of the medical and legal context, followed by identification of the main ethical issues involved in directed donation, and then explore these through a series of hypothetical cases similar to those encountered in practice. Ultimately, we set certain conditions under which directed deceased donation may be ethically acceptable. We restrict our discussion to the allocation of organs to recipients already on the waiting list.

"The persistent shortage of organs available for transplantation demands fair and objective allocation of the scarce available organs, based on preset transparent and regulated criteria. In most European countries, organs from deceased donors are allocated to patients on the organ waiting list by national Competent Authorities.3 The current worldwide norm is that organs donated after death are considered as an unconditional gift to the patients on the transplant waiting list according to the allocation system. This implies that donors (prior to their death), or their family members (after it), cannot determine to whom the available organs will be assigned, nor exclude any potential recipients.

...

"In a few countries, like the United States, United Kingdom, Japan, and recently Australia, directed deceased donation is possible in restricted cases, since national legislation does not prohibit it. In living donation however, directed donation is permitted in many countries, even when there is no genetic or emotional relationship between the donor and the intended recipient. This inconsistency between the living donation- and deceased donation system has been noted.4

"This paper explores whether directed deceased donation should be allowed, and if so under which conditions.

...

"The main argument against DDD is that this violates the  basic principle of an altruistic, unconditional gift to society; allowing DDD may turn out to be a “slippery slope” in the direction of conditional donation and discrimination against particular patient groups. Conditional donation could also reduce public support for the transplantation system, since it could reduce transparency and fairness of the system.

...

"What, then, are the conditions for ethical DDD at the present time?

1. DDD under strict conditions should not be prohibited by legislation or policy.

2. There must be evidence that the donor wanted or would have been willing to direct the organ to a particular family member or close friend.

3. The donor/family should generally not be able to  insist on only donating the organ intended for DDD; where other organs are transplantable there should be a willingness to donate other organs (at least one) to patients on the waiting list to preserve the societal altruistic aspect of donation and diminish the overall effect on the waiting list.

4. DDD should proceed only if there is no patient on the waiting list in extremely urgent need of an organ transplantation to avoid imminent death.

5. DDD should proceed only if there is a reasonable chance of successful transplantation.

6. The intended recipient should be on the waiting list or be under assessment for being included.

"If these conditions are met, the medical team should do their best to facilitate the wishes of the deceased patient and his/her family by enabling DDD to take place. Letting deceased donors direct their organs to loved ones under carefully controlled conditions could further enhance trust in organ donation and transplantation systems, and hence willingness to become a donor."

Abortion bans in some states lead to late stage abortions in others

Obstacles to abortions in some states mean that some people seeking to end a pregnancy will have a late stage abortion where it's legal--i.e. laws intended to ban abortions or to allow only very early abortions may be moving some abortions much later. 

The New Yorker has a photographic essay:

A SAFE HAVEN FOR LATE ABORTIONS. At a clinic in Maryland, desperate patients arrive from all over the country to terminate their pregnancies.  Photographs by Maggie Shannon.  —Margaret Talbot

"For several years, Morgan Nuzzo, a nurse-midwife, and her friend and colleague Diane Horvath, an ob-gyn, talked about opening a clinic that would provide abortions in all trimesters of pregnancy. In May, 2022, the draft opinion of the Supreme Court ruling that overturned Roe v. Wade was leaked, infusing their plan with fresh urgency. The women had launched a GoFundMe campaign earlier that spring, noting that stand-alone clinics made up the majority of providers offering abortion after fifteen weeks, and that many of these had closed in recent years. Within weeks, Nuzzo and Horvath had raised more than a hundred thousand dollars; that summer, they started training employees for the new clinic, Partners in Abortion Care, in College Park, Maryland. They saw their first patient that October, and by the end of 2023 they had treated nearly five hundred. The youngest was eleven years old, the oldest fifty-three.

...

"Abortions in the second or third trimester are rare—the vast majority of abortions in the United States are performed in the first thirteen weeks of pregnancy—and when they occur the circumstances tend to be desperate. Horvath told me, “We know that when people decide they need an abortion they want to have it as soon as possible. Nobody is hanging out until they get to twenty or thirty weeks, saying, ‘Oh, I think maybe I’ll have my abortion now.’ ” A common scenario, she said, went like this: “You’re in, say, Texas—you’re pregnant and you need an abortion. You found out you were pregnant at eight weeks, which is a very usual time to find out. You arrange for child care—sixty per cent of people who have abortions are already parents—you get the money together, you’re going to have to travel out of state. You go to the next state that you can go to, and you find out you’re too far along for them. So now it’s going to be three times as much money. The cost goes up because the complexity of care goes up. If you travel four or five states over, how many days off is that, how many days of child care?”

