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."
"Republicans in Congress have quietly blocked a proposal to expand military health coverage of in vitro fertilization treatment for service members and their families, heeding the calls of anti-abortion groups to limit access to a fertility option that President Trump vowed to make more widely available.
"The move is a shift from previous years, when there was enough bipartisan support for the idea of broadening the availability of I.V.F. for members of the military that it was included in the annual defense bill that passed both the House and Senate. Speaker Mike Johnson later stripped it out in final negotiations before the legislation became law, but the provision’s initial inclusion indicated that the vast majority of Republicans had been willing to accept it.
"This year, Republican senators banded together to bar the measure from being added to the defense bill in the first place. It illustrated how, while many G.O.P. members of Congress have said they are in favor of I.V.F. access, they have managed behind the scenes to thwart legislative efforts to ensure it."
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.
"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."
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There are many reviews of the international experience. Below is a recent one from physicians at Erasmus University in the Netherlands:
"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. "
Here's a story in the NYT, covering an uproar that's been in the German newspapers for a week or so now. A leader in the German governing coalition announced on social media that he and his husband had welcomed a new baby into their family, born via surrogacy in the U.S. But surrogacy in Germany is not legal, so this was a "for me but not for thee" hypocrisy moment there. (In general it's hard to ban effectively something that is legal in other jurisdictions: someone could write a book about that.)
"Mr. Spahn, 46, the leader of the party in Parliament, is a former federal health minister who has forged deep ties to the Republican Party under President Trump, including attending the 2024 Republican National Convention.
...
"Mr. Spahn stirred national outcry this week when he announced, on social media and in the tabloid paper Bild, that he and his husband, Daniel Funke, had become fathers to a son via a surrogate in the United States.
"Surrogacy is prohibited under German law. Mr. Spahn had defended that ban throughout his career, including as health minister.
"The birth announcement brought immediate cries of hypocrisy from across the political spectrum, including in Mr. Spahn’s own party. Some regional leaders of the Christian Democrats demanded his ouster. News outlets teemed with outrage.
...
"Mr. Spahn defended himself, essentially, on a technicality: German law does not punish parents who use surrogates abroad. He told a podcast interviewer he had struggled with the decision but chose to prioritize his family."
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Here's a related story: German couples in need of surrogacy are not the only ones, and the US is not the only destination.
"The rise in the use of surrogates abroad is leaving more babies at risk of becoming stateless, experts have said, amid growing calls for urgent global regulation of the practice.
"The warning follows the suspension of a 15-year effort by The Hague Conference on Private International Law (HCCH) to establish a global surrogacy convention, which was paused due to divisions among member states.
...
"UK surrogacy agencies argue that an outdated legal framework at home is pushing couples to seek surrogates abroad, where regulations to protect surrogates from exploitation can be less robust or do not exist at all. Anti-surrogacy campaigners say the practice is fundamentally abusive in all cases and are pushing for a global ban.
"Prof Michael Hellner, who chaired the HCCH working group, said hugely differing opinions on the ethics of surrogacy between the member states involved meant the project to create a global framework on legal parentage in surrogacy cases had proved impossible.
...
"Experts said statelessness could happen in cases where a country does not automatically grant nationality to a child born there, and where surrogacy is not legally recognised in either the country of birth or the child’s final destination.
"Hellner said the project had proved difficult when some countries were “violently opposed to anything that could be seen as legitimising surrogacy, which they think is a violation of human rights and dignity”.
...
"Most of these children were born abroad, mostly in the US, Ukraine, Nigeria, Georgia, Colombia and Mexico. British people using surrogates abroad to have babies are forced to apply to the UK family courts for a parental order to become the legal parents of their child and, in some cases, also need to apply for British citizenship for the child."
"With this bill, we are facing death head-on," declared French President Emmanuel Macron on March 10, 2024. More than two years later, the Assemblée Nationale cast a definitive vote on Wednesday, July 15, on the bill establishing a right to assisted dying. With the adoption of the law, France joins 11 other countries where people with severe illnesses can obtain a lethal substance on medical prescription, based on criteria varying from one legal system to another.
"The "French end-of-life model," a phrase Macron used in 2023, originated from the president's own initiative. However, its design resulted solely from the work of MPs after four rounds of readings, the Sénat having rejected the bill three times. Supporters have praised the bill as "balanced" and "secure," offering safeguards to ensure that recourse to assisted dying remains "an exception." Its critics, however, argue that the "safeguards" provided are not sufficient for preventing "abuse."
