Markets, Virtues and Ethics

 Do markets complement virtues, or sideline them?  Here's another entry into that discussion.

Reese, A., Pies, I. Solidarity Among Strangers During Natural Disasters: How Economic Insights May Improve Our Understanding of Virtues. J Ethics (2023). https://doi.org/10.1007/s10892-023-09460-7

"Abstract: The renaissance of Aristotelian virtue ethics has produced an extensive philosophical literature that criticizes markets for a lack of virtues. Drawing on Michael Sandel’s virtue-ethical critique of price gouging during natural disasters, we (1) identify and clarify serious misunderstandings in recurring price-gouging debates between virtue-ethical critics and economists. Subsequently, (2) we respond to Sandel’s call for interdisciplinary dialogue. However, instead of solely calling on economics to embrace insights from virtue ethics, we prefer a two-sided version of interdisciplinary dialogue and argue that virtue ethics should embrace economic insights. In particular, we argue that if virtue ethics is to preserve its social relevance under modern conditions, it should re-conceptualize its notion of virtue and re-evaluate the self-interested but effective—and in this sense solidary—help among strangers via markets as virtuous rather than devaluate it as greed, that is, as vicious price gouging.

...

"Most forms of virtue ethics share a central concern for the moral character of a person, the development of excellence, and an emphasis on avoiding vices and pursuing virtues. This means that in essence, the virtue ethics perspective focuses on good intentions and intended consequences. In contrast, modern economics fosters a systems approach to situational incentives and thus shifts the perspective to focus on the unintended consequences of intentional actions.

...

" Roth (2007) acknowledges repugnance and other kinds of assumed moral inappropriateness as real constraints on market design. He takes moral feelings seriously and proposes market arrangements that do not evoke such feelings. For example, many people experience a feeling of unease with the idea of being able to buy and sell kidneys, which is currently possible for Iranians in the Islamic Republic of Iran. By designing in-kind kidney exchanges, Roth has shown ways to facilitate market transactions that operate entirely without money and, as such, do not evoke repugnant reactions (Leider and Roth 2010; Roth 2016). Surely, there are still too many people desperately waiting for a kidney. However, the implementation of in-kind exchanges has saved lives. It has helped a significant number of people obtain a kidney that would have obtained none without such a system. In line with Roth, we take the virtue argument seriously. However, we choose a longer time horizon where the assumed moral inappropriateness is no longer a given constraint on market design but becomes, at least in principle, a variable.

...

"Sandel insists on deciding case by case whether we should give the virtue of (probably less effective) selfless help precedence over the assumed repugnance of (probably more effective) self-interested help via markets, or vice versa.

...

"Reassessments of social practices are not uncommon throughout history. Most people today perceive the practices of charging interest rates, dueling, and paying opera singers for their performance differently than their ancestors. 

Statement of Policy Principles and Solutions: Living Organ Donation, from the American Association of Kidney Patients (AAKP), the American Society of Transplant Surgeons (ASTS), and the American Society of Transplantation (AST)

 Here's a joint statement about living-donor kidney transplantation from the American Association of Kidney Patients (AAKP), the American Society of Transplant Surgeons (ASTS), and the American Society of Transplantation (AST). The statement opposes rethinking the ban on compensation for donors, suggests that other policies should be evidence-based, and opposes increased bureaucratization and cumbersome regulation of the transplant process.

Statement of Policy Principles and Solutions:  Living Organ Donation

"We stand together in our conviction that any policy changes impacting living organ donation, including those aimed at improving access to living donor transplantation and increasing the survival of already transplanted patients, must begin with principled and transparent dialogue with patients and the expert transplant teams who care for them.  

...

"The United States ranks in the top tier of nations in terms of living donor transplant rates,[1] meaning the current system for living donation works. However, disparities in access to living donor transplantation remain, and we must continue to improve and expand living donor transplantation for those in need.  As such, we support policy changes that are patient-centric, fiscally realistic, and ethically and legally sound. 

"Over the past decade some well-intended organizations and advocates have advanced ideas to increase access to living donor transplantation, including direct payments for or large financial incentives for organ transplants, that may appear expedient but can result in serious adverse consequences for transplantation and for patients. Many of these proposals pose serious unintended negative consequences to both donors and to public trust in organ donation. We fundamentally reject efforts to model changes to the current US system based on research or organ transplant practices in nations such as China and Iran whose governments fail to meet or ignore high international and US standards for ethical medical research and basic human rights.

...

"AAKP, ASTS, and AST strongly support the elimination of disincentives to transplantation and adamantly oppose coercive financial incentives to donate.

...

"AAKP, ASTS, and AST believe that improvements to the transplant system can best be made through ethically and legally sound, evidence-based, data driven policies informed and guided by patients and transplant professionals rather than by overhauling the entire transplant system.

"The transplantation system is a public-private partnership between the federal government and the transplant community and is designed, in part, to prevent overt political influence or other governmental interference in shared patient-physician decision making and clinical judgement. The relationship between patients, including living organ donors, and the doctors and medical institutions they choose to care for them must be protected and respected, as should the ability of individual transplant professionals to make clinical decisions in the best interest of those patients.

"Transplantation is heavily regulated by multiple federal agencies, including the Centers for Medicare and Medicaid Services (CMS), the Health Resources Services Administration (HRSA), and two HRSA contractors (the Organ Procurement and Transplantation Network (OPTN) and the Scientific Registry of Transplant Recipients (SRTR)).  Transplant centers are subject to duplicative (and often conflicting) requirements and surveys imposed by CMS and the OPTN. Living donor transplant programs are subject to additional scrutiny to ensure that donors are not pressured, coerced, or intimidated into donating an organ.  All living donor transplant programs are required to have independent living donor advocates that ensure that donors’ full and informed consent is given with a full understanding of the procedure and its potential risks and consequences.

"Into this existing and complex regulatory framework, some organizations are proposing policy and legislative changes that would either expand federal control over transplant by inserting yet another federal agency into the process or overhauling the entire transplant system to give federal agencies, as well as political appointees and politicians, greater authority to regulate living donor transplantation. Exposing the living organ donation system to such political influence and putting decision-making in the hands of non-transplant experts is a mistake with dangerous consequences for patient health, public trust, and donor and patient confidence.