Medical aid in dying, together, in the Netherlands

The Guardian has the story:

Duo euthanasia: former Dutch prime minister dies hand in hand with his wife. Dries and Eugenie van Agt, both 93, died as number of couples in Netherlands choosing joint end to life grows. by Senay Boztas  

"A Catholic former Dutch prime minister, Dries van Agt, has died by euthanasia, hand in hand with his wife Eugenie. They were both 93.

"Their deaths last Monday are seen as part of a growing trend in the Netherlands for “duo euthanasia”.

"Although still rare, euthanasia of couples was first noted in a review of all cases in 2020, when 26 people were granted euthanasia at the same time as their partners. The numbers grew to 32 the following year and 58 in 2022.

...

"Elke Swart, spokesperson for the Expertisecentrum Euthanasie, which grants the euthanasia wish of about 1,000 people a year in the Netherlands, said any couple’s requests for assisted death were tested against strict requirements individually rather than together.

“Interest in this is growing, but it is still rare,” she said. “It is pure chance that two people are suffering unbearably with no prospect of relief at the same time … and that they both wish for euthanasia.”

Netherlands to broaden euthanasia rules to cover children of all ages

Read more

"Euthanasia and assisted suicide have been legal in the Netherlands since 2002 for six conditions, including unbearable suffering, no prospect of relief and a long-held, independent wish for death.

"A second specialist must confirm the wish, and most cases are carried out by the family doctor at home."

Is algebra for 8th graders repugnant because it leads to calculus?

 The tide is shifting back towards teaching algebra in San Francisco middle schools.

The WSJ has the story:

In the Battle Over Early Algebra, Parents Are Winning. After schools prevented students from taking algebra before high school to reduce racial inequities, parents in San Francisco and Cambridge, Mass., pushed back. By Sara Randazzo

"San Francisco’s public school district set off a yearslong fight with parents when it decided to prevent students from taking algebra until high school, an attempt to combat racial inequities in math by waiting until more students were ready.

"Parents in favor of letting students start in middle school launched petitions, a ballot measure and a lawsuit, sparring with school officials over questions of equity and privilege.

"Now, it appears the parents who are pushing for eighth-grade algebra are winning.

"The San Francisco Unified School District said Friday that it would reverse its decade-old policy, a move that comes after a similar recent change by the school system in Cambridge, Mass., home to Harvard University.

"When to start students on algebra is a contentious topic because the subject is the gateway to a series of math classes culminating in calculus, which many see as crucial for STEM careers and selective college admissions. Students aspiring to take calculus before graduating have traditionally begun this sequence in eighth grade.

“A lot of the attention to eighth-grade algebra is based upon the feeling that that’s the point at which the race is won,” said Thurston Domina, an education professor at the University of North Carolina.

"In San Francisco, the district long argued that the policy of restricting algebra to high school wasn’t done to hold children back, but to reduce the inequities that result from sorting students by math ability at too young an age.

...

"Nationally, 48% of Asian students reach calculus before graduation, compared with 22% of white students, 14% of Latino students and 11% of Black students.

...

"Last year, California passed a new math framework that de-emphasizes early algebra access. Earlier drafts discouraged any eighth-grade algebra, citing the San Francisco school district’s policy as a more equitable approach. After hundreds of public comments and rounds of revisions, the final framework says students should accelerate in math if they are ready."

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I'm reminded of the wisecrack that says that fundamentalists disapprove of pre-marital sex because it leads to dancing, and they don't like dancing.

In this case, education reformers disapproved of 8th grade algebra because it leads to calculus...

Gambling in video games--entry level gambling for minors?

 In-game gambling for video game tools has become an unregulated form of online gambling that may provide minors with their first gambling fix...

