Repugnance to high incentives, by Robert Stüber

Here's a paper that seeks to understand why some transactions are permitted when only low incentives are offered, but banned when high incentives are offered. (Donation of human eggs is one example; high payments to participate in experiments is another...)

WHY HIGH INCENTIVES CAUSE REPUGNANCE: A FRAMED FIELD EXPERIMENT* by Robert Stüber

WZB Berlin March 2021

Abstract: A key feature of markets for repugnant transactions is that certain transactions seem to raise moral concerns only when they involve high monetary incentives. Using a framed field experiment with a representative sample, I show that these preferences exist, and I investigate why people display it. Participants can permit or prevent a third party from being financially compensated for registering as a stem cell and bone marrow donor. I find that a substantial fraction of individuals permit a low payment but prevent high monetary incentives. With the help of experimental treatment variation, I show that their preference to prevent high incentive offers is caused by the desire to protect individuals with high reservation prices. Evidence from a survey experiment with ethic committees emphasizes the practical importance of this finding. These results imply that shortages in the supply of controversial goods are unlikely to be solvable by providing higher incentives. 

********

Here's a short video presentation of (an early version of) the paper by Dr Stüber.  I understand that he will be moving from the WZP to NYU Abu Dhabi in September.

Public attitudes on compensation for donors

Poll: Americans Show Support For Compensation Of Organ Donors

"Federal law bans payments for organs. But given the need, we wondered what Americans thought about compensation for three kinds of donations that can be made while people are alive: kidneys, bone marrow and a portion of liver big enough to help someone whose liver is failing.

"So we asked 3,000 adults across the country as part of the NPR-Thomson Reuters Health Poll, and here's what they told us.
  "If compensation took the form of credits for health care needs, about 60 percent of Americans would support it. Tax credits and tuition reimbursement were viewed favorably by 46 percent and 42 percent, respectively. Cash for organs was seen as OK by 41 percent of respondents.

"Among people who said some form of compensation was acceptable, 72 percent said it should come from health insurers, followed by private charities at 62 percent and the federal government at 44 percent.
"For all forms of compensation, rates of support tended to fall among older respondents.

"There's been longstanding resistance to compensating donors financially in this country. There are concerns about exploitation and also worries that even small amounts of compensation would undercut a system that depends on altruism."

HT: Steve Leider (and see Leider, Stephen and Alvin E. Roth, “Kidneys for sale: Who disapproves, and why?” American Journal of Transplantation, 10 (May), 2010, 1221-1227.)

Top 2010 stories about repugnant transactions (and all time top repugnant transactions)

Repugnant transactions are those that some people don't want other people to engage in. They have had a big effect on which transactions we see, and which we don't. They change over time, sometimes quickly when they start to change, but they persist for a long time. How about these?

Top 5 in 2010

• Same sex marriage
• Don’t ask, don’t tell in military..
• In-vitro fertilization (Nobel prize in 2010)
• Other reproduction related transactions: surrogacy, eggs
• Body parts for transplantation—compensation for donors (Kidneys, bone marrow, deceased donation…)
• Assisted suicide
• Marijuana (in CA…and lots of crime in Mexico) or Finance(? E.g. securitized mortgages…)

Top 5 of all time

• Sex (outside of marriage, same sex marriage, pornography prostitution…)
• Servitude: Slavery and serfdom and indentured servitude, women’s (lack of) rights (wasn’t so repugnant, now very much so)
• Worship (Inquisition, expulsions, heresy, religious wars)
• Interest on loans (was repugnant, no longer so much)
• Alcohol and mind-altering and addictive drugs (makes the list because of all the associated crime)

Economic rewards to motivate blood donations, by Lacetera, Macis and Slonim

This just out in Science: Economic rewards to motivate blood donations. It suggests that old conclusions need to be revisited based on new evidence.

"The position and guidelines of the World Health Organization (WHO) and several national blood collection agencies for nearly 40 years have been based on the view that offering economic incentives to blood donors is detrimental to the quantity and safety of the blood supply (1). The guidelines suggest that blood should be obtained from unpaid volunteers only (2). However, whether economic incentives positively or negatively affect blood donations (and other prosocial activities) has remained the subject of debate since the positions were established (2–8).