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The Catholic Courier summarizes some of the opposition to the bill:
"PARIS (OSV News) — France’s bishops are strongly criticizing a “radical choice” made by French lawmakers to legalize “assisted dying.”
"A watershed vote by the National Assembly July 15 legalized assisted dying, including euthanasia and assisted suicide in certain cases.
"Cardinal Jean-Marc Aveline of Marseille and president of the bishops’ conference, lamented that “members of parliament have enshrined in French law the possibility of causing death.”
...
"For the bishops, one of the greatest dangers of the law stems from the fact that the principle that death can constitute a medical response to suffering has now become part of the legal heritage of the country. The choice to die can then be asserted as a right that could be extended to others.
“Experience in other countries shows that the criteria for access to assisted dying always tend to broaden, to the detriment of palliative care,” they noted.
"Meanwhile, “the effects of such legislation are not yet fully measured, but they are already taking shape,” the bishops warned. “Our relationship to vulnerability, old age, disability, and illness will change,” they added.
“The poorest are likely to be the first to pay the price: not wanting to be a burden on their children or grandchildren, elderly people in precarious situations may feel pressured to die,” the prelates warned.
"Catholic care facilities could face legal action for refusing euthanasia, assisted suicide on their premises For the bishops today, the most immediate and concrete concern is that, if the law goes into effect, care facilities — foremost among them Catholic institutions — could face legal action if they refuse to allow euthanasia or assisted suicide to take place on their premises. As it stands, the law will require the head of the facility or department to authorize outside practitioners to perform the lethal procedure.
"The bishops have therefore announced that they will “closely monitor the referrals to the Constitutional Council” that were announced prior to the vote.
...
"On July 14, while France was celebrating Bastille Day — the country’s biggest national holiday — Prime Minister Sébastien Lecornu surprised many by announcing that he would appeal to the Constitutional Council to submit the text of this law — to which he is personally opposed — for review. He justified this final recourse by citing the lack of agreement between the two chambers, the National Assembly and the Senate. A few days earlier, Senate President Gérard Larcher had announced his intention to take the same step.
"The Constitutional Council may approve the entire bill, strike down certain provisions, or issue interpretive reservations before the law is promulgated by Macron. The referral requested by the prime minister will focus in particular on the absence of a conscience clause allowing healthcare facilities — such as the Catholic nursing homes run by the Little Sisters of the Poor — to be legally authorized to refuse to provide such “assisted dying” services on their premises.
"Pending the outcome of the appeal, the bishops of France have reiterated their call to Catholics in France to “bear witness that another path is possible — one of faithful presence and attentive care that alleviates physical or psychological suffering, without ever abandoning anyone.”
"Speaker A: You have a pretty long chapter on same sex marriage in the book where you go through the sort of legislative history both in various states and the country. And after, like reading so much of the history of this, I would say, like, this is so Slate, I’m going to just come out and say that 95% plus of our listeners are perfectly fine with same sex marriage. It seems perfectly normal to us. It’s kind of hard for us to imagine why it was that we ever had a problem with it in the first place. But you went back, you Were looking at a bunch of contemporaneous literature. Do you have a sympathy for the anti side of the debate? Do you see where they were coming from?
Speaker B: Well, I think I see where they were coming from. I can do that without having necessarily a lot of sympathy for them. But they were tooled up quite early on. So for a long time in the United States, there were laws against sex that sometimes had the names unnatural acts in them. And in California, and I’m going to fudge the dates now, but sometime in the 1970s, long before there was any same sex marriage, they decided that laws against same sex sex violated the equal rights provisions of the California constitution. And so they changed them. They made those laws unconstitutional. And almost immediately after, like two years after, in the 1970s, the California legislature passed a law against same sex marriage. That is, the people who were looking into the far future and thinking that they really hated same sex marriage had felt protected by the laws against consensual sex between adults of, you know, say, sodomy. And all of a sudden they felt unprotected. So long before any same sex marriage became legal in the United States, there started to be laws against it.
Speaker A: That’s kind of wild. You’re just, you’re sort of like cutting it off at the past. It’s not legal anywhere. No one’s even trying to make it legal. We’re going to make it illegal just in case. And we saw that at the federal level as well.