The Guardian has the story:

‘It’s rotting young people’s brains’: the murky world of gambling in video games. In-game purchases of bonus items have long been available. But now gamers are being lured into casino-style betting to win them.  by Rob Davies

"For the uninitiated, “skins” are virtual items within a computer game that can be bought for money, or won as a reward for gameplay. Skins might be devastating weapons, a snazzy uniform for a character or – in a football game – a player who could be the missing link to complete an all-conquering team.

...

"Typically, skins are contained in “loot boxes” or “cases”, which gamers pay small sums for without knowing what they will get.

"Loot boxes have already become a lightning rod for controversy due to their gambling-style mechanism, although the UK government has refused to recognise them as gambling products.

"While skins can be found in loot boxes, they can also be bought in the online marketplace operated by online gaming platform Steam – the medium through which many games such as CS:GO are played.

"Through that marketplace, skins can also be transferred between players and into the game. There, competitors can use them to gain an advantage, or just for cosmetic effect.

"What bothered Jeff [a professional video gamer], however, was not so much the loot boxes or the skins in themselves but another phenomenon that they have spawned: skins gambling.

'This works like any other casino. You load up your account with funds, place a bet, watch the graphics spin and either win or lose.

"The big difference in this case is that the casino taking your bet has no gambling licence and, in some cases, no reliable mechanism to stop under-18s getting their first taste of gambling – via an online ecosystem that is, to many parents, a total mystery

...

"Some skins carry enormous price tags in the real world. One website that tracks skin prices values a “Gungnir” sniper rifle, available in the CS:GO game, at more than $18,000. A knife – a “factory new, case-hardened Karambit, pattern 387 (blue gem)” – is reputedly the most expensive CS:GO skin in history, attracting a $1.5m offer that its owner turned down. Further down the scale, guns, outfits, stickers and knives sell for hundreds of dollars.

...

"it can be literally child’s play to turn skins into hard cash. To use sites such as KeyDrop, players must have an account on the Steam platform, which was created by the maker of CS:GO, US-based game developer Valve.

"Steam has its own marketplace, where gamers can trade skins. Gift cards to help gamers buy such skins are big business at Christmas, an obvious choice for anyone with a relative or a friend who loves nothing more than spending hours in front of a game.

"The Steam marketplace is self-contained, at least initially. You can load cash into your wallet and use those funds to buy skins from Steam or from other gamers. You cannot, however, withdraw the funds. In ­theory, therefore, the marketplace is not somewhere you could properly cash out any winnings.

"But an industry has sprung up: third-party marketplaces such as SkinBaron and Skinwallet, where you can sell skins, including those won on gambling sites, for real money."

Morally contested markets on NPR's Planet Money (including kidneys, revenge and insider trading)

 The NPR show Planet Money discusses kidney sales, revenge, and insider trading. The hosts are enthusiastic about at least thinking about all of these.* 

They start with a discussion of organ transplants, and in the first 9 minutes of the show you can hear some parts of an interview with me, discussing tradeoffs (and possible titles for a book I'm working on).  Then they talk to Siri Isaksson about retaliation, and after that to Chester Spatt about insider trading.

Morally questionable, economically efficient

FEBRUARY 7, 2024 

By 

Mary Childs

, 

Greg Rosalsky

, 

Jess Jiang

, 

Willa Rubin

24-Minute Listen

• Download

 

They write:

"There are tons of markets that don't exist because people just don't want to allow a market — for whatever reason, people feel icky about putting a price on something. For example: Surrogacy is a legal industry in parts of the United States, but not in much of the rest of the world. Assisted end-of-life is a legal medical transaction in some states, but is illegal in others.

"When we have those knee-jerk reactions and our gut repels us from considering something apparently icky, economics asks us to look a little more closely.

"Today on the show, we have three recommendations of things that may feel kinda wrong but economics suggests may actually be the better way. First: Could the matching process of organ donation be more efficient if people could buy and sell organs? Then: should women seek revenge more often in the workplace? And finally, what if insider trading is actually useful?"

##########

*In their enthusiasm, they mis-state how few kidney exchanges were done before my colleagues and I got involved. (There weren't many, but more than two...)

As it happens, earlier this week I blogged about another interview, in the NYT, by Peter Coy (in print, not audio) that focused on kidney exchange:

Tuesday, February 6, 2024

Kidney exchange (and other bits of market design) in the New York Times

Update (5pm): now I see that on the Planet Money site there's a transcript.  Here's the part that I participated in:

SYLVIE DOUGLIS, BYLINE: This is PLANET MONEY from NPR.

