Iranian blog with ads for selling kidneys

Here's a website (in Persian) in which prospective kidney sellers advertise.

Google translate worked well enough to give me an idea of what the ads say; here are some of them translated by Afshin Nikzad...

The first line of each ad is bold, and has the following format:

Name (gender), Age, Blood type, Price.

Manizhe (female), 22, AB, $14.5K
single, athlete, bachelors in psychology.
Due to financial needs, I'm selling my kidney.

Massoume (female), 45, A+, negotiable price
Hello. I am a 45 year old woman, bachelors in business administration,
fluent in English, can work with computers, experience of work in a
real estate agency. I migrated from Tehran to a village in Mazandaran
6 month ago. I can't find any job fitting my work experience, and have
spent all my savings in the past 6 month. I am willing to sell an organ
(to save my dignity).
contact: 09376606455, http://zh32329292.blogfa.com

Sarah (female), 30, A+, negotiable price
urgent, urgent, urgent, urgent, urgent, urgent
I need to sell my kidney because I am in a lot of debts, and I am
broke [bankrupt].
Contact: 09385786869

unknown, 23, B+
I am in serious need of money, I am getting homeless; soon please.
please text your offered price. I really need money. Can travel to any
where, the buyer is responsible for all the expenses.
Contact: 09306890335

vahid (male), 28, A+, $20K
from Tehran. completely healthy. doesn't smoke or drink.
want to sell my kidney for financial problems.

Shahin (male), 24
Hello. I am in charge of the family since my father is ill. It has been
very difficult to go at work and study at the same time, I have quit
university since a few months ago. I'm really tired of this situation.
Please offer a fair price, cause I am in need; I am doing this cause I
see no other way.

? (female), 22, A+, negotiable price
Hello, I am a 22 year old woman, and I need to sell my kidney for my
college expenses. athlete. Can travel to any where in Iran. Price is
negotiable.
Contact: 09308665458.

Maryam (female), 25, AB+, $26K
healthy. need the money to pay debts.
The buyer is responsible for all other expenses.
contact: 09189978478

Amin (male), unknown, unknown, $8K
Hello. express sale. My child had eye-surgery and is in hospital right
now. I need to pay the expenses before the surgery. The price is $8K.
Sorry that I am writing like the dealers.
With best wishes for kidney patients.

Ali (male), 22, A+, negotiable price
For serious financial problems, and for my father's surgery, I need to
sell my kidney.
Contact: 09359818234

Amir (male), 41, A+
in urgent need to sell my kidney. I have two families and 8 children, I
am in debt because of my housing rents.
Contact: 09335751908

Milad (male), 19, O+, $40K
I have been under a lot of pressure in life, and it made me do such a
thing [selling his kidney] in this age. I hope no one would ever
experience a similar situation.
Very healthy. If you are determined to buy, the price is negotiable.
contact: 09337339240, http://miladmadise@yahoo.com

mojtaba (male), 31, O+, $8K.
very healthy.
Blood type: o+
Price: $8K"

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 kidney market in Iran: Russ Roberts interviews Tina Rosenberg (podcast)

This summer, Tina Rosenberg of the NY Times wrote about the Iranian kidney market, which I blogged about here:  Iran's market for kidneys in the NY Times

Now Russ Roberts at EconTalk has a podcast in which he interviews her:Tina Rosenberg on the Kidney Market in Iran

(He starts off by saying that in the podcast he did with me, I mentioned that there was a cash market in Iran, but he hadn't had time to follow up on that...)

Ms. Rosenberg spends some time talking about the fact that Iranian donors seem to feel stigmatized by selling a kidney, and prefer to remain anonymous, sometimes to the extent of not coming in for post surgical care, having given false contact information to the administrators involved.

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."

Cash for Kidneys: The Case for a Market for Organs. Becker and Elias in the WSJ

Gary Becker and Julio Elias have a reprise of their 2007 Journal of Economic Perspectives paper in this weekend's Wall Street Journal, in a cogent column called Cash for Kidneys: The Case for a Market for Organs.

Their 2007 JEP paper was called  Introducing Incentives in the Market for Live and Cadaveric Organ Donations (slightly more direct link here).