"These proposals raise the possibility that the federal government would mandate a “one-size fits all approach” to an incredibly complex set of clinical problems. Such an approach would likely result in fewer innovations and fewer opportunities to reduce barriers to transplantation, especially for historically underserved communities. There are many potential reforms to the transplant system that can be effective, have been suggested by the wider transplant community over the past decade, and should be adopted by Congress and federal agencies. However, any policy or legislative proposal that seeks to amend or replace the existing system with an even larger federal bureaucratic reach with the potential for federal interference in decisions made among organ donors and patients and the doctors and medical institutions they choose to receive care from should be viewed with skepticism.

"We oppose policy efforts that seek to place any governmental entity in the position of determining clinical criteria for living donor transplantation or otherwise interfering with the relationship between and among potential recipients, potential donors, and their caregivers.

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As a reader of many such joint statements, I wonder if the phrase  "coercive financial incentives" resulted from a compromise between those who believe that all financial incentives are coercive, and those who wish to leave the door open in the future to ordinary, non-coercive financial incentives, of the kinds that attach to so many human activities, and have done so much to relieve other kinds of shortages.

HT: Laurie Lee via Frank McCormick

NPR on black markets for kidneys from Nepal, for India

Here's an 8-minute video from National Public Radio about the black market for kidneys, trafficked from Nepal to India.  Some of the people interviewed indicate that they were duped; others decline to cooperate with prosecutors against the black market recruiters. A particular Indian hospital is named. Frank Delmonico makes an appearance near the end.  

(The video doesn't discuss any of the larger issues about the causes and consequences of the shortage of organs for transplant that make black markets busy and profitable, or how these might be addressed through legal and ethical efforts to increase the availability of transplants.)

.

HT: Frank McCormick

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Here's a post on the legal market for kidneys in Iran.

Monday, June 27, 2022

A Forum on Kidneys for Sale in Iran, in Transplant International

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Here's an article from earlier this week in the Washington Monthly

We Have to Make Organ Donors Whole. by Sally Satel, January 17, 2023 

"I’m alive because of kidney donations, but there wouldn’t be an organ shortage if we made it easier for those willing to literally give a piece of themselves. New York is taking a good first step."

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related earlier post:

Sunday, January 1, 2023

New York State's Living Donor Support Act (LDSA, S. 1594) was signed by Governor Hochul on Dec. 29

Gary Becker's last paper: appropriately, on a monetary market for kidneys (with Julio Elias and Karen Ye, JEBO, 2022)

 Gary Becker, who passed away in 2014, has a new paper, finished by his coauthors Julio Elias and Karen Ye. It recounts how the shortage of transplantable kidneys has only increased as the demand has grown, and the argument for paying donors is as strong as ever.  (In the meantime, the obstacles to that approach haven't vanished.)

The shortage of kidneys for transplant: Altruism, exchanges, opt in vs. opt out, and the market for kidneys*  by Gary S.Becker, Julio Jorge Elias, and Karen J.Ye, Journal of Economic Behavior & Organization, Volume 202, October 2022, Pages 211-226 (Another link to the paper is here, temporarily.)

Abstract: "In 2007 we published a paper on organ transplants that used data from 1990–2005. We proposed a radical solution of paying individuals to donate kidneys, and claimed that this would clean out the waiting list for kidney transplants in a short period of time. In this paper, we revisit the topic, and examine 14 years of additional data to see if anything fundamental has changed. We show that the main altruistic based policies implemented, such as kidney exchanges or opt out systems for organ procurement, have been unable to solve the problem of shortages. Our analysis suggests that, because of the reaction of direct living donors to increases in other sources of donations, the supply curve of kidney transplants is highly inelastic to altruistic policies. In contrast, a market in organs would eliminate organ shortages and thereby eliminate thousands of needless deaths."

Here's the most relevant part of the first footnote:

*"We started working on this paper together with Gary Becker in 2011. In 2012, we presented the paper at the Law and Economics Workshop and the MacLean Center's Seminar Series of the University of Chicago. The paper was unfinished when Becker passed away in May 2014. In this version of the paper, we updated the data and made some additions. The paper preserves all the economic analysis that was developed in the last version that we collaborated with Becker.

"Becker wrote his first article about the organ shortage in 1997, as part of his monthly BusinessWeek Column. The article was entitled How Uncle Sam Could Ease the Organ Shortage. In the article, he “suggest(s) considering the purchase of organs only because other modifications to the present system so far have been grossly inadequate to end the shortage.”

"In the 2000s, Julio Elias collaborated with Becker in a paper that uses the economic approach to analyze the consequences of legalizing the purchase and sale of kidneys for transplants from both deceased and living donors. In 2014, Becker published with Julio Elias a column in the Saturday Essay section of the Wall Street Journal entitled Cash for Kidneys: The Case for a Market for Organs. For Becker, the problem of the organ shortage and finding ways to solve it was a lifelong project. This paper reflects some of his last thoughts on this problem."

Here are their conclusions:

"The current state of the market of kidney transplants is a disaster. Over the last years, the waiting list has grown in over 4000 individuals each year, while transplants have grown by only about 250 per year. The result has been longer and longer queues to receive organs. 4000 patients died each year while waiting 3 and a half years on average for a transplant. According to our estimations, the annual social cost of those who die while waiting for kidney transplants is over $7 billion.

"Neither kidney exchange programs nor opt out systems nor educational campaigns to increase donations from altruistic donors have solved the problem of shortages. The main reason for their mild effects, as we show in this paper, is that the altruistic supply curve of kidney transplants is highly inelastic to these type of policies because of the reaction of direct living donors to increases in other sources of donations.

"The only feasible way to eliminate the large queues in the market for kidney transplants is by significantly increasing the supply of kidneys. The introduction of monetary incentives could increase the supply of organs sufficiently to eliminate the large queues and thereby eliminate thousands of needless deaths, and it would do so without increasing the total cost of kidney transplant surgery by a large percent.

"A market for the purchase and selling of organs would appear strange at first. However, much as the voluntary military today has universal support, the selling of organs would come to be accepted over time. " advantages of accepting payment for organs would eventually become clear, and people will wonder why it took so long for such an ovious and sensible remedy to the organ shortage to be implemented.

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Some related earlier posts:

Another take on compensating donors:

Tuesday, August 16, 2022

Kim Krawiec interviews Frank McCormick on the kidney shortage (and how to end it)

Commentary on the  legal monetary market for kidneys in Iran (and how it differs from illegal black markets):

Monday, June 27, 2022

A Forum on Kidneys for Sale in Iran, in Transplant International

The Pontifical Academy of Science says that compensating donors is a crime against humanity:

Friday, February 17, 2017

Vatican statement on organ transplantation

All my posts on compensation for donors (not just kidney donors) are here.