"Evidence consistent with the WHO position came originally from uncontrolled studies using nonrandom samples and, subsequently, from surveys and laboratory studies indicating that economic incentives can “crowd out” (decrease) intrinsic motivations to donate and can attract “worse” donors (9). This evidence arguably affected policies, such as bans on compensation for blood and organ donations in many countries.
...
"With a few early exceptions based on small, nonrepresentative samples (12), field trial evidence on how economic incentives affect blood donations has been absent. But field-based evidence from large, representative samples has recently emerged. The results are clear and, on important questions, opposite to the uncontrolled studies, surveys, and laboratory evidence preceding them."
...
"Conclusion

"In light of the recent evidence, it is time to re-examine policy guidelines for increasing and smoothing blood supply, including whether incentives can play a role. There are efforts under way from different parts of society toward using rewards to increase donations. The U.S. 9th Circuit Court of Appeals' 2012 ruling legalizing compensation for bone marrow donations through apheresis was initiated by private individuals (32). A company prompted a 2010 European Court of Justice ruling that allowed importation of blood products obtained from compensated donors (33). Researchers and clinicians have noted that some WHO guidelines (e.g., emphasis on exclusive use of nonremunerated donors and centralizing blood collection organizations) are unintentionally adversely affecting blood collection in sub-Saharan Africa (34).

"In addition to economic incentives, policy-makers should consider nonpecuniary rewards (e.g., symbolic and with social recognition) and various appeals. Debates on ethical issues around giving rewards for donations (35) should be encouraged. But there should be little debate that the most relevant empirical evidence shows positive effects of offering economic rewards on donations."

Is economic repugnance closely related to biological disgust?

Colleagues often send me articles related to this blog, but the one I have received the most copies of recently is yesterday's NY Times article: Survival’s Ick Factor, about recent studies related to the emotion of disgust, and its possible evolutionary significance in e.g. keeping people away from sources of infection such as feces.

Many people have sent me the article because of my own interest in ickonomics, aka repugnant markets and transactions. A repugnant transaction is one that some people want to engage in, and others think they shouldn't be allowed to. I'm willing to exclude the case of ordinary, pecuniary negative externalities. The issue that initially made all of this very salient to me is the ban, almost everywhere, on buying and selling kidneys (which generated my interest in kidney exchange). But I quickly realized that there are lots of repugnant transactions, and I began a 2007 article on the subject by asking why you can't eat horse meat in California. (It's against the law, passed by popular referendum in 1998.)

Which brings me to the point of this post.

I don’t think the kind of repugnance I study is fundamentally related to biological/evolutionary disgust. The reason there are laws against eating horsemeat, for example, is that it isn’t innately disgusting, so some people want to do it, and others don’t want them to. But there aren’t any laws against eating feces…(sorry, yuck).

Now, I bet that your brain is economical, and that you might recruit some of the same neurons you use to feel disgust to remind you of things you don't like. So I'm not surprised that there are correlates between propensity to feel disgust and some political opinions, for example.

But, to come back to kidney sales, I can't see that the repugnance to selling transplant kidneys for money can be closely related to the disgust that may be inspired by transplantation itself (and the associated blood and guts), since transplantation itself is almost universally regarded as a good thing. That is, the part of the transaction that involves bodily fluids, and might inspire the kind of disgust that would keep you from contamination in other people's innards, isn't regarded as repugnant. Nor is kidney donation, which involves the surgical removal of a kidney. It's only the introduction of money into the transplant transaction that makes it repugnant. (And as we've recently seen with bone marrow, this repugnance to introducing money is alive and well, and crosses party lines.)

And I'm pretty sure there's no evolutionary disgust aroused by money (if only because money was invented pretty late in the evolutionary game...).

Misc. organ transplant links

The links below, which I collected over some time but never turned into blog posts, all have something interesting to say about transplantation.

Should We Legalize the Market for Human Organs? An NPR debate among Sally Satel, Amy Friedman, and Lloyd Cohen (arguing for), and James Childress, Frank Delmonico, and David Rothman (arguing against).

Lingering myths discourage organ donation from American Medical News:
"Only 38% of licensed drivers have joined their states' organ donor registries, with many deterred by long-held misconceptions about how the transplant system works, according to poll results released in April."

Organ donations decline with economy from the Miami Herald.
The numbers of organ donors is down, and experts say one reason may be the recession. But "Because of legislative action, Floridians starting in July will be able to register online to be an organ donor at donatelifeflorida.org ."

