The first 100 cases of organ donation after euthanasia in the Netherlands

 Here's a controversial market with something for everyone to argue about: organ donation after euthanasia, including psychiatric patients, in the Netherlands.

van Dijk, N., Wijffels, S., Wind, T. et al. The first 100 cases of organ donation after euthanasia in the Netherlands: lessons from preliminary experiences. BMC Med Ethics (2026). https://doi.org/10.1186/s12910-026-01590-5 

"Background
Organ donation after euthanasia (ODE) is an evolving, patient-initiated procedure in the Netherlands. While it gives meaning to donors at the end-of-life, it introduces complex ethical and practical challenges for healthcare professionals. This study aims to describe the clinical characteristics and donation outcomes of the first 100 ODE procedures in the Netherlands, while outlining the practical and ethical dilemmas encountered.

Methods
A retrospective analysis was performed on prospectively collected data from the first 100 ODE procedures conducted between September 2012 and February 2023. To gain deeper insight into practical experiences and ethical themes, these data were discussed with organ donation coordinators and intensivists involved in the procedures. The analysis focused on clinical characteristics and donation outcomes, as on ethical and practical challenges.

Results
Neurodegenerative disorders were the primary underlying cause of suffering (52%), followed by psychiatric conditions (31%). The first 100 procedures resulted in 408 transplanted organs. Most procedures were performed in intensive care units, with general practitioners performing euthanasia. Key ethical and practical challenges included the tension between clinical protocols (e.g., fasting) and patient comfort, the medicalisation of the dying process through invasive monitoring, and the logistical barriers of starting ODE from home (ODEH). Furthermore, ethical concerns persist regarding euthanasia in psychiatric and dementia cases, and the emotional burden on healthcare professionals.

Conclusions
Patient-initiated ODE is feasible and allows patients to fulfil altruistic end-of-life wishes, but introduces complex ethical and practical challenges. Balancing organ donation with a dignified, non-medicalised death requires careful planning, especially as ODE expands to psychiatric and early dementia cases. Healthcare professionals face emotional and logistical burdens, yet are motivated by the positive impact on donors and recipients. Insights from these initial cases contributed to the development of the 2024 Dutch guideline, which supports both local and centralised procedures and which removed distinctions between somatic and psychiatric suffering. Further research should explore relatives’ perspectives to understand the broader impact of ODE(H). "

The Carob Trust Prize for Academic Courage: An award for scientists who overcome unjustified attacks on their work

 Here's the announcement of a new prize, initially to be awarded for work in the social sciences, reflecting the fact that social science can be politically contentious.

The Carob Trust Prize for Academic Courage: Celebrating the Pursuit of Knowledge 

"The Carob Trust Prize honors academics who pursue bold ideas that challenge prevailing orthodoxies—whether political, intellectual, or methodological—and hold the potential to reshape knowledge, policy, or society. The Prize supports scholars whose work is original, rigorous, impactful, and courageous—even when it is unpopular. " 

"Selection Criteria
Intellectual Independence: A proven commitment to following logic and evidence wherever they lead, regardless of academic or political pressure.
 

Non-Conformist Ideas: Originality and boldness of research agenda. Willingness to ask questions that others avoid—whether uncomfortable, underfunded, or unfashionable.
 

Impact and Vindication: Work of excellent quality that has shifted academic debate, public discourse, or policy. Evidence that ideas criticized at the time have proven—through data, replication, or influence—to possess enduring value. "

"Timeline
Nov. 1, 2026:  Nominations due
Spring 2027:Announcement of Prize winners "

 #######

Here's a column in the WSJ about the prize:

An Award for Scholars Who Tell the Truth
The Carob Trust Prize for Academic Courage will honor social scientists who face unjustified attacks.
By Roland Fryer and Bill Ackman 

Ukraine weighs legalizing pornography to raise tax revenue and buy drones

 Here's a story from the WaPo whose headline already conveys a lot about the economics of tradeoffs:

Ukraine weighs legalizing pornography to raise tax revenue and buy drones
Facing a massive defense budget shortfall, Ukraine has not been able to cash in on the millions of dollars earned by its clandestine adult-content industry. By Francesca Ebel and Anastacia Galouchka
 

"KYIV — For years, Ukraine’s huge but illegal porn industry has operated in the shadows. Law enforcement generally looked the other way, while some officials abused their power to extort bribes from people found to be skirting the law.

"Then, two years into Russia’s full-scale invasion, the federal tax authorities discovered that nearly 8,000 Ukrainian OnlyFans creators had made more than $131 million during 2023 alone.

"Now, with Ukraine facing giant military expenses and a $27 billion budget gap, lawmakers are moving to decriminalize pornography — a momentous step for a country long stained by a reputation for exploiting and exporting women as sex workers. 

...

"Raising money on the backs of adult-content creators, however, is a fraught proposal in Ukraine, where the women’s protest group Femen rose to worldwide fame by demonstrating topless to decry sexual exploitation and patriarchal authoritarianism.

"Critics of the bill fear that it could undermine public morality, as well as increase the risk of human trafficking and child sexual abuse. 

...

"Supporters of legalization say that it will protect women, not encourage abuse.

“Human trafficking is based on coercion: A person is deceived; their documents are taken away,” Oksana said. “The modern creator economy is completely different. An adult woman verifies her identity and age on the platform and determines her own boundaries.” 

Iran's kidney market, reviewed in Al-Madina: Journal of Islamic Law

The new English language journal Madina: Journal of Islamic Law has, in it's inaugural issue, a literature review of the Iranian kidney market. (It appears only to have reviewed papers that were also published in English.) The title summarizes the conclusion, that the market aligns with the goals of Islamic law.