And here's my 2007 paper on repugnance (that came out in the same issue of JEP as the Becker and Elias paper), and was a first attempt at understanding some of the obstacles that face proposals to compensate donors of kidneys (and other things):

• Roth, Alvin E. "Repugnance as a Constraint on Markets", Journal of Economic Perspectives, 21:3, Summer, 2007, pp. 37-58.

I'm slowly writing a book that will expand on it.

A Forum on Kidneys for Sale in Iran, in Transplant International

 Just published in Transplant International (which is the journal of the European Society for Organ Transplantation), is a paper describing the Iranian market for kidneys in the city of Mashad, and three commentaries on it.  

 Here's the original paper:

Kidneys for Sale: Empirical Evidence From Iran  by Tannaz Moeindarbari and Mehdi Feizi

And here are three short commentaries.

Kidneys for Sale? A Commentary on Moeindarbari’s and Feizi’s Study on the Iranian Model  by Frederike Ambagtsheer1, Sean Columb, Meteb M. AlBugami, and Ninoslav Ivanovski

Kidneys for Sale: Are We There Yet? (Commentary on Kidneys for Sale: Empirical Evidence From Iran) by Kyle R. Jackson, Christine E. Haugen, and Dorry L. Segev

Criminal, Legal, and Ethical Kidney Donation and Transplantation: A Conceptual Framework to Enable Innovation  by Alvin E. Roth, Ignazio R. Marino, Kimberly D. Krawiec and Michael A. Rees

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The commentary by Roth, Marino, Krawiec and Rees contrasts the legal Iranian market with the dangerous black markets that operate elsewhere, outside of regular medical institutions.

Here's a recent long article that pulls together much of the discussion on compensation for donors and on sale of kidneys and transplant black markets:

Organ Trafficking, Can the illicit trade be stopped? By Sarah Glazer,  CQ Researcher, June 24, 2022 – Volume 32, Issue 22

HT: Frank McCormick

Afghanistan’s trade in organs--and children

 Here's the story in the WSJ:

‘No Father Wants to Sell His Son’s Kidney.’ Afghans Pushed to Desperate Measures to Survive. Afghanistan’s deepening humanitarian crisis fuels booming organ trade  By Sune Engel Rasmussen

"For those willing, an illegal but barely hidden business in the western city of Herat offers a reprieve from the downward spiral. Two hospitals in town offer kidney transplants that attract Afghans from across the country, performing 15-20 surgeries a month. Officials turn a blind eye. Buying and selling organs is illegal, as in most other countries. But scores of Afghans have come here to make the trade.

...

"Finding a seller of a kidney isn’t hard. Notes advertising private organ sales are plastered on walls and lampposts in Herat and other cities. Kidney brokers distribute business cards offering to put buyers in touch with sellers.

...

"Mr. Mohammad and his wife decided that unless they sold a child, they would have to sell an organ. Both of them were unsuited, as Mr. Mohammad had kidney stones and his wife had diabetes. Their oldest son made up to three dollars a day collecting plastic for recycling, so was spared. The choice fell on Khalil Ahmad, their second son.

...

"Ghulam Hossein came to Herat from the eastern Nangarhar province after a doctor told him his kidneys were failing. It took him 25 days to find a seller.

“I have no words to thank this man,” Mr. Hossein said about the donor, who needed money after being forced to sell his small grocery store, and who visited Mr. Hossein after the operation.

“I know he was poor but it takes huge courage and sacrifice to sell your kidney,” Mr. Hossein said. “I am more concerned now about his health than my own.”

*********

Here's an earlier story from the Guardian:

I’ve already sold my daughters; now, my kidney’: winter in Afghanistan’s slums. Crushing poverty is forcing starving displaced people to make desperate choices  by  M Mursal and Zahra Nader, 23 Jan 2022

“I was forced to sell two of my daughters, an eight-by and six-year-old,” she says. Rahmati says she sold her daughters a few months ago for 100,000 afghani each (roughly £700), to families she doesn’t know. Her daughters will stay with her until they reach puberty and then be handed over to strangers.

"It is not uncommon in Afghanistan to arrange the sale of a daughter into a future marriage but raise her at home until it is time for her to leave. However, as the country’s economic crisis deepens, families are reporting that they are handing children over at an increasingly young age because they cannot afford to feed them.

"Yet, selling her daughters’ future was not the only agonising decision Rahmati was forced to make. “Because of debt and hunger I was forced to sell my kidney,” she tells Rukhshana Media from outside her home in the Herat slum."

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And from the BMJ:

Afghans driven to sell kidneys on black market in the face of extreme poverty BMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o587 (Published 04 March 2022)  by Gareth Iacobucci

"People in Afghanistan are resorting to selling their kidneys on the black market to feed their families as the country faces extreme poverty.

"The United Nations estimates that 24 million people in Afghanistan—more than half of the population—are in need of lifesaving humanitarian aid. This is 30% higher than in 2021 when the Taliban seized control of the country.

"Illegal organ trading already existed in Afghanistan before the Taliban’s takeover, but a combination of economic sanctions, severe drought, and covid-19 have led to the black market surging as many more people experience extreme poverty.

"A lot of the trade is focused in the western city of Herat, close to the border with Iran."

An experimental study whose participants are compensated donors in the legal Iranian market for kidneys, by Kelishomi and Sgroi

 A recent working paper from Warwick reports an experiment and survey study whose participants are compensated kidney donors (and prospective donors) in the legal Iranian monetary market for kidneys.

Kelishomi, Ali Moghaddasi, and Daniel Sgroi. A Field Study of Donor Behavior in the Iranian Kidney Market. No. 1381. University of Warwick, Department of Economics, October 2021.

Abstract: Iran has the world’s only government-regulated kidney market, in which around 1000 individuals go through live kidney-removal surgery annually.  We report the results of the first field study of donor behavior in this unique and controversial market. Those who enter the market have low income, typically entering to raise funds.  They have lower risk tolerance and higher patience levels than the Iranian average.  There is no difference in rationality from population averages.  There is evidence of altruism among participants.  This might shed light on the sort of people likely to participate if other nations were to operate suchmarkets.

From the introduction:

"There is no doubt that the notion of paying for a kidney raises ethical concerns and some see this form of market transaction as incompatible with the “sacred value” of human life (Elias et al., 2015). However, given the apparent success of the Iranian kidney market and the existence  of long waiting lists, patient suffering and significant loss of life elsewhere, there has also been something of a re-evaluation of the potential for regulated organ markets in the developed world

...

