organ transplant is a systemic problem and by donating you are helping kickstart a trend that fixes the system. However, having more kidney donors, while a boost in overall QALY equivalent to donating a few thousand dollars, is more than likely to harm people who need kidney transplants in the long run.
...
By addressing the organ transplant problem now, you are actively diminishing the pool of money and the pool of candidates for teams working to improve organ transplants.
I wanted to write briefly to say a sincere thanks for writing this. I wrote a previous EA forum piece on kidney donation (which I think was linked here), have worked on the issue for a number of years, and answered some questions about kidney donation for Scott Alexander (whose post I believe prompted this one). I haven’t been working on kidney donation for my day job for a while, and I wish I had the time to comment on this piece more thoughtfully. But I did just want to chime in and say I really appreciate your writing this. I don’t agree with all the points, but I believe many of them are cogent and are worth serious consideration by people exploring kidney donation. I know it’s not easy to publicly critique arguments made my influential people in the EA community, and I think it’s a very valuable thing and you should be commended for it.
“Donating a kidney results in an over 1300% increase in the risk of kidney disease. A risk-averse interpretation of the data puts the increase in year-to-year mortality after donation upwards of 240%.” Could you provide these in absolute terms as relative terms are pretty meaningless and rhetoric
Thank you for writing this! I think most people considering kidney donation should read something like this. That being said, I would hesitate to recommend this piece to a prospective donor, at least in its current form. I can’t respond in-depth, but maybe the most succinct way to explain why is that I think it has some elements of a soldier mindset. I’ll use the skin in the game sub-section as an example:
Many of the people in the “Harvard” school of Nutrition indeed eat vegetarian diets and limit protein intake, or at least avoid large amounts of saturated fat and fatty meat.
Why is Harvard in scare quotes? That’s just the name of the school. I noticed this throughout the piece, including in the title of section 1c. I don’t think this adds to your argument, and I worry it’s just a rhetorical attack against all medical and professional establishment.
Have most of the researchers looking at kidney donation donated a kidney? Have most nephrology researchers donated a kidney? Most surgeons doing kidney transplants? … Maybe they are all evil people? They will not take even a marginal risk to save a life. Maybe they are all insane and are unable to translate what they learn from data into reality. But then you at least have to accept that you’d be making your decision based on research done by evil and/or insane people.
Is believing that the entire medical establishment is “evil or insane” actually the most parsimonious explanation for one of many stated-revealed preference gaps in the world? I think I should exercise for 60 minutes a day, but I often fail to do that. Does that make me insane? Of course, I think your actual goal is to hint at medical professionals not even endorsing donation in theory:
… Or maybe, their understanding is nuanced enough that they don’t think the risk is marginal.
Nephrologists spill a lot of ink discussing the risks of kidney donation (which I take it you’ve read much of). Why can’t we just trust the things they say about what they think the risk is?
I might have some motivated reasoning here since I donated a kidney. But, for what it’s worth, my experience of the kidney donor evaluation process was basically a bunch of professionals trying to convince me that risks are real and non-negligible, that there are limits to what we can infer about them from the existing literature, that if I have any doubts I shouldn’t donate, etc.
But it wasn’t a screed against it by any means. It seems like the overall take that the vast majority of nephrologists and experts in the field have landed on is something like: “kidney donation is sufficiently safe for the healthy donor, and it provides such significant benefits for the average recipient, that we can, in good faith, devote much of our careers to facilitating it.” [1] And hospitals, notorious for taking overly conservative approaches to care as to avoid legal liability, at least in the US, have agreed with that assessment.
I still think it’s worth critically scrutinizing the purported risks, but I don’t think it’s necessary to postulate that medical professionals secretly think the operation isn’t worth it, nor that they are all “evil and/or insane.”
The “active harm by donating” argument is very unconvincing for me. Specifically, the analogy to blood donation does not strike me as adequate. It’s just not true that “the existence of altruistic blood donors means that ruthless capitalists are not going to invest in creating artificial blood” — a quick Google search shows that there have been numerous startups that have sought to do so and are seeking to do so. That very poorly attested $7.6 billion number is huge, especially considering that number is just for US sales! That’s about the value of US sales of Ozempic generated in 2022 — a drug that has resulted in such enormous flows of money to its Danish producers that it’s impacting the country’s monetary policy.
So that analogy really does not hold, and I think it doesn’t hold in the same ways it does not hold for kidney donation — even with altruistic kidney donors, thousands die every year waiting for a kidney, and there is enormous demand for organs in general (again, a casual Google search for “artificial organ market” suggests it’d be in the tens of billions of dollars per year). A single person donating their kidney could save someone’s life; it is very unclear how that marginal donation and life saved sets back artificial organ research.
