Brocher conference on boundaries for incentives in organ donation Oct 27-29 in Geneva

 I'm on my way to the Brocher Foundation, near Geneva, for a conference organized by Swisstransplant (SWT) and the Declaration of Istanbul Custodian Group (DICG), on

 Constructive dialogue interrogating boundaries for incentives in organ donation  

"The shortage of organs available for transplantation poses a major challenge to healthcare systems. Some proposals aim to introduce incentives to encourage organ donation. This workshop examines the ethical implications of these strategies and discusses acceptable limits for promoting donation while respecting human dignity." 

"I'm more worried about democracy than artificial intelligence": Italian press on Moral Economics in advance of the International Festival of Economics

In the run-up to the  International Festival of Economics in Turin starting today, Vanity Fair in Italy publishes an interview with me under this headline:

Alvin Roth: «Sono più preoccupato per la democrazia che per l’intelligenza artificiale»

 "I'm more worried about democracy than artificial intelligence" 

 

The Festival itself publishes this article:

ROTH E LA SFIDA DEI MERCATI RIPUGNANTI  ROTH AND THE CHALLENGE OF REPULSIVE MARKETS 

 

And here's an essay I sent in English, translated into Italian, which you can translate back pretty well:)

Eco­no­mia in cerca di morale
Esi­stono mer­cati con­tro­versi (alcol, gioco d’azzardo, utero in affitto...) su cui i vari Paesi hanno posi­zioni diverse, riflette il Nobel Alvin E. Roth: non sem­pre si arri­verà al con­senso col­let­tivo, ma è lecito esplo­rare com­pro­messi La Lettura
Di ALVIN E. ROTH (tra­du­zione di Rita Bal­das­sarre)

Economy in search of morale
There are controversial markets (alcohol, gambling, surrogacy...) on which the various countries have different positions, reflects the Nobel Prize winner Alvin E. Roth: collective consensus will not always be reached, but it is legitimate to explore compromises 

The once and future market for prostitution in Rhode Island

 Kim Krawiec, the great legal scholar of repugnant transactions, has written that rare (almost never seen) book review that extends the empirical study of an important, well-studied social science event, namely Rhode Island's experience of legal prostitution. It provides an illuminating followup to the germinal paper by Cunningham and Shah. (Prostitution in R.I. is one of the controversial markets covered in Moral Economics, and I believe Krawiec's book review is headed for a forthcoming symposium on the book in Œconomia ­­.)

The Smallest State's Big Experiment by Kimberly D. Krawiec
 October 09, 2026

Abstract
Rhode Island’s accidental decriminalization of prostitution in 1980 is typically told as the story of a legal change that went unnoticed for more than two decades. This review of Alvin Roth’s latest book, Moral Economics, challenges that standard account and explores its implications for Roth’s argument that markets need social support to flourish. Drawing on court records, contemporaneous news reports, arrest statistics, and legislative proceedings, I show that the statutory change was noticed almost immediately. Prostitution-related arrests continued, not because police and prosecutors were ignorantly arresting and charging sex workers and clients under a statute that no longer existed, but because the legal system adapted using tools – primarily the loitering prohibition that survived the 1980 rewrite – that have long been used to police behavior and individuals considered repugnant. After a 2003 judicial ruling closed an important enforcement avenue against indoor sex work and vaulted the market into the open, a coalition formed around trafficking concerns that eventually paved the way for recriminalization in 2009. Rhode Island’s accidental experiment with decriminalized sex work provided neither the deliberately designed regulatory framework nor the political backing that could build the type of social support that Roth insists (correctly, in my view) markets need to function well. 

Canada tweaks its Medical Aid in Dying law

 Canada has reversed its plan to expand access to medical aid in dying to people with only psychiatric illnesses, after a long controversy (now characterized as a  lack of "perfect consensus." But Canada has expanded access to allow those with progressive diseases to make advanced commitments, ahead of the day when they no longer may be capable of consent.

Canada Halts Plan to Allow Medically Assisted Death for the Mentally Ill.  People who have mental illness alone will not qualify for assisted death, but patients who have other conditions and expect to have a cognitive decline can make an advanced request.  By Vjosa Isai

"Canada will reverse its plan to allow people whose sole condition is a mental illness to seek medically assisted death, the government announced on Wednesday, abandoning a move to expand access to these patients.

“While there is not a perfect consensus on this issue, we believe this is the correct approach,” Sean Fraser, the minister of justice, told reporters on Parliament Hill.