"Given the nature of the debate it seems important to consider the characteristics of those likely to  come  forward  as  donors  if  a  market  is  established  and  to  ask  what  special  features  they may possess.  Since there is only one existent regulated market, this must involve a controlled examination of participants in the Iranian kidney market.  Our paper reports the outcome of an unprecedented first study of patient behavior in the Iranian kidney market in which we obtained direct access to donors before and after surgery. We provided full incentives where appropriate during our experimental treatments, providing incentive payments of around $50 (in terms of purchasing power parity) on top of a show-up fee of roughly $15.2 We also collected data that is similar to existing generic data on the Iranian population. This allows us to not only provide comparisons within our sample but also between our sample and Iranian averages where data is available.

...

" The study started in August 2017 (shortly after the end of sanctions between the UK and Iran) and live sessions continued until May 2019,with further telephone interviews and follow-up sessions continuing until February 2021.  78 subjects were first interviewed post-donation while the remaining 137 were interviewed pre-donation.  Of the pre-donation group 91 were contacted a second time to confirm their final status in February 2021.  35 had donated by this point with the remaining 56 dropping out of the market (30 for medical reasons and 26 through choice).  Following this process we were able to measure behavioral variables such as risk aversion, time preference (patience), altruism, rationality (consistency with GARP, the generalized axiom of revealed preference), and a wide variety of demographic and socioeconomic data.  Where feasible we incentivized answers and used the most prominent measures available.  We also examined why these patients enter the market and what alternatives might have been available to them.  We are able to compare our patient data with available data for typical Iranians to provide a benchmark (Falk et al., 2018)

...

"While the typical donor is in considerable financial difficulty, they are significantly more patient and exhibit lower tolerance for risk than an average Iranian (though conditional on entering the market those with lower patience are more likely to have donated during our study).   Those who go through with the process exhibit higher levels of altruism than those who drop out.   We find no difference in rationality between participants in the market and the subjects in a leading study of rationality from which we take our core measure  (Choi  et  al.,  2014).   We  would  argue  that  alternative  options  for  those  in  financial difficulty such as approaching a loan shark might be more appealing to the risk-loving (and perhaps more impatient) since this offers an immediate solution but replaces it with a serious and risky long-term liability, while the organ market is a difficult short-term prospect but does not result in higher levels of debt in the long run. Our findings on altruism are consistent with the idea that, while donors are being paid, they are nevertheless taking part in a difficult process that has the potential of saving a life, and this may also be important when considering alternatives."

Kidney black market at an Afghan hospital

 The NY Times reports today on an Afghan hospital at which people in need of a transplant can buy a kidney.  The report focuses on apparently poor after-care for donors, who are interviewed recovering in nearby apartments.  It would be interesting to know more about how that compares to the situation in neighboring Iran, where there is a legal monetary market for kidneys for transplant.

In Afghanistan, a Booming Kidney Trade Preys on the Poor. Widespread poverty and an ambitious private hospital are helping to fuel an illegal market — a portal to new misery for the country’s most vulnerable.  By Adam Nossiter and Najim Rahim

"The illegal kidney business is booming in the western city of Herat, fueled by sprawling slums, the surrounding land’s poverty and unending war, an entrepreneurial hospital that advertises itself as the country’s first kidney transplantation center, and officials and doctors who turn a blind eye to organ trafficking.

...

"For the impoverished kidney sellers who recover in frigid, unlit Herat apartments of peeling paint and concrete floors, temporarily delivered from crushing debt but too weak to work, in pain and unable to afford medication, the deal is a portal to new misery. In one such dwelling, a half-sack of flour and a modest container of rice was the only food last week for a family with eight children.

"For Loqman Hakim Hospital, transplants are big business. Officials boast it has performed more than 1,000 kidney transplants in five years, drawing in patients from all over Afghanistan and the global Afghan diaspora. It offers them bargain-basement operations at one-twentieth the cost of such procedures in the United States, in a city with a seemingly unending supply of fresh organs.

...

"On the fourth floor of the hospital, three out of four patients in recovery said they had bought their kidneys.

“I feel fine now,” said Gulabuddin, a 36-year-old imam and kidney recipient from Kabul. “No pain at all.” He said he had paid about $3,500 for his kidney, bought from a “complete stranger,” with an $80 commission to the broker."

...

"“My father would have died if we had not sold,” said Jamila Jamshidi, 25, sitting on the floor across from her brother, Omid, 18, in a frigid apartment near the city’s edge. Both had sold their kidneys — she, five years ago, and he, one year ago — and both were weak and in pain."

The Iranian kidney market in Mashhad, by Mehdi Feizi and Tannaz Moeindarbari in Clinical Transplantation

Here's a new article in Clinical Transplantation:

Characteristics of kidney donors and recipients in Iranian kidney market: Evidence from Mashhad
Mehdi Feizi  Tannaz Moeindarbari
First published: 06 August 2019 https://doi.org/10.1111/ctr.13650

Abstract: The Iranian model of kidney transplantation is an example of a regulated living unrelated renal donation. In this paper, we collected and analyzed a unique dataset of 436 paired kidney donors and recipients, including their characteristics and the realized price of a kidney in Mashhad. As opposed to the global picture of kidney donation, we find that women are less likely to donate and more likely to receive a kidney. Moreover, the average price of a kidney amounts less than 2 years of work with the minimum level of wage.
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The article elicited a commentary by Gabe Danovitch, an eminent nephrologist at UCLA who speaks and writes frequently in opposition to compensation for donors:

COMMENTARY
Financial neutrality should replace the Iranian paid donor market
Gabriel Danovitch
First published: 16 July 2019 https://doi.org/10.1111/ctr.13665

He explains his opposition to markets in general this way: "the term “regulated market” is oxymoronic with respect to markets in general and specifically when it comes to human organs..."

(One wonders how the market for nephrologists works, and for medical specialists and subspecialists generally.  Someone should study that...)
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The article on Mashhad includes some very interesting description of the market there:

"Since the first live kidney transplant in Mashhad on 2 April 1985 until December 2017, more than 2500 people have had a kidney transplant in the Montaserie Organ Transplantation Hospital. It is operating as a center for dialysis and the only center in Mashhad and neighboring regions for transplantation of kidney, liver, and bone marrow. According to the latest reports, more than 7000 people from different age groups are now waiting for a kidney in Mashhad.

