This is a situation where people pretend to think an issue (such as paying kidney donors) has important ethical problems that philosophers have debated for centuries, but really they find the issue gross and 'unnatural'. The visceral feeling that something is wrong comes first, the ethical problems are invented to provide rational justification for the feeling. Paying Ukrainian farmers for seed oil: normal. Paying Ukrainian women for surrogacy: something something exploitation. The ethical objections frequently make no sense.
There is a good quote by the economist Joan Robinson: "The misery of being exploited by capitalists is nothing compared to the misery of not being exploited at all."
I do agree that there's a reasonable realist argument for allowing payments, but I'm not sure that a dislike of a world in which poor people sell their body parts to survive is just an irrational feeling that it is gross ..
> a dislike of a world in which poor people sell their body parts to survive is just an irrational feeling that it is gross
I think the main problem here is that preventing people from selling their organs does not prevent this world, it just prevents one type of escape from that world.
Allowing selling of organs does not create poverty, and if people feel coerced to sell their organs, it's not because they were doing amazingly well before - they just had no escape!
Is that the world we are protecting against though? If we allowed transactions, is it realistic to worry that poor people the world over will start selling their body parts en masse just to survive? Or is it more of a situation where a small number of poor people will see a large financial upside and lots of people in wealthy countries will see a huge improvement in health? I just don't see how this leads to a situation where poor people the world over decide their path to financial freedom is selling their body parts on the newly created open market.
I think that is the question - if 5% of people in poor countries do this and get big payouts, that could easily lead to economic conditions in those countries where people who don't do this are more immiserated and this is a ticket to the middle class.
Your argument effectively says "discourage or disallow things that give people an advantage over anyone else". Having both parents enter the workforce, for example, gave families an advantage and "a ticket to the middle class", while families who opt not to do this are "immiserated".
Another example might be college education: ticket to the middle class, people who don't do it are immiserated.
No, not quite. It's "discourage or disallow things that give people a very strong advantage over others but with potential major harm to them". This is the only reason I see to ban performance-enhancing drugs in sport for instance.
If there's no harm to people for doing the thing that gives the advantage, then I would say we should encourage everyone to do it. But if there is a known big harm of one kind, and a potential major advantage of another kind, and if we think that people might mistakenly judge the advantage to be bigger than the harm, then there's at least potentially good reason to step in to make sure people don't feel forced to engage in Faustian bargains.
If, in their judgment, the risk is worth the reward, people will engage in the behavior regardless. All you get is adding "I might get caught and suffer consequences" to the risk bucket, which means it is people who are more desperate or aggressive who will make that choice.
Many things in life have "potential major harm", depending on who is doing the evaluating of the risk and benefit. Car loans, business loans, school loans are good financial examples. Long commutes. Frequent air travel. Working the night shift.
You can cite studies showing both parents working full-time is harmful to their health and the health of the children. It is difficult to draw a clear line about what harm is acceptable.
"...if we think that people might mistakenly judge the advantage to be bigger than the harm..." This is somewhat condescending and presumptive. Who are "we" to judge whether or not it is worth it, and why is our judgement better or more valid than the people being affected? Frequently the dividing line between "mistake" and not is "did I get what I wanted and avoid the bad outcome?"
I think it is much clearer if the argument is doing something that advantages oneself but puts OTHERS at risk for major harm. Drunk driving, for example. Or perhaps driving in general.
Humans are generally bad at evaluating risk and probability (read any of Taleb's books!), but this doesn't mean we can and should intervene when people choose to put their own selves and well-being at risk for possible benefit.
The PED example is a pretty terrible one. The problematic knock on effect is that the professional sports leagues are, by definition, limited in their opportunities. So only a TINY percentage of people can make it into the leagues, and those that do get an ENORMOUS windfall (a $10k payment to a poor person in a 3rd world country is huge, but even that pales in comparison to the tens of millions of dollars professional athletes stand to gain), so the competition becomes such that people who are cheating push out others who aren't, so those that don't want to participate but want to be a major leaguer feel like they have to use to keep their dreams alive. But in this instance, there's a large surplus of people who need organs, so there is ample opportunity, and you can simple expand the demand as necessary and then reduce the payments to compensate, so the windfall becomes lesser and the pressure becomes lower, but it is still a perfectly viable transaction to voluntarily engage in. You're not pressuring people OUT of the marketplace who WANT to be in it in the way that PEDs function. It really is just another situation similar to both parents working, or an individual working a more hazardous job that pays higher but involves more risk. Those jobs and opportunities already exist all over the world (including in developed nations like the US, where we pay people more for riskier work), and nobody bats an eye, but for some reason this becomes a situation where people imagine these horror story scenarios to obscure the reality of the world we live in.
Why is that? How would 5% of the population receiving a significant cash infusion cause the immiseration of the rest of the population? Those with more will spend more in their communities, and a capital infusion seems like a great first step towards improving any local community's development prospects. It seems like the results of doing this would be either a) not large enough to significantly impact the nation's economy, in which case fears of it becoming seen as the only way to enter the middle class are clearly misplaced, or b) it results in a significant improvement in the lives of many, who can then spend their extra money in the economy, improving the prospects of those around them who didn't participate. I'm not really sure what the option is that says that some people will be better off, but then all the other people will somehow be worse off and will then HAVE to engage in the program in order to escape their poverty. What am I missing here?
The idea would be that, in at least some cases, increasing resources for some members of a community is more likely to create inflation that penalizes other members of the community, rather than the economic multiplier effect. It's an empirical question which is more likely to result.
And of course, this is forever muddled by the continuing popularity of Marx's view that every mutually beneficial transaction is "exploitation" if one of the parties can be classified as more of a capitalist than the other.
Is anybody going to engage with the idea that extremely poor people in extremely poor countries tend to be embedded in economic systems with extremely limited personal autonomy?
Most of this conversation is about individual choices about how people use their bodies, but in a lot of places it seems like a kidney market would just lead immediately to corrupt governments forming kidney export farms out of prisoners and political dissidents.
Intuition is a legitimate source of moral insight. For all its faults and limitations, it's certainly no worse or more limited than moral theories based on maximizing incredibly fuzzy concepts like 'freedom' and 'utility' (which ultimately often boil back down to intuitive judgments).
I disagree. Your gut shouldn't be the end all be all, but certainly a very smart and knowledgeable person can argue something completely false, and you may not have the tools to contradict their argument.
There is something different about selling your time, labor, or skills, and selling use of your body. For one thing, it can't be undone.
A gay couple I know used a surrogate to have two kids. She had children of her own, and served as a surrogate before. The first kid was fine. The second one, she experienced major medical problems during the birth, and lost her ability to have more children.
That didn't end my support for surrogacy, but it's not the same as working a thankless job harvesting rapeseed.
> The visceral feeling that something is wrong comes first, the ethical problems are invented to provide rational justification for the feeling.
This is an objection to all moral theories. Utilitarianism is the completely implausible theory that pleasure is the good and we have an obligation to maximize it. The only reason anyone believes such a silly theory is that they have a feeling that pleasure is good, so they decide it is the good!
The way to do moral reasoning is to start with intuitions and then systematize them. You don't get to handwave intuitions away. If a lot of people think something is bad, then you at least have to explain why they are having a moral illusion, not call their intuitions "visceral" whereas other moral feelings are, one supposes, "cerebral" and therefore superior.
Since when "pleasure" (I prefer 'utility' as I find it closer to the idea utilitarianism is trying to convey) being good and suffering being bad is completely implausible?
It's implausible that pleasure is THE good. It is a good. But it's not even a very important good. People routinely choose, e.g., to die in war, or less dramatically, to shock themselves when bored. People choose careers and lovers and day to day activities based on a million other things than expected pleasure ROI. To keep the idea from being totally implausible, you have to switch out "pleasure" for "utility" when pressed, but "utility" is an incoherent concept. It just means "whatever it is that people actually are maximizing." Tautologies are fun, but now the seemingly intuitive argument for utilitarianism ("pleasure is the good; therefore we should maximize it universally…") has been reduced to "Whatever it is that people are maximizing is the good. We already are maximizing it by definition, but if somehow we weren't, we really ought to, I guess?"
So I am not a philosophe but I don't think anyone switched utility for pleasure. It seems to me utilitarians understood from the get go that "pleasure" was too narrow. As you said, people will defer pleasure or do unpleasant things for rewards other than pleasure. Even Epicureans were moderate if I recall my introductory class on philosophy of 25 years ago...
The tautological comeback is more interesting, imho. And I don't have the knowledge to fight it back. It just seems to me that, if a serial killer was to say "hey, I am maximising my good, fuck off", utilitarians wouldn't be on board.