Speaker B: Absolutely. When the state of Massachusetts finally, when its courts finally legalized same sex marriage in Massachusetts, the federal government passed a law called the defense of marriage act, which was intended to defend marriage against same sex marriage. So that’s a really unusual state of affairs. And again, when I say that’s a repugnant transaction, One of the things I emphasize in the book is I don’t mean that I disapprove of it or that you should, but that some people do. And the long political fight makes it clear that the people who objected to it objected very strongly.
Speaker A: I mean, I was around for a lot of these court cases and legislative moves, but even at the time, I didn’t entirely understand where the opponents were coming from. So is it mostly like a biblical thing?
Speaker B: So I think it’s partly a religious thing and some of that is biblical. There were some passages in Hebrew Bible even that could be interpreted as disapproving of same sex relations. And when you look back at the long history of humanity, there were lots of taboos about sex. And I think one way to think of them is, for most of human history, sex between a man and a woman often resulted in pregnancy, and pregnancy often resulted in a live birth in a baby. And society has and had some interest in making sure that babies were taken care of. And one way to do that is to say babies should be born into families, and therefore before people have sex, they should be married to each other. And so there are a whole set of taboos that might be thought of as society’s way of trying to take care of babies. But of course, technology changes. And contraception, reliable contraception, means that it’s possible to have sex without too much risk of a baby. In vitro fertilization, IVF means that it’s possible to have babies without sex. So all of a sudden, some of those barriers that may have seem essential to the orderly running of society didn’t seem so essential. And I think that opened up room for us to think more about who could have sex with whom and who could form a family with whom.
"In the decade since Canada legalized euthanasia, known there as medical assistance in dying, or MAID, its physician-assisted death regime has developed into one of the most permissive in the world. Between 2016 and 2024, 76,475 Canadians received lethal doses from doctors or nurse practitioners. The 16,499 cases in 2024 accounted for 1 out of 20 deaths in Canada. In some regions of Quebec, the rate is 13 out of 100.
"Now, however, Canada might finally be maxing out on MAID. On June 17, a special parliamentarycommittee recommendedthat the government “indefinitely exclude” patients whose only medical condition is a psychiatric one such as depression or schizophrenia. Pro-euthanasia activists had urged that MAID eligibility be expanded to include them, but “safe and equitable implementation” of MAID in such cases is simply not possible, the committee said.
...
"The committee also took the testimony of doctors from the Netherlands, one of two countries (Belgium is the other) where psychiatric euthanasia has long been allowed as part of a broader MAID regime — and where it has recently gone from rare exception to troublingly frequent occurrence. Nearly 850 people have received lethal injections for psychiatric suffering there since 2020, including teenagers as young as 16.
In fact, at roughly the same time as the Canadian commission issued its report, the Dutch themselves were tapping the brakes on psychiatric euthanasia. The Netherlands’ main professional organization for psychiatrists has issued new guidelines requiring stricter prior scrutiny for euthanasia requests."
"Ultimately, the committee makes the following recommendation: Recommendation 1 That the Government of Canada amend the Criminal Code to indefinitely exclude persons whose sole underlying medical condition is a mental illness from eligibility for medical assistance in dying. "
In an interview with Benzinga after the release of his new book Moral Economics, Stanford economist Alvin Roth said the strongest use-case for the technology may not be public platforms like Polymarket or Kalshi, but inside corporations. He described a scenario where engineers building a product know about delays that senior executives, working from optimistic reports, do not. A prediction market inside the company can get the information to the top faster.
...
"He said election markets are unlikely to face serious insider-trading risk, but neither are they guaranteed to beat good polling. “I don’t know that prediction markets do a lot better on elections than good polls do,” he said.
"He flagged a different concern: manipulation. State actors or well-funded propaganda operations could push large sums into a market to engineer a favorable price."
...
"Securities markets exist in part to help companies raise capital, he said, which requires public trust. Prediction markets do not carry the same burden, so the harm from insider activity is less clear.
"He added that if real insider trading is happening off political news, the likelier venue is the commodities market. “The price of Brent Crude moves rapidly when the president says something,” Roth said."
"The economist Al Roth, a professor at Stanford University, shared a 2012 Nobel Prize for his work in market design and matching theory. He spoke with Sarah Kessler about his latest book, “Moral Economics,” which offers a framework for understanding controversial markets, and how it applies to prediction markets. The conversation has been edited and condensed.
