Dubner interviews me about kidney sales and such

Repugnance radio* turns out to have two parts, and the second part is a Freakonomics blog post with a link to a podcast (which you can also download free at itunes), in which my voice is heard. Organ transplants are the main subject, from various angles.

Remind me to figure out how to have mood music come on when I speak, as I do in the podcast... (I might choose different mood music...)

If there's a transcript on the web at some point, I'll link to that for those of you who don't have a half hour to listen. 

*The Levitt quote about economists in my earlier post about the NPR broadcast also made it into the podcast...

Auctions of airport slots: dead in the water, again.

The latest news on plans to auction off takeoff and landing slots at NY's LaGuardia airport: DOT scraps auction plan for NYC airports .

NYC's airports are the most congested in the nation, but plans for an auction have been politically troubled from the start (see some of my related earlier posts). What is the nature of the politics? Perhaps some of the airlines that fly in and out of NYC airports actually like the congestion, since it keeps out new competition by preventing airlines that don't presently have any slots from getting any.

Freakonomics has a non-auction suggestion for relieving the congestion: Shut Down LaGuardia.

Organs for transplant: supply and demand

An interesting post at Freakonomics brings to attention a paper in the International Journal of Health Services by Herring, Woolhandler, and Himmelstein titled
INSURANCE STATUS OF U.S. ORGAN DONORS AND TRANSPLANT RECIPIENTS: THE UNINSURED GIVE, BUT RARELY RECEIVE

The subtitle tells much of the story, the paper finds that "16.9 percent of organ donors but only 0.8 percent of transplant recipients were uninsured"

The paper begins with the following story:
"In September of 2005, one of us (Herring), then a third-year medical student, cared for a previously healthy 25-year-old uninsured day laborer who arrived at the emergency department with rapidly advancing idiopathic dilated cardiomyopathy. The patient was ultimately deemed unsuitable for cardiac transplantation.
The decision on transplantation was driven, in part, by realistic concern about the patient’s inability to pay for long-term immunosuppressive therapy and to support himself during recovery. Absent such resources, the likelihood of a successful outcome is compromised (1–4). The clinicians caring for him faced a wrenching dilemma: deny the patient a transplant, or use a scarce organ for a patient with a reduced chance of success. He died of heart failure two weeks after his initial presentation. This tragedy inspired us to examine data on the participation of the uninsured in organ transplantation, both as recipients and as donors."

HT Scott Kominers

Thoughts on 'extreme altruism,' focusing on nondirected kidney donors

Here's an interesting article about altruism, non-directed kidney donors, and the difficulty of studying them (but maybe they are the opposite of psychopaths):
The Selfless Biology of the Extreme Altruist
What is the opposite of a psychopath? What is the limit of human goodness?
by Tanya Basu
(the url is as informative as the headline: https://www.inverse.com/article/28280-kidney-donation-extreme-altruism-can-people-be-selfless)

The article focuses on one particular non-directed donor, but also discusses some altruism researchers (and has a slightly confused view of economics).

Here are some sentences that particularly caught my eye:

"In 2015, Brooks and his wife were on a summer road trip. They were listening to Freakonomics, the NPR podcast spun off from the best-selling pop-economics book, when an episode called “Make Me a Match” came on. It was a profile of the Stanford economist Al Roth, whose Nobel Prize-winning work considered kidney donation matching as an economic market, maximizing its efficiency and potential. Roth’s work was unique because it looked at this unique market as an example of how non-monetary systems could run efficiently purely by matching, no system necessary. Brooks — otherwise a smooth talker — stammers when describing the power of that podcast, saying he felt he’d “been struck by lightning” when he first heard it. He shudders with emotion describing the realization that he, too, should donate his kidney."
...
"By September, he’d matched with a patient on the National Kidney Registry; by November, he’d given up his spare kidney to a total stranger (he later learned her name was Danielle). In February 2016, he founded Donor to Donor which matches non-direct donors with those looking for a kidney, citing his experience as an epiphany in shaping his life’s purpose. Before meeting me at the Yale Club, he’d convinced a potential donor to go through with the operation. He described the feeling of doing so as being something like getting a good grade."