Faisal, Ahmad, Abdul Khakim Mahfud Zubaidi, Ahmad Nizar Zuhdi Al Hakimi, and Roya Goldoust. “The Iranian government’s efforts to facilitate foundation-led kidney donation align with the Maqāsid al-Sharī’ah.” Al-Madina: Journal of Islamic Law 1, no. 1 (2026): 28–48. 

Abstract
The issue of kidney transplantation, particularly through compensated living-unrelated donors, represents a complex intersection of medical necessity, ethical debate, and international governance. Iran is unique in legally regulating compensated kidney donation, aiming to address the chronic shortage of transplantable organs while providing structured financial incentives to donors. This study analyzes Iran’s
kidney donation system through the lens of maqāsid al-sharī’ah, emphasizing the objective of hifz al-nafs (preservation of life), to evaluate both the ethical legitimacy and life-saving effectiveness of the policy. Employing a qualitative-descriptive approach, the research synthesizes empirical evidence on donor demographics, motivations, compensation mechanisms, and clinical outcomes, alongside normative Islamic ethical considerations and international standards such as the WHO Guiding Principles and the Declaration of Istanbul. Findings reveal that while Iran’s system significantly enhances patient survival and fulfills the core goal of hifz al-nafs, donor participation is heavily influenced by economic necessity, raising ethical concerns about voluntariness, long-term welfare, and equitable access. Moreover, the system’s interaction with foreign patients highlights challenges in cross-border governance and the potential for transplant tourism. The study contributes academically by integrating empirical outcomes with Islamic normative ethics, and practically by offering insights for policymakers, religious authorities, and international health organizations on navigating the tension between life preservation, ethical legitimacy, and socioeconomic realities. The research underscores that while the Iranian model demonstrates pragmatic life-saving benefits, ethical safeguards for donors must remain central to uphold the objectives of maqāsid al-sharī’ah."

Heroin, hitmen and black markets on Behavioral Grooves

The hosts of the podcast Behavioral Grooves open by chatting about heroin and hitmen, followed by a discussion among the three of us: 

  Behavioral Economics: When Markets Clash with Morals | Al Roth

"Horse meat, kidneys, prostitution. What happens when the things people want to buy, sell, and trade collide with what society has deemed “off-limits”? Nobel Prize-winning economist Alvin “Al” Roth joins us to explore the behavioral science behind controversial markets, from repugnance and social norms to black markets, incentives, and informed consent. We also dig into his work redesigning the kidney exchange market and how asking a different question can open up new possibilities for solving seemingly impossible problems.

Topics
[0:00] Intro and Speed Round with Alvin “Al” Roth
[9:21] What Is a Market?
[13:10] Repugnance vs. Disgust
[20:00] How Social Norms Shape Markets and Morality
[24:12] Do Laws Change Morality, or Does Morality Change Laws?
[28:25] Drugs, Hitmen, and the Social Support Behind a Ban
[34:23] Rethinking the Market for Prostitution
[38:12] Can Money Be Coercive?
[46:12] Redesigning Kidney Donation With Incentives
[50:42] What Do We Do When the Data Can't Change Minds?
[52:47] “Ought Implies Can” and the Limits of Moral Rules
[1:03:05] Grooving Session: What We Learned From Al Roth"

A passionate proponent of transplants is (temporarily) unregistered as a donor: Greg Segal in the NYT

I'm a little shaken to learn that (even*) Greg Segal has temporarily suspended his registration as a potential deceased organ donor.  My registration remains active, but I'm watching with attention the regulatory and other reforms that are being contemplated for the system of deceased donation in the U.S.

What I Found Out About Organ Donation Shocked Me
By Greg Segal
Mr. Segal is the founder and chief executive of Organize, a nonprofit focused on reforming the organ donation system. 

 "I founded Organize, a nonprofit making it easier to register to become an organ donor. In 2015, Organize was selected for a role embedded inside the U.S. Department of Health and Human Services, which put us on the radar of whistle-blowers. I soon became inundated with allegations from people working inside the organ donation industry who felt they had nowhere else to turn.

"I know as well as anyone that organ donation saves lives — over 40,000 annually in the United States in recent years. But I was stunned to learn that organ procurement organizations — the federal contractors that coordinate organ donation from the deceased — that made those transplants possible were routinely violating ethical standards and putting patients at risk.

"I heard allegations of negligence and financial fraud, including industry executives’ billing taxpayers for joyrides on private jets meant to transport organs; of organizations performing unnecessary procedures as part of a scheme to overbill Medicare. (Organ procurement organizations are nonprofits, but that doesn’t mean they aren’t trying to maximize financial reimbursements.) I’ve heard of poorer Americans waiting to receive organs passed over in favor of wealthier ones.

"But one case in particular led me to remove myself from the donor registry and testify before Congress."

#######

He goes on to recount one of the most disturbing cases reported recently in the NYT (which I think were at least in part uncovered through the work of his Organization).

See

Friday, June 6, 2025 Disturbing NYT report about an Organ Procurement Organization in Kentucky

 and

Sunday, July 20, 2025  Organ donation after circulatory death: the NYT recounts some disturbing cases

also

*Saturday, August 9, 2025  Withdrawals from deceased donor registries   

Would Jesus like Waymo?

Are robots (and robot cars) repugnant?  To Baptists?  

