More on the debate over kidney sales: transcript of interview

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

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

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


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


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

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

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

Michael Sandel on markets and economists

The Boston Review hosts a Forum on Michael Sandel's arguments against markets:

Forum:
How Markets Crowd Out Morals

Shout

Michael J. Sandel

Some economists think markets can benefit all spheres of human activity. But they’re wrong: markets can erode important goods and social norms.


Not only are there some things money can’t buy, but there are also many things it shouldn’t.

---

Responses

Richard Sennett

When the market is everywhere, we lead a socially impoverished existence.

Matt Welch

Because Sandel disagrees with people’s choices, he wants to take those choices away.

Anita L. Allen

Financial incentives are improperly used to induce African Americans to embrace “good” behaviors.

Debra Satz

Debating the place of the market is less about the value of goods than about inequality.

Herbert Gintis

Tolerance, equality, and democracy have only flourished in market societies.

Lew Daly

Making money, formerly an exclusive realm of cosmic evil, is now “doing God’s work.”

Samuel Bowles

Even market enthusiasts know that society can’t function if people are the amoral, self-interested calculators of blackboard economics.

Elizabeth Anderson

The profit motive is corrupting the justice system.

John Tomasi

Free markets are a kind of fairness.

Michael J. Sandel replies

By keeping markets in their place, we can avoid their corrosive effects.

---

Sandel lays out his views more fully than in the quote at the top of the page (if not always more clearly) in the lead essay of the forum: How Markets Crowd Out Morals, and in his reply to the commentators, some sympathetic and some less so. Bowles and Welch and Gintis all suggest that the level of the discussion could be raised by considering evidence, of various kinds.

See my earlier posts on Michael Sandel's views on markets.

Update: Nicholas Kristof weighs in in his May 30 NY Times column, citing some of the more lurid examples of things bought and sold.

Markets, broadly defined

I'm in Helsinki, participating in the second workshop of the Markets & Marketization program, that will bring together philosophers and philosophers of science with economists, sociologists, political scientists and others interested in markets very broadly defined.

Workshop II  Friday-Saturday, 7-8 January, 2011; Tentative program

Friday 7.1.

10.00 - 11.00 Alvin Roth (Harvard): "What does market design teach us about markets?"

11.10 - 11.30 Comment: Patrik Aspers

11.30 - 11.50 Comment: Emrah Aydinonat

11.50 - 12.30 Discussion

14.00 - 15.00 Ronald Noë: On biological markets (title TBA)

15.00 - 16.00 Risto Heiskala: "Coordination of human interaction: the BTCIEMP scheme"
(’BTCIEMP’ stands for: biology, traditions, cultural categorization, ideology, economy, military power and political power)

16.30 - 17.30 Jens Beckert: On the sociology of markets (title TBA)

Saturday 8.1.

10.00 - 11.00 Debra Satz (Stanford): The Moral Limits of Markets

11.10 - 11.30 Comment: Adrian Walsh

11.30 - 11.50 Comment: John O’Neill

11.50 - 12.30 Discussion

Kidneys: compensation and altruism

 Apropos of my debate with Debra Satz this afternoon, here are two articles about kidney donation, from pure altruism or with compensation, in the New York Times and in The Journal of Medicine and Philosophy.

In the NYT:

Let People Sell Their Kidneys. It Will Save Lives., By Dylan Walsh, April 2, 2024

"There are 100,000 people in the United States waiting for a kidney. More than half a million are on dialysis, which from my experience I know to be more of a means of survival than a form of living. ... The National Kidney Foundation estimates that without more investment in preventing diabetes and other ailments, more than one million people will be suffering from kidney failure by 2030, up from over 800,000 now.

...

"Creating a market for kidneys is not a new concept, but it’s historically been met with disgust: Sell what? To be fair, some of the ways to structure such a market would be irresponsible, coercive and deserving of that disgust.

"But others are more thoughtful and prudent. One approach is to make the federal government the sole purchaser of kidneys. Donor and recipient would never meet. Compensation would be fixed, haggling impossible. After the kidney is acquired, the transplant process would unfold in the typical manner."

#####

In The Journal of Medicine and Philosophy:

Semrau, Luke. "The Altruism Requirement as Moral Fiction." In The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine, p. jhae011. US: Oxford University Press, 2024.

"Abstract: It is widely agreed that living kidney donation is permitted but living kidney sales are not. Call this the Received View. One way to support the Received View is to appeal to a particular understanding of the conditions under which living kidney transplantation is permissible. It is often claimed that donors must act altruistically, without the expectation of payment and for the sake of another. Call this the Altruism Requirement. On the conventional interpretation, the Altruism Requirement is a moral fact. It states a legitimate constraint on permissible transplantation and is accepted on the basis of cogent argument. The present paper offers an alternative interpretation. I suggest the Altruism Requirement is a moral fiction—a kind of motivated falsehood. It is false that transplantation requires altruism. But the Requirement serves a purpose. Accepting it allows kidney donation but not kidney sale. It, in short, rationalizes the Received View."

Here's the concluding paragraph:

"I have argued that the Altruism Requirement is a moral fiction. No sound arguments demonstrate its truth. It continues to enjoy widespread endorsement on account of its perceived link to the Received View. It is taken as a means of allowing kidney donation but not kidney sale. Thus, it is unsurprising that, on examination, in ethical argument and in the practice of transplantation, it is, de facto, a No Payment Requirement."

Everything for Sale? The Ethics and Economics of Compensation for Body Parts, at Johns Hopkins, May 7

I'm in Baltimore for the next few days...

The Johns Hopkins Berman Institute of Bioethics
and the Johns Hopkins Carey Business School present
The 2015 Robert H. Levi Leadership Symposium
and Carey Symposium in Markets and Ethics

	Everything for Sale?The Ethics and Economics of Compensation for Body Parts
	Thursday, May 7, 2015 4:30 p.m. - 6:00 p.m.
	Reception to follow
	Johns Hopkins School of Nursing Alumni Auditorium 525 N. Wolfe Street Baltimore, MD 21205
	Welcome: Ruth Faden Andreas C. Dracopoulos, Director and Philip Franklin Wagley, Professor Johns Hopkins Berman Institute of Bioethics Bernard T. Ferrari Professor and Dean Johns Hopkins Carey Business School Introduction: Mario Macis Assistant Professor of Economics and Management Johns Hopkins Carey Business School Panelists include: Professor James Childress Professor Michele Goodwin Professor Alvin Roth Professor Debra Satz Moderator: Jeffrey Kahn Robert Henry Levi and Ryda Hecht Levi Professor of Bioethics and Public Policy Johns Hopkins Berman Institute of Bioethics