"In Mashhad, approximately 60 individuals refer to the IKF every week to sell their kidney. Of these donors, about 15 individuals are actively pursuing the process, while the rest are dissuaded due to various reasons. Out of these individuals, about one‐fifth are medically approved for kidney donation, after the 3 or 4 weeks of examinations.

"From the demand perspective, every end stage renal disease (ESRD) patient aged below 70 in Khorasan Razavi Province without having a willing related donor is referred through a nephrologist's letter to the IKF in Mashhad to enter the kidney waiting list according to their blood type. These patients can be entered in the waiting list of hospitals to receive a kidney from a deceased donor as well.

"From the supply perspective, each potential kidney donor, between 22 and 40 years old, should register at the IKF after undergoing the preliminary medical tests and bringing the notarized consent of him/herself and his/her family, including both parents for singles, only the spouse for married men, and the spouse and both parents for married women.
...
There are four different matching lines for each blood type, and the IKF usually pair each donor with a renal patient with the matching blood type in the waiting list based on a first come, first‐served basis. Nevertheless, this is not the only way of matching, and both sides can also publically advertise and find each other outside the IKF matching system. However, they have to register there and do the required paperwork and medical tests, as the transplantation centers only accept donors referred by the IKF, as a market maker.

"A renal patient should pledge in cash half the official price of a kidney to the IKF following the initial registration of the waiting list. Once a patient is matched to a donor and they both agree upon a price, the patient pays the remaining price of a kidney to the IKF via a cheque. After carrying out the transplantation, the IKF transfers all the amount of money received from the patient to the donor. However, the IKF neither receives any financial interest nor benefits from any monetary transactions, as it is a charity after all. Although there is no official ceil price, the IKF in Mashhad informally tries its best to convince and incentivize the donor not to ask a high price.
...
"Almost all kidney donors mostly face severe and urgent financial needs, for example, paying off debts (especially home rentals and blood money) and even living expenses, especially for single‐mother households. Thus, financial issues constitute the most frequent and primary motive for living unrelated donors in Iran.
...
"According to this law, compensated kidney donation in Iran is only possible between two individuals from the same nationality with the legal residence permits, especially refugees in Iran from Afghanistan.

"Since there is a large number of Afghan refugees in Mashhad, the IKF has formed a limited market for them. At the main kidney market for Iranians, donors do not have to wait to find a match, as there are always patients looking for a compatible kidney, especially those with a rare blood type such as AB. However, at the kidney market for Afghans, there is no patient in a queue to get a kidney and donors have to stay on the waiting list to find a suitable recipient.

"Moreover, for Afghan citizens, the amount of money a patient should pay to compensate a donor is determined not based on the official price of a kidney in Iran, but rather in a wholly agreed manner. In 2014, the total cost of kidney transplantation was about 6329 USD. While the government pays all kidney transplantation costs for Iranian patients and donors, Afghan renal patients should pay the hospital fees and other costs related to transplantation, which is estimated about 350 million IRR, almost 8650 USD, and reaches about 800 million IRR, almost 19 775 USD, with the cost of kidney purchase.
...
[Among Iranians] "Not only donors tend to be financially motivated for donation, but also recipients are not wealthy, as 47% of them are unemployed."

Official and unoffical Iranian kidney marketplaces--online prices

The Journal of Urology has published an in-press short paper about an informal website that seems to operate alongside the official Iranian monetary market for kidneys. (Thanks to Jim Brooks for the pointer.)

 Donor Willingness to Accept for Selling a Kidney for Transplantation: Evidence from Iran  by Mehdi Feizi and Tannaz Moeindarbari

"The Iranian model of kidney donation, established in 1988, is a state-funded system of living  renal  transplant  where  the  government  pays  for  all  transplant-related  expenses.  The Iranian Kidney Foundation, IKF hereafter, is in charge to match recipients and compensated donors. On the supply side, each donor registers at the local IKF after conducting preliminary medical  tests.  On  the  demand  side,  any  ESRD  patient  could  enter  the  kidney  waiting  list according to his/her blood type. A renal patient is matched to a donor, basically with the same blood type, based on the first come, first served.

"Both sides could also find each other outside the IKF, say in an online kidney matching website. However, since the transplant is exclusively possible through an official letter from the IKF,  they  have to register there."
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The article goes on to analyze prices asked and offered for kidney donation at the online kidney website that they refer to, http://www.koliee.ir/ .  It's in Farsi, but when I ask Google to translate it, their home page looks pretty interesting.  (It seems to offer the opportunity to search for kidneys by price as well as blood type.)

It contains some cautionary sentences:

"If you want to reach your goal without problems on this website, refuse to pay any money before the operation. Also, carry out kidney donation only through the Association for the Protection of Nephrology in your city."

It would be interesting to understand how websites like this interact with the official kidney market.

They also have a list of "our other websites" (again, in translation). The first one deals with surrogacy:

 Rental uterus

 My card

 Kidney donation

 The purse

 Amateur crafts

 Toggle Finder

 Mbti test

 Hello

 Buy and Sell a Loan

 Gnocard

Stanford GSB celebrates Mohammad Akbarpour

Mohammad Akbarpour: Humanizing Math for the Greater Good
"The Stanford GSB economist discusses his groundbreaking research into kidney exchanges, wealth inequality, and “anything that wakes me up at night.”
...
"In 2012, ...He and four of his close friends, who had all attended high school, college, or graduate school together, were feeling unsatisfied with their influence beyond Stanford’s manicured campus. Then Salman Khan, the founder of Khan Academy, presented at Stanford GSB.

"After watching Khan’s talk, Akbarpour and his friends built KelaseDars, also known as KhanacademyFarsi, to which Akbarpour has now contributed more than 280 videos on subjects ranging from high school Newtonian physics to college-level game theory. The website as a whole has delivered more than 5 million free lessons to Farsi speakers who would otherwise not have access to a high-quality education. Many of them live in Afghanistan and Iran.
...
"It was hectic and hard, “but it was a beautiful experience with a magnificent team,” Akbarpour says. “KelaseDars is the most meaningful thing I’ve done with my life.”

And here:

PBS asks: should the U.S. follow Iran in allowing a market for kidneys for transplant?

PBS asks the question
Iran pays kidney donors. Should the U.S. follow?

You can read the transcript or watch the video at the link.