Your book explores what you call repugnant markets — meaning some people don’t think they should exist — like prostitution, surrogacy and drugs. How do prediction markets fit in?
When I think about repugnance and prediction markets, I think back to when Darpa proposed a policy prediction market that became characterized as a terrorist prediction market, and people really objected to that.
That objection was sort of misplaced. It would be great if terrorists who were planning attacks wanted to tip their hand by betting on them in advance. But also, if you were a terrorist who knew about the 9/11 attacks in 2001, and you wanted to make money, you wouldn’t bet on a prediction market. You would short United Airlines and American Airlines. What do you make of all the reports of insider trading on prediction markets?
The reason we forbid insider trading in securities markets is to give people confidence in them. Securities markets have an important financial function that is threatened by insider trading, and I’m not sure that prediction markets necessarily do.
What worries me about the current state of prediction markets and Washington insiders is more the blurring of private and public functions. I don’t think that being an associate of the president should allow you to bet on a Truth Social post by President Trump. That is very bad public policy, but not necessarily an indictment of prediction markets per se.
Do you have an opinion on whether prediction markets should be regulated by the C.F.T.C. or state gambling authorities?
Futures markets, like securities markets in general, play other roles in society. If you’re a farmer who’s growing wheat, a futures market allows you to sell your wheat before you’ve planted it, which allows you to buy the fertilizer and make plans. That’s one role for federal regulators.
The contract has a delivery date. It says on a certain day a freight car is going to deliver potatoes to me. If, for example, someone tried to corner the potato market by reserving all the freight cars so that you wouldn’t be able to deliver on the contract, the regulator could intervene. With prediction markets, there’s nothing that has to be delivered. It’s just that someone has to adjudicate whether the bet was a yes or a no. That requires maybe some kind of regulation, but that seems more like a customer relations thing.
Is there anything that you would change about the design of prediction markets?
I have some ideas about what we can do about gambling and addiction. An appropriate regulator or consumer protection agency could start to require that apps allow you to put a limit on your betting.
Before the game starts, you can say to the app: When I’ve lost a hundred dollars, shut down. Don’t let me make any more bets.
And that might help some people just the way bartenders are supposed to stop serving you if you’ve had too much to drink. "
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.
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In terms of lives lived well and deeply, here's an earlier post of mine about teachers and students.
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.
I'll be speaking Sunday at the American Transplant Congress, on kidney exchange. It will be hard to squeeze in all the recent developments in my half hour, including current controversies.
I'm no expert on the production of foie gras, but I am glad to see arguments about repugnant transactions and controversial markets that take seriously the concerns of opponents.
"There is now a proposedballot initiativemoving through Washington that wouldban foie gras entirely. No producing it, no selling or serving it. Fines between $1,000 and $5,000 per violation. License suspension for repeat offenses
...
""I am asking you to not sign the petition. But first I want to do something the other side rarely does, which is to take their concerns seriously.
"Gavage — force-feeding through a tube inserted down a bird’s throat — looks terrible. I know because I have seen it. I understand completely why someone sees footage of it and reacts with horror. If you imagine the same thing done to human beings, it looks like violence.
"But here is what I also know, and what the activists with the megaphones do not know and do not want to know because it would complicate the argument they have decided to make.
...
' A duck’s esophagus, where the gavage tube is inserted, is desensitized, without a gag reflex, and it is capable of swallowing whole crustaceans and scaly fish in the wild. Its windpipe is separate from the esophagus, meaning the gavage process has no impact on breathing. More importantly, this overfeeding is something the bird does naturally. Before their annual migration, ducks gorge — they stuff themselves with excess food. The calories are stored as fat, not only in the liver but in the expanded esophagus. (The verb “gorge” comes from this behavior.) What foie gras farming does is amplify a natural biological process rather than invent a cruel one .
...
"The producer I buy foie gras from exemplifies the kind of care and attention good farming demands. Their ducks are raised for 15 weeks, about twice the poultry industry standard, in open barns, on a vegetarian diet. Force-feeding by hand happens three times a day for the final three weeks. Each feeding takes approximately 1½ seconds, and, from my observation, the ducks barely seem to notice it."
"I asked Roth if he’s a libertarian, since libertarians say people should be free to do what they want as long as it doesn’t hurt others. No, Roth told me.
“People who call themselves libertarians often don’t like market regulation of any sort, but I’m a market designer,” Roth said. “I think that good regulations help markets work well.”