5000 Market Design blog posts and counting

 Peter Coles and I started this blog in September 2008, to help alert students in our market design class at Harvard that market design was everywhere.  Sometime recently I passed the 5000 posts mark.  It turns out I like to blog about market design, broadly construed. And I'm still teaching market design.

The modal tag on my posts turns out to be repugnance, as I've been fascinated by trying to understand which kinds of transactions and markets get social support and which don't. Various design efforts that I've been involved in also have been the subject of multiple posts, with tags like residents and fellows,  school choice, and kidney exchange. 

Some of my favorite posts (from an incomplete series, whenever I manage to get a picture) commemorate dissertation defences. And under a variety of tags (such as market designers) I like to mark when students and colleagues are celebrated or win a prize. (I look forward to writing more of those.)

Less fun is the growing number of posts tagged  RIP, in which I note the passing of people with whom I've intersected, mostly but not always in a market design connection.

In the first years of the blog I allowed comments, but after I got involved in kidney exchange, I had to regularly erase comments--typically sprinkled each night among old posts--that offered to buy kidneys, at unrealistically high prices, phishing for fools. So at some point I shut down comments, noted in this post: August 25, 2018  No comment(s)

Here are ten posts from the last five years that caught my eye as I scrolled through them before giving up on the clunky scrolling device:

September 30, 2020 A modest proposal for the design of presidential debates

March 2, 2018 The Economist discusses repugnant transactions

January 6, 2018 The open culture of academic economics

April 12, 2017 A bridge of life: Global kidney exchange between Mexico and the U.S.

February 21, 2017 Ken Arrow (1921-2017)

Monday, January 30, 2017 Economists as artisans, doctors, entrepreneurs...dentists, engineers and plumbers

December 5, 2016 The human side of kidney exchange: video from NAS (5 minutes)

February 26, 2016 A Freakonomics listener was inspired to become a non-directed kidney donor by the podcast on kidney exchange

March 12, 2016 Lloyd S. Shapley 1923- 2016

May 22, 2015 Mohammad Akbarpour defends his dissertation 

Roger Myerson and Paul Romer on designing nations and cities

Two emininent economists have been thinking about design on the largest of scales.

Roger Myerson thinks about nation building in general, and Iraq in particular, and reflects on the role of political leaders' reputations, for patronage among other things.

Paul Romer thinks about macro-market-design in the form of new "charter cities," to be modeled roughly on Hong Kong.

Here is Roger, in "A Field Manual for the Cradle of Civilization:Theory of Leadership and Lessons of Iraq, " Journal of Conflict ResolutionVolume 53 Number 3 June 2009 470-482. (HT Paul Milgrom)

"Agency incentive problems in government make patronage an essential aspect of statebuilding, and political leaders become fundamentally constrained by their reputations. Democratic competition requires many leaders to develop independent reputations for exercising power and patronage responsibly, which can be encouraged by political decentralization."

Roger then recounts Xenophon's description of the rise of Cyrus (Koresh), the Persian leader.

"The key to Cyrus’s success was his apparent love of justice, which was inculcated by his education and which enabled him to earn the trust and loyalty of a great army. But what kind of justice was it that Cyrus loved so much? It was certainly not justice for poor peasants, whose crops were gathered to support his conquering forces.
What Cyrus loved was justice for the soldiers who served his cause. Apparently Cyrus’s greatest pleasure in life was to judge the valor of troops in battle and to reward them richly for their accomplishments, asking nothing for himself. As a mechanic knows the names of his tools, Cyrus learned the names of all the captains in his army, so that each could be confident of his service being remembered. When everybody recognized Cyrus as the best leader to distribute their booty after a victory, he could take power, first over the multinational coalitional forces and, ultimately, over Asia."


Paul Romer, explains the idea of charter cities here, and in a Q&A at Freakonomics, here: Can “Charter Cities” Change the World? A Q&A With Paul Romer

He argues that to credibly move to better rules, you might have to do some things all at once and start fresh. (He suggests a good place to start would be to have a new Cuban city administered by Canada at Guantanamo Bay, to try to recreate the experience of Hong Kong.)