I like to use the sentence "maximising utility under constraints" (the constraints being things like "we don't divvy up a healthy person into 10 organs to help 10 persons" i.e. basic freedoms and autonomy rights) but I admit it might just be a nice image rather than a well thought out philosophical concept.
FWIW, my favorite easy summary of moral things is the Maslow Pyramid. We're all trying to climb it, from the most holy saints to the most wretched sinners... but I've seen people saying it's tautological too?
Utilitarianism is the theory that serial killers are bad because they are inefficiently distributing utility. They hoard their own utility at the cost of their victims and the loved ones of their victims. The pain they inflict greatly outweighs any possible individual benefit from killing. So far, so good. Every theory of ethics should have a simple answer for deciding easy cases.
But Utilitarianism brings with it a number of absurdities. Is it better if the person you kill is a loner and won't be much missed? What if they're a loner and depressed? What if, per the trolley examples, you distribute the organs? If you've already killed someone and don't plan to do it again (eg it was a crime of passion), it's bad to feel bad about it and mope. You've gotta move forward and experience utility again because we want to maximize utility everywhere.
Utilitarianism does not allow for many normal actions in life. People usually think that "breaking promises is bad" but Utilitarianism requires us to cash that out as "it's bad to develop a reputation for breaking promises if that leads to an overall reduction in net utility over time." Keeping promises should be an easy case, but Utilitarianism struggles to explain why I shouldn't always just do whatever seems to have the highest ROI at the moment.
Utilitarianism has no defense against "utility monsters": individuals or groups of individuals who take great collective pleasure in the suffering of others, such that it mathematically outweighs the suffering. It just has to bite the bullet and say that it's a local maxima, and while it would be better all things equal to get to past the maxima, the maxima is strictly better than its immediate surroundings. That's an implausible outcome.
Utilitarianism initially seems plausible because we say "utility is like pleasure or happiness but more generally in the wholistic sense". However once you expand utility like that, it just loses whatever intuitive plausibility it had. In general Utilitarianism requires "hedonic calculus" to be theoretically possible, if not actually doable. However, it's not clear that any experiences are comparable, let alone able to be stably ranked and weighted.
People try to patch up Utilitarianism by adding ad hoc defeaters or limitations or by suggesting rule following as a general strategy, but basically all of these mean abandoning Utilitarianism per se and replacing it with another theory that just happens to run on Utilitarian grounds for the most part. I think most people are fine with saying, "yes, under ordinary conditions Utilitarianism provides a rough and ready guide to action" but it is exactly in the hard cases—the case where want our theory of ethics to provide guidance!—that it completely falls apart. It provides no guide to action, it requires us to believe things that have no intuitive plausibility, it creates absurd results that people reject, and no one actually follows it. The EA people come closest to attempting to follow it, but even they fail because it's just a bad and unworkable theory.
I _think_ based on Carl's final paragraph, that Carl was being sarcastic on that one, as an explanation why intuition(like, pleasure is good) is actually a basis for moral theories.
Has there been any work done on how allowing legal payments for organ donations would affect the human trafficking situation with regard to organs? I can see how it would both increase and decrease trafficking, but I'm not sure how it would play out in real life in the US.
In keeping with Slow Boring's "Secret Congress" model, there is actually a bill working through the 117th Congress that would address some of the barriers to living organ donation, but comes well short of creating a paid donation market: The Living Donor Protection Act of 2021 (H.R. 1255/S. 377).
Currently, there are no federal laws to protect donors from losing their jobs while on leave for
organ donation and 25% of living donors have gone on to be denied or charged more for life insurance.
This bill would prohibit insurance companies from denying or limiting life, disability or long-term care insurance to living donors, prohibit insurance companies from charging higher premiums to living donors, and allow living organ donors to use time granted through the Family and Medical Leave Act (FMLA) to recover from donation.
It's not perfect, but currently has overwhelming bipartisan support in both chambers of Congress. If this sounds like something you think Congress should be working on, reach out to your Members and ask them to join on if they haven't already! And Matt - Feel free to use any of you connections on Capitol Hill to help move this through the Secret Congress.
I'm not expressing an opinion on the bill or its merits, here, but I feel like it seems really weird in the context of a post lamenting the utility loss caused by market distortions to be praising a bill that by its terms sets out to distort the insurance market. If living donors are, in fact, worse insurance risks, shouldn't they be charged more?
I mean, yeah it seems to be it would be better if we could pay people $X and that was more than enough to cover the increase in life insurance costs, then you don't market distort the life insurance.
But... much like the carbon tax vs. subsidize green energy fight, sometimes the market distortion is just so much more palatable to people that, as long as the net utility is positive vs. the status quo, it might be the best available option?
But if we want to encourage more donations, what's wrong with the insurance companies raising premiums on the rest of their customers to cover the living donor subsidies? It might be better to make it a public rather than a private subsidy, but that doesn't mean the latter should be out of bounds.
If people decline to donate due to a fear of incurring non-covered costs, then that is the market failure, not the proposed regulation of insurance companies.
Fair point, though while it certainly isn’t settled:
“Living kidney donor survival appeared similar to general population sample (statistical comparison not possible)”
(Ibrahim HN, Foley R, Tan L, et al. Long-term consequences of kidney donation. The New England journal of medicine. 2009 Jan 29;360(5):459–469.)
“Long-term living kidney donor mortality was not higher vs age-and comorbidity-matched controls.”
(Segev DL, Muzaale AD, Caffo BS, et al. Perioperative mortality and long-term survival following live kidney donation. JAMA. 2010 Mar 10;303(10):959–966.)
“Most people can live a normal life with just one kidney. Kidney function usually stabilizes 70 to 75% of previous function in a few months after surgery. Risk of kidney failure is not any greater if you have one versus two kidneys…. Risk for high blood pressure may be higher as one gets older compared to a non-donor but it can be managed with medications.”
I had to think a lot about the bioethical issues around new medical technologies for my book, Radiation Evangelists, so I know a bit about this topic. I really enjoyed this post; I think it gets all the big ideas right. That said, I do want to offer a little bit of nuance in the other direction on some of the particular problems with marketization in pharma, biotech, and medicine. I'm still a fan of increased marketization, for all the increased human welfare reasons described in the article, but I also know that some stuff is going to go wrong in predictable ways.
Human challenge trials, in particular, are an issue where I think the benefits have been heavily overstated. I'm not saying they don't exist. But they have been the subject of a lot of theoretical hype at this point, and the problem with theoretical hype is that it always ignores a lot of stuff. The problems fall into a few buckets.
The first bucket is risk-reward. The question you should basically ask yourself is, "How many people am I willing to kill to prove that ivermectin and hydroxychloroquine don't work?" Recall that both of those treatments were touted by boosters as not just treatments for Covid, but prophylactics, i.e. they would prevent infection or serious illness. The good news on these treatments is that they were generally available, so we got to run an actual, real-world human challenge trial with these medications; people voluntarily took them in the midst of a live-ammunition pandemic, and we watched the result play out, which was that some people died, other people suffered the serious negative side effects of the drugs, and there were no gains relative to Covid baseline mortality.
So ask yourself, "Did I think the people taking horse pills were courageous pioneers?"
And of course, you have to remember that hydroxychloroquine and ivermectin had backers with an interest in the outcomes, which complicates the whole story. We're actually seeing a version of this play out with the Chinese vaccines, where the interests had a lot to do with state diplomacy. Again: it's a complicated story. You could just as easily note that Russia also rushed out its Sputnik vaccine, and that one has held up as being pretty good. So I'm not saying this story goes cleanly in either direction. I'm just saying that for every Moderna, you need to prepare for an Ivermectin and a Sinovac, and that complicates things considerably, in part because...
The second bucket has to do with the real world considerations around trial size and efficacy over time. Remember, to produce worthwhile results, drug trials have to be really, really big, not just to determine whether they work, but to determine what types of rarer side effects and health risks you are dealing with, particular in specific populations (i.e. J&J had a higher risk of clots in particular groups) and to give you a time horizon. Just to take one quick example, imagine a vaccine with an initial efficacy of 80% and an incredibly rapid fall-off rate, like it loses 50% efficacy in one month. Such a vaccine would be pretty useless. It would also pass a human challenge trial.
Challenge trials are either not going to get you the information you need, because they are too small or too time-limited, or they are going to employ such large groups of people over long enough periods that they end up de facto looking very similar to the existing structures, in terms of timelines. Could you have shaved a couple of weeks or a month off the Covid vaccine rollout process? Maybe, but...
The third bucket might be termed "real world considerations around pharmaceutical rollouts." Human challenge trials do not solve any of your other bottlenecks on a pharma rollout process. We saw this with Covid vaccines: they tried to spool up production in parallel to the human trials, and the trials outran the production stand-up by several months. It is not at all clear that releasing the vaccines a month earlier would have made a big difference in the rollout, since we know that the vaccine being produced in those initial batches was being used to vaccinate people BECAUSE PEOPLE IN THE TRIALS WERE BEING VACCINATED. It's not like the vaccine was sitting around on a shelf, going stale or something.