The Washington Post has the story:

Would Jesus like Waymo? Baptists have thoughts.
As religious groups contend with artificial intelligence, some Baptist pastors are lobbying against a bill that would allow driverless cars to operate commercially in D.C. They say autonomous vehicles are antihuman. By Liam Scott
 

"Would Jesus like Waymo? The Rev. A. Michael Charles Durant doesn’t think so.

“Jesus either walked or rode a beast,” Durant said in an interview at the Tenth Street Baptist Church in Washington, where he serves as pastor. “He would be opposed to technology that was opposed to people, and I believe that this is opposed to people.”

...

"In recent months, Durant has joined local Baptist pastors and other top leaders in the National Baptist Convention — which bills itself as the largest Black religious organization in the United States — in opposing autonomous vehicles, including in the District, where the D.C. Council is weighing a bill that would legalize their commercial operation.

...

“God created us to be interdependent,” Durant said from his green-carpeted office. “The greatest danger is not that humans will be not needed, but that we create an environment where humans don’t need each other.”

"Their opposition to autonomous vehicles comes as religious communities grapple with artificial intelligence and what the technology means for the human condition and all its messy beauty.

“Automation can dehumanize humanity. The Book of Genesis declares that God created man, and then he breathed into man’s nostrils, and man became a living soul,” said C.H. Johnson, the pastor at Christ Missionary Baptist Church in Maryland. “If we’re not careful, technology can rob us of our humanity, can rob God’s creation of our humanity.” 

...

"In his first encyclical, published in May, Pope Leo XIV elevates the ethics of AI to a religious imperative. In “Magnifica Humanitas,” Leo argues that the unconstrained proliferation of AI may threaten humanity and foster inequity.

...

"Not all religious leaders oppose robotaxis. At an April event hosted by the Innovation Majority Institute think tank, the Rev. Thomas Bowen, from Shiloh Baptist Church in D.C., recalled when taxis drove right by him as a Black man in the District and New York years ago. He said he was excited when Uber and Lyft came on the scene but that he has faced similar issues with those services.

“Why should I have to put on a suit to get a taxi?” said Bowen, who is the general secretary of the Washington-based Progressive National Baptist Convention.

...

"For the National Baptist Convention’s annual gathering this week in Florida, Durant, chairman of the group’s board, prepared a video to screen in which he called on his fellow pastors to oppose autonomous vehicles in their communities around the U.S." 

A.I. guardrails: Trump Says “a STRONG AND SMART (High IQ!) PRESIDENT" is all that’s needed to rein in A.I.

 The debate over how to regulate, promote, and defend against new developments in A.I. has taken a market design turn, with increased calls for regulation to limit the likelihood of both unintended consequences and malicious use.  This apparently looks to President Trump like an easy problem, already solved.

The NYT has the story: 

Trump Says a Smart President Is All That’s Needed to Rein In A.I.
The president again rejected calls to try to regulate the industry, even as some of its leaders are speaking more openly about the risks of rapidly developing artificial intelligence.   
By Jonathan Swan Sept. 14, 2026


"President Trump on Monday rejected calls from leading artificial intelligence executives for new limits on the technology, writing on social media that the only guardrail the industry needed it already had: “a STRONG AND SMART (High IQ!) PRESIDENT.”

Surrogacy (on each side of the Atlantic)

 Crossing the Atlantic today, to return home from Paris, this story in The Atlantic seems apropos:

Mothers for Sale.  Most of Europe bans commercial surrogacy. The United Nations likens it to slavery. But in the United States, business is booming.  By Helen Lewis

"Since the legalization of same-sex marriage, male couples have become the big growth market for American surrogacy, but the practice is booming among aspiring parents—married or single, straight or gay—who can afford the cost of hiring someone else to carry their child. In 2024, 11,821 embryos were transferred to surrogates in American clinics associated with the Society for Assisted Reproductive Technology, up from 8,461 three years earlier, and the United Nations estimates that the global worth of the industry is almost $15 billion. Most surrogacy in America today is commercial, meaning that the carrier is paid, and gestational, meaning that the carrier has no genetic relationship to the child.

...

" many liberal Americans are surprised to discover that their country is an outlier in its enthusiasm for commercial surrogacy. In Britain, where I live, a ban on the practice enjoys substantial support among feminists, who worry about the power differential between paid surrogates and wealthy would-be parents. (Altruistic surrogacy, in which the surrogate carries a baby solely out of generosity, is less controversial and is permitted.) A recent UN report went even further, declaring that commercial surrogacy “constitutes the sale of children, which is a crime,” and that “surrogacy arrangements can amount to or resemble slavery.” 

...

"Because so much can go wrong, every country in the European Union has banned commercial surrogacy. France’s centrist liberal president, Emmanuel Macron, has described the practice as “not compatible with the dignity of women.” Italy’s right-wing populist leader, Giorgia Meloni, has enacted one of the strictest anti-surrogacy frameworks in the world. Not only is domestic surrogacy banned, but any Italian citizen who brings home a baby born to an overseas surrogate risks jail and a fine of up to 1 million euros. Many other developed countries have either tightly restricted surrogacy or chosen, as Britain and Canada have, to allow only the altruistic version. Israel allows surrogacy but imposes a raft of conditions: The commissioning parents must not have more than two children already, must not have serious criminal convictions, and must be of the same religion as the surrogate.