He too isn't afraid to think big:

"Q. It all sounds great as a theoretical exercise, but honestly, don’t your colleagues tell you that something like this will never happen?

A. They do say this, which is actually kind of ironic when you line it up with the other things they say. They recognize that the construct of a charter city is something that could make everyone better off. They admit that there is no technological or economic constraint that keeps us from building many of these. Then they say that for political reasons, it will never happen. They tell me that you can’t change politics; you can’t overcome nationalism; there is no way for countries to work together to extend the reach of good rules. Then these same economists suggest that we should just stick to business as usual. We should offer conventional economic advice and assume that political systems will naturally follow our advice when we point to something that could make everyone better off. But of course, they have already revealed that they don’t believe this. What’s going on here is a kind of self-censoring. Economists seem to think that we should propose things that are acceptable and that political systems will pursue, but that we should avoid proposing or even discussing things that are controversial or politically incorrect. I think we’d do our jobs better if we just said what’s true without trying to be amateur politicians. "

Romer and Myerson seem to have different views of where economics ends and politics begins.

High frequency ticket buying, by scalper bots

Freakonomics asks Why Is the Live-Event Ticket Market So Screwed Up?

They talk to a bunch of good economists.  Here's Eric Budish on the subject of why it's odd that tickets are "underpriced," in the sense that it's profitable for software bots to buy them up before the humans can get in the act, and then resell them...

"BUDISH: That’s competition on — to an economist — a strange dimension: competition on speed rather than price; that’s the connection to my stuff on high-frequency trading. It’s competition, but it’s not a productive form of competition."

Read (or listen) to the whole thing at the link.

Opposite of repugnance: Protected transactions

I've been thinking lately about transactions that are the opposite of repugnant, i.e. transactions that, as a society, we often seek to promote, for reasons other than efficiency or pure political expediency.

In yesterday's post I mentioned monogamous marriage between a man and a woman, which in many countries and U.S. states is promoted over other forms of marriage (such as polygamy or same sex marriage).

Home ownership in the US is an obvious one, in this post-housing-bubble financial crisis, in which there have been Federal bailouts of the various Government Sponsored Entities like Fanny Mae and Freddy Mac, set up to promote home ownership.

Food production by small farmers, not only in the US, but also in Europe and Japan: we protect this by subsidies, price supports, government supported crop insurance programs, etc.

Fishing by small fishing boats: if we were only interested in protecting fish to keep fisheries sustainable, we might regulate fisheries by imposing seasonal limits on how much could be caught. But in many cases we also set daily limits (e.g. some fishermen on Cape Cod are limited to catch no more than 400lbs of scallops a day). This makes large, factory fishing uneconomical, and protects small local fishermen.

The right to purchase guns probably falls into this category in the U.S.

Of course, as with repugnant transactions, protected transactions may involve a lot of complications, like providing public goods and protecting rights. But it may be that to better understand which kinds of transactions may come to be regarded as repugnant, it will help to understand which kinds of transactions are sometimes protected.

Update: looking at the comments, commuting alone in a car seems worth including on the list of protected transactions in the U.S. (And thank you to Dubner at Freakonomics for his generous plug of this blog...)

Update on that Medicare Auction

Peter Cramton writes to update us on the progress of the letter he organized about A poorly designed Medicare auction .

"I want to thank you again for being a signatory on the letter to Chairman Stark expressing our concerns with the flawed Medicare Competitive Bidding Program. I sent the letter linked below to Chairman Stark late on Sunday night. He responded within two days with a letter to the head of Medicare concluding, “I urge you to give these comments and recommendations serious consideration. I would also request that you inform me in a timely way as to whether CMS plans to incorporate any of the recommended changes and if not, why not.”  The full letter is linked below.