Between then and now the number of people on the waiting list for kidneys has gone up. Their 2007 article has these sentences: "Almost 17,000 persons were waiting for a kidney transplant in 1990. But this number grew rapidly, so that about 65,000 persons were on this waiting list by the beginning of 2006."

This weekend's WSJ column starts with the sentence "In 2012, 95,000 American men, women and children were on the waiting list for new kidneys, the most commonly transplanted organ."

So, the arguments that they repeat have gotten stronger over time: the shortage of organs is costly in every sense, and could likely be relieved by allowing kidneys to be bought and sold by live donors, and allowing the purchase of organs from deceased potential donors, i.e. by repealing the part of the 1984 National Organ Transplant Act that makes such sales a felony in the United States. (Similar laws exist in most of the developed world: the only country that seems to have an explicitly legal market for kidneys is Iran, although many black and grey markets exist.)

So, why hasn't this argument made any headway, either in the U.S. or overseas? Is patient repetition of the argument the best way to make the case? I don't know the answers, but I think that the repugnance of organ sales is a subject worth studying, not just for science but also for those who might like to influence policy.

In the same issue of the JEP as Becker and Elias (2007) was my article Repugnance as a Constraint on Markets (more direct link here), which sought to understand not just the repugnance to kidney sales, but to many economic transactions, in different places and times, e.g. to charging interest on loans, or having markets for slaves or indentured servants. I noted that kidney exchange doesn't arouse the repugnance that sales do. I've since blogged about a lot of different repugnant transactions including compensation for donors (as of this writing my most recent post on transactions that some regard with repugnance is headlined Womb transplants in Sweden (where surrogacy is illegal)...)

Note that the prohibition on organ sales is not some law that remains on the books merely through inattention. This is illustrated by the recent events surrounding the tug of war over whether it might be legal to compensate (even) bone marrow donors. Briefly, the ninth circuit court of appeals issued a ruling that said that in some circumstances bone marrow donors could be compensated, but then the Department of Health and Human Services proposed regulations that would keep the ban in place.   So the opposition to organ sales--even to compensating bone marrow donors--is alive and well.

But things don't go all in one direction. Bob Slonim reminds me that while we rely on unpaid donation of whole blood in the United States, most of our supply of blood plasma comes from paid donors.

I've participated in some efforts to understand better the repugnance to compensating organ donors, e.g. here's a survey with Steve Leider about who disapproves of kidney sales, and some correlates of such disapproval:
Leider, Stephen and Alvin E. Roth, ''Kidneys for sale: Who disapproves, and why? American Journal of Transplantation  10 (May), 2010, 1221-1227.

More recently, Muriel Niederle and I conducted a different sort of survey, which assessed the relative willingness of Americans to contemplate monetary rewards for the heroism associated with kidney donation:
"Niederle, Muriel and Alvin E. Roth, “Philanthropically Funded Heroism Awards for Kidney Donors?” forthcoming in Law & Contemporary Problems, 77:3, 2014.

Judd Kessler and I have a paper forthcoming in the American Economic Review papers and proceedings (May 2014) called "Getting More Organs for Transplantation," in which we summarize the issue this way:

"Kidney sales are often the leading example of a repugnant transaction cited by those who would put stricter limits on markets in general (e.g. Sandel 2012, 2013), because of their sense that such sales arouse widespread opposition. A representative sample survey of Americans conducted by Leider and Roth (2010) suggests that disapproval of kidney sales correlates with other socially conservative attitudes, but that it does not rise to the level of disapproval of other repugnant transactions such as prostitution. In addition, there is evidence that the manner of the payment to an organ donor may mitigate some of the repugnance concerns. Niederle and Roth (forthcoming 2014) find that payments to non-directed kidney donors are deemed more acceptable when they arise as a reward for heroism and public service than when they are viewed as a payment for kidneys."