I would strongly argue that you could have made a much bigger difference and saved many more lives in 2020 by pouring resources and expertise into ramping up production and pre-building a robust distribution network. Everyone who was running around screaming about human challenge trials should instead have been running around screaming about logistics. Those people who signed up for human challenge trials? Their efforts would have been far better used as labor to staff gigantic vaccination clinics on Day 1.
I could raise similar kinds of questions or add similar types of nuance to all the other issues raised in the column. Again, none of this is to say that I don't think the column was good. I'm pretty much on-board with the claims and proposals.
But human challenge trials and marketization of med stuff in general tends to be presented as "one weird trick to solve X problem in medicine." A place that has been super guilty of this throughout the pandemic was Marginal Revolution, which I used to read religiously and now almost never look at, because so much of their pandemic stuff was total garbage and it made me start wondering (uncharitably) about their other content. Alex and Tyler are very smart guys, but human challenge trials was just one of about ten "one weird trick" pandemic responses that they were five-alarm on that just don't hold up to actual scrutiny.
Matt closes by writing, "More broadly, this whole set of blocked transactions strikes me as an area where humanity is massively underperforming for no real reason." And, honestly, I think to some degree he is correct on this issue. However, when you encounter issues where you feel this way, I think it is useful to deploy a Chesterton's fence skepticism about your own assessment. There are almost always reasons why people do things. They might be really bad reasons--I think with kidneys, a lot of the reasons are bad--but there is almost never no real reason, even if the reason is something totally infuriating. And if you don't understand the reason, you are probably going to fail at solving the problem.
That shouldn't be surprising. The world is complicated. But a lot of legit smart people lose sight of that, because the downside of the world being complicated is that it is no fun. There aren't clever solutions that get you around the slow, difficult, and sometimes tedious work of boring hard boards.
I think the other concern about human challenge trials is will the FDA move with any speed even if it is found to be successful. I'm a participant in the Novavax trial and my kids are in the Moderna under 5 trial and nothing I've seen from either of those has indicated that the FDA would quickly approve even if it got the data faster. It's been over a year from when the data was supposed overwhelmingly positive that they ethically felt they had to give everyone in the trial the real vaccine. The government is also clearly fine with it's effectiveness since I've been counted as "fully vaccinated" for nearly a year as well. It's been approved and used in about a dozen other countries so they are clearly capable of producing at scale and safely with no new unseen side effects like J&J. All the same feelings apply to my kids and Moderna, though less so on each category (it's less effective, it hasn't been as delayed, etc.) I feel like there's much less incentive for a fast trial process if regulators are just going to sit on it for months on end anyways.
This is one more case of politics as a vocation vs politics of ultimate ends. People advocate positive visions totally divorced from the practical consequences of their actions. It applies to just about everything: the last three (serious) Slow Boring posts have been about regulation, the evolution of Democratic messaging, and US abortion policy, and it's been relevant to all three.
It's especially disappointing to see self-declared champions of disadvantaged communities acting in this way.
I’m starting to think more along the lines of just “it’s especially disappointing to see self-declared champions of disadvantaged communities.” Period.
Few of these communities actually seem to want their “Allies” speaking on their behalf. Perhaps we might stop the DEI/Activism organizations from prioritizing the voices of the well-off kids whose parents can bankroll a “career” in activism through unpaid internships over those who’ve genuinely suffered but can’t afford to buy their way to being the loudest voice in the room.
“ The main downside according to Dylan Matthews is that by going from two to one, you slightly increase your chance of ending up with zero. It’s a real, but not very large, risk.”
Just a reminder that if you donate a kidney and later need a kidney you’ll be put at the top of the transplant list.
If we want to consider popularism when making arguments for opening these kinds of markets, then I think it is important to push specifically for small and extremely-regulated markets that are focused on ensuring that it isn’t possible for abuses to occur. You briefly mention India’s former surrogacy market, but it was rife with genuinely awful abuses. Coercion, lack of care for the surrogates’ health, and even cases of straight-up baby selling that was disguised as surrogacy. (The Vice documentary on this was really excellent, from that super-brief period in the 2010s when Vice was making good output.)
A lot of the people who are most inclined to argue for opening a market also tend to be more skeptical of market regulations (or at least tend to not feel that market regulations aren’t a selling point for opening a particular market). But I think the arguments for opening these kinds of markets would be much more persuasive to the average person if they started off by saying that we know that abuses X, Y, and Z can occur in these scenarios, and these new markets would have rules A, B, and C to ensure those abuses don’t happen.
Imagine this: A politician of a middle income country suddenly decides to allow paid surrogates for foreigners.
To the median voter, that would look a lot like that politician looking out for the national interest of foreigners.
Why not appeal to the middle-income-countries-Bailey's and restrict it? (i.e. pay surrogacy only for nationals or members of a certain cultural region, as Latin America)
That would restrict some of the material gains for the mothers, but also... maybe make it pass a democratic legislature?
Disclaimer: I actually know nothing about current paid surrogacy laws beyond what Matt wrote, which makes it look completely illegal in most countries.
Hey I just donated my kidney last week! I can attest to the negative reaction towards the idea of creating a market for kidneys.
I’m not a libertarian by any means but a few days after surgery, I was having dinner with family and I suggested it would be a good idea for there to be a market to sell kidneys so that the supply of donors would grow.
My brother in law thought it was a terrible idea and brought up folks then being “forced” to do it out of economic reasons. They also asked what would happen to those that couldn’t afford to pay for a donor (which I thought was a fair point). I assume there would still be other altruistic donors or perhaps the government or an organization such as the national kidney foundation could subsidize those with less means.
Replying to your family: aren't we all (I mean all, from the dawn of time) forced to do things we'd rather not do out of economic necessity? Also, insurance programs (private/govt) should pay donors, not individuals. This should still stimulate demand, and can be calibrated against cost of care savings and donation rates.
**Edit, of course, as now, you need some form of insurance to get a transplant.
Is it more ethical for thousands to suffer and even die on dialysis each year when a treatment exists?
Are the bad bioethics here secretly funded by the CEOs of DaVita and Fresenius...?
I mean, there's forced generally to do some economic activity, and forced specifically to sell your kidney. I just don't see anything at all making the later true here.
There may be people in the world who would rather have that exact setup. I’m sure you can imagine populations who would rather any alternative compared to how they make a living currently
I don’t find it that convincing but I think the “forced” concept is most persuasive when you have work requirements. Want snap benefits? Well go sell your kidney or do sex work. Another reason to have robust labor markets and universal support programs.
Good for you. On payment thing, apparently dialysis makes up close to 1% of the entire federal budget, so presumably the government could step in here.
Iran is the only country that allows payment for kidneys, and apparently they have the state run the exchanges.
My husband and I have children from a gestational surrogate (a "traditional" surrogate would be our sperm and her eggs, a "gestational" surrogate is implanted embryos) done here in the states.
The agency we used, like the Ukrainians, required that surrogates already have children of her own, and emphasized many of the things Matt mentioned for the Ukrainian program. I'd also mention one thing _we_ felt was that if there were some sort of awful complication of some sort that rendered her unable to bear children in the future, at least she had kids already.
We certainly liked this arrangement - and it wasn't her first surrogacy so she did too.
I would say the biggest difference between this and international surrogacy, especially with someone from a different language background is it's easier to stay in touch with her.
But in our case, we benefited _greatly_ from being able to pay a surrogate, and she obviously felt she benefited as well.
My plan is that since kidney donation is such a positive good for the government, that we should allow kidney donors to enroll into Medicare and waive all premiums going forward. We could call it "Medicare for All Donors."
Pretty sure that Bernie and Ted Cruz would hate this plan equally
If their other kidney goes, they are automatically eligible for Medicare anyway—this would probably save some money, but I bet you wouldn’t see that many takers.
Yes, but most donor's other kidney doesn't go so they don't get that benefit. Instead, as soon as you donate an organ, you get "free medicare" for the rest of your life. Seems like it would be a great way to introduce Medicare for all and increase organ donors.
This would also be smart because it's very cheap. People who donate kidneys would tend to be younger and healthier than your normal Medicare recipient, so their annual medical costs are likely to be very low (while they're also still contributing to Medicare through their wages).
It sounds like a win-win to me. Except for the part about this being a gateway to Medicare for All -- that's a pretty big leap.
This is pretty genius, though youre right, I can hear the "we shouldn't have to live in a country where people are trading their organs for healthcare!" cries now.