HT: Mohammad Akbarpour

An anthropologist (Dr. Elham Mireshghi) looks at the market for kidneys in Iran

Elham Mireshghi completed her Ph.D. in Anthropology at UC Irvine in 2016. Her dissertation is
Kidneys on Sale? An Ethnography of Policy, Exchange, and Uncertainty in Iran

Here's the abstract:
"Since 1997, Iran has implemented the world’s only program for living paid kidney donation. The program has been developed and administered by a non-profit NGO – the Kidney Patient Foundation (KPF). Though sanctioned by Shi‘a Muslim jurists and celebrated in the West as the “Iranian Model,” the program has been rife with moral unease and uncertainty in Iran. While organ donation after death is valorized, undergoing transplantation for cash is stigmatized. Furthermore, there is little agreement among policy actors that facilitating paid organ giving is a good idea. In this dissertation, I examine kidney “selling” both at the level of the exchange – where I analyze the experiences of kidney givers and recipients – and at the level of institutional and bureaucratic process, legal and scientific reasoning, and practical and ethical negotiation, to explain how Iran came to uniquely sanction and bureaucratically routinize kidney selling. I disentangle the dense threads of moral reasoning and experience among a range of actors - from donors and recipients to doctors, policy activists, and Islamic jurists – that undergird the policy’s development and implementation. I have conducted ethnographic field research (2011-2013), including observation inside medical and Islamic institutions in Tehran and Qom, and indepth interviews of kidney givers and patients, KPF personnel, doctors and legal scholars and jurists. I have also analyzed Islamic legal texts, as well as visual and textual media.

"My analysis brings together analytic approaches within the anthropology of public policy, medicine, morality, and exchange, while also contributing to a growing interest in Iranian Studies to venture beyond themes of repression and resistance. I consider Iran’s living kidney giving program within the context of Iran’s post-revolution medical modernization projects, its haphazard economic liberalization, and ongoing commitment to social welfare, alongside an examination of the role of Islamic jurists and other “experts” in policy making. I elucidate the socio-economic conditions and aspirations that motivate kidney givers, and the “medical imaginary” that facilitates their decision as well as the legal reasoning of jurists. Lastly, I offer an alternative to the “commodity paradigm” in examining exchanges involving money that can contribute to bioethical discussions of organ sales."



Here's a paragraph describing the reduction in waiting time for a kidney transplant resulting from the market:

"The culmination of these regulations has resulted in a much shorter wait for kidney transplants in Iran than is the case in, for example, the United States, where paid donation is prohibited and most organs from unrelated donors come from cadavers and brain-dead individuals. This has often been touted as one of the most important outcomes of permitting kidney sales. In the US, if one does not find a donor among family or friends or an “altruist” living stranger, then the wait can take nearly four if not more years. In Iran, the wait can be a little over a year, if not less; though celebratory reports on what is now called the “Iranian Model” often claim that there is no waiting list at all .... If a patient chooses non-living donation, then much like the US the wait can take much longer than a year. "

Much of her interaction was with a social worker who was reluctant to enroll kidney sellers:
"Management was not unaware of Ms. xxx’s principled opposition to kidney selling and her attempts at talking people out of it. Ms. xxx explained to me once that she framed her activities as a benefit for the organization in the form of counseling for sellers. It would garner legitimacy for a program that had frequently come under domestic and international scrutiny, she argued. So management and Ms. xxx shared an interest in counseling prospective donors while assuring that a certain number made it to the list. For management, the interest had to do with protecting the organization’s credibility while also assisting in the treatment of suffering kidney patients. For Ms. xxx, it had to do with ensuring that fewer young men and women fell into what she called the “sick cycle of disease and poverty” (what she deemed to be the likely result of kidney selling) while also maintaining her employment."

One aspect of her work concerns the religious rulings that permit the Iranian kidney market.

Here's a quote from Ayatollah Makarem Shirazi  about what can be sold:
“The severing of an organ from a living person and the transplantation of that to someone whose kidneys have both decayed (fasid) is permissible on the condition that the owner (sahib) of the organ consents, and his life (jan) is not put into danger; and caution requires that if money is received in exchange, that it be in exchange for the permission to proceed with the taking (giriftan) of the organ, and not the organ itself.”

 I blogged about this part of Dr. Mireshghi's work earlier here:

Friday, June 5, 2015

The Shi'a religious jurisprudence behind Iran's legal market for kidneys

Kidney donor/sellers in Iran face social stigma--2 papers

The first of these two recently published papers is a report compiling interviews taken some time ago:

Coercion, dissatisfaction, and social stigma: an ethnographic study of compensated living kidney donation in Iran
Sigrid Fry‑Revere,  Deborah Chen,  Bahar Bastani,  Simin Golestani,  Rachana Agarwal, Howsikan Kugathasan, and Melissa Le
International Urology and Nephrology, https://doi.org/10.1007/s11255-018-1824-y, Online, February 2018

Abstract: "This article updates the qualitative research on Iran reported in the 2012 article by Tong et al. “The experiences of commercial kidney donors: thematic synthesis of qualitative research” (Tong et al. in Transpl Int 25:1138–1149, 2012). The basic approach used in the Tong et al. article is applied to a more recent and more comprehensive study of Iranian living organ donors, providing a clearer picture of what compensated organ donation is like in Iran since the national government began regulating compensated donation. Iran is the only country in the world where kidney selling is legal, regulated, and subsidized by the national government. This article focuses on three themes: (1) coercion and other pressures to donate, (2) donor satisfaction with their donation experience, and (3) whether donors fear social stigma. We found no evidence of coercion, but 68% of the paid living organ donors interviewed felt pressure to donate due to extreme poverty or other family pressures. Even though 27% of the living kidney donors interviewed said they were satisfied with their donation experience, 74% had complaints about the donation process or its results, including some of the donors who said they were satisfied. In addition, 84% of donors indicated they feared experiencing social stigma because of their kidney donation."