"Letter from 167 Concerned Auction Experts on Medicare Competitive Bidding Program" to Chairman Stark, Health Subcommittee, Ways and Means, U.S. House of Representatives, 26 September 2010. [Letter from Chairman Stark to CMS] 

Yesterday, the deputy head of CMS, who is in charge of the competitive bidding program, contacted me to request a meeting  to discuss the issues. We have not met yet, but I am optimistic that something good will come from this. Please be patient. Washington has now effectively shut down until after the elections. This will be a slow burner, but thanks to all of you the chance of a sensible outcome is positive. One could not say that a week ago.

A thousand thanks!

Best,

Peter

PS You may find the [Excerpts from replies] of interest. The excerpts are anonymous. Finally, here is a Freakonomics Blog with Ian Ayres that appeared today in the Opinion Pages of the New York Times.

Professor Peter Cramton

Economics, Tydings Hall

University of Maryland

College Park MD 20742-7211

Update: Peter and Brett E. Katzman have a followup column in The Economists' Voice (Oct. 2010): Reducing Healthcare Costs Requires Good Market Design

More on the debate over kidney sales: transcript of interview

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

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

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


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


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

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

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

Anesthesia was once repugnant

A wonderful story by Mike Jay in the Boston Globe, The day pain died , recounts how the first surgical use of anesthesia came long after its pain-killing properties were known. An impediment to its use, however, was the thought that pain relief was repugnant, i.e. there was something wrong in having a pain free operation.

Here is the beginning of Jay's story, and the end (emphasis added):
"The date of the first operation under anesthetic, Oct. 16, 1846, ranks among the most iconic in the history of medicine. It was the moment when Boston, and indeed the United States, first emerged as a world-class center of medical innovation. The room at the heart of Massachusetts General Hospital where the operation took place has been known ever since as the Ether Dome, and the word "anesthesia" itself was coined by the Boston physician and poet Oliver Wendell Holmes to denote the strange new state of suspended consciousness that the city's physicians had witnessed. The news from Boston swept around the world, and it was recognized within weeks as a moment that had changed medicine forever.
But what precisely was invented that day? Not a chemical - the mysterious substance used by William Morton, the local dentist who performed the procedure, turned out to be simply ether, a volatile solvent that had been in common use for decades. And not the idea of anesthesia - ether, and the anesthetic gas nitrous oxide, had both been thoroughly inhaled and explored. As far back as 1525, the Renaissance physician Paracelsus had recorded that it made chickens "fall asleep, but wake up again after some time without any bad effect," and that it "extinguishes pain" for the duration.
What the great moment in the Ether Dome really marked was something less tangible but far more significant: a huge cultural shift in the idea of pain. Operating under anesthetic would transform medicine, dramatically expanding the scope of what doctors were able to accomplish. What needed to change first wasn't the technology - that was long since established - but medicine's readiness to use it.
Before 1846, the vast majority of religious and medical opinion held that pain was inseparable from sensation in general, and thus from life itself. Though the idea of pain as necessary may seem primitive and brutal to us today, it lingers in certain corners of healthcare, such as obstetrics and childbirth, where epidurals and caesarean sections still carry the taint of moral opprobrium. In the early 19th century, doctors interested in the pain-relieving properties of ether and nitrous oxide were characterized as cranks and profiteers. The case against them was not merely practical, but moral: They were seen as seeking to exploit their patients' base and cowardly instincts. Furthermore, by whipping up the fear of operations, they were frightening others away from surgery and damaging public health.
The "eureka moment" of anesthesia, like the seemingly sudden arrival of many new technologies, was not so much a moment of discovery as a moment of recognition: a tipping point when society decided that old attitudes needed to be overthrown. It was a social revolution as much as a medical one: a crucial breakthrough not only for modern medicine, but for modernity itself. It required not simply new science, but a radical change in how we saw ourselves."
...
"Once Morton had successfully demonstrated his technique of ether anesthesia, it was quickly seen that its implications reached considerably beyond the dental business. Before 1846 was out, it had been successfully tried by the most celebrated surgeon in Britain, Robert Liston, who pronounced that the new "Yankee dodge" had "the most perfect and satisfactory results" and was "a fine thing for operating surgeons." It was enthusiastically championed by an emerging generation of medical humanitarians, and the new buzzword "anesthesia" crystallized the sense of novelty and medical miracle. Chemistry had, as Thomas Beddoes had prophesied, come to rule over pain.
Despite its successes, resistance to the idea didn't vanish overnight. Until the end of the century, some doctors would maintain that pain had a necessary role in the preservation of life, but from 1846 onward they were outnumbered by those who insisted that it was the job of a physician to inflict as little of it as possible. Some religious voices would hold out for a good deal longer: Pope Pius XII would confirm that "the Christian's duty of renunciation and of interior purification is not an obstacle to the use of anaesthetics" only in February 1957.
Despite the long resistance, that demonstration in the Ether Dome marked a transition that was as irreversible as it was historic. The practice of medicine finally achieved a goal that it had, until that moment, never truly been able to imagine: loosening pain's age-old stranglehold on humanity. And in a sense, the invention was the least of it. The real milestone witnessed in Boston that day was the moment when culture had finally caught up with chemistry."