That paper closes with this thought on the presently available options: 
"While these potential donors could save thousands of additional lives, at current rates of medical need, these donors alone would not be able to supply all the demand. Consequently, we must continue working on numerous fronts to solve this growing problem. "

In summary, the issue of whether and how organ donors might be compensated is an important policy issue that also touches on an important and still poorly understood social science phenomenon. Repetition of the basic arguments may move the discussion forward as the background facts become more severe, and it's great to see the issue addressed in such a public forum as the WSJ. But it may also be that repetition of arguments is not enough. To make progress in the face of opposition, it seems likely to be useful to understand better the nature of the opposition.

A skeptical view of the Iranian market for kidneys, from Shiraz

Here's an article (gated) from a recent issue of Transplantation, describing how the transplant program in Shiraz is discouraging patients from the (legal) market there for buying kidneys from living unrelated donors (they impose a six month waiting time for such transplants). Most patients who have transplants at Shiraz are receiving deceased donor kidneys.

Transplantation:

June 2016 - Volume 100 - Issue 6 - p 1165–1169

doi: 10.1097/TP.0000000000001164

In View: Around the World

Paid Living Donation and Growth of Deceased Donor Programs

Ghahramani, Nasrollah MD

Abstract

Abstract: Limited organ availability in all countries has stimulated discussion about incentives to increase donation. Since 1988, Iran has operated the only government-sponsored paid living donor (LD) kidney transplant program. This article reviews aspects of the Living Unrelated Donor program and development of deceased donation in Iran. Available evidence indicates that in the partially regulated Iranian Model, the direct negotiation between donors and recipients fosters direct monetary relationship with no safeguards against mutual exploitation. Brokers, the black market and transplant tourism exist, and the waiting list has not been eliminated. Through comparison between the large deceased donor program in Shiraz and other centers in Iran, this article explores the association between paid donation and the development of a deceased donor program. Shiraz progressively eliminated paid donor transplants such that by 2011, 85% of kidney transplants in Shiraz compared with 27% across the rest of Iran's other centers were from deceased donors. Among 26 centers, Shiraz undertakes the largest number of deceased donor kidney transplants, most liver transplants, and all pancreas transplants. In conclusion, although many patients with end stage renal disease have received transplants through the paid living donation, the Iranian Model now has serious flaws and is potentially inhibiting substantial growth in deceased donor organ transplants in Iran.

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."

********

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."

Should there be a donor kidney market? Latest version of a familiar debate

The Los Angeles Times published a short debate between two familiar interlocuters, Ben Hippen and Frank Delmonico: Pro/con The consequences of a donor kidney market

"With a waiting list for a kidney at almost 83,000 Americans, the push to offer cash and other incentives grows. Two experts offer their opposing views on a donor kidney market."

"People who need kidneys are dying unnecessarily, and an organ market would save lives."
Dr. Benjamin Hippen is a transplant nephrologist at the Carolinas Medical Center in Charlotte, N.C.
"The most compelling reason for setting up a market for organs is that there really isn't any other plausible solution to the growing disparity between the demand for and supply of organs. Even if we were to maximize organ procurement from deceased donors, we still couldn't meet the demand.

"As that demand grows, it's not just potential kidney recipients who get desperate — it's also potential donors, who often have a close-up view of what their loved ones are going through. We then see people with health problems, like high blood pressure or obesity, say that they're willing to take on a certain amount of risk so that their loved one can live a better life.

"A regulated market would be, in some sense, safer — the pressure would be taken off folks who want to be donors but perhaps shouldn't be for medical reasons. Transplant professionals could then select the healthiest donors, who are at the lowest risk for long-term complications. With a regulated market, we could say to high risk-donor candidates, "No, you shouldn't be a donor, and your loved one isn't going to suffer as a consequence of that decision."

"There's also a significant difference between what it costs to maintain a transplant versus what it costs to maintain someone on dialysis. In 2007, $28 billion was spent nationally on people on dialysis; about $2.2 billion was allocated to kidney transplantation. So transplants are vastly more cost-effective, and in general they confer a longer survival benefit. Also, a larger proportion of people are able to go back to work compared with people on dialysis.

"The unregulated, underground black market in organs in developing countries has been catastrophic for both donors and recipients. But the reason that someone who is desperately poor may be able to sell their kidney on the black market is that people in countries of comparative wealth have failed to solve their own supply problem. That is a policy failure. If the demand for organs could be met through legal, ethical strategies, some of the driving forces that support black markets would disappear.