I generally agree with quite a bit of this, but two minor points:
1) I think you're avoiding the 'of course, if you make it a market, then you also make selling plasma or selling a kidney, or selling your uterus something that states will require before they provide you, say, disability, or other forms of welfare. Because, after all you can support yourself, so why shouldn't you have to do this?' problem.
2) On the kidney note specifically, I actually got fairly far down the road of voluntary kidney donation, before it was discovered that some relatives have polycystic kidney disease, which is genetic. I was perfectly happy to do some sort of test to see if I carry the markers, but the test isn't covered (at least for a voluntary donor) by either the program, or insurance and the estimated cost from the hospital was 5-10k (why I couldn't tell you). I was unwilling to pay that out of pocket for a chance to do a nice thing for a stranger, but, if you're over 40, then the procedure is just to do the ultrasound they have to do anyway and see if you've actually got cysts. So, I'm waiting until I'm 40, then I'll circle back...
That’s insane—that’s the sort of thing that should absolutely be paid for. I don’t buy the idea that loads of people would be lining up to donate kidneys if there were a payment offered, but certainly if someone is willing to donate ALL expenses associated with that should be covered, including transportation and time off for recovery.
Whole blood donors used to be compensated here but aren't anymore because of safety concerns. I'm a platelet donor, which takes four hours door-to-door, two plugged into a machine. A goddam miserable experience but better now than 40 years ago, when I first did it. In order to give, I have to answer a lot of nosy questions about my health & habits, and then the donation is tested for AIDS. There are never enough donors; I don't see why it wouldn't make sense to compensate folks to get supply up. At a minimum, I'd not feel so bad about not answering the phone when the Red Cross calls.
Good on you being a platelet donor! I’m also a platelet donor and don’t find the process miserable, but it is really time-intensive. I consider it my “binge TV and have a phlebotomist pop Oreos in my mouth” time. There definitely always is a shortage of donors, though, and for good reason - time is money, and very few people want to give up four hours of their time for a voluntary, altruistic medical procedure, and since you can donate weekly you have to field constant Red Cross calls begging you to come in.
I wish I could give blood. I used to do it all the time before I got put on a long-term, low dose antibiotic. There many reasons why some people can't give blood.
Here’s why people hate this — I used to live near a plasma donation place in the US. They put up explicit ads marketing to the local university students about how if tuition and textbooks are too expensive, you should consider selling your plasma.
The place is called “B-Positive Plasma”. Dystopian name, dystopian ads. Imagine extending this to kidneys and that’s unbelievably dark.
I think rationally compensation for kidney donors is a sound idea. But people’s screaming intuition that it’s terrible isn’t pure irrational gross out — it comes from real problems in the US right now — you’d have to be real careful to deal with those.
Maybe I'm a cold and heartless, but this seems good to me??? B-Positive seems like they are marketing to possibly the best audience possible. College students are typically young and would be able to handle recovery from plasma donations better. Helping them get through college seems like exactly the kind of payment we would want. Hopefully if they are going through college than they are smart enough not to be duped...though that's probably wishful thinking on my part.
I guess I agree that it's better to target university students than most other groups.
However I don't think it's about being duped, it's just that the prices of textbooks are pretty much beyond the students' control due to monopoly and borderline corruption. Prices seem to have consistently increased at around 3x to 4x the inflation rate for a long time.
(Buying used or old edition textbooks is increasingly not an option because the publishers can induce colleges to use online homework systems requiring a one time use code. And the schools don't care because they don't pay for it.)
It is irritating to see this place with a cheerful name basically profit because students are getting ripped off by universities and publishers. I guess not their fault, but they don't have to crow about it in the advertisements -- that's what's most dystopian.
Except the profitability of the place with the cheerful name is basically independent of whether the donors are paid -- one of the truly bizarre (even immoral, IMO) things about legal restrictions on payment for blood, organ, etc. donations is that everybody else in the entire supply chain *except the donor* gets paid for their work and can make a profit, at least in the US. (I'm presuming in many other countries with national health care systems the supply chain is government owned and thus not subject to profit concerns.)
If the costs of books and tuition came down (or didn't) and instead they advertised that this was a good way to get beer/pot money, you would feel better about it?
You literally only cited irrational (or at least arational) aesthetic objections. "These ads targeting informed sellers seem "dark" to me, so we should have men with guns make sure more people die of preventable disease and fewer can afford books".
"The other is that this is such a big deal that the issue would benefit from a more pragmatic, more moderate, less dogmatic approach on the part of those who favor markets and financial compensation. In other words, we should treat this the way we should treat any serious policy problem: try to actually fix it by developing politically appealing framings, messages, and policy ideas rather than just pounding the table and complaining about the stupidity of superstitious aversions to markets."
To go a bit off-topic, I would point out that a lot of YIMBYs ought to take this advice as well. I don't think Matt is a particularly bad offender, but he has a huge megaphone with YIMBY audiences and could persuade a lot of people to be more politically effective in a way that would pay real dividends. Local government has a lot of play in the joints and there's a ton more that YIMBYs could accomplish there if more of them would view the goal not as "enshrine a rational approach to property rights into municipal law" but a more pragmatic "increase housing sqft in your city wherever you can through whatever levers are available."
My experience is that YIMBY groups tend to be very pragmatic about this sort of thing -- we all know that going around and yelling "abolish free parking" would be stupid. However, random posters might be another story.
I guess what I'd say is there are levels of pragmatism. You're right that standard YIMBYs are more pragmatic than the "abolish cars" crowd. But they can be more pragmatic still. For instance, all the YIMBY energy I see is in favor of making broad, universal changes to land use policy (outlawing certain types of restrictive zoning across the board, etc). That's great, but I'd like to see more YIMBYs get their hands dirty at the municipal level. Tinker with rules for individual zoning categories. Lobby politicians to rezone specific streets or parcels with growth potential where neighborhood backlash is less likely. That stuff is not very high-minded and doesn't really move the ball on advancing YIMBY Theory, but it will still contribute to getting more sqft built and increasing the population.
It is somewhat ironic that you produce this essay while Roe v Wade is on the precipice of dissolution. It can certainly be a comfort to childless couples who have sufficient resources to employ a surrogate. However, what struck me was the danger of baby trafficking. By which I mean, young women forced into surrogacy. This has the advantage of not exposing the traffickers to the trials of moving young females across international borders.
While, in principle, I'm in favor of establishing markets where possible, I'm distinctly cool towards marketing of some irreplaceable human tissues. I have a friend who nearly died providing a liver to a relative. The surgeries are definitely non-trivial. Although not currently available, I believe custom grown replacement organs would be a superior alternative.
I’m still annoyed we didn’t do human challenge experiments because I do think it might have moved vaccines and therapeutics along faster.
One thing that is under appreciated is that we would have to do some preliminary experiments to determine what dose is necessary and how to most effectively infect people (most people who get infected with this coronavirus don’t infect anyone else even a household member so just sticking people in a room with an infected person won’t work reliably), but the information from those experiments would also be very valuable.
I did notice that there was some concern that some of the volunteers might not fully understand what they were getting into. One way of dealing with that would be to do the initial challenge experiments on people working in biomedical research who would absolutely understand the risks.
As an aside, I would volunteer to be infected with sars-cov-2 way before I’d volunteer to be infected with norovirus.
I do think that we'd gain some useful information about what sort of dose and setting produces infection. I don't think we would have gained that much more information about vaccines in a relevantly faster way. We might have moved approval forward a few weeks at best, but we were already dose-limited within a few weeks of the starts of the vaccination campaign, so all that would have happened is a few hundred thousand people got their first dose a few weeks earlier, not hundreds of millions of people getting doses months or years earlier.
The statistics on plasma sources are particularly damning because one of the most common justifications people provide for why organ, tissue, etc. donation should not be compensated is because it will purportedly *depress* the supply because, supposedly, no one will voluntarily donate anymore, but simultaneously hardly anybody will be willing to make compensated donations. I look forward to shoving these stats in the face of the next person making that argument, which I've always found intuitively ridiculous, but it's nice to have empirical verification.
I don't think this is exactly the relevant empirical test. There are real reasons why people might be much more hesitant to accept economic rewards for a much riskier transaction than for one that you recover from in a week or so. There are weaker reasons to think that offering an economic reward diminishes the altruistic reason people have for doing it, but I don't think anyone is donating plasma altruistically these days.
This is a situation where people pretend to think an issue (such as paying kidney donors) has important ethical problems that philosophers have debated for centuries, but really they find the issue gross and 'unnatural'. The visceral feeling that something is wrong comes first, the ethical problems are invented to provide rational justification for the feeling. Paying Ukrainian farmers for seed oil: normal. Paying Ukrainian women for surrogacy: something something exploitation. The ethical objections frequently make no sense.