Here's an excerpt from the discussion of social stigma:  

"Some donors had a general sense that people had negative impressions of donors. One donor pointed out, “When people find out that you have donated, they start looking at you in a different way. They start keeping their distance.” Another donor explained what he thought was going through
people’s heads: “Oh, he sold his kidney, he’s not a good person.”
***********
and here's a paper with reports from an internet survey:

The Social Stigma of Selling Kidneys in Iran as a Barrier to Entry: A Social Determinant of Health
Mohammad Mehdi Nayebpour  Naoru Koizumi
World Medical and Health Policy, Volume10, Issue1, March 2018,
Pages 55-64
"Abstract
Iran is the only country in the world currently with a legalized compensated kidney donation system, in which kidney sellers are matched with end‐stage renal disease patients through a regulated process. From a practical point of view, this model provides an abundance of kidneys for transplantation as opposed to the American model that relies on altruistic donation. The major concern about adopting the Iranian model is the possibility of exploitation. A large body of literature exists on this topic, but few have focused on its cultural aspects. This paper sheds light on the cultural implications of the Iranian model by providing empirical evidence on the social stigmas against kidney sale in Iran. We claim that these stigmas act as barriers to entry to the supply market of kidneys. Due to the conditions created by social stigmas, kidney sellers are forced to consider not only monetary rewards but also cultural factors. Thus, they tend to be more cautious and try to avoid impulsive decisions. Such social stigmas act as unofficial regulatory forces to keep kidney sale as the last resort for the poor, to diversify the supply market by age, and to stretch the decision‐making process in the absence of a mandatory waiting period for transplantation."

from the discussion:
"Our survey demonstrated that an immense amount of negative stigma is directed toward kidney sellers in Iran from society. Comparison of our findings to those reported by Ghods et al. (2001), who studied the actual characteristics of kidney sellers, reveals stark differences between perception and reality. Ghods et al. interviewed 500 kidney sellers in Iran in 2001 (Ghods et al., 2001). The study reports that only 6 percent of them were actually illiterate (while 71 percent of our respondents thought kidney sellers are illiterate), 88 percent had elementary to high school degree (while only 22 percent of our respondents thought kidney sellers have a high school education), and 6 percent had university degrees and above (6 percent of our respondents thought kidney sellers have above high school education). This gap between the actual profile and the perception of kidney sellers indicates that while Iranians benefit from the current policy, they have a grave stigma against it. The other important gap between perception and reality appears in question 5. About 15 percent of people consider that kidney sellers are drug addicts and 56 percent are not sure whether kidney sellers are drug addicts or not. This particular perception is stunning, since by law kidney sellers undergo a series of strict medical tests before becoming eligible for selling. "

Super bowl thought by Kim Krawiec: football players are paid, why not kidney donors?

While checking up on the super bowl, I'm reminded that Kim Krawiec posted this:
 Super Bowl Week OpEd

"As the Super Bowl approaches, Phil Cook and I have an OpEd running in the Raleigh News & Observer and a few other publications:

Why ban payment to kidney donors but not football players?

BY PHILIP J. COOK AND KIMBERLY D. KRAWIEC 

February 01, 2018 01:06 PM

Super Bowl week rivets national attention on America’s most popular and lucrative sport, professional football. If stories of concussion and permanent injury to players make some fans uneasy, there is always the reassuring fact that the players volunteer for the job and are well compensated – so well compensated that there are untold thousands of young men who would gladly take their place.

Football is so ingrained in our culture that we generally accept this situation without much scrutiny. However, our research got us thinking about the stark contrast with another risky but valuable activity – kidney donation.

About 6,000 people per year donate one of their two kidneys. This selfless act has some risk to the donor, both from the surgery and years later when there is a chance the remaining kidney will fail. In return, kidney donors are rewarded with the knowledge they helped save the life of a loved one. They receive nothing tangible. Indeed, federal law bans compensation for kidney donors, as do the laws of all other countries except Iran (really).

So, why do we pay football players to entertain the public, but are unwilling to pay kidney donors to save lives?

The stakes in both cases are high, but much higher in kidney donation. The total value of NFL teams is about $60 billion. If, in some unlikely future, the risk of serious permanent injury to players led to a ban on professional play, that value would be destroyed.

Meanwhile, the ban on compensation for living kidney donation currently costs thousands of lives and billions of dollars in taxpayer money every year. The waiting list for a kidney now includes 100,000 patients, who for the most part are kept alive by renal dialysis at federal government expense. If they survive long enough, typically more than five years, in this debilitated state, they may hope to rise to the top of the list and receive a kidney from a deceased donor.

Deceased donors are a limited resource: few people die under conditions that permit donation and the United States already procures a large percentage of healthy kidneys from deceased donors. What is needed are many more living donors. Current estimates suggest an offer of $50,000 per living donation would be adequate to recruit sufficient numbers to meet the needs of all transplant-eligible renal patients. This would eliminate the waiting list and prevent thousands of unnecessary deaths and years of unnecessary disability. Given standard value-of-life estimates, the present value of the public benefit of converting to a system of compensated donation would exceed $1 trillion – many times the value of professional football.

It should be noted that the alternative to the current ban on compensation is not a laissez-faire free market. Rather, the current system for regulating the allocation of available kidneys could be readily expanded. A nonprofit or government organization could offer a fixed payment to living donors who were screened to be physically and mentally sound, and then fully informed of the risks. To avoid “impulse” donations, there could be a mandatory waiting period.

And it should be noted that the medical risks to kidney donors are far less than the risks of a football career; most donors lead normal lives, while most NFL veterans are, to some degree, disabled.

Inevitably the chance to sell a kidney for $50,000 would be most attractive to people who are struggling financially. Some ethicists opine that a compensated system would exploit the poor. Yet, more than a few NFL players also come from poor homes and 70 percent are black, causing many to view the concussion crisis as another example of racial inequality. In our view, the risk of exploitation is not a legitimate reason for forbidding compensation to kidney donors, thus denying the poor full use of one of their potential assets.

Millions of Americans, not just NFL players, work in occupations that have a substantial risk ofserious injury. Loggers, fishermen and others accept these risks in exchange for compensation. Extending that list to include kidney donors is just common sense.

PHILIP COOK IS TERRY SANFORD PROFESSOR EMERITUS OF PUBLIC POLICY AND PROFESSOR OF ECONOMICS AND SOCIOLOGY AT DUKE UNIVERSITY’S SANFORD SCHOOL OF PUBLIC POLICY. KIMBERLY KRAWIEC IS THE KATHRINE ROBINSON EVERETT PROFESSOR OF LAW AT DUKE LAW SCHOOL."

More debate about legalizing kidney sales

There's nothing new in this debate, but here is more on compensating kidney donors.  As far as I can see, the weakest argument against compensating donors is that the illegal black markets for kidneys work badly...

From Gizmodo:
Should You Be Allowed to Sell Your Kidney?