"In general, Europeans think of Americans’ enthusiasm for paid surrogacy the way we regard their fondness for guns and capital punishment: inexplicable. The piquant difference, however, is that surrogacy is a cause of the American left rather than the right. Red states tend to have tighter limits on surrogacy. Louisiana, for example, restricts surrogacy to married heterosexual couples using their own sperm and eggs. By contrast, when New York legalized commercial surrogacy in 2020, LGBTQ activists hailed it as a triumph for “fertility equality.”

The debate cuts across political traditions and defies easy categorization. When surrogacy goes well, the result is a happy family that would not otherwise have existed. When it goes wrong, however, it can do so in unpredictable and emotionally crushing ways. At its core, the ethical question is this: How much physical and emotional risk should individuals be allowed to take on in the name of a commercial transaction? 

...

"America also stands virtually alone as a rich country that permits incoming surrogacy tourism from elsewhere. Many of these international intended parents are from China, where surrogacy is banned and where, until recently, family size was limited by the one-child policy. These customers have exacting standards. 

...

"Look abroad, though, and it’s a different story. Some agencies offer “guaranteed baby” packages for as little as $50,000. Surrogacy destinations pop up anywhere the local laws are lax, such as Northern Cyprus, a territory that exists in a legal limbo and is recognized only by Turkey. (The problem is that babies born there can end up stateless.) For parents from Russia, nearby Georgia is a similar no-questions-asked destination.

"India used to be the most favored low-cost destination, but in 2015, Prime Minister Narendra Modi, citing fears of exploitation, banned commercial surrogacy for foreigners. Ukraine’s appeal as a surrogacy destination has diminished since Russia’s invasion in 2022, although the leading agency there, BioTexCom, told me that the company is still handing off one baby born via surrogacy every day on average, at a cost of about $60,000. A representative of the agency initially told me that it was planning to open a clinic in Kazakhstan, to cater to the growing Asian market. In July, however, that country abruptly banned foreign surrogacy amid concerns about exploitation. " 

 

Privacy, A.I. and the backlash against Flock license-plate readers

 Privacy while driving seems to be more important than privacy while surfing the internet, to judge from recent reactions to automated license-plate readers produced by the company Flock Safety.

Here's the story from the Atlantic: 

Why the Flock Backlash Has Gotten So Intense
The sudden anger about these cameras seems to reflect more than just wariness about the surveillance system.  By David A. Graham 

"As corporate names go, Flock is cleverly flexible. It evokes the many cameras that compose the company’s surveillance system and also a group of sheep, protected by a watchful shepherd. The recent backlash against the company, however, more closely resembles a flight of starlings, seeming to erupt out of nowhere and move as one unified body. 

...

"Flock is useful because it is ubiquitous. Reforms such as strict data-retention limits would only marginally answer privacy concerns, and anything more drastic would undermine the system’s efficacy. As National Review’s Charles C. W. Cooke noted, no one doubts that Flock works. “Lots of things would reduce crime if implemented,” he wrote. “That doesn’t mean that those things are necessarily a good idea in a free republic.” Impositions on privacy to reduce crime are a particularly tough sell when crime is dropping sharply: Recently released FBI statistics show that violent crime dropped nearly 10 percent last year, part of a consistent trend since it spiked in 2020 and 2021. Preliminary statistics suggest that 2026 might be even safer. When safety is a less urgent concern, people are less willing to sacrifice privacy for security.

"Moreover, the Flock backlash fits into a broader moment of anger—at corporations in general, and at tech companies and artificial intelligence in particular. “Americans feel they have less and less control over their own lives, and they increasingly blame large corporations,” the Financial Times columnist Rana Foroohar recently wrote. Anxiety about AI and surveillance is big and abstract, and the companies and people pushing these anxieties are far away from most Americans. Polls show widespread apprehension about the growth of AI—a Gallup poll this summer found that about half of Americans think AI will do as much harm as it will good; another 39 percent said that it’s mostly bad. But people don’t have a lot of ways to communicate those fears. "

The Gray Area, on Moral Economics and controversial markets

 Here's a podcast recorded some weeks ago that has just  been published. We talk kidneys and other controversial markets covered in Moral Economics.

 

Abortion opponents seeking to ban surrogacy in Texas (and supporters are thinking about more regulation)

 Human reproduction gives rise to lots of different controversies, with the partisans not always aligned across issues the ways you might suppose. Here are two articles responding to a recent controversy in the news, one about a proposed ban on surrogacy in Texas, and one proposing more comprehensive regulation as a way of supporting access to surrogacy in the face of opposition.

Here's an article from the 19th News (named after the 19th Amendment to the US constitution, which gave women the right to vote), about how abortion opponents in Texas are hoping to also outlaw surrogacy there. 

Why abortion opponents are turning their attention to banning surrogacy 

 "Anti-abortion activists and lawmakers in Texas are pressing to limit or even outlaw surrogacy, a new step toward restricting major forms of infertility treatment.

"Surrogacy, though far from common, has entered the national spotlight this summer, the result of an explosive case in which an Alaska woman named McKenna West — who had been hired to carry a pregnancy for a California-based couple — traveled to Texas to seek medical care after refusing to have an abortion. She gave birth in Dallas last week.

...

"the case has become a lightning rod for national anti-abortion activists, including Texas Attorney General Ken Paxton, who intervened in the case on behalf of West to argue that the child must receive life-sustaining treatment in Texas, even though court records indicate his parents sought for him to receive care in California. (Paxton, who has frequently allied himself with social conservatives, is in a competitive race to represent Texas in the U.S. Senate.) West has secured representation from the Alliance Defending Freedom, a prominent anti-abortion legal group. 

Abortion opponents have argued that the case underscores a need to outlaw surrogacy entirely.  