There is a good quote by the economist Joan Robinson: "The misery of being exploited by capitalists is nothing compared to the misery of not being exploited at all."
I do agree that there's a reasonable realist argument for allowing payments, but I'm not sure that a dislike of a world in which poor people sell their body parts to survive is just an irrational feeling that it is gross ..
> a dislike of a world in which poor people sell their body parts to survive is just an irrational feeling that it is gross
I think the main problem here is that preventing people from selling their organs does not prevent this world, it just prevents one type of escape from that world.
Allowing selling of organs does not create poverty, and if people feel coerced to sell their organs, it's not because they were doing amazingly well before - they just had no escape!
Is that the world we are protecting against though? If we allowed transactions, is it realistic to worry that poor people the world over will start selling their body parts en masse just to survive? Or is it more of a situation where a small number of poor people will see a large financial upside and lots of people in wealthy countries will see a huge improvement in health? I just don't see how this leads to a situation where poor people the world over decide their path to financial freedom is selling their body parts on the newly created open market.
I think that is the question - if 5% of people in poor countries do this and get big payouts, that could easily lead to economic conditions in those countries where people who don't do this are more immiserated and this is a ticket to the middle class.
Your argument effectively says "discourage or disallow things that give people an advantage over anyone else". Having both parents enter the workforce, for example, gave families an advantage and "a ticket to the middle class", while families who opt not to do this are "immiserated".
Another example might be college education: ticket to the middle class, people who don't do it are immiserated.
No, not quite. It's "discourage or disallow things that give people a very strong advantage over others but with potential major harm to them". This is the only reason I see to ban performance-enhancing drugs in sport for instance.
If there's no harm to people for doing the thing that gives the advantage, then I would say we should encourage everyone to do it. But if there is a known big harm of one kind, and a potential major advantage of another kind, and if we think that people might mistakenly judge the advantage to be bigger than the harm, then there's at least potentially good reason to step in to make sure people don't feel forced to engage in Faustian bargains.
If, in their judgment, the risk is worth the reward, people will engage in the behavior regardless. All you get is adding "I might get caught and suffer consequences" to the risk bucket, which means it is people who are more desperate or aggressive who will make that choice.
Many things in life have "potential major harm", depending on who is doing the evaluating of the risk and benefit. Car loans, business loans, school loans are good financial examples. Long commutes. Frequent air travel. Working the night shift.
You can cite studies showing both parents working full-time is harmful to their health and the health of the children. It is difficult to draw a clear line about what harm is acceptable.
"...if we think that people might mistakenly judge the advantage to be bigger than the harm..." This is somewhat condescending and presumptive. Who are "we" to judge whether or not it is worth it, and why is our judgement better or more valid than the people being affected? Frequently the dividing line between "mistake" and not is "did I get what I wanted and avoid the bad outcome?"
I think it is much clearer if the argument is doing something that advantages oneself but puts OTHERS at risk for major harm. Drunk driving, for example. Or perhaps driving in general.
Humans are generally bad at evaluating risk and probability (read any of Taleb's books!), but this doesn't mean we can and should intervene when people choose to put their own selves and well-being at risk for possible benefit.
I mean, isn't that the hero's journey?
The PED example is a pretty terrible one. The problematic knock on effect is that the professional sports leagues are, by definition, limited in their opportunities. So only a TINY percentage of people can make it into the leagues, and those that do get an ENORMOUS windfall (a $10k payment to a poor person in a 3rd world country is huge, but even that pales in comparison to the tens of millions of dollars professional athletes stand to gain), so the competition becomes such that people who are cheating push out others who aren't, so those that don't want to participate but want to be a major leaguer feel like they have to use to keep their dreams alive. But in this instance, there's a large surplus of people who need organs, so there is ample opportunity, and you can simple expand the demand as necessary and then reduce the payments to compensate, so the windfall becomes lesser and the pressure becomes lower, but it is still a perfectly viable transaction to voluntarily engage in. You're not pressuring people OUT of the marketplace who WANT to be in it in the way that PEDs function. It really is just another situation similar to both parents working, or an individual working a more hazardous job that pays higher but involves more risk. Those jobs and opportunities already exist all over the world (including in developed nations like the US, where we pay people more for riskier work), and nobody bats an eye, but for some reason this becomes a situation where people imagine these horror story scenarios to obscure the reality of the world we live in.
Why is that? How would 5% of the population receiving a significant cash infusion cause the immiseration of the rest of the population? Those with more will spend more in their communities, and a capital infusion seems like a great first step towards improving any local community's development prospects. It seems like the results of doing this would be either a) not large enough to significantly impact the nation's economy, in which case fears of it becoming seen as the only way to enter the middle class are clearly misplaced, or b) it results in a significant improvement in the lives of many, who can then spend their extra money in the economy, improving the prospects of those around them who didn't participate. I'm not really sure what the option is that says that some people will be better off, but then all the other people will somehow be worse off and will then HAVE to engage in the program in order to escape their poverty. What am I missing here?
The idea would be that, in at least some cases, increasing resources for some members of a community is more likely to create inflation that penalizes other members of the community, rather than the economic multiplier effect. It's an empirical question which is more likely to result.
> a dislike of a world in which poor people sell their body parts to survive is just an irrational feeling that it is gross
Welcome to the revolution comrade.
And of course, this is forever muddled by the continuing popularity of Marx's view that every mutually beneficial transaction is "exploitation" if one of the parties can be classified as more of a capitalist than the other.
Well, as J. K. Galbraith said, under capitalism, man exploits man; under communism, it's just the opposite. (Please let the joke breathe, folks.)
Is anybody going to engage with the idea that extremely poor people in extremely poor countries tend to be embedded in economic systems with extremely limited personal autonomy?
Most of this conversation is about individual choices about how people use their bodies, but in a lot of places it seems like a kidney market would just lead immediately to corrupt governments forming kidney export farms out of prisoners and political dissidents.
Intuition is a legitimate source of moral insight. For all its faults and limitations, it's certainly no worse or more limited than moral theories based on maximizing incredibly fuzzy concepts like 'freedom' and 'utility' (which ultimately often boil back down to intuitive judgments).
I disagree. Your gut shouldn't be the end all be all, but certainly a very smart and knowledgeable person can argue something completely false, and you may not have the tools to contradict their argument.
There is something different about selling your time, labor, or skills, and selling use of your body. For one thing, it can't be undone.
A gay couple I know used a surrogate to have two kids. She had children of her own, and served as a surrogate before. The first kid was fine. The second one, she experienced major medical problems during the birth, and lost her ability to have more children.
That didn't end my support for surrogacy, but it's not the same as working a thankless job harvesting rapeseed.
> The visceral feeling that something is wrong comes first, the ethical problems are invented to provide rational justification for the feeling.
This is an objection to all moral theories. Utilitarianism is the completely implausible theory that pleasure is the good and we have an obligation to maximize it. The only reason anyone believes such a silly theory is that they have a feeling that pleasure is good, so they decide it is the good!
The way to do moral reasoning is to start with intuitions and then systematize them. You don't get to handwave intuitions away. If a lot of people think something is bad, then you at least have to explain why they are having a moral illusion, not call their intuitions "visceral" whereas other moral feelings are, one supposes, "cerebral" and therefore superior.
Since when "pleasure" (I prefer 'utility' as I find it closer to the idea utilitarianism is trying to convey) being good and suffering being bad is completely implausible?
It's implausible that pleasure is THE good. It is a good. But it's not even a very important good. People routinely choose, e.g., to die in war, or less dramatically, to shock themselves when bored. People choose careers and lovers and day to day activities based on a million other things than expected pleasure ROI. To keep the idea from being totally implausible, you have to switch out "pleasure" for "utility" when pressed, but "utility" is an incoherent concept. It just means "whatever it is that people actually are maximizing." Tautologies are fun, but now the seemingly intuitive argument for utilitarianism ("pleasure is the good; therefore we should maximize it universally…") has been reduced to "Whatever it is that people are maximizing is the good. We already are maximizing it by definition, but if somehow we weren't, we really ought to, I guess?"
So I am not a philosophe but I don't think anyone switched utility for pleasure. It seems to me utilitarians understood from the get go that "pleasure" was too narrow. As you said, people will defer pleasure or do unpleasant things for rewards other than pleasure. Even Epicureans were moderate if I recall my introductory class on philosophy of 25 years ago...
The tautological comeback is more interesting, imho. And I don't have the knowledge to fight it back. It just seems to me that, if a serial killer was to say "hey, I am maximising my good, fuck off", utilitarians wouldn't be on board.
I like to use the sentence "maximising utility under constraints" (the constraints being things like "we don't divvy up a healthy person into 10 organs to help 10 persons" i.e. basic freedoms and autonomy rights) but I admit it might just be a nice image rather than a well thought out philosophical concept.