"If, indeed, the current system isn't meeting demand, then there's a sense in which it's unethical not to establish regulated incentives for living donors or to think more carefully about not doing so. The cost is being paid by the people who are dying on the waiting list, getting sicker on dialysis or selling their kidneys under terrible circumstances."

"An organ market would exploit the world's poor and set the precedent for medical transplant tourism that puts everyone at risk."
Dr. Francis Delmonico is the director of renal transplantation at Massachusetts General Hospital and a professor of surgery at Harvard Medical School. He is also the medical director of the New England Organ Bank in Newton, Mass.

"Despite the good intentions of those who would suggest that an organ market could be regulated, it's impossible to do so. A market for organ sales enables brokers and extra payments, and in a global society, the market could not be restricted to the United States.

"Right now, our country sets the tone on this issue. Once we say it's OK to have a market here, it condones markets everywhere else in the world, and with medical tourism being what it is, those in search of kidneys will go to the place where it's the cheapest price — Americans won't be limited to undergoing transplants locally.

"From there, transplant tourism in global markets brings unanticipated consequences. It increases the risk for diseases like hepatitis, tuberculosis or malignancy, and it also opens the door to a variety of unethical practices involving the donor and their medical care.

"The central problem of organ sales is that it's a victimization and exploitation of poor people, notwithstanding good intention. The source of these organs is always the lowest socioeconomic class of a particular country — we know that has been the case in the Philippines, in Pakistan, in Egypt and in Iran. And the payment isn't that substantial of an amount, so rather than making them better off or helping them, the money is quickly used, and the donor is left with one less kidney. It's a reality that there's no escaping.

"It's true that there has been a plateau of living donors in this country, and something has to be done. For that reason, I do believe in eliminating disincentives for donors. The living donor who doesn't have health insurance should have it — and even life insurance — provided for them, as it pertains to the donation event."

HT: Ted Roth

One surgeon's argument against compensating organ donors, but for removing financial disincentives

Here's another addition to the discussion of how and whether to incentivize live kidney donation, and/or remove financial disincentives to donating, by the medical director of Kidney and Pancreas Transplantation at New York Presbyterian Hospital/Columbia University Medical Center,


Cash for human kidneys: A bad idea is back, By David Jonathan Cohen, MD

Here's the part of his argument--about how incentives in a poorly regulated market could introduce lower quality kidneys from less medically qualified donors--that may be less familiar to readers of the "compensation for donors" posts on this blog. My comments follow...

"I’ve arrived at this position based on my three decades of experience as the medical director of one of the largest kidney transplant programs in the United States, performing more than 100 live donor transplants every year. In this role, as I examine potential live kidney donors, I have seen first-hand how far people will go to try to help loved ones. Many unsuitable donors try to persuade me to allow them to donate anyway, despite high medical risks. Others take steps even more extreme—and dangerous. Consider the 37-year-old woman who, without telling me, stopped her anti-depressants knowing that a history of depression might make her ineligible to donate to her friend. Or the 51-year-old cocaine addict who wanted to help her brother and forged a letter from her physician stating that the cocaine was treatment for a nasal condition. Had we not uncovered this, the outcome for donor and recipient would likely have been disastrous. 

Some go to other transplant centers and change their stories or covertly take medications to normalize their blood pressure or blood sugar in hopes of passing the evaluation, putting their own health at risk and potentially leading to the donation of unsuitable kidneys. 

Now imagine if there were a significant financial reward at stake, increasing the incentives to lie or dissemble. Many would surely do their best to disguise any medical conditions that might prevent them from donating in order to collect the reward, thereby adding to their own medical problems and potentially donating kidneys of lesser quality and thus harming the recipients. After all, they would now be donating to a stranger in order to enrich themselves or to address an urgent financial need, not to save a loved one. 