" Peter Coy, the veteran New York
Times economics columnist, writes about kidney exchange, after an
interview/conversation sparked by a recent working paper of mine, Market Design and Maintenance. (He's a rare economic journalist who reads economists' papers.)
He's
also a rare interviewer: his column includes the names of more of my
coauthors than I can recall in any other interview. In order of
appearance: Tayfun Sonmez and Utku Unver, Frank Delmonico, Susan
Saidman, Mike Rees (implicitly) when he names Mike's nonprofit Alliance for Paired Kidney Donation, and Elliott Peranson. Market design is, after all, a team sport."
"For generations, the world’s top horse breeders have carefully mixed bloodlines for temperament, strength, conformation and athleticism. Each new foal bore the promise of outperforming a carefully chosen set of parents. It isn’t quite natural selection, but it isn’t far off.
"Now the equestrian world might be hitting a plateau: exact genetic replicas of successful horses and ponies. In other words, clones.
...
"Polo player Adolfo Cambiaso, regarded by many in the sport as the greatest of all time, essentially created the sporthorse cloning industry when he made a slew of genetic copies of his best ponies, starting in the early 2000s—and began winning tournaments on them.
"In 2010, a clone of his champion mare Cuartetera sold at auction for $800,000, an eye-popping sum for a polo pony at the time
...
"Cloning is a controversial practice, but particularly so in horse sports. It is banned in thoroughbred racing and competitors in other disciplines are divided, with some saying it creates unrealistic expectations and stifles advances in breeding.
...
"The Fédération Equestre Internationale, the governing body for Olympic horse sports, banned clones from competition in 2007. But it reversed that decision in 2012 after determining they didn’t provide competitors with an unfair advantage, due to the myriad environmental factors that go into producing a champion, like parentage, training, the rider, the type of food it eats and even the shoes it wears.
...
"Buenos Aires-based Kheiron Biotech, an equine cloning company, produced around 400 cloned horses during the season that ended in February, mostly of various polo ponies. "
"To really understand the nuts and bolts of economics, look to the black market. Alvin E. Roth is Craig and Susan McCaw Professor of Economics at Stanford University and the George Gund Professor of Economics and Business Administration Emeritus at Harvard University. He was awarded the Nobel Prize in Economics in 2012. He joins host Krys Boyd to discuss his work on organ donation which led him to study what he called “repugnant transactions” like sex and drugs and why he feels banning them completely doesn’t always have the effect we think it does. His book is “Moral Economics: From Prostitution to Organ Sales, What Controversial Transactions Reveal About How Markets Work.”
Transcript (also at the above link)
Here's a very contemporary Texas question:
"Krys Boyd [00:25:48] I’m really curious, Alvin, about whether making things illegal has much of an effect on things. I live in Texas, where recreational marijuana is against the law. I can tell you just anecdotally that it appears to not stop very many people. You pose this interesting question about why the laws work pretty well to keep people from committing murder for hire, but not so well at all from buying and selling illegal drugs. "
"Kidneys, surrogacy, prostitution, gambling, price gouging, assisted dying: some transactions make people recoil, even when all parties consent. Cato’s Ryan Bourne talks with Nobel Prize-winning economist Alvin Roth about his new book, Moral Economics, what makes markets “repugnant,” what economists can add to moral debates, and why banning exchange rarely makes scarcity, exploitation, or hard trade-offs disappear."
Below, Alvin Roth shares five key insights from his new book, Moral Economics: From Prostitution to Organ Sales, What Controversial Transactions Reveal About How Markets Work.
Alvin is the Craig and Susan McCaw Professor of Economics at Stanford
University and the George Gund Professor of Economics and Business
Administration Emeritus at Harvard University. A pioneering expert in
the field of market design, he was awarded the Nobel Prize in Economics
in 2012. He is also a member of the National Academy of Sciences and
past president of the American Economic Association.
What’s the big idea?
There’s an old joke about economics and sociology that says
economists try to understand the choices people make, and sociologists
try to understand why people don’t really have any choices. Alvin looks at how societies try to decide whether to allow some choices and ban others.
There are lots of morally contested markets and transactions that
some people would like to engage in, but others think shouldn’t be
allowed. Often, the objections are stated in terms of moral or religious
reasons. And the transactions that the opponents seek to ban don’t harm
them personally—they might not even know the transactions had occurred
unless someone tells them.