...

"Kristan Hawkins, the president of the national anti-abortion group Students for Life of America, argued on the social media platform X that surrogacy “is human trafficking with better marketing.”

...

“It’s reasonable to expect some legislation will move at least out of the Senate on this topic,” John Seago, the head of Texas Right to Life, an anti-abortion organization that opposes surrogacy in all forms, told The 19th. Seago’s organization also opposes the freezing of and destruction of embryos that are not used for pregnancy, a standard component of IVF. 

...

"The Texas Public Policy Foundation, an influential right-wing think tank in the state, has also argued in favor of banning surrogacy. And the state Republican Party adopted a platform this summer saying it would support outlawing any “commercialization of human reproduction in Texas.”  

######

 And here's a call for more (and more national) regulation of surrogacy, in the WSJ:

Surrogacy Is Getting Weird
Dozens of American babies commissioned by Chinese billionaires, felony charges, embryo mix-ups and more.  By  Emma Camp 

Controversial markets in Canada

 I talk with Gemma Boothroyd, about Moral Economics and controversial markets in Canada, including medical aid in dying, about which she has a story of her own.

 CANADALAND #1414 Repugnant Markets: Where Blood is Sold and Kidneys Swapped
“Sometimes the transplants weren't done in a sterile environment. They weren't done in a hospital. They were done in an apartment somewhere. There are some very bad black markets.” - Nobel Laureate economist Alvin Roth 

 Gemma Boothroyd Reporter

"They’re shamed, banned, or driven underground but “repugnant markets” have a way of surviving. Organ sales, MAID, even blood sales fall into the category. Nobel Prize-winning economist Alvin Roth comes to Canadaland to discuss his latest book, Moral Economics: From Prostitution to Organ Sales, What Controversial Transactions Reveal about How Markets Work.

 You can listen here. (but you have to listen to some ads too:(

Further Reading:

• The Nobel Prize – Alvin E. Roth
• Can economics save lives? –  Alvin E. Roth
• Repugnance as a Constraint on Markets – Alvin E. Roth
• A Conversation with Alvin Roth – The Conversation
• Kidney Paired Donation Program – Canadian Blood Services

 

Host: Gemma Boothroyd

 

The Paradox of Protection: Overregulation Threatens Living Kidney Donation in Mexico,

 Protections intended to thwart organ trafficking may inadvertently also "protect" legitimate patients and donors from receiving life-saving medical care.

The Paradox of Protection: How Overregulation Threatens Living Kidney Donation in Mexico, by Francisco J. Reyna-Sepulveda and Javier Sanchez-Maldonado, Transplantation, Publish Ahead of Print, July 27, 2026. | DOI: 10.1097/TP.0000000000005860 

 

 

"Globally, unrelated and nondirected living kidney donations have become important mechanisms for expanding transplant access.1 Structured programs in the United States and Spain support unrelated donation through rigorous psychological evaluation, independent donor advocacy, and transparent oversight systems.3,4 For example, nondirected donors serve as critical initiators of kidney paired donation chains, substantially amplifying transplant opportunities beyond a single donor-recipient pair.3-5 However, a recent regulatory shift in Mexico threatens to effectively preclude these pathways in practice, leaving living kidney donors (including living liver donors) with genuine altruistic intent declined and vulnerable patients losing critical access to life-saving transplants.

"WHEN ALTRUISM REQUIRES PROOF
"On August 4, 2023, the National Transplant Center and the Federal Commission for Protection against Health Risks issued a High Health Directive (Alta Directiva Sanitaria), establishing mandatory standardized protocols for Mexican transplant centers.6 This directive emerged in response to well-documented regional concerns regarding organ trafficking, transplant tourism, regulatory gaps, and the “legal simulation” of donor-recipient relationships. These concerns are entirely legitimate and align with the principles articulated by the Declaration of Istanbul on Organ Trafficking and Transplant Tourism.7 

...

"Although the directive does not explicitly outlaw nondirected donation, its evidentiary requirements effectively preclude it at the committee level. As a result, viable donor candidates may be categorically declined for regulatory rather than medical reasons.  

...

"Although data isolating the exact proportion of donor evaluations declined solely for documentation rather than medical or psychosocial factors are currently unavailable, Mexican National Registry data highlight a concerning sign.9 During the 12 mo preceding the directive’s publication, 438 unrelated living donor kidney transplants were performed nationally, compared with 354 during the subsequent 12 mo—a 19% decline. " 

...

"This directive severely limits Mexico’s potential to establish domestic paired-exchange networks or participate in cross-border paired kidney exchanges. The Global Kidney Exchange model, for instance, incorporates pairs from middle-income countries into US-initiated chains to overcome financial and immunological barriers.10 This approach has been accompanied by ethical discussion in the transplant literature, particularly regarding concerns about potential inducements and unintended exploitation.10" 

...

"Ultimately, the critical question is not whether expanding living kidney donation should be permitted, but whether a transplant system can be considered ethically complete if a viable living kidney donor candidate is categorically declined for regulatory rather than medical reasons." 

Peter Coy on Moral Economics in The Free Press

 The Nobel Laureate Who’d Buy Your Kidney
What is bad about prostitution? Why is it wrong to eat horses? Al Roth’s latest book asks the most provocative moral questions. He gave The Free Press some of his answers.
By Peter Coy 

"I was a little surprised to find out that Roth has a wide streak of provocation in his personality. It comes across in his new book, Moral Economics: From Prostitution to Organ Sales, What Controversial Transactions Reveal about How Markets Work, published in May. In a mild, just-asking-questions tone, Roth digs into one prohibited or controversial activity after another: buying sex, eating horses, selling organs, assisting suicide, carrying a stranger’s baby. He asks why many of these activities are prohibited or restricted even though some people clearly want them. And he thinks about whether it’s possible to design markets for them in a way that preserves people’s freedom to transact while protecting those who don’t want to. 