Gabe Danovitch, a distinguished transplant nephrologist and an active opponent of compensation for donors, is quoted saying this about markets:
"Any attempt at so-called regulating… a market, by definition, is not regulated. Markets don’t like regulations. Let’s say we were to allow a regulated market, and a donor would get $30,000. I’m just throwing this out. Why wouldn’t Singapore say you can get 50? In Doha you can get 80? And why wouldn’t the donors go around the world to get the best price? If we were to do that in the United States, it would be a disaster."

This argument strikes me as strange: is the problem with compensating donors  that it might open up competition for American transplant centers??

Danovitch also makes an argument that, as a nephrologist who evaluates potential donors, he couldn't trust them as much if they were getting paid.
**************

On a related matter, this from the LA Times
'Kidney for sale': Iran has a legal market for the organs, but the system doesn't always work

The Iranian kidney market--Associated Press

The Associated Press has a nice story on the Iranian market in which donors can be compensated for kidneys. Here's the version in the Denver Post

In Iran, unique system allows payments for kidney donors

Some interesting paragraphs:

"Iran started kidney transplants in 1967 but surgeries slowed after the 1979 Islamic Revolution and the storming of the U.S. Embassy in Tehran, in part due to sanctions. Iran allowed patients to travel abroad through much of the 1980s for transplants — including to America. But high costs, an ever-growing waiting list of patients and Iran’s grinding eight-year war with Iraq forced the country to abandon the travel-abroad program.

"In 1988, Iran created the program it has today. A person needing a kidney is referred to the Dialysis and Transplant Patients Association, which matches those needing a kidney with a potential healthy adult donor. The government pays for the surgeries, while the donor gets health coverage for at least a year and reduced rates on health insurance for years after that from government hospitals.

"Those who broker the connection receive no payment. They help negotiate whatever financial compensation the donor receives, usually the equivalent of $4,500. They also help determine when Iranian charities or wealthy individuals cover the costs for those who cannot afford to pay for a kidney.

"Today, more than 1,480 people receive a kidney transplant from a living donor in Iran each year, about 55 percent of the total of 2,700 transplants annually, according to government figures. Some 25,000 people undergo dialysis each year, but most don’t seek transplants because they suffer other major health problems or are too old.

"Some 8 to 10 percent of those who do apply are rejected due to poor health and other concerns. The average survival rate of those receiving a new kidney is between seven to 10 years, though some live longer, according to Iranian reports.
...

"Poverty around the world drives black market kidney sales, a lucrative business the World Health Organization estimated represented at least 5 percent of all transplants in 2005, though it acknowledges that figure is only a guess. The U.N. health agency’s guiding principles on organ transplantation call for banning organ sales, though it allows for “reimbursing reasonable and verifiable expenses,” including the loss of income by a living donor."

The ASSA / AEA meetings, preliminary program

This year's ASSA preliminary program is now online:  https://www.aeaweb.org/conference/2018/preliminary 
The AEA sessions were organized by President Elect Olivier Blanchard (and his program committee).  David Laibson will give the Ely lecture.

Here are two sessions that caught my eye from just the first page (of 11).

Thursday, Jan. 4, 2018   5:30 PM - 7:00 PM
 Marriott Philadelphia Downtown, Grand Ballroom Salon H
 Econometric Society Presidential Address

Drew Fudenberg, Massachusetts Institute of Technology 

Inner Workings of Organ Markets and Organ Allocation

Paper Session

• Chair: Eric Budish, University of Chicago

The Inner Workings of Kidney Exchange Markets

Nikhil Agarwal

,

Massachusetts Institute of Technology

Itai Ashlagi

,

Stanford University

Eduardo Azevedo

,

University of Pennsylvania

Clayton Featherstone

,

University of Pennsylvania

Omer Karaduman

,

Massachusetts Institute of Technology

Abstract

The market for kidney exchange was created to address the shortage of kidneys for donations. The market allows patients with a willing but incompatible live donor to swap donors, so that they can perform transplants, and has grown to about 800 transplants per year. This paper uses detailed administrative data to describe the functioning of this market. The most striking finding is that the market is fragmented into dozens of small platforms instead of working in a single large platform, with most transactions happening in platforms that operate within a single transplant center. This may lead to substantial inefficiency if there are increasing returns to scale to matching patients in a large, thick market.

A Regulated Market for Kidneys

Mohammad Akbarpour

,

Stanford University

Abstract

The persistent shortage of kidneys for transplantation is a global problem for end-stage renal disease (ESRD) patients. Many countries have tried to address this issue by increasing deceased donation, by introducing kidney exchange programs, and by optimizing the allocation algorithms. Despite such efforts, the problem of shortage is growing in most countries, with more than 100,000 people waiting for a kidney transplant only in the U.S. Iran is the only country in the world that has introduced a different program of living unrelated renal donation, which includes two kinds of monetary compensation of donors: a "gift for altruism" from the government to donors, as well as an additional compensation from the patients themselves. We will discuss the impacts of this program on waiting times, organ shortage, and its equilibrium effects on other kinds of live donation.

Strategic Behavior in the Kidney Waitlist

Nikhil Agarwal

,

Massachusetts Institute of Technology

Itai Ashlagi

,

Stanford University

Paulo J. Somaini

,

Stanford University

Abstract

A transplant can improve a patient's life while saving several hundred thousands of dollars of healthcare expenditures. Organs from deceased donors, like many other common pool resources (e.g. public housing, child-care slots, publicly funded long-term care), are rationed via a waitlist. The efficiency and equity properties of design choices such as penalties for refusing offers or object-type specific lists are not well understood and depend on agent preferences. This paper establishes an empirical framework for analyzing the trade-offs involved in waitlist design and applies it to study the allocation of deceased donor kidneys. We model the decision to accept an offer from a waiting list as an optimal stopping problem and use it to estimate the value of accepting various kidneys. Our estimated values for various kidneys is highly correlated with predicted patient outcomes as measured by life-years from transplantation (LYFT). While some types of donors are preferable for all patients (e.g. young donors), there is substantial heterogeneity in willingness to wait for good donors and also substantial match-specific heterogeneity in values (due to biological similarity). We find that the high willingness to wait for good donors without considering the effects of these decisions on others results in agents being too selective relative to socially optimal. This suggests that mild penalties for refusal (e.g. loss in priority) may improve efficiency. Similarly, the heterogeneity in willingness to wait for young, healthy donors suggests that separate queues by donor quality may increase efficiency by inducing sorting without significantly hurting assignments based on match-specific payoffs.

Discussant(s)

Utku Unver, Boston College

Glen Weyl, Microsoft Research

Benjamin R. Handel, University of California-Berkeley