FWIW, my favorite easy summary of moral things is the Maslow Pyramid. We're all trying to climb it, from the most holy saints to the most wretched sinners... but I've seen people saying it's tautological too?
Utilitarianism is the theory that serial killers are bad because they are inefficiently distributing utility. They hoard their own utility at the cost of their victims and the loved ones of their victims. The pain they inflict greatly outweighs any possible individual benefit from killing. So far, so good. Every theory of ethics should have a simple answer for deciding easy cases.
But Utilitarianism brings with it a number of absurdities. Is it better if the person you kill is a loner and won't be much missed? What if they're a loner and depressed? What if, per the trolley examples, you distribute the organs? If you've already killed someone and don't plan to do it again (eg it was a crime of passion), it's bad to feel bad about it and mope. You've gotta move forward and experience utility again because we want to maximize utility everywhere.
Utilitarianism does not allow for many normal actions in life. People usually think that "breaking promises is bad" but Utilitarianism requires us to cash that out as "it's bad to develop a reputation for breaking promises if that leads to an overall reduction in net utility over time." Keeping promises should be an easy case, but Utilitarianism struggles to explain why I shouldn't always just do whatever seems to have the highest ROI at the moment.
Utilitarianism has no defense against "utility monsters": individuals or groups of individuals who take great collective pleasure in the suffering of others, such that it mathematically outweighs the suffering. It just has to bite the bullet and say that it's a local maxima, and while it would be better all things equal to get to past the maxima, the maxima is strictly better than its immediate surroundings. That's an implausible outcome.
Utilitarianism initially seems plausible because we say "utility is like pleasure or happiness but more generally in the wholistic sense". However once you expand utility like that, it just loses whatever intuitive plausibility it had. In general Utilitarianism requires "hedonic calculus" to be theoretically possible, if not actually doable. However, it's not clear that any experiences are comparable, let alone able to be stably ranked and weighted.
People try to patch up Utilitarianism by adding ad hoc defeaters or limitations or by suggesting rule following as a general strategy, but basically all of these mean abandoning Utilitarianism per se and replacing it with another theory that just happens to run on Utilitarian grounds for the most part. I think most people are fine with saying, "yes, under ordinary conditions Utilitarianism provides a rough and ready guide to action" but it is exactly in the hard cases—the case where want our theory of ethics to provide guidance!—that it completely falls apart. It provides no guide to action, it requires us to believe things that have no intuitive plausibility, it creates absurd results that people reject, and no one actually follows it. The EA people come closest to attempting to follow it, but even they fail because it's just a bad and unworkable theory.
I _think_ based on Carl's final paragraph, that Carl was being sarcastic on that one, as an explanation why intuition(like, pleasure is good) is actually a basis for moral theories.
Ah, okay, fair enough
Has there been any work done on how allowing legal payments for organ donations would affect the human trafficking situation with regard to organs? I can see how it would both increase and decrease trafficking, but I'm not sure how it would play out in real life in the US.
In keeping with Slow Boring's "Secret Congress" model, there is actually a bill working through the 117th Congress that would address some of the barriers to living organ donation, but comes well short of creating a paid donation market: The Living Donor Protection Act of 2021 (H.R. 1255/S. 377).
Currently, there are no federal laws to protect donors from losing their jobs while on leave for
organ donation and 25% of living donors have gone on to be denied or charged more for life insurance.
This bill would prohibit insurance companies from denying or limiting life, disability or long-term care insurance to living donors, prohibit insurance companies from charging higher premiums to living donors, and allow living organ donors to use time granted through the Family and Medical Leave Act (FMLA) to recover from donation.
It's not perfect, but currently has overwhelming bipartisan support in both chambers of Congress. If this sounds like something you think Congress should be working on, reach out to your Members and ask them to join on if they haven't already! And Matt - Feel free to use any of you connections on Capitol Hill to help move this through the Secret Congress.
I'm not expressing an opinion on the bill or its merits, here, but I feel like it seems really weird in the context of a post lamenting the utility loss caused by market distortions to be praising a bill that by its terms sets out to distort the insurance market. If living donors are, in fact, worse insurance risks, shouldn't they be charged more?
I mean, yeah it seems to be it would be better if we could pay people $X and that was more than enough to cover the increase in life insurance costs, then you don't market distort the life insurance.
But... much like the carbon tax vs. subsidize green energy fight, sometimes the market distortion is just so much more palatable to people that, as long as the net utility is positive vs. the status quo, it might be the best available option?
But if we want to encourage more donations, what's wrong with the insurance companies raising premiums on the rest of their customers to cover the living donor subsidies? It might be better to make it a public rather than a private subsidy, but that doesn't mean the latter should be out of bounds.
If people decline to donate due to a fear of incurring non-covered costs, then that is the market failure, not the proposed regulation of insurance companies.
Fair point, though while it certainly isn’t settled:
“Living kidney donor survival appeared similar to general population sample (statistical comparison not possible)”
(Ibrahim HN, Foley R, Tan L, et al. Long-term consequences of kidney donation. The New England journal of medicine. 2009 Jan 29;360(5):459–469.)
“Long-term living kidney donor mortality was not higher vs age-and comorbidity-matched controls.”
(Segev DL, Muzaale AD, Caffo BS, et al. Perioperative mortality and long-term survival following live kidney donation. JAMA. 2010 Mar 10;303(10):959–966.)
“Most people can live a normal life with just one kidney. Kidney function usually stabilizes 70 to 75% of previous function in a few months after surgery. Risk of kidney failure is not any greater if you have one versus two kidneys…. Risk for high blood pressure may be higher as one gets older compared to a non-donor but it can be managed with medications.”
(https://www.nebraskamed.com/transplant/common-questions)
I had to think a lot about the bioethical issues around new medical technologies for my book, Radiation Evangelists, so I know a bit about this topic. I really enjoyed this post; I think it gets all the big ideas right. That said, I do want to offer a little bit of nuance in the other direction on some of the particular problems with marketization in pharma, biotech, and medicine. I'm still a fan of increased marketization, for all the increased human welfare reasons described in the article, but I also know that some stuff is going to go wrong in predictable ways.
Human challenge trials, in particular, are an issue where I think the benefits have been heavily overstated. I'm not saying they don't exist. But they have been the subject of a lot of theoretical hype at this point, and the problem with theoretical hype is that it always ignores a lot of stuff. The problems fall into a few buckets.
The first bucket is risk-reward. The question you should basically ask yourself is, "How many people am I willing to kill to prove that ivermectin and hydroxychloroquine don't work?" Recall that both of those treatments were touted by boosters as not just treatments for Covid, but prophylactics, i.e. they would prevent infection or serious illness. The good news on these treatments is that they were generally available, so we got to run an actual, real-world human challenge trial with these medications; people voluntarily took them in the midst of a live-ammunition pandemic, and we watched the result play out, which was that some people died, other people suffered the serious negative side effects of the drugs, and there were no gains relative to Covid baseline mortality.
So ask yourself, "Did I think the people taking horse pills were courageous pioneers?"
And of course, you have to remember that hydroxychloroquine and ivermectin had backers with an interest in the outcomes, which complicates the whole story. We're actually seeing a version of this play out with the Chinese vaccines, where the interests had a lot to do with state diplomacy. Again: it's a complicated story. You could just as easily note that Russia also rushed out its Sputnik vaccine, and that one has held up as being pretty good. So I'm not saying this story goes cleanly in either direction. I'm just saying that for every Moderna, you need to prepare for an Ivermectin and a Sinovac, and that complicates things considerably, in part because...
The second bucket has to do with the real world considerations around trial size and efficacy over time. Remember, to produce worthwhile results, drug trials have to be really, really big, not just to determine whether they work, but to determine what types of rarer side effects and health risks you are dealing with, particular in specific populations (i.e. J&J had a higher risk of clots in particular groups) and to give you a time horizon. Just to take one quick example, imagine a vaccine with an initial efficacy of 80% and an incredibly rapid fall-off rate, like it loses 50% efficacy in one month. Such a vaccine would be pretty useless. It would also pass a human challenge trial.
Challenge trials are either not going to get you the information you need, because they are too small or too time-limited, or they are going to employ such large groups of people over long enough periods that they end up de facto looking very similar to the existing structures, in terms of timelines. Could you have shaved a couple of weeks or a month off the Covid vaccine rollout process? Maybe, but...