Doctors, too, would be confronted with terrible dilemmas. Take the potential donor who desperately needs cash or cash equivalent to prevent foreclosure on a home, pay for education for their children, or keep their business open. What is the responsible caring physician to do? It’s easy to say that this would not factor into a medical decision, but doctors are human. It’s hard to see how such considerations could be entirely avoided. " 

******************
This is just a small piece of the longer post, so take a look yourself.

I follow this whole debate closely, and I'm struck by how arguments about many aspects (both pro and con, or con and pro, depending on where you stand) are hampered by the lack of data. So arguments are theoretical, and it seems to me that many of the arguments used with confidence to support one conclusion could equally support the opposite.

Here, Dr Cohen notes the desperation which motivates the "many unsuitable donors" who would like to give a kidney to a loved one to conceal aspects of their medical history (so that they can donate anyway). He argues that would only get worse if kidneys could be purchased. (Just to fix ideas, let's suppose that kidneys could only be purchased by the Federal government, that they would be distributed as deceased donor kidneys now are--i.e. without too much regard to ability to pay--and that there would be stringent health checks before donation--and followup after.)  In such an environment, one could imagine that the need for potential donors to mis-represent their medical history would decrease, rather than increase, if, in this hypothetical world with payments, their loved ones would get transplants through the national system. (To be clear, I am also speaking here without data, since outside of Iran there aren't any legal markets for kidneys, and the Iranian market doesn't work at all like the hypothetical I've just described...)

Speaking of Iran, the same kind of argument-that-could-support-opposite-positions is made with respect to whether large monetary payments might 'coerce' unwilling or unsuitable donors to sell their kidneys. That's an interesting question, but Iranian surgeons have sensibly pointed out that there can be coercion without money: if your mom thinks you should give a kidney to your brother you might be coerced, and that kind of coercion might be decreased if kidneys were more available through e.g. a national market.

So...speaking as an experimental economist and market designer who has watched the waiting list for kidneys grow and grow (see my post on kidney statistics)...I'm increasingly inclined towards allowing the States to experiment cautiously with increasing incentives and removing disincentives to donation...

The market for kidneys in Iran

The Iranian economist Farshad Fatemi at the Sharif University of Technology sent me this link to his very interesting working paper The Regulated Market for Kidneys in Iran.

Among other things, it is full of institutional detail and comparisons. Here are a few things that caught my eye.

Comparing total (live plus deceased) kidney donation across countries, per million population, the most recent figures (from 2007) are Iran 27.1%; UK 33.5%; Spain 49.5%; US 54.7%. (His source is the Barcelona-based Transplant Procurement Management Organization, whose international database I have yet to fully explore.)

His description of the market for kidneys in Iran includes the following

"After the donor passes the initial tests, the administrators contact the first patient in the same waiting list as the donor’s blood type [and other components of a match]...
If the patient who is on the top of the waiting list at the moment is not ready for the transplant ..., the next patient will be called... until a ready patient will be found. Then a meeting between the two parties is arranged (they are provided with a private area within the foundation building if they want to reach a private agreement) and they will be sent for tissue tests. If the tissue test gives the favourable result, a contract between the patient and the donor will be signed and they will be provided with a list of the transplant centres and doctors who perform surgery.
When the patient and the donor are referred to transplant centre, a cheque from the patient will be kept at the centre to be paid to the donor after the transplant takes place. The guide price has been 25m Rials (≈ $2660) until March 2007 for 3 years and at this time18 it has been raised to 30m Rials (≈ $3190). This decision has been made because the foundation was worried of a decreasing trend in number of donors.

"In some cases, the recipient will agree to make an additional payment to the donor outside the system; it is not certain how common this practice is, but according to the foundation staff the amount of this payment is not usually big and is thought to be about 5m to 10m Rials (≈ $530 to $1060). The recipient also pays for the cost of tests, two operations, after surgery cares, and other associated costs (like accommodation and travel costs if the patient travels from another city). Insurance companies cover the medical costs of the transplant and the operations are also performed free of charge in state-owned hospitals.
"In addition, the government pays a monetary gift to the donor for appreciation of her altruism (currently, 10m Rials), as well as automatic provision of one year free health insurance, and the opportunity to attend the annual appreciation event dedicated to donors...
"The minimum monthly legal wage for 2007 was Rials 1,830k (later raised to 2,200k for 2008). The minimum payment of Rials 45m is around 2 years of minimum wage. "
...
"[T]o prevent international kidney trade, the donor and recipient are required to have the same nationality. That means an Afghan patient, who is referred to the foundation, should wait until an Afghan donor with appropriate characteristics turns up. This is to avoid transplant tourism. "
...
"the donors are mostly men (Table 7). This can be because of the two facts. Firstly, the ages between 22 and 35; when the donation is accepted; is the fertility age; and women are less likely to be considered as potential donors. Secondly, as we mentioned before since men are supposed as the main breadwinner of the family, it is more likely that they sell their kidneys in order to overcome financial difficulties. Female donors count for around 18% of traded kidneys in our data; it is in contrary with the Indian case where 71% of the sold kidneys were from female donors (Goyal et al. 2002)."