(SOUNDBITE OF COIN SPINNING)

MARY CHILDS, HOST:

A couple decades ago, Al Roth was working on solving this problem - people who needed kidneys weren't getting matched effectively with people who had kidneys to donate.

AL ROTH: Part of the kind of work I do is called matching theory.

GREG ROSALSKY, HOST:

Al helped create this, like, beautiful, elegant algorithm that would match kidney donors with recipients.

CHILDS: You obviously won a pretty big prize for this work.

ROTH: I did. I recommend it.

CHILDS: OK. Yeah (laughter). You like the prize. It's a good prize.

ROTH: Yeah.

CHILDS: That's good to know.

ROTH: A week long of parties.

CHILDS: The prize he won? - it was the Nobel Prize in economics.

ROSALSKY: As you might know, Al's matching work vastly improved the way people get kidneys and saved literally thousands of lives. Like, in the year 2000, before Al's work, there were only two paired kidney transplants - two. Thanks to Al's algorithm, there are now about a thousand per year.

CHILDS: But, Al says, his Nobel Prize-winning algorithm - it isn't even the best way to get people kidneys. Technically, he says, the best way is to grow kidneys in a lab, so it's not even the second-best way.

I'm just envisioning you doing all this matching work knowing that this is, like, a little goofy. Like...

ROTH: Oh.

CHILDS: ...There's a easier way.

ROTH: I hope it's a lot goofy...

CHILDS: (Laughter).

ROTH: ...The work I'm doing, anyway.

CHILDS: (Laughter).

ROTH: No, no. That's right. So could we figure out a way to have more donors to have fewer deaths? I bet we could.

ROSALSKY: OK, so there is a much easier, more efficient way to get people kidneys. It's the way people get most things - with money. Like, what if we could just buy and sell organs?

ROTH: Oh, we'd have a lot more organs. That's how we get most of our stuff. There's a famous passage quoted from Adam Smith, which I'm going to paraphrase, but it says something like, it's not through the generosity of the butcher and the baker that you get your food. You buy it from them. It's how they - that's how they sustain their families - is by selling you food. And that's how you get food, and that's why there's enough food.

CHILDS: Right. The kidney market already has supply and demand. It just doesn't have prices to balance them because buying and selling kidneys is illegal in basically the entire world. So here we are. We don't have enough kidneys. We desperately need more, and yet, we refuse to pay more than $0 for them.

ROSALSKY: And as Al saw while working on kidneys, people had moral objections to the idea of paying for organs. They had concerns that just didn't really make sense to him as an economist.

ROTH: But when I started to look, it turns out there are lots of markets like that.

CHILDS: Lots of markets where people just don't want to allow a market. They feel icky about putting a price on something. Al has a list - for example, surrogacy - a legal and flourishing industry in much of the U.S., not in much of the rest of the world; assisted end of life - perfectly fine medical transaction in Oregon, illegal where I am in Virginia.

ROSALSKY: Al is actually working on a book about all of this.

ROTH: Its working title is "Repugnant Transactions And Controversial Markets." And the idea is that sometimes economists have perfectly good ideas that other people don't think are perfectly good.

ROSALSKY: Al has sort of made his own little subdiscipline in economics about this.

ROTH: "Ickonomics" (ph), "Yuckonomics" (ph) - you know, I trade in book titles. I'm open to suggestions.

CHILDS: You can email Al with your book title suggestions, though honestly, that's kind of hard to beat. In the meantime, when we have those knee-jerk reactions and our gut repels us from considering the icky thing, economics would like to humbly submit that maybe we should.

(SOUNDBITE OF JORDACHE V. GRANT AND SKINNY WILLIAMS' "OLDER HEADS")

CHILDS: Hello, and welcome to PLANET MONEY. I'm Mary Childs.

ROSALSKY: And I'm Greg Rosalsky. Today on the show, we apply an elegant economic framework to Al's market, the trading of human organs, to whether or not we should exact revenge on our enemies, and to whether or not we should trade on inside information.

(SOUNDBITE OF JORDACHE V. GRANT AND SKINNY WILLIAMS' "OLDER HEADS")

CHILDS: When we face difficult situations that don't have an absolutely clear right answer, economist Al Roth says borrowing tools from economics can be useful.