The article comes from Jay's new book The Atmosphere of Heaven.

Update: Dubner at Freakonomics follows up on this post and draws some interesting comments, including this one:

“So discredited had narcotic drugs become by the middle of the seventeenth century that when Nicolas Bailly, a barber-surgeon of Troys, administered a narcotic potion to a patient before an operation, the venture aroused widespread condemnation. Bailly was arrested and fined for practicing witchcraft. The stupefaction of patients by administration of herbal remedies was then forbidden in France under heavy penalty.”
(Victor Robinson, M.D.: Victory Over Pain. A History of Anesthesia, London: Sigma, 1947. p.40)— kaloniki "

A living kidney donor podcast by Ned Brooks

 Here's a link at which you can hear Ned Brooks, on the latest episode of Donor Diaries. 

"Ned is a high-profile activist for living kidney donation and the founder of The National Kidney Donors Organization.  Ned’s appearance on Freakonomics podcast and his TEDx Talk on living kidney donation are often mentioned by living kidney donors as an early inspiration for their donation."  

https://www.donordiaries.com/episodes

Laurie Lee interviews me about kidney exchange, repugnance, and more (podcast)

 Laurie Lee interviews me in her podcast Donor Diaries.

Donor Diaries

Coffee and Kidneys with Al Roth

https://www.buzzsprout.com/1748941/13094958?t=35 (You don’t have to log in; just click on “Listen Now”.)

***********

Here is her written description:

"Exchanging kidneys is a complicated process that involves multiple collaborations between kidney patients, living donors, transplant centers, insurance companies, airlines and more.  It’s truly remarkable if you stop to think about the number of people and organizations that need to come together to make 1 paired exchange possible.  We only started exchanging kidneys between non-compatible pairs a little over 20 years ago, so it’s a somewhat new process.  Have you ever wondered how this was made possible?

"Meet Nobel Laureate Al Roth who is an economist and Stanford University professor.  Al designs markets.  He’s one of the prominent players who has made kidney exchange possible.  In a nutshell, his work has revolutionized kidney exchange around the world by using economic theory to make kidneys more available.

"In October 2012, Al was the co-recipient of the 2012 Nobel Memorial Prize in Economic Sciences, together with Lloyd S. Shapley, for “ the theory of stable allocations and the practice of market design."

"Al Roth is well known for his application of economics to real world problems.  In this podcast episode we touch a wide range of topics ranging from paired exchanges, prostitution, surrogacy, and more.  All of these markets are examples of repugnant markets.  Kidney Donation can be characterized as a repugnant market, and Al will tell us all about it! 

Links:

Abundant/ CrowdSource for Life Film
Al Roth’s Blog
Al Roth’s Website
Freakonomics Make Me a Match Episode with Al Roth

Donor Diaries Website
Donor Diaries on Facebook
Crowd Source for Life

Patricia Kravey on non-directed organ donation

From my recent email, a nuanced yet inspiring story from non-directed donor Patricia Kravey.

"I’ve been meaning to write you for five years so it’s time I finally got around to it, but I’ll try to keep it short.

I’d been thinking about being an altruistic for many years without people being able to understand why. When my husband heard your interview on Freakonomics he finally got it and shared the podcast with me.

