Imagine your kid is sick.
An infection struck, rapidly killing off internal tissue and leaving them bedridden for weeks in the ICU. One day your child was healthy, the next, gravely ill. Medication dealt with the bacteria, but the damage was too severe for a body to heal on its own. One kidney went, and then the other. Without a transplant, they will have to make regular trips to the hospital for dialysis and face all kinds of secondary medical problems.
You get tested, as do the rest of your family members who are eligible to donate. But no luck. Your child ends up on a waiting list thousands and thousands of names long. You wait for weeks or months without good news.
Of course, there are thousands of healthy people in your city, millions more in your country. Some of them must be eligible matches. You scrounge up your life savings, pull funds out of your retirement account, put an ad online offering $20,000 to anyone who donates a healthy kidney to your kid. Responses flood in, crowds of people willing to get tested to save your kid and earn some cash.
But the doctor tells you that none of those people can donate. In the United States, as in most of the rest of the world, it’s illegal to buy and sell body parts like kidneys.
In a new paper published by the National Bureau of Economic Research, Nicola Lacetera lays out the key reasons for this rule:
- If people got to buy organs, it would lead to an unequal system where wealthy people got access to body parts at the expense of people who couldn’t pay for life-saving transplants.
- Poor people might choose to sell body parts to meet pressing economic needs, leading to a situation where people are functionally coerced by the inequalities of capitalism into giving up organs.
- Sick people might hide their sicknesses in order to profit from donating infected tissue.
- Broadly speaking, we have a social aversion to morally “repugnant” transactions, often involving buying and selling bodily services. There is a deeply-ingrained intuition that transactions (like prostitution, or even slavery) that involve trade in human flesh degrade the moral character of a society.
But it’s also unquestionably true that a properly-orchestrated organ market could save lives.
In the US, 119,000 people are on the waiting list for a donation, and an average of 22 people die every day waiting for an organ. It’s pretty clear that creating a financial incentive to donate would have an impact on those numbers. (Lacetera offers some specific evidence that people are more likely to donate tissues like blood plasma when there’s money on the table.)
And there exist solutions to at least some of the moral problems. For example: A third party, like the government or insurance companies, could ensure that the list of people who need transplants remains ranked in order of need. Patients who need organs most would be first in line, and no one could pay to go to the front of the line. Paying someone who wants to sell a kidney to someone in need wouldn’t throw all that off — the fresh kidney would just have to go to the highest-need person who is a match, not the highest bidder. That could increase supply without unequally pushing lifesaving organs (or bone marrow or other body parts) toward wealthy patients.
In a system like this, the government or insurance companies would pay for the organ, not the person who needs it. While that seems like an expensive prospect, it could actually save society money in the long-run. Lacetera writes that each kidney transplant would lead to about $200,000 in direct savings — and as much as $1.1 million when you factor in indirect savings from increased health and life expectancy.
(There are also alternative solutions, like kidney exchanges, which Lacetera didn’t address.)
On top of that, a form of delayed payment might prevent people from donating to resolve short-term debts.
Still, Lacetera acknowledges, it’s hard to imagine a pay-for-donation system that didn’t involve some exploitation or at least broad inequalities. The poor will always have more reason to go through the risk and pain of giving up kidneys, parts of livers, or bone marrow under a market economy. There’s good reason to get squeamish when capitalism threatens to touch our most personal choices.
So Lacetera set up an experiment. Through Mechanical Turk, the Amazon system for massive psychological experiments (and other “micro-tasks”), he asked people their opinions on different paid donation schemes. He found that with no additional information, about 50% of respondents in a control group were on board with some form of paid donation.
When another group received evidence that payment could save lives, along with information on how it might be done equitably, about 70% said it was a good idea.
All of which is to say, if you can make a compelling enough lifesaving case, people are willing to leave aside their internal aversions.
So should we allow people to buy and sell organs? Expect your answer to change depending on the patient on the table.
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