In the Kidney Trade: Seller Beware
"Need a kidney? You may be able to buy one in Pakistan, which has become one of the world’s largest “kidney bazaars,” according to an article published in the May-June issue of The Hastings Center Report, a bioethics journal.
But who sells their kidneys, and what becomes of these people afterwards? The article, by two doctors and a psychologist from Karachi, paints an ugly picture of the kidney business and challenges the argument made by some that selling organs is a great financial boon to the poor and that they are grateful for the chance to do it. "

A Better Way to Get a Kidney Daniel Rose in a NY Times OpEd proposes we shift to "opt out" for deceased donors.

National Paired Donation Network (Steve Woodle) does an exchange in Pittsburgh: Kidney exchange benefits boy, 5, and woman

Larissa MacFarquhar: Paying for Kidneys
Megan McArdle: Department of Bizarre Arguments

"Exploitation" of the Poor is a Poor Reason to Ban Organ Markets from the Volokh Conspiracy

Milford men take part in four-way kidney swap (when we helped start NEPKE, only pairwise exchanges were initially feasible, but NEPKE became a pioneer in including 3- and 4-way exchanges in its optimization algorithm...)


Britain's only saviour sibling twins: At the age of two, little do they know it but Amy and Anthony Maguire are Britain's only 'saviour sibling' twins, created to be donors for their sick older brother.
Bone marrow donation requires a perfect match.
"The twins were born after IVF treatment was used to select embryos which are a match for their brother Connor so that blood taken from their umbilical cord at birth may one day be used to offer him life-saving treatment."

Organ donation to get halachic approval
A uniquely Israeli obstacle to organ donation wends its way towards resolution:
"Chief Rabbinate tries to encourage religious public to become organ donors by resolving halachic quandaries surrounding process, issuing special donor card "

Public call for organ donations (China Daily), and
China Announces Voluntary Organ Donor System (NY Times)
CD: "China launched a national organ donation system yesterday in a bid to gradually shake off its long-time dependence on executed prisoners as a major source of organs for transplants and as part of efforts to crack down on organ trafficking."...
"Currently about one million people in China need organ transplants each year while only 1 percent receive one, official statistics show.
Only about 130 people on the mainland have signed up to donate their organs since 2003, according to research on the promotion of organ donation after death by professor Chen Zhonghua with the Institute of Organ Transplantation of Tongji Hospital."...
"China issued an organ transplant law in 2007 that bans organ trafficking and only allows donations from living people to blood relatives and spouses, plus someone considered "emotionally connected."
However, organ middlemen have been faking documents in order to make a person who is desperately in need of money be considered "emotionally connected" to the recipients, reports said.
Living transplants increased to 40 percent of total transplants from 15 percent in 2006, Chen Zhonghua said.
"That's one of the daunting tasks facing us as we try to end the organ trade by establishing this system," Huang noted.
Other goals include preventing organ tourism, improving transplant quality, better defining donors' rights and satisfying patients' needs for transplants in an ethical manner."

NYT: "At least one million people in China need organ transplants each year, but only about 10,000 receive them, according to government statistics. Dr. Huang said that most of those organs — as high as 65 percent, by some estimates — are taken from death row inmates after their executions."...
"The practice of harvesting organs from executed Chinese convicts has been widely reported in the past, although it was only confirmed in 2005, by Dr. Huang, at a medical conference in Manila. The government has routinely denied other allegations that prisoners’ organs regularly found their way to the black market, often for sale to wealthy foreigners, and that executions were sometimes scheduled to coincide with the need for a specific organ.
At a news conference in Shanghai held Wednesday to unveil the new organ-donation system, one transplant surgeon was quoted by the newspaper as saying that the taking of organs from convicts was sometimes subject to corruption. "

Cascades of convalescent plasma for Covid-19, and chains of exchanges, by Kominers, Pathak, Sönmez, and Ünver

Covid-19 convalescent plasma is a new thing in the world, that came into existence only when the first human was infected and recovered from the Covid-19 disease that is now pandemic. It isn't clear yet whether it will be clinically valuable, but recovered antibodies have been valuable for some other diseases, so there's excellent reason to hope that will be the case now too.  And as the number of people grows who have recovered from Covid-19, it is likely that the supply of antibodies is growing much faster, since antibody-containing plasma can be donated once a month or so. (There are  ongoing studies of antibody production by recovered patients, examining how long the antibodies remain at high levels, post-recovery). Of course, most of that supply is sequestered in the blood of recovered patients, so there's a non-trivial issue of collection and distribution.