...

"Roth entertains so many ideas that others strenuously resist that I asked if he calls himself a libertarian. No, he said. “People who call themselves libertarians often don’t like market regulation of any sort,” he said. “But I’m a market designer. I think that good regulations help markets work well.” Cigarettes and alcohol, for example. They can be sold, but not to children. That’s a reasonable balance. 

...

"If you want to design markets that enable beneficial exchanges while protecting the vulnerable, you may have to persuade people that a market in some repugnant good or service is tolerable. Roth seems to have taken on that task in Moral Economics. He never told me what to think. He just asked me what I think, and to think about what I think. It’s an economist’s kind of mischief—relentlessly, cheerfully inquisitive about the rules we’ve decided to live by but have never quite explained to ourselves.
Kidney transactions don’t seem so repugnant to me anymore. Would I sell a kidney to a stranger? Um, maybe, some day. Would I buy a kidney from a stranger if I really needed one? Hell, yeah."

Deceased organ donation by Ashlagi and Roth in the Annual Review of Economics (with open questions)

 Here's a review paper concentrating primarily on transplantation of  organs (primarily kidneys) from deceased donors. It closes with a set of open research questions.

Organ Allocation and Transplantation  by Itai Ashlagi and Alvin E. Roth,  Annual Review of Economics, Volume 18, 2026, Vol. 18:613-645, August 2026, https://doi.org/10.1146/annurev-economics-092425-123425     
 
ABSTRACT: There is a large shortage of solid organs for transplants. This survey reviews the allocation of organs (particularly kidneys), with an emphasis on how deceased donor organs are obtained and allocated in the United States but with pointers to related issues involving living donors and transplantation around the world. We review some of the key institutional details and theoretical and empirical studies and describe some open questions that we hope will continue to attract attention from researchers interested in the economic and operational aspects of organ allocation.

 
1. INTRODUCTION
 "Since at least the turn of the century, organ transplants have attracted considerable interest from economists. This is due both to their importance in modern medicine and to the fact that organ transplantation deals directly with some of the most basic questions of economics—namely, how to efficiently allocate scarce resources and how to make them less scarce. "

...

OPEN QUESTIONS AND RESEARCH DIRECTIONS
 
This section highlights research opportunities, some of which have been raised above.

1.  Can we design allocation rules free of justified envy that place hard-to-match organs quickly enough so that they remain transplantable? A large number of recovered organs that might be transplanted are discarded. How can we increase utilization of marginal-quality organs and get them accepted after fewer offers and less CIT? How can we do this in a transparent and equitable way? How can we use the information about organ quality that arrives during the offering process? 91 How can we use offer refusals in real time? How should we design allocation rules in the presence of social learning and potential information cascades (Zhang 2010, Doval et al. 2024)? How should the variability in centers’ willingness to accept marginal organs be accounted for?
2.  How to design priorities to balance efficiency and equity? How can priorities be designed to account for both longevity and urgency (Zhang et al. 2024, Lazenby et al. 2025)? How can priorities depend on patients’ treatments, taking into account that treatment decisions may in turn depend on priorities (Sweat 2023)? Countries use different priority rules, and there is a need to compare these to better understand trade-offs between these rules. The OPTN is seeking to implement continuous distribution allocation policies for hearts and kidneys, which will assign priority points smoothly across patient and match features. There are not yet studies that offer guidance to the resulting (in)efficiencies. 92
3.  How should organ quality be measured and reported? The KDPI is currently used for both acceptance decisions by surgeons and prioritization in the allocation system. As supply changes over time, percentiles correspond to different qualities. For example, a KDPI of 85% (which is the threshold for requiring patient consent to receive an offer) in 2018 corresponds to (i.e., has the same underlying nonnormalized KDRI risk measure as) a KDPI of 75% in 2024 due to the recovery of more organs and therefore the higher availability of organs of marginal quality. Would the use of the nonnormalized KDRI substantially change behavior and outcomes?
4.  How should surgeons’ and patients’ preferences be elicited? The OPTN allows transplant centers to express preferences via filters that screen organ offers. Despite this, many organs are still declined hundreds and even thousands of times (Agarwal et al. 2021, Guan et al. 2025). How can we better design these filters? Can we use AI to help recommend filters or to predict organ refusals in real time? More broadly, how should waitlist mechanisms be designed given incomplete patient and center preferences?
5.  How should transplant centers’ performance be measured? Should transplant centers be incentivized to accept marginal organs, for example, for patients facing many years of dialysis? How should we regulate transplant centers? Are new incentive schemes useful in increasing utilization? For example, how will the acceptance rate and pre-transplant mortality rate metrics impact centers’ behavior? The CMS has also launched the Increasing Organ Transplant Access model, 93 using a long-term field experiment that offers monetary incentives based on the number of transplants performed, graft survival, and percentage of accepted offers (Chan & Roth 2026.) How should we incorporate the huge role that transplant centers play in acceptance/rejection decisions when studying organ allocation mechanisms (Chan & Roth 2024, Ashlagi et al. 2025a)? There is a need for research on designing centers’ performance measures that include outcomes for patients on the waiting list.
6.  How should OPO performance be measured? OPOs vary in performance in terms of organ recovery and utilization, and incentive schemes remain controversial. How effective is the new tier system for monitoring OPOs based on donation and age-adjusted transplant rates? How should OPOs be incentivized to improve performance and transparency and to coordinate with transplant centers (see Chan & Roth 2024, Bae et al. 2026, Skowronski et al. 2026)?
7.  What should we incorporate in transplant centers’ preferences? Most theoretical models treat patients as the decision makers who accept or reject organ offers. In practice, however, transplant centers exercise substantial discretion over acceptance decisions, listing practices, and setting filters. How do equilibrium outcomes reflect centers’ preferences? There is a need for empirical and theoretical studies of how centers’ characteristics and incentives shape outcomes.
8.  Can we design simulation tools that account for equilibrium behavior? Simulations and historical data have been instrumental to the study and design of allocation policies. Existing simulations apply myopic acceptance models that are invariant to the allocation rules. There is a need for simple modern simulation tools that account for the incentives of patients and centers. 94 It would be interesting to create tools that generate not only better equilibrium predictions but also short-term equilibration effects. 95
9.  What kinds of experiments should the OPTN conduct? The OPTN conducts very few controlled experiments, despite facing ongoing allocation policy decisions. While simulation tools are useful to inform policy, field experiments offer another approach. Experiments can generate useful data to evaluate different approaches (e.g., for expediting placements). The size and heterogeneity of the United States present opportunities to test different approaches; but they also raise questions about whether different approaches would work differently in different regions, and about how to overcome the reluctance to conduct experiments.
10.  How can countries with low transplant rates be helped? Many countries have low living and/or deceased donation rates. Understanding the underlying barriers (organization structure, population preferences, etc.) would be fruitful in making progress toward increasing transplant rates (see, e.g., Okubo et al. 2026).
11.  What can be done to increase incentives for organ donation in ways that attract social support? What accounts for the widespread reluctance to increase organ donation by compensating donors? How can economists better explain the value of incentives in addressing scarcity and gather persuasive evidence to engage in a productive dialog with those who fear that this will increase rather than decrease black markets, or who feel there are fundamental religious or ethical objections to compensating organ donation? [For some thoughts on this, readers are referred to Roth (2026b)]. 