Your chapter on Kidney Chains has changed my life and the five people who received kidneys in the chain I was a part of. Without the power of knowledge from your book I would not have understood why my hospital was resistant to creating a national chain that went outside their hospital system. From your chapter I called the National Kidney Registry and UNOS to ask how they formed chains, how many people could receive kidneys in their chains and the barriers hospitals encounter in joining their programs. On the phone I was thrilled to speak to Ruthanne Leishman, she was in your book, she was famous!

After learning the cost for hospital to join NKR even though they have lengthy donor chains; I told my hospital, where I was also an employee, that I would only be donating through them if they participated in a chain through UNOS. Despite my request to wait the hospital ran their program and matched me internally. So I had this heavy weight of decision to give to the highly sensitized person my hospital matched me with or to pursue a donor chain. After sleepless nights I came up with what I thought was the perfect solution. I would agree to give to the recipient within the hospital and their mismatched donor would be the person officially enrolled in the UNOS program.

The surgery to my anonymous recipient went smoothly. I cried when the doctors told me he was doing well.

Months later I bumped into my transplant coordinator in the hallway at the hospital and she excitedly told me a news story was being released tonight. The mismatched donor of the person I had given to had completed her surgery and the kidney chain and continued on in the mad rush of 24 hours across the country. The news story was going to be about the hospital’s first national donor chain and the person who started it.

Since my donation wasn’t within the exciting 24 hours my hospital had decided I wasn’t part of the chain. I wasn’t included in the news story or even formally told about it. The story showed my recipient who I hadn’t decided if I was going to meet yet. My colleagues saw the story that night and could tell it was my story that didn’t include me.

Your book helped me understand why the hospital and the media would do that as well.

I did meet my recipient in person later. He was a lovely man. Charming, appreciative and so full of energy. He visited me at my office at the hospital several times and he sent a gift for my baby shower. I felt very lucky and grateful to have met him.

Four years after the transplant he died. Skin cancer got him. His wife told me the doctors had led him to believe that the kidney he’d received from me could be passed on. Of course it couldn’t be since it could contain cancer cells.

I have mixed feelings about being an altruist donor. It wasn’t perfect. It wasn’t the story or the fulfilling experience I had hoped it would be. But it was better and it benefited more people because of you. I hope people tell you everyday that your work has changed lives.

Thank you.

Best regards,

Patricia Kravey (Harvey)

https://komonews.com/news/healthworks/seattle-kidney-chain-changes-8-lives-its-the-gift-of-life

https://blog.swedish.org/swedish-blog/how-donating-a-kidney-gave-me-joy-and-someone-else-his-life-back

(in rereading my interview in Swedish Medical Center's blog, I’m embarrassed that I didn’t cite you!)"

Repugnant gambles

Justin Wolfers has a blog post at Freakonomics in which he observes that the Australian Federal Treasurer regards bets about the recession repugnant if placed on a book making site, although fine if placed in options markets. (This even though the bettors on the bookmaking site apparently are of the opinion that Australia will avoid a recession...)

Market for matchmakers: sorting by price

Dating and matchmaking services vary widely on a number of dimensions, one of which is price. Below I'll talk about services whose prices vary from zero to an initial fee of $20,000. One question is how much if anything does that already tell you about who might use which services?

Penny-Pinchers Might Unite at Free Dating Site
"Match.com, which is owned by Internet company IAC/InterActiveCorp and also runs dating site Chemistry.com, was set to announce Thursday the launch of DownToEarth.com. ...DownToEarth.com joins other free dating sites like Plentyoffish.com and OkCupid.com, and expects to bring in revenue from ads. It is geared toward Web dating newcomers and lets users put up post-rendezvous ratings regarding the truthfulness of others' pictures and profiles."

Online Dating Putting You Off? Try a Matchmaker
"Matchmakers prescreen potential matches, focusing on long-term compatibility rather than “short-term chemistry,” Ms. Clampitt said.
While online sites allow unlimited fantasizing, matchmakers encourage clients to take their heads out of the clouds. “Sometimes we will get a guy who is a good-looking man, but no Brad Pitt, and he wants a thin model,” said Shoshanna Rikon, the owner of Shoshanna’s Matches, a Yenta-style matchmaking service in Manhattan that includes an in-person interview and a Web presence, and charges about $1,500 for eight dates. “We try to be more realistic with who we set him up with.""