In his sample of 598 transplants (Table 6), 539 were "traded kidneys," 10 "non-traded" and 49 "Cadaver", i.e. the vast majority of kidney transplants were live donor transplants with compensation to the donor.

In defense of pilot studies for organ donor incentives

The third in the series of forthcoming AJT papers about incentives/disincentives for donation discusses the basis for pilot studies (see earlier posts 1 and 2)

Between Scylla and Charybdis: Charting an Ethical Course for Research Into Financial Incentives for Living Kidney Donation
J. S. Fisher1, Z. Butt, J. Friedewald, S. Fry-Revere, J. Hanneman, M. L. Henderson, K. Ladin, H. Mysel, L. Preczewski, L. A. Sherman, C. Thiessen andE. J. Gordon*
Article first published online: 31 MAR 2015
DOI: 10.1111/ajt.13234

"The transplant community appears to be in a state of equipoise regarding the ethical soundness of empirically investigating a regulated system of financial incentives for living kidney donation. ...Proponents of financial incentives for nondirected living donors posit that incentives would increase the supply of high quality organs, prolong quantity, improve quality of life of recipients, and offset the societal cost by reducing the patient population receiving dialysis [10, 11]. Opponents argue that financial compensation beyond recovering expenses would: (1) cause undue pressure to donate, (2) exploit at-risk individuals (such as the poor), (3) commodify the human body, (4) exacerbate disparities in access to transplants between different socioeconomic strata, and (5) negatively impact public opinion and potentially lead to decreased organ donation rates [12, 13]. However, the debate over the intended and unintended effects of a federally regulated system of financial incentives in the United States remains unresolved partly due to a lack of empirical data.

Critics commonly turn to national programs outside the United States (e.g. India, China, Philippines, Eastern Europe) where black market incentives are the rule to justify concerns that financial incentives are exploitative of living donors. We do not disagree that paying donors illegally is exploitive. Other countries like Israel, Saudi Arabia, Iran, Singapore, and Ireland, however, have implemented legal compensation policies that assist living kidney donors to varying degrees and with varying success. However, these programs developed organically without extensive transparency or oversight, rather than as part of a prospective study designed with embedded outcome measures. Thus, it is unclear whether the successes of such policies are translatable to the US context given the differences in our governmental, medical, and societal infrastructures. Until rigorous, relevant data are properly collected, there is no way to determine whether concerns are warranted about potentially adverse effects of financial incentives on patient safety, exploitation, autonomy, and public trust as part of a US federally regulated system.

Members from several academic and professional organizations have called for pilot studies to investigate the provision of financial incentives to eligible living kidney donors to increase donation rates [14-17]. Logistical parameters for such studies have been suggested [18, 19]. However, while proposals for pilot studies commonly advance arguments for financial incentives, they have not systematically addressed the ethical concerns raised by opponents of a pilot study. This paper provides an ethical justification for conducting a pilot trial to study the feasibility and impact of a federally regulated system utilizing financial incentives on living kidney donation rates.''
...
in conclusion...
"the first step to resolve equipoise will require one or more carefully designed pilot studies to assess individual perceptions to determine if a course can be charted between exploitation and undue influence. Only such pilot studies can inform the transplant community as to whether larger, randomized controlled trials may be ethically undertaken to determine if ultimately, a federally regulated financial incentives program could feasibly and effectively increase living kidney donation rates without living donors incurring perceptions of negative psychological experience or generating negative public reaction.