The New Bazaar on Moral Economics

 Cardiff Garcia interviewed me about Moral Economics, and we began by talking about medical aid in dying, and moved briskly on to other controversial markets such as pornography and prostitution.

   The New Bazaar
Economist Alvin Roth, winner of the economics Nobel in 2012 for his work on market design, joins Cardiff to discuss his new book, Moral Economics: From Prostitution to Organ Sales: What Controversial Transactions Reveal About How Markets Work.

The book is about morally contested markets: transactions that participants would like to engage in but that others think they shouldn't be allowed to, even when it’s hard to identify measurable harms to those objectors. It's also a great way to understand how markets interact with the law, politics, social norms, income inequality, human psychology, and so much more than just monetary exchange.

In this chat, Alvin and Cardiff discuss:
• Medical aid in dying and the economics of “repugnant” markets
• Sex work, trafficking, and the unintended consequences of criminalization
• Plural marriage and the challenge of designing new legal protections
• Sports gambling and the rise of prediction markets
• Kidney exchanges, the transplantation shortage, and the opposition to cross-border exchanges

Throughout the conversation, they confront the trade-offs involved in both allowing controversial markets and trying to ban them.

Related Links

• Moral Economics: From Prostitution to Organ Sales: What Controversial Transactions Reveal About How Markets Work (https://basic-venture.com/titles/alvi...) 

Delayed feedback on a controversial talk--and some positive signals of potential for change

 One feature of giving talks to unfamiliar audiences is that you only get noisy feedback on how your talk was received.  This past June, I gave the Starzl Lecture at the American Transplant Congress in Boston. (The ATC is jointly organized by the two big American transplant societies, the AST and the ASTS,*)  I spoke to an audience of about 1500 people (just a guess, but I could see some empty seats in an auditorium set up for 2,000).  My talk included topics, including global kidney exchange, that have raised controversies.  

Afterwards, what seemed like a lot of people came to speak to me, and were enthusiastic about my talk.  But "a lot of people" was fewer than 100. So what about everyone else? (It probably wouldn't be statistically kosher to assume that those who came to congratulate me were a representative sample:)   

Since global kidney exchange has led to some people calling me an organ trafficker, I didn't have any measure of the general sentiment of the meeting.

I got some reassuring news recently when the ATC sent out an email soliciting ideas for talks for next year's meeting, in Seattle.  The email came with a picture from this oat meeting:

 

 So I'm guessing this means that my talk was well received by people responsible for organizing the next meeting.

And, indeed, I'm getting multiple signals that there's an appetite for productive change in the transplant community.  I hope to have more to say about that in the coming year.

######

*Acronyms:

ATC American Transplant Congress 

 AST American Society of Transplantation

ASTS American Society of Transplant Surgeons 

Multi-hospital kidney exchange in Brazil

An article in Floha de S. Paulo, tells of the first inter-hospital kidney exchange in Brazil:

 Transplante renal pareado amplia opção para pacientes que têm doador, mas não podem receber o rim  by Claudia Collucci

English translation:
Paired kidney transplant expands options for patients who have a donor but can't receive the kidney

https://www1.folha.uol.com.br/equilibrioesaude/2026/06/transplante-renal-pareado-amplia-opcao-para-pacientes-que-tem-doador-mas-nao-podem-receber-o-rim.shtml

Article summary: 

For the first time in Brazil, two transplant centers in different cities carried out a paired kidney donation — swapping incompatible living donors so each recipient gets a compatible kidney from someone else's donor instead. The initiative was led by Hospital das Clínicas at USP's medical school (HCFMUSP) in São Paulo and Santa Casa de Juiz de Fora in Minas Gerais.