The New Arranged Marriage
"Janis Spindel Serious Matchmaking Incorporated's fees begin -- begin! -- at $20,000 for an initiation fee, plus $1,000 for a one-year membership that includes 12 dates. That also includes a background check and a home visit, during which Janis spends time with the client, to get a sense of him and verify that he is who he says he is (i.e., rich or very rich). Her image consultant also comes to inspect his wardrobe and, if necessary, make plans to revamp his look. Janis has many clients outside the New York area (in Tampa, Miami, Los Angeles, Toronto, Las Vegas). An out-of-town client must fly Janis and an assistant first class and put them up in a hotel for the home visit. Additionally, a marriage bonus is expected -- sometimes it's a car or extravagant jewelry; other times it's cash. She has received gifts in the $75,000-to-$250,000 range. "

This latter service primarily charges fees to men, and actively recruits attractive women to match them to. This reminds me of a 1993 paper by Mark Bagnoli and Ted Bergstrom called "Courtship as a Waiting Game" which considers why husbands are often older than wives. In their model, people live for two periods. In period 1, men and women are each endowed with a "quality" between 0 and 1, and a woman's quality is common knowledge at period 1, but, although men know their own quality at period 1, it only becomes common knowledge at period 2. So, in their model, the highest quality men wait until period 2, and marry the highest quality women. I guess that, in this model, the $20,000 above would be a signal of male quality... :)

Of course, the value of a match could be a subject of dispute; e.g. here's an 1885 report from the NY Times about a matchmaker suing to receive his full fee after a marriage was arranged but called off. Needless to say, matrimony need not be the only object of matchmaking; Daniel Hamermesh has a Freakonomics post describing an internet site "Ashley Madison, which matches up married women and men who wish to have a quick fling. " (I couldn't figure out their fee structure from the easy to access parts of their web page, but they do offer a $249 refund under their "Affair Guarantee Program" if you fail to have one...)

ReRegulation of the financial markets

A lot of market design is done, thoughtfully or on the fly, by regulators. A good overview of recent events in the financial market meltdown is at
Freakonomics: Diamond and Kashyap on the Recent Financial Upheavals

Kidney donor athlete: Steve

Kidney donors have to be in excellent health, and the site Kidney Donor Athletes celebrates some exceptional donors, particularly as they return to their physically active lives after donating a kidney.

The recent entry Meet Kidney Donor Athlete, Steve!,  is inspiring on multiple levels. It is the story of the donor (and the people he met along the way) who started the chain at Virginia Mason hospital in Seattle, that I blogged about after hearing from the transplant nephologist Dr. Cyrus Cryst:

Monday, March 25, 2019

Followup on the latest Freakonomics kidney exchange chain

Here's how he describes his wife's reaction to his decision to become a non-directed donor:
"My wife said to me “This is the weirdest midlife crisis I have ever heard of.”  I told her, “You know, some guys buy Corvettes and have affairs.”  That quieted her down.  For a minute."

And here's a thought on where chains can go:
"I was elated to learn that the other donation would be to a Native Alaskan woman from Utqiagvik, Alaska, which is the northernmost town in the U.S.  Just think of how terrifying it must be to live in an Arctic village with a serious health problem.  Her odds of receiving a kidney were very small.  There is no way she could have gotten herself to Seattle in time to receive a deceased person’s kidney.  She does not live right around the corner.  And, having spent much of my working career sailing all over the Bering Sea and the Arctic Ocean, I have a deep emotional connection to Alaska.  It just felt right."
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In separate correspondence, I learned that one of the hardships for Debbie, from Utqiagvik in Alaska, was that for some time after her transplant "it meant I couldn't eat raw whale muktak (outer skin and blubber of the whale ) which i love..."