ROTH: Economists deal in trade-offs, and one of the things about trade-offs is you have to say to yourself, supposing there's something we really don't like, what will happen if we ban it? And if the answer is it won't go away, but it'll go underground or become criminalized or become very irregular, then you might prefer to regulate it rather than ban it.

ROSALSKY: And there are real problems with banning things. For example, remember that time we tried to ban alcohol, like, in the 1920s and 1930s?

ROTH: We discovered that it gave rise to a big criminal economy and didn't completely wipe out alcohol at all. So we legalized it. And the legal market for alcohol, with all its problems, is a lot nicer in many ways, a lot more socially useful than the criminal market - you know, Al Capone and the Saint Valentine's Day massacre and, you know, Eliot Ness.

CHILDS: Alcohol, as you may know, is legal today. Selling kidneys - no, not legal - with kidneys, we are in our Prohibition era.

ROTH: There is a black market for kidneys. And often it's pretty terrible because the almost-universal laws against compensating kidney donors have driven that market underground. And what underground often means is out of the hospitals and into hotel suites and apartments...

CHILDS: Eugh (ph).

ROTH: ...And - yes, so medically very bad, as well as, you know, not just illegal but dealing with criminals - medically very bad, bad for the donors, bad for the recipients.

CHILDS: And that's what we have today. That's the market we have chosen. We have the black market with money and the legal market with no money.

ROSALSKY: So Al has been thinking about solutions to this. Like, what can we do realistically to incentivize more kidney donations? How else could we go about creating a market for kidneys to be, as Al likes to put it, more generous to kidney donors?

CHILDS: And when Al thinks about how to design a market, he prioritizes investigating what exactly it is that we're objecting to so he can build a market that fixes or avoids those problems. And in the case of kidneys...

ROTH: There are metaphysical objections. You know, it's just wrong. But the objections that seem to touch on the world seem to say that you can't do this without exploiting poor people because poor people are so vulnerable that just offering them money takes away their agency.

CHILDS: The first reaction is just a gut reaction, which doesn't help inform Al on design. The second reaction is that money can be coercive, that if people have no money and you offer them money to participate in a study, they might have to do the study, especially if you offer a huge amount, like a life-changing amount of money. It's just too compelling. They wouldn't have a choice.

ROSALSKY: This argument does strike Al as unreasonable.

ROTH: There's lots of jobs that we pay people to do because otherwise no one would do them. And you can earn a decent living being a meatpacker. But that's one of the things that bothers people. They say, why should we allow a market that will be mostly - most of the participants will be in the lower parts of the income range? And of course, that isn't very sympathetic to people who are lower income, right? In other words...

CHILDS: Right.

ROTH: ...We need jobs that people with lower income can get. That's why they have some income - is that there are jobs.

CHILDS: Luckily, there is a really obvious, easy solution to this objection - just solve poverty.

ROTH: There'd be a lot less repugnance to monetary transactions if there was no income inequality.

CHILDS: (Laughter).

ROTH: If you wanted to sell me your kidney, but we all had the same income and the same prospects, it just might not be a big thing.

CHILDS: OK, failing that, Al mentioned another way to create a kidney market, a way to get kidneys only from people who aren't that poor - a tax break.

ROTH: People who are wealthy enough to benefit from tax credits on income tax aren't the poorest of the poor. So it might be that the way to start paying kidney donors is to say, we will give you a tax break on everything after the first $10 million of income in the year that you - you know, and then only hedge fund managers would donate kidneys, and that would be repugnant.

CHILDS: But there's a twisted logic to it because at least they could - like, should something go awry in the surgery or in the...

ROTH: Yeah, they'd be fine. They'd be fine. Yeah.

ROSALSKY: Perfect. Like, now we have a few ideas of how to make this happen without paying people for kidneys. We could resolve income inequality, or we could just, you know, do a tax credit and receive only hedge fund manager kidneys. And - right? - there's something a little goofy about all this because these solutions are trying to account for objections that are just hard to design around 'cause those objections are at least partly stemming from some messy human feeling or intuition that just won't let us exchange things in the normal way.

CHILDS: So do you think there'll ever be a U.S. market for kidneys?

ROTH: Well, I think we're not doing a good job yet and that we ought to find a way to be more generous to donors so that we have more of them.

CHILDS: And what that looks like - you're open to suggestion?

ROTH: I'm open to suggestions.