First kidney exchange in South Africa

South Africa's Daily Maverick has the story:
Saving lives: South Africa joins paired kidney exchange revolution, ANDREA TEAGLE  SOUTH AFRICA 06 AUG 2015

"On March 6, 2015, South Africa’s first kidney exchange took place at the Donald Gordon Medical Centre in Johannesburg. After having been kept alive by dialysis for years, 24-year-old Vivek [not his real name] and 60-year-old Allison Stevenson were both given a new lease on life.
...
"This was South Africa’s first paired kidney exchange. And it happened almost by chance.
“This youngster in Port Elizabeth – his mother was so anxious about him, she phoned the transplant centre in Johannesburg … It was like the next week that I phoned up.” Stevenson recalls, “And there, Belinda (a transplant coordinator), had this file on her desk, where the aunt didn’t match the nephew. It just so happened that she matched me, and Sally matched Vivek.”
...
"South Africa relies primarily on deceased kidney donations. Of the 4,300 people on the waiting list for life saving, most are waiting for a kidney. There is only a small hope of getting one: just 0.2% of the population are registered as organ donors. And a host of medical requirements need to be satisfied for a match. The waiting list is like a mile long tightrope to life and many people never make it across.
...
"This is an example of what economists call a mismatched market. And for at least one economist, Stanford Professor Alvin Roth, it posed an exciting challenge. Roth and his colleagues were able to apply a model to the problem they had initially built out of mathematical curiosity. In 2012, this work won him a joint Nobel Prize in Economics.
Roth’s matching program builds little bridges between supply and demand. The simplest case is a two-way exchange like Stevenson’s. By decoupling the donors from their intended (but incompatible) recipients, and recoupling them with compatible ones, long chains of transplants can take place that otherwise would have been impossible.
...
"In South Africa this type of optimised matching is but a dream.
The National Health Act allows for living donors to donate to a blood relative or a spouse. If the donor is not a relative, he or she must apply for special permission from the Department of Health. In South Africa – as in every other country in the world with the exception of Iran – the sale of organs is illegal.
The hesitancy to implement paired matching, although the law does not in fact prohibit it, is likely partly due to fear of abuses through monetary exchange. (It is, however, lawful for the donor to be reimbursed for “reasonable costs” associated with the transplant.)
However, Stevenson’s case shows that paired exchanges can be subjected to the same careful scrutiny as direct donations. Only after establishing that neither donor had been coerced, misled or financially incentivised, did the Department of Health give the go-ahead. Further, the pairs were not allowed to meet or communicate prior to the operation, so Stevenson has never met her actual donor.
...
"The successful matching is an important step towards overcoming what surgeon Francis Delmonico, who was involved in the original matching program in the US, described as “the frustration of a biological obstacle to transplantation”. However, without a registry of living donors, finding a paired match will require hours of effort, and many will not be as lucky as Stevenson."

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

Kidney sales and trafficking

There have been a number of recent stories about criminal organ-trafficking rings around the world.  Here's a long quote from the one that seems most credible, from Bloomberg (in which Frank Delmonico is among those quoted), followed by links to two related stories.

Organ Gangs Force Poor to Sell Kidneys for Desperate Israelis
"Aliaksei Yafimau shudders at the memory of the burly thug who threatened to kill his relatives. Yafimau, who installs satellite television systems in Babrujsk, Belarus, answered an advertisement in 2010 offering easy money to anyone willing to sell a kidney.

He saw it as a step toward getting out of poverty. Instead, Yafimau, 30, was thrust into a dark journey around the globe that had him, at one point, locked in a hotel room for a month in Quito, Ecuador, waiting for surgeons to cut out an organ, Bloomberg Markets magazine reports in its December issue.

...

"Organ trafficking is on the rise, as desperate people seek transplants in a world that doesn’t have enough donors. About 5,000 people sell organs on the black market each year, according to Francis Delmonico, an adviser on transplants to the World Health Organization.

It’s against the law to buy or sell an organ in every country except Iran, says Delmonico, who is president-elect of the Montreal-basedTransplantation Society, which lobbies governments to crack down on illicit procedures.