Compensating kidney donors: a call to action by Brooks and Cavanaugh in the LA Times

 Here's a clarion call for compensation of living kidney donors, from two nondirected kidney donors.  It's not the first, and very likely not the last, given the difficulty of modifying the existing law.  But it makes the case very clearly (and proposes that a tax credit spread over ten years might be the way to move foreward).

Opinion: A single reform that could save 100,000 lives immediately BY NED BROOKS AND ML CAVANAUGH, JULY 9, 2023 

"Never in the field of public legislation has so much been lost by so many to one law, as Churchill might’ve put it. The National Organ Transplant Act of 1984 created the framework for the organ transplant system in the United States, and nearly 40 years later, the law is responsible for millions of needless deaths and trillions of wasted dollars. The Transplant Act requires modification, immediately.

"We’ve got skin in this game. We both donated our kidneys to strangers. Ned donated to someone who turned out to be a young mother of two children in 2015, which started a chain that helped an additional two recipients. And Matt donated at Walter Reed in 2021, after which his kidney went to a Seattleite, kicking off a chain that helped seven more recipients, the last of whom was back at Walter Reed.

"Ned founded, and Matt now leads, an organization that represents nearly 1,000 living donors

...

"eight years ago, when Ned donated, the number of living kidney donors was 6,000. With all the work we’ve done since, the number of living donors is still about 6,000 annually. In the United States, nearly 786,000 people suffer from end-stage kidney disease, more people than can fit in the 10 largest NFL stadiums combined.

...

"More Americans die of kidney disease than of breast or prostate cancer, and one in three of us is at risk. This illness is widespread, but what makes it worse is the staggering financial burden borne by everyone. The head of the National Kidney Foundation testified in March that Medicare spends an estimated $136 billion, nearly 25% of its expenditures, on the care of people with a kidney disease. Of that, $50 billion is spent on people with end-stage kidney disease, on par with the entire U.S. Marine Corps budget.

...

"The National Organ Transplant Act prohibits compensating kidney donors, which is strange in that in American society, it’s common to pay for plasma, bone marrow, hair, sperm, eggs and even surrogate pregnancies. We already pay to create and sustain life

...

"The ethical concerns regarding compensation are straightforward. Nobody wants to coerce or compel those in desperate financial straits to do something they would not have done otherwise. The challenge, then — until artificial or nonhuman animal substitutes are viable options — is to devise a compensation model that doesn’t exploit donors.

"Compensation models have been proposed in the past. A National Institutes of Health study listed some of the possibilities, including direct payment, indirect payment, “in kind” payment (free health insurance, for example) or expanded reimbursements. After much review, we come down strongly in support of indirect payment, specifically, a $100,000 refundable federal tax credit. The tax credit would be uniformly applied over a period of 10 years, in the amount of $10,000 a year for those who qualify and then become donors.

"This kind of compensation is certainly not a quick-cash scheme that would incentivize an act of desperation. Nor does it commoditize human body parts. Going forward, kidney donation might become partly opportunistic rather than mostly altruistic, as it is now. But would it be exploitative? Not at all."

...

Ned Brooks and ML Cavanaugh are living kidney donors, and Brooks is the founder of the Coalition to Modify NOTA.

********

Here are all my posts that mention Ned Brooks, starting with this one:

Friday, February 26, 2016

A Freakonomics listener was inspired to become a non-directed kidney donor by the podcast on kidney exchange

Repugnance radio

Freakonomics Radio on NPR's Marketplace had a short segment called It's repugnant, but hey, it's efficient!, in which they speak about organ sales, among other things.

In it, Steve Levitt says
"One of the easiest ways to differentiate an economist from almost anyone else in society is to test them with repugnant ideas. Because economists, either by birth or by training, have their mind open, or skewed in just such a way that instead of thinking about whether something is right or wrong, they think about it in terms of whether it's efficient, whether it makes sense. And many of the things that are most repugnant are the things which are indeed quite efficient, but for other reasons -- subtle reasons, sometimes, reasons that are hard for people to understand -- are completely and utterly unacceptable."

In the comments, they get the following crack:
"There is one organ that nobody will ever need: The brain of an economist."