I post market design related news and items about repugnant markets. See my Stanford profile. I have a 2026 book : Moral Economics The subtitle is "From Prostitution to Organ Sales, What Controversial Transactions Reveal About How Markets Work."
A child receiving medical aid in dying clearly arouses more repugnance than when an adult accesses MAID. But surely that isn't because we think that a child dying in agony can tolerate it better than an adult. Difficult cases should make everyone think more clearly about their positions.
" A doctor in the Netherlands assisted in the death of a terminally ill child aged between 1 and 12 for the first time, a Dutch minister told lawmakers.
"Sophie Hermans, the minister of health, welfare and sport, disclosed the death in a letter this week to the Dutch House of Representatives. Assistance in death for children in this age range has been legal under certain rules since 2024.
"She wrote that it had been reported late last year to an expert committee that reviews such cases, and was its first notification for a child between 1 and 12.
"Ms. Hermans’s letter referred to “a termination of life” without giving specifics.
...
"In 2020, the Dutch government announced plans to allow doctors to end the lives of terminally ill children who are under 13 years old. Hugo de Jonge, the health minister at the time, predicted that the rule — which went into effect in 2024 — would facilitate the deaths of about five children a year. " Before the rule change, the country already allowed doctors to assist the deaths of people who are over 12 or less than a year old as long as their parents had consented.
...
"In Colombia, assisted death is allowed for children between the ages of 6 and 12, so long as the child understands the concept of death. Belgium also allows children to die with the help of a doctor."
The moral philosophers Peter Singer & Kasia de Lazari Radek interviewed me about Moral Economics on their podcast Lives Well Lived. At the end, they ask their guests to think about their own life, and to what extent their own life has been well lived. That's a bit like being asked what you would like to have inscribed on your tombstone. So I hedged a bit. But the conversation that followed was interesting, so if you scroll down you'll see the transcript of that last bit, which starts about minute 1:09 in the recording.
Jun 25, 2026 "Nobel Prize-winning economist Alvin Roth explains how innovative market designs can reduce exploitation and save lives. Drawing on his pioneering work in kidney exchanges, Roth explores some of society’s most contentious moral dilemmas involving organ markets, surrogacy, and unpacks the ethical tensions surrounding what he calls “repugnant transactions.”
"Lives Well Lived is hosted by Peter Singer & Kasia de Lazari Radek. Episodes consist of interviews with remarkable guests who have lived well, both in the sense of living an ethical life, but also in that they are fulfilled and happy with what they have achieved in their lives. Some of these guests will be well-known figures, but others who are doing extraordinary things will be unfamiliar to almost all of our listeners. The conversations will often cover ground that involves ethics, how to live well, and how to make a positive difference in the world. It will inspire and empower its audience to change their own lives for the better. "
Here's the transcript of the last few minutes of the conversation (starting around minute 1:09 of the recording).
PETER: We always asked our guests to think about their own life, and to what extent their own life has been well lived, and by what criteria they make that judgment? Would you like to comment on that, Al?
Al: Sure. Has my life been well lived so far? Well, first, I've had a very fortunate life so far. I am lucky in my family, and my children, and my grandchildren, and my friends. And when you talk about friends, one thing that's often not talked about are the relations that professors have with students. So I've made lifelong friendships with many students who are productively engaged around the world, and that's very gratifying, and I hope it helps make my life worthwhile.
But also, I'm a market designer, and market design is very outward facing part of, economics. And, one of its goals is, a phrase even older than effective altruism, which is tikkun olam (תִּיקּוּן עוֹלָם) mending the world. And one of the things that market designers try to do is fix markets when they're broken or create them when they're absent. When you think of something like kidney exchange, you know, in a different podcast, on a different subject, I could tell you about victory after victory, where thousands, many thousands of transplants have been done, and lives have been saved through kidney exchange, even though it's in a war that we're losing: the shortage of kidneys is growing faster than the increase in transplants as diabetes grows, and high blood pressure, things like that. So, I would hope that some of my life has looked well lived, not just from the inside, but perhaps also from the outside.
Peter: Absolutely sure that it has. You're right. And what you've done for kidney markets is just one example, where you've saved many lives, and I think that obviously would be an important part of living well. despite the fact that the problem, as you say, has not been solved as a whole.
Kasia: It must be very satisfying.
Al: People often say that to me, and it will be satisfying when I'm retired. Right now, it's still frustrating, right? There's so much left to do, and it's not so easy to do it. But the times are changing. In two weeks, I'm gonna be opening up the American Transplant Conference in Boston, and, you know, there are people who invite me to these things. I sometimes joke with my young colleagues that as the old people who feel a lot of repugnance die off, it'll be left to just us young people. And we'll see.
I was in a transplant conference in Cairo in November. in which we tried to reach consensus on the question of, should countries have to be self sufficient in transplantation, which is the traditional position of the World Health Organization and some other organizations. And, of course, it works against countries that don't have much kidney exchange, because you need a big pool of patient-donor pairs to find lots of exchanges. And in that spirit, incidentally, during COVID, I was in the United Arab Emirates for the first kidney exchange between the UAE and Israel. And, that had to overcome a lot of obstacles, but it makes a lot of sense, because the UAE and Israel each have only a population of about 10 million. And that's not enough to find kidneys in your domestic pool for the hard to match patients, for patients who have a lot of antibodies to human proteins. So, we would like to see much more cooperation and not just between rich countries, but also inviting patients from poor countries, patient-donor pairs, to take part in American kidney exchange. And that's something that remains very controversial, but I think that we might be on the verge of making some progress with that. That's something that Peter has written about also.