The surgeries happened simultaneously at both hospitals — a donor from São Paulo traveled to Juiz de Fora to donate to the Minas Gerais recipient, while the donor from Minas Gerais went to Hospital das Clínicas in São Paulo to donate to the São Paulo patient. 

the two hospitals use an internationally developed (U.S.-built) platform that cross-references immunological traits, body size, and donor kidney quality to identify the best-matching combinations — this is functionally the same kind of algorithm we've been discussing with NKR.

Brazil has no specific regulation for paired kidney donation under its National Transplant System, so the procedure currently proceeds only as research. 

 

HT: Dr. Gustavo Ferreira 

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Earlier:

Thursday, January 22, 2026

Kidney exchange in Brazil (a clinical trial)

Here's a video in which Mike Rees, the founder of the Alliance for Paired Kidney Donation (APKD) describes how (with the help of a grant from Stanford Impact Labs) the APKD is helping Brazilian transplant docs get kidney exchange going there. 

 Earlier:

Tuesday, February 27, 2024  Stanford Impact Labs announces support for kidney exchange in Brazil, India, and the U.S.

 Thursday, October 10, 2024  Kidney exchange in Brazil, continued (with pictures)

 

Kidney exchange in Germany can draw on the experience in other countries

 Here's an editorial arguing that as the recently legalized kidney exchange in Germany is implemented, attention should be paid to the controversies that have been encountered and addressed elsewhere, including those about non-directed donors, and the governance and transparency of transplant decisions.

 Benning L, Lu W, Budde K , Josephson, M.  Germany’s move toward kidney paired exchange and non-directed donation: governance lessons from abroad, Kidney International Reports, 2026 

"In 1986 F.T. Rapaport outlined a core idea behind kidney paired exchange: that a registry can coordinate incompatible donor-recipient pairs so that incompatibility becomes a solvable matching problem rather than a barrier to transplantation1. Today, forty years later, Germany is on the verge of making that coordination legally possible. In October 2025, the German federal cabinet approved a draft amendment to the Transplantation Act that would enable kidney paired exchange and non-directed anonymous living kidney donation, while strengthening donor protection and establishing the legal basis for a national program with a central matching function. If operationalized, Germany would move from a restrictive framework for living kidney donation, historically tied to a strict requirement of a close relationship between donor and recipient, toward a governance model that supports kidney exchange and donor chains at scale.

"This moment is internationally relevant because Germany now faces the same policy questions that have shaped kidney paired exchange implementation elsewhere. The impending change creates an opportunity to learn from other countries on key issues, including who should govern a registry, which safeguards ensure legitimacy, how to balance privacy and transparency regarding organ quality, and how to promote access without risking commercialization. Rather than being mere technical considerations, these questions are constitutive for the legitimacy and public trust required for kidney paired exchange to function as a public good. 

"Early debates about living kidney donation repeatedly straddled suspicion and admiration. In the 1970s, living non-related and particularly non-directed donors were sometimes portrayed in medical discourse as psychologically unstable or even pathological, raising concerns about whether such donors should be permitted to proceed2,3. 

...

" History offers two more lessons: (i) Donor protection and respecting donor agency are not mutually exclusive: psychosocial assessment, independent counseling, and rigorous consent procedures can reduce coercion and misunderstanding while still recognizing donors as autonomous agents making a deliberate moral choice. (ii) Public legitimacy is fragile and easily lost: If suspicion dominates, programs risk being viewed as illegitimate or unfair. If, on the other hand, enthusiasm and implementation moves faster than safeguards, programs risk scandal, backlash and, ultimately, lose public support. Germany’s 2012 transplant scandal, involving the manipulation of patient data to improve waiting-list positions, offers a cautionary example of how deficits in transparency and accountability can erode trust in transplantation more broadly and disrupt an entire program4."

##########

 There are many reviews of the international experience.  Below is a recent one from physicians at Erasmus University in the Netherlands:

Stijn C. van de Laar, Hidde A. de Heus, Annelies E. de Weerd, Matthijs F. Klaassen, Robert J. Porte, Robert C. Minnee Frank J.M.F. Dor, A Comprehensive Review of Strategies to Advance Kidney Exchange Programs and Optimize Effectiveness and Outcomes, Kidney International Reports, Volume 11, Issue 7, July 2026, 106539

"Living donor kidney transplantation (LDKT) offers superior graft survival and cost-effectiveness compared with deceased donor transplantation (DDKT), yet the availability of immunologically compatible living donors limits its reach. Kidney exchange programs (KEPs) can overcome these barriers by matching incompatible pairs through paired exchanges, domino chains, and nonsimultaneous extended altruistic donor (NEAD) chains. This review summarizes the evolution and current landscape of national and international KEPs. We examine operational challenges (cold ischemia time [CIT], logistical coordination, algorithmic fairness, and ethical and regulatory heterogeneity) and explore innovations in matching algorithms, international kidney exchange debates, and machine perfusion technologies. We conclude by proposing strategic priorities to optimize capacity, equity, and outcomes in future kidney exchange efforts. " 

####### 

Earlier: 

Friday, March 27, 2026 Germany legalizes kidney exchange !!