As readers of this blog know, many countries prohibit the sale of plasma. Will Americans continue to support a commercial market for Covid-19 convalescent plasma in the current pandemic?  A distinguished group of market designers has written a paper considering how to apply techniques developed for kidney exchange to the task of collecting convalescent plasma from recovered Covid-19 patients, if it becomes impossible to buy and sell it. In particular, they consider how to create chains of donations, without using money, to overcome the shortages they anticipate.

Here's an easy to read account by Scott Kominers, one of the authors.

How to End the Plasma Shortage for Coranavirus Patients

Scott Duke Kominers, Bloomberg News  May 11, 2020

"convalescent plasma is in short supply: although it’s hard to estimate precisely, some statistics suggest the U.S. may need twice as much as we have on hand.

"In a new paper, Parag A. Pathak, Tayfun Sonmez, M. Utku Unver and I propose a market design strategy that could help close the gap. Our approach makes use of two special features of the way plasma donation works.

"First, convalescent plasma is collected from recently recovered patients, which means that today’s patients become tomorrow’s prospective donors, assuming they manage to beat the virus. ... That suggests the shortage isn’t from lack of potential supply.

"Second, plasma donation is more than one-for-one: the typical donor can give enough plasma at one time for multiple treatments, and they can potentially donate more than once. As a result, assuming plasma therapy does help patients recover, there is a so-called flywheel effect: the more we use the treatment, the more plasma is available -- provided enough recovered patients are willing to donate.

"Many people would like to donate plasma to help a loved one, but can’t for various reasons:  Their blood types might be incompatible or they might live far away and be unable to travel. To address these sorts of obstacles, my collaborators and I suggest that each plasma donor could receive a voucher that can be used to give a family member or friend priority for plasma treatment. Because donation is more than one-for-one, it’s possible to honor vouchers while still increasing the pool of plasma available to treat other patients.

...

"A similar analysis suggests a role for a pay-it-forward system, where we make a point of treating patients who pledge to donate plasma, assuming they recover and are medically able to do so. Because recovered patients can typically donate more plasma than was needed for their own treatment, this again can help increase the plasma supply in the long run. As a result, my collaborators and I show that, somewhat paradoxically, prioritizing patients who pledge to donate can still end up expanding treatment for the patients who are unable to pledge, or just choose not to.

"Both of these policies are similar to systems we’ve used to expand kidney donation in the U.S.: Priority vouchers are sometimes granted when a living donor gives a kidney to a third-party before one of their family members needs a transplant. And pay-it-forward incentives are used in kidney exchange chains, where a patient with a medically incompatible prospective donor receives a kidney from a third-party donor, and then their donor later gives a kidney to some other patient."
******
Here is the paper itself:

Paying It Backward and Forward: Expanding Access to Convalescent Plasma Therapy Through Market Design
Scott Duke Kominers, Parag A. Pathak, Tayfun Sönmez, M. Utku Ünver
NBER Working Paper No. 27143
Issued in May 2020

Abstract: COVID-19 convalescent plasma (CCP) therapy is currently a leading treatment for COVID19. At present, there is a shortage of CCP relative to demand. We develop and analyze a model of centralized CCP allocation that incorporates both donation and distribution. In order to increase CCP supply, we introduce a mechanism that utilizes two incentive schemes, respectively based on principles of “paying it backward” and “paying it forward.” Under the first scheme, CCP donors obtain treatment vouchers that can be transferred to patients of their choosing. Under the latter scheme, patients obtain priority for CCP therapy in exchange for a future pledge to donate CCP if possible. We show that in steady-state, both principles generally increase overall treatment rates for all patients—not just those who are voucher-prioritized or pledged to donate. Our results also hold under certain conditions if a fraction of CCP is reserved for patients who participate in clinical trials. Finally, we examine the implications of pooling blood types on the efficiency and equity of CCP distribution.

Here's some of the motivation for their model:

"There is an active debate in economics and philosophy on the appropriate role of market-based

mechanisms with compensation for human products used in medicine or medical research like kidneys, blood, blood products, sperm, breast milk, bone marrow, and other.11 Since, as far as we know, there is no current market where infected patients can buy CCP or where recovered patients can sell CCP, we do not consider this possibility as part of our model.

...