The third bucket might be termed "real world considerations around pharmaceutical rollouts." Human challenge trials do not solve any of your other bottlenecks on a pharma rollout process. We saw this with Covid vaccines: they tried to spool up production in parallel to the human trials, and the trials outran the production stand-up by several months. It is not at all clear that releasing the vaccines a month earlier would have made a big difference in the rollout, since we know that the vaccine being produced in those initial batches was being used to vaccinate people BECAUSE PEOPLE IN THE TRIALS WERE BEING VACCINATED. It's not like the vaccine was sitting around on a shelf, going stale or something.
I would strongly argue that you could have made a much bigger difference and saved many more lives in 2020 by pouring resources and expertise into ramping up production and pre-building a robust distribution network. Everyone who was running around screaming about human challenge trials should instead have been running around screaming about logistics. Those people who signed up for human challenge trials? Their efforts would have been far better used as labor to staff gigantic vaccination clinics on Day 1.
I could raise similar kinds of questions or add similar types of nuance to all the other issues raised in the column. Again, none of this is to say that I don't think the column was good. I'm pretty much on-board with the claims and proposals.
But human challenge trials and marketization of med stuff in general tends to be presented as "one weird trick to solve X problem in medicine." A place that has been super guilty of this throughout the pandemic was Marginal Revolution, which I used to read religiously and now almost never look at, because so much of their pandemic stuff was total garbage and it made me start wondering (uncharitably) about their other content. Alex and Tyler are very smart guys, but human challenge trials was just one of about ten "one weird trick" pandemic responses that they were five-alarm on that just don't hold up to actual scrutiny.
Matt closes by writing, "More broadly, this whole set of blocked transactions strikes me as an area where humanity is massively underperforming for no real reason." And, honestly, I think to some degree he is correct on this issue. However, when you encounter issues where you feel this way, I think it is useful to deploy a Chesterton's fence skepticism about your own assessment. There are almost always reasons why people do things. They might be really bad reasons--I think with kidneys, a lot of the reasons are bad--but there is almost never no real reason, even if the reason is something totally infuriating. And if you don't understand the reason, you are probably going to fail at solving the problem.
That shouldn't be surprising. The world is complicated. But a lot of legit smart people lose sight of that, because the downside of the world being complicated is that it is no fun. There aren't clever solutions that get you around the slow, difficult, and sometimes tedious work of boring hard boards.
I think the other concern about human challenge trials is will the FDA move with any speed even if it is found to be successful. I'm a participant in the Novavax trial and my kids are in the Moderna under 5 trial and nothing I've seen from either of those has indicated that the FDA would quickly approve even if it got the data faster. It's been over a year from when the data was supposed overwhelmingly positive that they ethically felt they had to give everyone in the trial the real vaccine. The government is also clearly fine with it's effectiveness since I've been counted as "fully vaccinated" for nearly a year as well. It's been approved and used in about a dozen other countries so they are clearly capable of producing at scale and safely with no new unseen side effects like J&J. All the same feelings apply to my kids and Moderna, though less so on each category (it's less effective, it hasn't been as delayed, etc.) I feel like there's much less incentive for a fast trial process if regulators are just going to sit on it for months on end anyways.
This is one more case of politics as a vocation vs politics of ultimate ends. People advocate positive visions totally divorced from the practical consequences of their actions. It applies to just about everything: the last three (serious) Slow Boring posts have been about regulation, the evolution of Democratic messaging, and US abortion policy, and it's been relevant to all three.
It's especially disappointing to see self-declared champions of disadvantaged communities acting in this way.
I’m starting to think more along the lines of just “it’s especially disappointing to see self-declared champions of disadvantaged communities.” Period.
Few of these communities actually seem to want their “Allies” speaking on their behalf. Perhaps we might stop the DEI/Activism organizations from prioritizing the voices of the well-off kids whose parents can bankroll a “career” in activism through unpaid internships over those who’ve genuinely suffered but can’t afford to buy their way to being the loudest voice in the room.
“ The main downside according to Dylan Matthews is that by going from two to one, you slightly increase your chance of ending up with zero. It’s a real, but not very large, risk.”
Just a reminder that if you donate a kidney and later need a kidney you’ll be put at the top of the transplant list.
If we want to consider popularism when making arguments for opening these kinds of markets, then I think it is important to push specifically for small and extremely-regulated markets that are focused on ensuring that it isn’t possible for abuses to occur. You briefly mention India’s former surrogacy market, but it was rife with genuinely awful abuses. Coercion, lack of care for the surrogates’ health, and even cases of straight-up baby selling that was disguised as surrogacy. (The Vice documentary on this was really excellent, from that super-brief period in the 2010s when Vice was making good output.)
A lot of the people who are most inclined to argue for opening a market also tend to be more skeptical of market regulations (or at least tend to not feel that market regulations aren’t a selling point for opening a particular market). But I think the arguments for opening these kinds of markets would be much more persuasive to the average person if they started off by saying that we know that abuses X, Y, and Z can occur in these scenarios, and these new markets would have rules A, B, and C to ensure those abuses don’t happen.
Yes, exactly.
Imagine this: A politician of a middle income country suddenly decides to allow paid surrogates for foreigners.
To the median voter, that would look a lot like that politician looking out for the national interest of foreigners.
Why not appeal to the middle-income-countries-Bailey's and restrict it? (i.e. pay surrogacy only for nationals or members of a certain cultural region, as Latin America)
That would restrict some of the material gains for the mothers, but also... maybe make it pass a democratic legislature?
Disclaimer: I actually know nothing about current paid surrogacy laws beyond what Matt wrote, which makes it look completely illegal in most countries.
Hey I just donated my kidney last week! I can attest to the negative reaction towards the idea of creating a market for kidneys.
I’m not a libertarian by any means but a few days after surgery, I was having dinner with family and I suggested it would be a good idea for there to be a market to sell kidneys so that the supply of donors would grow.
My brother in law thought it was a terrible idea and brought up folks then being “forced” to do it out of economic reasons. They also asked what would happen to those that couldn’t afford to pay for a donor (which I thought was a fair point). I assume there would still be other altruistic donors or perhaps the government or an organization such as the national kidney foundation could subsidize those with less means.
Replying to your family: aren't we all (I mean all, from the dawn of time) forced to do things we'd rather not do out of economic necessity? Also, insurance programs (private/govt) should pay donors, not individuals. This should still stimulate demand, and can be calibrated against cost of care savings and donation rates.
**Edit, of course, as now, you need some form of insurance to get a transplant.
Is it more ethical for thousands to suffer and even die on dialysis each year when a treatment exists?
Are the bad bioethics here secretly funded by the CEOs of DaVita and Fresenius...?
I mean, there's forced generally to do some economic activity, and forced specifically to sell your kidney. I just don't see anything at all making the later true here.
There may be people in the world who would rather have that exact setup. I’m sure you can imagine populations who would rather any alternative compared to how they make a living currently
I don’t find it that convincing but I think the “forced” concept is most persuasive when you have work requirements. Want snap benefits? Well go sell your kidney or do sex work. Another reason to have robust labor markets and universal support programs.
Good for you. On payment thing, apparently dialysis makes up close to 1% of the entire federal budget, so presumably the government could step in here.
Iran is the only country that allows payment for kidneys, and apparently they have the state run the exchanges.
My husband and I have children from a gestational surrogate (a "traditional" surrogate would be our sperm and her eggs, a "gestational" surrogate is implanted embryos) done here in the states.
The agency we used, like the Ukrainians, required that surrogates already have children of her own, and emphasized many of the things Matt mentioned for the Ukrainian program. I'd also mention one thing _we_ felt was that if there were some sort of awful complication of some sort that rendered her unable to bear children in the future, at least she had kids already.
We certainly liked this arrangement - and it wasn't her first surrogacy so she did too.
I would say the biggest difference between this and international surrogacy, especially with someone from a different language background is it's easier to stay in touch with her.
But in our case, we benefited _greatly_ from being able to pay a surrogate, and she obviously felt she benefited as well.
My plan is that since kidney donation is such a positive good for the government, that we should allow kidney donors to enroll into Medicare and waive all premiums going forward. We could call it "Medicare for All Donors."
Pretty sure that Bernie and Ted Cruz would hate this plan equally
If their other kidney goes, they are automatically eligible for Medicare anyway—this would probably save some money, but I bet you wouldn’t see that many takers.
Yes, but most donor's other kidney doesn't go so they don't get that benefit. Instead, as soon as you donate an organ, you get "free medicare" for the rest of your life. Seems like it would be a great way to introduce Medicare for all and increase organ donors.
This would also be smart because it's very cheap. People who donate kidneys would tend to be younger and healthier than your normal Medicare recipient, so their annual medical costs are likely to be very low (while they're also still contributing to Medicare through their wages).
It sounds like a win-win to me. Except for the part about this being a gateway to Medicare for All -- that's a pretty big leap.
Love this idea
This is pretty genius, though youre right, I can hear the "we shouldn't have to live in a country where people are trading their organs for healthcare!" cries now.