For example, same-sex marriage is a morally contested transaction:
two people want to marry each other, and some other people don’t think
same-sex marriages should be allowed—even though you can’t tell if
someone is married unless they tell you, for instance, by wearing a
wedding ring. For centuries, marriage was regarded as inherently
heterosexual. But, after considerable controversy, the U.S. and many
other countries have legalized same-sex unions.
This isn’t a unique situation. Lots of controversial markets are
connected to reproduction. There have been bans at different times and
places on contraceptives, in vitro fertilization, abortion, and
surrogacy. That is, there have been laws enshrining opposing views about
whether a woman should be able to prevent becoming pregnant during sex (by buying contraception), should be able to initiate a pregnancy without sexual intercourse (via IVF), or be able to terminate
a pregnancy via abortion, not to mention being a surrogate or having a
surrogate bear a baby. In the U.S., all those things have been through
the courts multiple times and with different results.
Notice that reliable contraception and IVF involve modern disputes
about modern technologies. Before reliable contraception, sex between a
man and a woman often resulted in pregnancy, and before assisted
reproductive technology, like IVF, sex was the only avenue to
pregnancy. Many traditional laws and norms that attempted to keep sex
within the bounds of marriage between a man and a woman were attempts to
ensure that babies would be born into families. But if pregnancy
becomes a choice, and if there are other ways to have a child than
intercourse between a man and a woman, then the door opens to more
expansive views about who can have sex with whom, and who can start a
family. So, while expanding marriage to include same-sex couples doesn’t
depend on modern technology, we can see that the changes in
reproductive technology may have moved the needle on what kinds of
marriages and related transactions receive social support.
Of course, bans on extra-marital sex, prostitution, or abortion never
succeeded in making those things disappear, even though they raised
barriers.
2. Bans on markets need social support to work well.
Some bans work well while others give rise to active black markets.
For example, why is it so easy to buy drugs, but so hard to hire a
hitman? U.S. laws aren’t so different for drug dealers and hitmen: if we
catch them, we send them to prison for a long time. Yet our prisons are
filled with drug dealers, and there have been years in which more than
100,000 people died from opioid overdoses. But murder for hire is so
rare that it doesn’t even make it into the national crime statistics,
and homicides from any cause are vastly fewer than drug overdose deaths.
At least some of the difference has to do with how people think about
drugs and murder. If I told you I was looking to buy some heroin, you
would be surprised, but you wouldn’t call the police (and if you did,
they would tell you that they were busy with more pressing calls). But
if I told you I was looking to hire a killer, you might very well call
the police, and when you did, they would encourage you to tell me that I
might find an available hitman at a certain bar, where I would find
myself trying to hire an undercover detective. To put it another way,
there are neighborhoods where drugs are readily available, and the
neighbors look away, but not so many neighborhoods where killers are the
norm, in part reflecting that the social norm against drugs is much
more porous than against murder.
“At least some of the difference has to do with how people think about drugs and murder.”
I don’t know how we should best make progress in dealing with the
markets for addictive, lethal drugs. Not only are we losing the “War on
Drugs,” but it won’t even accept our surrender: experiments with
decriminalizing drug use have shown the potential to make cities less
livable. We’re going to need to experiment, to find better ways to
proceed.
It’s worth noticing that we’ve learned to live with legal markets for
tobacco and alcohol, even though each of those causes more deaths than
are due to drug overdoses. And we’re wrestling with some other kinds of
addiction, such as gambling (particularly on your phone, during a game).
The drug epidemic teaches us that well-intentioned policies can fail.
By and large no one approves of heroin, but we haven’t succeeded in
vanquishing it any more than we succeeded in making alcohol disappear
during Prohibition.
3. Moral intuitions aren’t enough by themselves.
We need to gather and pay attention to evidence about the
consequences of particular policies. This is hard when moral intuitions
collide, partly because much moral argumentation rests on weak or no
evidence. But we can’t afford to judge our policies just by their
intentions. We have to at least look at their consequences, too.
Nevertheless, moral intuitions are important and consequential, so we
need to understand them better. There are some things that many moral
intuitions have in common. For example, concern about the possible
exploitation of vulnerable people is often an issue.
4. Sometimes adding money to a transaction arouses repugnance.
For example, paying in cash is what turns sex into prostitution.
Often, the objection to introducing money into transactions is that it
might be an undue influence that could coerce the poor into
transactions that they (or we) would prefer not to take part in. But
that’s over-broad: many people work for financial pay at jobs they
wouldn’t otherwise do. And many goods and services that we need wouldn’t
be available if they couldn’t be paid for.