"Because CCP is a form of plasma, a natural question is whether a compensated market for CCP will develop. In our model, there is no option to pay to receive CCP or be paid for donating CCP, but a donor can designate the voucher in our model to particular patient in need. As a result, our model of CCP falls between the two extremes described above. We expect that in a crisis moment, there is unlikely to be an active compensated market for CCP (even though it may be impossible to fully prohibit resale of vouchers). If a price-based market does develop, society may deem it unacceptable."

***************

I am more optimistic than they are about the likely available supply of convalescent plasma if it proves useful, through existing commercial channels. My optimism is based on the large thriving commercial market for plasma and plasma-derived antibodies in the U.S., and around the world.  I'll try to blog about the general plasma and antibody (immunoglobulin) market tomorrow, and perhaps more on Covid-19 antibodies later this week.

Wolverines beat Buckeyes in organ donation this year

For you Michigan fans who were disappointed this weekend on the football field, here's some heartening news:U-M beats Ohio State in annual organ donation challenge

"Ann Arbor, Mich. - U-M racked up a victory over Ohio State this week, signing up more people to the state’s organ donor list and winning the annual Wolverine-Buckeye challenge.

"U-M signed up 79,958 donors to Ohio State’s 57,083 in the challenge that ended at midnight on Thanksgiving.

"We all enjoy winning a victory against our rival from Ohio," says Tony Denton, Executive Director of University Hospitals and Chief Operating Officer, U-M Hospitals and Health Centers.

"But the real winners will be the people who rely on these life-saving gifts, organs and tissues that will give thousands of people a second chance at life," Denton says.

"Every day, 19 people die while waiting for an organ transplant and another 138 people are added to the national waiting list. The University of Michigan Health System began a new effort this year, dubbed Wolverines For Life, to encourage organ, tissue, eye, blood, and bone marrow donation by U-M employees, patients, students, alumni, fans and everyone in the state of Michigan.

"To kick off this effort, U-M Football Coach Rich Rodriguez, along with Health System leaders, encouraged people to join in the annual Wolverine-Buckeye challenge. The challenge allowed people to sign up as organ donors upon their death and have their pledge tallied for their favorite school.

HT: Steve Leider

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

Insurance for organ donors in Ireland: is it compensation?

Frank McCormick points out this interesting story from Ireland:

If you're donating an organ, you can now get insurance cover
The new Royal London Ireland offering has come in for criticism...

"Royal London Ireland has announced that it will now offer a "financial cushion" for policyholders who donate a kidney, bone marrow or portion of a lung or liver to another family member.

The first-of-its-kind "organ donor cover" has been introduced as part of the insurance provider's Specified Serious Illness (SSI) cover.

Under the newly-revamped policy offering, Royal London will pay a €2,500 one-off lump sum to living donors.

In the wake of the news, concerns have been raised that it amounts to "cash for organs" and is unsavoury and unethical.

Mark Murphy, chief executive of the Irish Kidney Association, has said:

"We don't need insurance companies offering these things, we have a compensation scheme... It's not necessary, it's not needed. They shouldn't be doing it, on the basis that it's not needed."

 Colette Houton, Royal London's underwriting and claims lead, commented:

"The supply of organ donations is an ongoing issue in this country, with an ever-increasing demand from those who are unfortunate enough to need organ transplantation.

"This shortage has led to more people receiving organs from living donors...

"It would be nice to think our pay-out could potentially help to offset the cost incurred as part of the admirable, altruistic acts that living donors are carrying out...

"Potential donors can face loss of earnings coupled with high medical bills and expenses and our goal is to alleviate these worries and concerns somewhat, by providing some financial aid to support them through surgery and recovery time.

"Living organ donation is an admirable, altruistic act and a lump sum can, at least, help to offset any costs the donor incurs following the operation and recovery involved."
*********

Here's a related press release from the Irish Brokers Association:
Royal London Launch Best-in-Class Serious Illness Cover

The Iranian kidney market in Mashhad, by Mehdi Feizi and Tannaz Moeindarbari in Clinical Transplantation

Here's a new article in Clinical Transplantation:

Characteristics of kidney donors and recipients in Iranian kidney market: Evidence from Mashhad
Mehdi Feizi  Tannaz Moeindarbari
First published: 06 August 2019 https://doi.org/10.1111/ctr.13650

Abstract: The Iranian model of kidney transplantation is an example of a regulated living unrelated renal donation. In this paper, we collected and analyzed a unique dataset of 436 paired kidney donors and recipients, including their characteristics and the realized price of a kidney in Mashhad. As opposed to the global picture of kidney donation, we find that women are less likely to donate and more likely to receive a kidney. Moreover, the average price of a kidney amounts less than 2 years of work with the minimum level of wage.
***********

The article elicited a commentary by Gabe Danovitch, an eminent nephrologist at UCLA who speaks and writes frequently in opposition to compensation for donors:

COMMENTARY
Financial neutrality should replace the Iranian paid donor market
Gabriel Danovitch
First published: 16 July 2019 https://doi.org/10.1111/ctr.13665

He explains his opposition to markets in general this way: "the term “regulated market” is oxymoronic with respect to markets in general and specifically when it comes to human organs..."