I generally agree with quite a bit of this, but two minor points:
1) I think you're avoiding the 'of course, if you make it a market, then you also make selling plasma or selling a kidney, or selling your uterus something that states will require before they provide you, say, disability, or other forms of welfare. Because, after all you can support yourself, so why shouldn't you have to do this?' problem.
2) On the kidney note specifically, I actually got fairly far down the road of voluntary kidney donation, before it was discovered that some relatives have polycystic kidney disease, which is genetic. I was perfectly happy to do some sort of test to see if I carry the markers, but the test isn't covered (at least for a voluntary donor) by either the program, or insurance and the estimated cost from the hospital was 5-10k (why I couldn't tell you). I was unwilling to pay that out of pocket for a chance to do a nice thing for a stranger, but, if you're over 40, then the procedure is just to do the ultrasound they have to do anyway and see if you've actually got cysts. So, I'm waiting until I'm 40, then I'll circle back...
That’s insane—that’s the sort of thing that should absolutely be paid for. I don’t buy the idea that loads of people would be lining up to donate kidneys if there were a payment offered, but certainly if someone is willing to donate ALL expenses associated with that should be covered, including transportation and time off for recovery.
Whole blood donors used to be compensated here but aren't anymore because of safety concerns. I'm a platelet donor, which takes four hours door-to-door, two plugged into a machine. A goddam miserable experience but better now than 40 years ago, when I first did it. In order to give, I have to answer a lot of nosy questions about my health & habits, and then the donation is tested for AIDS. There are never enough donors; I don't see why it wouldn't make sense to compensate folks to get supply up. At a minimum, I'd not feel so bad about not answering the phone when the Red Cross calls.
Good on you being a platelet donor! I’m also a platelet donor and don’t find the process miserable, but it is really time-intensive. I consider it my “binge TV and have a phlebotomist pop Oreos in my mouth” time. There definitely always is a shortage of donors, though, and for good reason - time is money, and very few people want to give up four hours of their time for a voluntary, altruistic medical procedure, and since you can donate weekly you have to field constant Red Cross calls begging you to come in.
I wish I could give blood. I used to do it all the time before I got put on a long-term, low dose antibiotic. There many reasons why some people can't give blood.
Here’s why people hate this — I used to live near a plasma donation place in the US. They put up explicit ads marketing to the local university students about how if tuition and textbooks are too expensive, you should consider selling your plasma.
The place is called “B-Positive Plasma”. Dystopian name, dystopian ads. Imagine extending this to kidneys and that’s unbelievably dark.
I think rationally compensation for kidney donors is a sound idea. But people’s screaming intuition that it’s terrible isn’t pure irrational gross out — it comes from real problems in the US right now — you’d have to be real careful to deal with those.
Plasma donations paid for most of my spring break in 2005. Felt win win.
Maybe I'm a cold and heartless, but this seems good to me??? B-Positive seems like they are marketing to possibly the best audience possible. College students are typically young and would be able to handle recovery from plasma donations better. Helping them get through college seems like exactly the kind of payment we would want. Hopefully if they are going through college than they are smart enough not to be duped...though that's probably wishful thinking on my part.
I guess I agree that it's better to target university students than most other groups.
However I don't think it's about being duped, it's just that the prices of textbooks are pretty much beyond the students' control due to monopoly and borderline corruption. Prices seem to have consistently increased at around 3x to 4x the inflation rate for a long time.
(Buying used or old edition textbooks is increasingly not an option because the publishers can induce colleges to use online homework systems requiring a one time use code. And the schools don't care because they don't pay for it.)
It is irritating to see this place with a cheerful name basically profit because students are getting ripped off by universities and publishers. I guess not their fault, but they don't have to crow about it in the advertisements -- that's what's most dystopian.
Except the profitability of the place with the cheerful name is basically independent of whether the donors are paid -- one of the truly bizarre (even immoral, IMO) things about legal restrictions on payment for blood, organ, etc. donations is that everybody else in the entire supply chain *except the donor* gets paid for their work and can make a profit, at least in the US. (I'm presuming in many other countries with national health care systems the supply chain is government owned and thus not subject to profit concerns.)
If the costs of books and tuition came down (or didn't) and instead they advertised that this was a good way to get beer/pot money, you would feel better about it?
It would in fact feel a lot less coercive!
You literally only cited irrational (or at least arational) aesthetic objections. "These ads targeting informed sellers seem "dark" to me, so we should have men with guns make sure more people die of preventable disease and fewer can afford books".
"The other is that this is such a big deal that the issue would benefit from a more pragmatic, more moderate, less dogmatic approach on the part of those who favor markets and financial compensation. In other words, we should treat this the way we should treat any serious policy problem: try to actually fix it by developing politically appealing framings, messages, and policy ideas rather than just pounding the table and complaining about the stupidity of superstitious aversions to markets."
To go a bit off-topic, I would point out that a lot of YIMBYs ought to take this advice as well. I don't think Matt is a particularly bad offender, but he has a huge megaphone with YIMBY audiences and could persuade a lot of people to be more politically effective in a way that would pay real dividends. Local government has a lot of play in the joints and there's a ton more that YIMBYs could accomplish there if more of them would view the goal not as "enshrine a rational approach to property rights into municipal law" but a more pragmatic "increase housing sqft in your city wherever you can through whatever levers are available."
My experience is that YIMBY groups tend to be very pragmatic about this sort of thing -- we all know that going around and yelling "abolish free parking" would be stupid. However, random posters might be another story.
I guess what I'd say is there are levels of pragmatism. You're right that standard YIMBYs are more pragmatic than the "abolish cars" crowd. But they can be more pragmatic still. For instance, all the YIMBY energy I see is in favor of making broad, universal changes to land use policy (outlawing certain types of restrictive zoning across the board, etc). That's great, but I'd like to see more YIMBYs get their hands dirty at the municipal level. Tinker with rules for individual zoning categories. Lobby politicians to rezone specific streets or parcels with growth potential where neighborhood backlash is less likely. That stuff is not very high-minded and doesn't really move the ball on advancing YIMBY Theory, but it will still contribute to getting more sqft built and increasing the population.
It is somewhat ironic that you produce this essay while Roe v Wade is on the precipice of dissolution. It can certainly be a comfort to childless couples who have sufficient resources to employ a surrogate. However, what struck me was the danger of baby trafficking. By which I mean, young women forced into surrogacy. This has the advantage of not exposing the traffickers to the trials of moving young females across international borders.
While, in principle, I'm in favor of establishing markets where possible, I'm distinctly cool towards marketing of some irreplaceable human tissues. I have a friend who nearly died providing a liver to a relative. The surgeries are definitely non-trivial. Although not currently available, I believe custom grown replacement organs would be a superior alternative.
I’m still annoyed we didn’t do human challenge experiments because I do think it might have moved vaccines and therapeutics along faster.
One thing that is under appreciated is that we would have to do some preliminary experiments to determine what dose is necessary and how to most effectively infect people (most people who get infected with this coronavirus don’t infect anyone else even a household member so just sticking people in a room with an infected person won’t work reliably), but the information from those experiments would also be very valuable.
I did notice that there was some concern that some of the volunteers might not fully understand what they were getting into. One way of dealing with that would be to do the initial challenge experiments on people working in biomedical research who would absolutely understand the risks.
As an aside, I would volunteer to be infected with sars-cov-2 way before I’d volunteer to be infected with norovirus.
I do think that we'd gain some useful information about what sort of dose and setting produces infection. I don't think we would have gained that much more information about vaccines in a relevantly faster way. We might have moved approval forward a few weeks at best, but we were already dose-limited within a few weeks of the starts of the vaccination campaign, so all that would have happened is a few hundred thousand people got their first dose a few weeks earlier, not hundreds of millions of people getting doses months or years earlier.
Yeah good point. The supply was a main limit for vaccination. And there was a shortage of raw materials and even the glass vials to put them in.
The statistics on plasma sources are particularly damning because one of the most common justifications people provide for why organ, tissue, etc. donation should not be compensated is because it will purportedly *depress* the supply because, supposedly, no one will voluntarily donate anymore, but simultaneously hardly anybody will be willing to make compensated donations. I look forward to shoving these stats in the face of the next person making that argument, which I've always found intuitively ridiculous, but it's nice to have empirical verification.
I don't think this is exactly the relevant empirical test. There are real reasons why people might be much more hesitant to accept economic rewards for a much riskier transaction than for one that you recover from in a week or so. There are weaker reasons to think that offering an economic reward diminishes the altruistic reason people have for doing it, but I don't think anyone is donating plasma altruistically these days.
There are a few of us there every week at the Red Cross giving platelets and plasma, but, no pun intended, it’s hard to get new blood in.