“Many people work for financial pay at jobs they wouldn’t otherwise do.”
Pharmaceuticals made from blood plasma are a good example. Many
countries ban payments to plasma donors and try (almost always
unsuccessfully) to generate as much as they need of the large amounts of
plasma required to treat many diseases from unpaid donors. How do they
make up for the shortfall? Fortunately, you can buy plasma and
plasma-derived medicines from the U.S. We’re the Saudi Arabia of blood
plasma, exporting tens of billions of dollars of plasma products each
year, collected largely from plasma donors who are paid.
5. Religion remains important in many controversies.
It plays a large role in the growth of legal medical aid in dying, in the U.S. and elsewhere.
Overall, in pursuing moral economics, we have to keep in mind the maxim that ought implies can, and the things we feel morally obligated to do, whether by supporting them or banning them, have to be things that we can
do. To understand those limits, we need evidence, including
experimentation, to figure out how to proceed when we’re worried by all
our options.
"despite the severity of the allegations — an affair that raised serious blackmail risks, attending openly partisan events, and lying to investigators when caught — the Eleventh Circuit and the Judicial Conference both concealed the judge’s identity. They even adjusted the very minor sanction to allow the judge “to word the letters of apology vaguely so as to ensure that a letter could not be ‘used against [the Subject Judge] in some way.’”
...
"The Eleventh Circuit thought it had been so clever in anonymizing its report. The reports don’t include a name or a district, and refer only to “Subject Judge” throughout. The reports even assiduously avoid identifying the judge by gender, proving that even conservative judges can figure out how pronouns work with minimal effort. And yet the reports failed to obscure a number of details that made working out the judge’s identity possible.
...
Handing the reports into two different AI models and turning on all the “deep research” modes, the bots churned for several minutes comparing the reports to publicly available information. Both models delivered lengthy reports reaching the same conclusion. So how did these models do it?
...
"the models instantly filtered out the entire state of Florida. The official reports are littered with references, in varying contexts, to the office of “District Attorney.” Florida uses “State Attorneys” for its local prosecutors. After that, the bots noted that the sanction barred the judge from ever serving as chief judge of their district — meaning the judge was not senior status and not currently the chief judge. The report indicates that investigators spoke with clerks dating back to 2020, disqualifying anyone elevated after that. Discussing the judge attending a DA’s primary victory party, the bot pointed out that the judge had claimed to know the candidate based on their time at the office, narrowing the scope to judges with state prosecutorial experience who overlapped with a sitting DA who won a primary. And had martinis at the victory party. The AI models decided that matched with Atlanta’s Fani Willis. [as the DA]
Once it narrowed the list down, the bot also searched the dockets of possible judges to match the claim in the reports that the high-ranking law enforcement officer did not materialize into a conflict because no cases involving that police department showed up on the judge’s docket.
For good measure, the bot went ahead and took a guess at the officer’s identity too.
In about 10 minutes of work, the AI unraveled all the work these judges put in to keep this confidential. With nothing but a couple of published court documents and the open web. In the time someone might brew a cup of coffee, the most basic possible workflow defeated the Eleventh Circuit’s entire anonymization strategy."
"On June 9, 2025, after the [NY State] Assembly approved the bill, Ms. Netherland was in the State Senate chamber, watching the aye votes mount, and seeing it pass.Gov. Kathy Hochul signedan amended version in February; it is scheduled to take effect Aug. 5.
“A breakthrough moment,” said Kevin Díaz, president of Compassion & Choices, which has spearheaded the long campaign for such laws. After almost 30 years — Oregon’s law, the first in the country, was enacted in 1997 — the addition of two populous states means that almost a third of Americans will live in one where medical aid in dying is legally available. “It shows that there’s broad support for this model,” Mr. Díaz said.
Polls consistently back that claim. APew Research Center surveylast spring found that almost two-thirds of respondents didn’t consider the practice “morally wrong,” either because they thought it was acceptable or not a moral issue."
As the title suggests, the statement focuses on removing financial disincentives for organ donation.
But I'm struck by the last item on the list:
"Additional Steps "In advocating for the elimination of disincentives to living donation, AST will examine, in parallel, the legal,ethical, and practical considerations involved in a pilot study of financial incentives for living organ donation."
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