(One wonders how the market for nephrologists works, and for medical specialists and subspecialists generally.  Someone should study that...)
**********

The article on Mashhad includes some very interesting description of the market there:

"Since the first live kidney transplant in Mashhad on 2 April 1985 until December 2017, more than 2500 people have had a kidney transplant in the Montaserie Organ Transplantation Hospital. It is operating as a center for dialysis and the only center in Mashhad and neighboring regions for transplantation of kidney, liver, and bone marrow. According to the latest reports, more than 7000 people from different age groups are now waiting for a kidney in Mashhad.

"In Mashhad, approximately 60 individuals refer to the IKF every week to sell their kidney. Of these donors, about 15 individuals are actively pursuing the process, while the rest are dissuaded due to various reasons. Out of these individuals, about one‐fifth are medically approved for kidney donation, after the 3 or 4 weeks of examinations.

"From the demand perspective, every end stage renal disease (ESRD) patient aged below 70 in Khorasan Razavi Province without having a willing related donor is referred through a nephrologist's letter to the IKF in Mashhad to enter the kidney waiting list according to their blood type. These patients can be entered in the waiting list of hospitals to receive a kidney from a deceased donor as well.

"From the supply perspective, each potential kidney donor, between 22 and 40 years old, should register at the IKF after undergoing the preliminary medical tests and bringing the notarized consent of him/herself and his/her family, including both parents for singles, only the spouse for married men, and the spouse and both parents for married women.
...
There are four different matching lines for each blood type, and the IKF usually pair each donor with a renal patient with the matching blood type in the waiting list based on a first come, first‐served basis. Nevertheless, this is not the only way of matching, and both sides can also publically advertise and find each other outside the IKF matching system. However, they have to register there and do the required paperwork and medical tests, as the transplantation centers only accept donors referred by the IKF, as a market maker.

"A renal patient should pledge in cash half the official price of a kidney to the IKF following the initial registration of the waiting list. Once a patient is matched to a donor and they both agree upon a price, the patient pays the remaining price of a kidney to the IKF via a cheque. After carrying out the transplantation, the IKF transfers all the amount of money received from the patient to the donor. However, the IKF neither receives any financial interest nor benefits from any monetary transactions, as it is a charity after all. Although there is no official ceil price, the IKF in Mashhad informally tries its best to convince and incentivize the donor not to ask a high price.
...
"Almost all kidney donors mostly face severe and urgent financial needs, for example, paying off debts (especially home rentals and blood money) and even living expenses, especially for single‐mother households. Thus, financial issues constitute the most frequent and primary motive for living unrelated donors in Iran.
...
"According to this law, compensated kidney donation in Iran is only possible between two individuals from the same nationality with the legal residence permits, especially refugees in Iran from Afghanistan.

"Since there is a large number of Afghan refugees in Mashhad, the IKF has formed a limited market for them. At the main kidney market for Iranians, donors do not have to wait to find a match, as there are always patients looking for a compatible kidney, especially those with a rare blood type such as AB. However, at the kidney market for Afghans, there is no patient in a queue to get a kidney and donors have to stay on the waiting list to find a suitable recipient.

"Moreover, for Afghan citizens, the amount of money a patient should pay to compensate a donor is determined not based on the official price of a kidney in Iran, but rather in a wholly agreed manner. In 2014, the total cost of kidney transplantation was about 6329 USD. While the government pays all kidney transplantation costs for Iranian patients and donors, Afghan renal patients should pay the hospital fees and other costs related to transplantation, which is estimated about 350 million IRR, almost 8650 USD, and reaches about 800 million IRR, almost 19 775 USD, with the cost of kidney purchase.
...
[Among Iranians] "Not only donors tend to be financially motivated for donation, but also recipients are not wealthy, as 47% of them are unemployed."