Peter: Yes, I certainly hope so, and because I'm now working as a regular visiting professor in Singapore, which is another small country, the population of about 6 million, there's a very good case for saying that Singapore should also get into international kidney exchanges, and perhaps assist some of the poorer countries in its region. So we're trying to make that argument, and let's hope we succeed. One thing I've tell you, there might be bad news. I don't believe that when you retire from Stanford, you're going to stop working on these issues and be able to relax and feel satisfied, because I know I retired from Princeton 2 years ago, but the issues that I'm concerned about, whether it's the factory farming or global poverty, or all these kidney issues as well, I'm still concerned about, I can't let them go just because I'm no longer paid to be a professor at Princeton.
#########
In terms of lives lived well and deeply, here's an earlier post of mine about teachers and students.
Here's a new report from Italy on initiating kidney exchange chains with a deceased donor.* In Italy to date, 34 deceased donor initiated chains generated 84 transplants (34 from deceased donors and 50 from living donors), including 56 among incompatible pairs and 28 to candidates on the waitlist.
"Integrating deceased and living donation through deceased-donor (DD)-initiated chains can expand kidney transplant access in small paired exchange pools. The Italian DEC-K program allocates a DD kidney to initiate a chain (chain-initiating kidney, CIK) among incompatible living-donor (LD) pairs, ultimately returning a LD kidney to the national waiting list (WL). We report the first long-term national results of this donor organ allocation model.
"Methods: All DEC-K chains performed in Italy (2018-2025) were retrospectively analyzed. Recipients were stratified by kidney source (CIK vs LD).
... "Results: Thirty-four DEC-K chains generated 84 transplants (34 DD and 50 LD), including 56 among incompatible pairs and 28 to candidates on the WL. Donor withdrawal occurred once. Four chains were terminated early after CIK transplantation due to newly developed contraindications to donation. At a median follow-up of 60 months, 1- and 3-year graft survival was 100% in both groups, while patient survival was 97.1% for CIK and 98.0% for LD. Three CIK and one LD recipients died with functioning graft (suicide, sepsis, urothelial carcinoma, and acute myocardial infarction, respectively). One CIK recipient experienced graft loss after 40 months due to chronic rejection. Adjusted eGFR trajectories were comparable between CIK and LD (P = 0.48). Chain-ending kidney recipients, with 4 graft loss overall (1 antibody-mediated rejection and 3 vascular thrombosis), showed outcomes comparable to LD (P = 0.64 for eGFR; P = 0.57 for graft survival).
"Conclusions: The DEC-K program proved feasible, safe, and effective in expanding transplant opportunities for incompatible and hard-to-match patients."
########
* Some earlier posts on deceased donor initiated chains:
The FT has brief reviews of four new economics books: Moral Economics, The Common Good Economy: A New Compass, We Need to Tax Billionaires, and Money: The Inside Story
The price of good intentions Four new books that examine the morals, markets and money behind modern capitalism. by Tej Parikh
Here are the remarks about the one of the four that I'm most familiar with:
"At a time when public outrage can shape policy decisions faster than ever before, Nobel Prize-winning economist and Stanford professor Alvin Roth makes a compelling case for evidence over instinct in Moral Economics: What Controversial Transactions Reveal About How Markets Work (Basic Books £25/Basic Venture $35). Roth, whose pioneering work in market design transformed systems for kidney donation, examines some of the most contentious exchanges in modern society, including prostitution, organ sales, drugs and medical aid for the dying.
"In the process, Roth delivers some eye-opening hard-truths to those who might think moral intuition ought to underpin all regulation and law. He shows why most policy decisions involve unavoidable moral trade-offs, and how bans of activities deemed objectionable can result in transactions being pushed underground (where they become harder to regulate). He also makes the case for treating markets in distasteful services as moral tools, not failures.
“My goal is not to tell you what to think, but to help you think,” Roth writes in the introduction. He largely succeeds. This is an entertaining and mind-opening read from start to finish. Some may find the discussions about morally “repugnant” topics somewhat offensive — but that’s the point."
The latest episode of Freakonomics looks at the controversies and philosophies involved in the growing legalization of medical aid in dying (MAID). Stephen Dubner interviews people with multiple perspectives, and offers a personal insight of his own.
"DUBNER: I have a sister who died last year, it was a pretty rotten death, honestly, and she wanted to hasten it. We couldn’t physically orchestrate it. And it really made me see this issue in a new way. It just seemed, you know, I don’t want to say the scales fell from my eyes, but I’d never encountered it first-hand. And it made me think that almost anyone who did encounter it first-hand might have a reckoning, might be in favor of it. But I don’t know, maybe that’s just me. Do you have any sense of how broad the support is for it generally?
ROTH: We’re an aging population, so I think not only do more people have a reason to contemplate their own death, but more people know a peer who’s died, and certainly parents have died, and relatives, you know, siblings and friends. So I would think that anyone who’s seen an agonizing death should at least give some thought to whether we should be legalizing medical aid in dying."
You can listen or read the transcript at this link:
Who Gets to Choose a “Good Death”? New York is the latest state to legalize medical aid in dying. Stephen Dubner speaks with the governor who signed the law, a Nobel Prize-winning economist, a death doula — and an ethicist who thinks the very idea is wrong.
"SOURCES: Kathy Hochul, governor of New York. Suzanne O'Brien, death doula, founder of Doulagivers Institute. Al Roth, economist at Stanford University. Daniel Sulmasy, physician, philosopher, director of the Kennedy Institute of Ethics at Georgetown University.
Posts