"A law, introduced under the former Prime Minister Justin Trudeau, that allowed people with intolerable suffering from incurable mental health conditions to access a medically assisted death was initially poised to take effect in March 2023. Access for these patients was postponed for a year after public and some medical-community concerns that the existing system was not yet prepared to evaluate applications from these patients. In March 2024, the government delayed again, this time until March 2027, pending reviews by a panel of experts.

"With the clock ticking toward that deadline, Mr. Fraser said the government “very recently” formalized its stance and that Canadians can soon expect parliament to pass legislation that will indefinitely bar people whose sole medical condition is a mental disorder from seeking medically assisted death.

"The government is broadening the law to allow people with serious illnesses to make advance requests for medically assisted death if they anticipate their cognitive health will decline in a way that would prevent them from providing consent for the procedure in the future. This is already available to patients in the province of Quebec. The ability to make an advance request for assisted death has considerable public support."

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). "

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.” 

Organ trafficking research

 Frederike Ambagtsheer is the principal investigator of a Dutch project conducting organ trafficking research, whose website discusses their work:

welcome to organ trafficking research

This platform presents research projects on the human organ trade that are conducted by Erasmus MC's Organ Trafficking Research Group. We further provide information for interested audiences (e.g. students, researchers, law enforcement, law -and policy-makers, etc) about the complexities of this crime and the responses there-to.

The organ trafficking research group is based at Erasmus MC's Department of Internal Medicine, Section Nephrology and Kidney Transplantation in Rotterdam(opens in new tab), The Netherlands. This department is part of the recently established Erasmus MC Transplant Institute (opens in new tab)which houses one of the largest kidney transplantation centers in Europe.

...

what we do

We are an enthusiastic and dedicated team of researchers that conduct empirical research on different facets of organ trade and trafficking. Our research is structured into various projects. Methods include a mix of qualitative and quantitative research strategies including systematic literature reviews, surveys, ethnographic research, crime scripting and network analysis.

We conduct research in countries across the globe and we focus on all stages of the organ trading chain, including organ buying, selling, the organisation of illegal transplants and law enforcement responses. We also explore alternative measures such as allowing financial rewards for organ donation. In addition, we advise governments and (inter)national organizations on how to address organ trade problems.

Our research is funded by organisations including the European Commission, the European Research Council and the Dutch Research Council (NWO)."

 

 

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"

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." 

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. " 

 

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 

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." 

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)]. 

Regulation after a first occurrence : Cornell bans students from skinning bears in a dormitory kitchen

 It turns out that Cornell had no rule preventing students from skinning bears in a communal dormitory kitchen.  But now they do. (A lot of regulation works like that... keep an eye on AI...)

Students Skinned a Bear in a Dorm. Cornell Realized It Should Ban That.
After two Cornell University students skinned a black bear in a communal kitchen last year to make a meal, the school changed the rules.  By Miles G. Cohen

Congressional Republicans find IVF repugnant (by stealth, in an election year)

 Public rhetoric and parliamentary maneuvering display opposite positions on IVF in an election year.

G.O.P. Kills Bid to Expand I.V.F. Access in the Military
In a notable shift, Republican senators voted unanimously against a proposal to expand the military’s coverage of fertility treatments. By Annie Karni

"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."

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."

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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:

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. " 

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Earlier: 

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

Surrogacy: a political scandal in Germany, and fertility tourism around the world

 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.)

Uproar Over Surrogate Baby Prompts German Official’s Sudden Resignation
Jens Spahn, a top leader of Chancellor Friedrich Merz’s party, resigned his post after announcing that he had a baby by surrogate, which is illegal in Germany.   By Jim Tankersley

"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 Guardian reports:

Rise in overseas surrogates ‘increases risk of stateless babies’
Calls grow for global regulation as rising numbers of westerners use surrogates in countries with different laws  by Jessica Murray and Rachel Hall

"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." 

MAID in France

 After a multi-year legislative struggle, France's  Assemblée Nationale legalized medical aid in dying for some patients.

Le Monde has the story:

What's in France's assisted-dying law?
The law adopted on Wednesday establishes the right to assisted suicide or euthanasia for patients experiencing constant suffering from serious and incurable illnesses, under strictly regulated conditions.
By Béatrice Jérôme 

"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."

##########

 The Catholic Courier summarizes some of the opposition to the bill:

France’s bishops criticize vote legalizing ‘assisted dying’
Caroline De Sury/OSV News | 07.16.2026

"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.”