‘Exploit Shortages’

“There have been successes fighting organ trafficking around the world,” Delmonico says. “But organ trafficking continues to flourish because criminals exploit shortages of organ donors.”

Bloomberg Markets reported in June that U.S. citizens and others from the Americas suffering from kidney failure were going to Nicaragua and Peru to buy organs in a shadowy trade that injured and killed donors and recipients.

That U.S.-Latin American connection is dwarfed by a network of organ-trafficking organizations whose reach extends from former Soviet Republics such as Azerbaijan, Belarus and Moldova to Brazil, the Philippines, South Africa and beyond, a Bloomberg Markets investigation shows.

Many of the black-market kidneys harvested by these gangs are destined for people who live in Israel.

...

"Delmonico, a professor of surgery at Harvard Medical School, has spent the past six years lobbying governments and doctors around the world to combat organ trafficking. He says Israel’s government is cracking down.

The Knesset, Israel’s legislative body, passed the Organ Transplant Law in 2008, setting penalties, including imprisonment of up to three years, for buying and selling organs and requiring hospitals to scrutinize transplants by nonrelatives and foreigners.

Breaking up Gangs

In an effort to draw more legal organ donors, the law also offers volunteers compensation for lost wages and travel expense and provides them with additional health insurance. Israeli police have been among the most aggressive in the world against organ traffickers, breaking up three international gangs since 2008.

The government has also banned insurers from funding most transplants outside Israel.

The dearth of available organs in Israel has spawned a new class of criminals, mainly immigrants from the former Soviet Union, says Jerusalem Police Superintendent Gilad Bahat.

Investigators on five continents say they have uncovered intertwining criminal rings run by Israelis and eastern Europeans that move people across borders -- sometimes against their will -- to sell a kidney.

“The criminal here is the middleman who profits from the sick and the poor,” says Bahat, who investigated an organ- trafficking ring in Jerusalem. “It touches my heart that people will sell part of their body because they need money to live.”

...

"The Brazilian case is still wending its way through international courts. In November 2010 in Durban, Netcare Ltd. (NTC) -- South Africa’s largest hospital company -- pleaded guilty to violating the Human Tissue Act, which prohibits buying and selling organs.

Netcare paid 7.8 million rand ($848,464) in fines and penalties. It admitted to allowing 92 transplants in which donors from Brazil, Israel and Romania sold kidneys to Israeli patients. Four doctors are awaiting trial on trafficking charges.

In Brazil, 12 people connected to the Netcare case were convicted and jailed, with sentences from 15 months to 11 years.

In Kosovo, Ratel, who has dual citizenship in Canada and Great Britain and was appointed by the European Union to help restore the country’s criminal justice system, is overseeing a pivotal organ-trafficking case. It includes participants and victims from Belarus, Moldova, Turkey and four other countries.

Center for Trafficking

The EU has administered the courts in Kosovo since 2008, the year the country the size ofConnecticut declared independence from Serbia after a civil war. Ratel, who arrived in March 2010 as part of the European Union Rule of Law Mission in Kosovo, says the country has become a center for organ trafficking.

Ratel built a case against nine doctors, hospital administrators and recruiters on charges of buying and selling kidneys for patients in Georgia, Germany, Israel, Poland and Ukraine, as well as Canada and the United States.

...

"“This is organized crime,” Ratel says. “There is significant coercion and threats of violence.”

Organ traffickers search the world for hospitals willing to perform illicit transplants. Sometimes, sellers are flown to cities just to wait for procedures, and then traffickers move them to other parts of the globe when they find a recipient and a hospital willing to cooperate.

While the illegal organ trade may be run by seasoned criminals, it depends on the complicity of doctors and hospitals, says Oleg Liashko, a member of Ukraine’s parliament.

“I doubt this could happen without the hospital and doctors knowing about it,” says Liashko, who has investigated organ trafficking and is calling for more-severe criminal penalties in organ transplant laws. “They either know or look the other way because of the money involved. This is corruption, pure and simple.”

********

Here's a story that follows up on the U.S. side: Kidney Broker Said to Use Johns Hopkins in Organ-Traffic Case
********

And here's a graphic (but probably less credible) story from Egypt: Refugees face organ theft in the Sinai