Interesting that you’re referring here, as a counterfactual, to a drug that was put on hold for a very long time because weight loss was not a large enough market—only managed to be developed with diabetes as the focus target, and got repurposed for weight loss later.
Also, GLP-1 agonists were a thing for cca 16 years, but the tweaks and research necessary to make them suitable enough for mass-market weight loss only came about in the last 6, and the approval process and scaleup of production took a long time.
Do you believe this would have been faster had weight loss been a 10x bigger market for whatever reasons?
I don’t think so, no, in part because I don’t think that there’s a linear relationship between hypothesized market size and the like likelihood of a product being developed. A breast cancer vaccine could be worth like a hundred billion dollars, but of course, there are real scientific obstacles there. Maybe we can get something like a universal breast cancer vaccine some day, but in the mean time, it seems rather absurd to argue that chemotherapy is net harmfulbecause it suppresses the need for vaccine development.
Weight loss represents an enormous industry in the US. This has been true for decades. (Not devoting a lot of time to research, I found this figure cited in an FTC report based on research by the Atlanta Business Chronicle: ” consumers spent an estimated $34.7 billion in 2000 on weight-loss products and programs.”) But development of obesity drugs has been extremely difficult — historically, “a bottomless pit into which people shove money and time,” according to one journalist. In other words, there’s far more than market size at play.
That a relatively small number of kidney donors somehow suppress (tens of?) billions of dollars worth of value does not seem plausible to me, and moreover, I still don’t think that extra hypothetical market size is likely to substantially influence whether artificial organ transplants are developed faster.
Executive summary: The post argues against donating a kidney to a stranger, cautioning that kidney donations cause harm to donors, have unclear ethics, and stem from misguided motivations.
Key points:
Kidney donations severely downgrade health and quality of life, increasing risks of kidney disease, mortality, and loss of physical and cognitive capacity.
The long-term impact is negative, as more donors today reduces incentives to develop better solutions like organ growth.
Psychological biases make kidney donation seem more altruistic than other acts that help more with less harm.
Better ways to help include donating money, tackling solvable problems directly, or waiting until older to donate with less personal risk.
The fuzzy ethics and low impact mean donating now is unwise given the high personal risks and potential to damage your ability to do good later.
Address other inconsistencies first before assuming such a high-risk, low-upside act is the best way to contribute.
This comment was auto-generated by the EA Forum Team. Feel free to point out issues with this summary by replying to the comment, andcontact us if you have feedback.
So your donation of a single kidney is buying a few mediocre years of life, in exchange for taking away a few million dollars of the table from any company developing “the proper way” of doing this.
If this practice would spread, we’d live in blood-land, where no money is left on the table.
This argument doesn’t hold up to scrutiny. Is AMF hurting because by distributing bednets and preventing people from getting malaria, you are reducing the incentive to create a malaria vaccine since it would now be less good to create this vaccine.
I can make a million different versions of this. In a nutshell, yes, helping solve a problem makes it smaller and thus less good can be done by others since the problem is now smaller.
Also, allow me to make a small reversal test. You say there is a small market for kidney organs disincentivizing the capital markets from coming in and investing in solutions. If we could, should we be trying to increase the prevalence of kidney disease to increase the potential size of the market for forming kidneys from the recipient’s own cells so that there is a larger reward pool to motivate investors to solve the problem? After all, there are also positive externalities, since growing kidneys is similar to growing any other organ. So advances in this field could be extrapolated and lead to the curing of many other conditions.
“Just do good” is an easy heuristic up until it runs against “just kill yourself” at which point I think we should actually do the utility calculation beyond the 1st degree effects, yes.
My claim is that we shouldn’t be using utilitarian ethics to judge this and instead do the heuristically obvious things, that’s what EA <sometimes> does.
But those heuristics have boundaries which are usually set at harming self and others.
The reason I make this argument is because self-harm is only justified in a very naive utilitarian framework, I believe a mature framework of ethics avoids it in other ways. And I am making this argument primarily for young naive people (like myself) who might not have that fully developed frame of ethics. Some of which might still be utilitarians.
In other words, I would not do the reverse and I don’t think that the “makes the market less efficient” argument stands up to scrutiny in any sensible framework of ethics. But neither does altruistic kidney donation, so I am trying, to the best of my abilities, to showcase the fallacy in the ethical framework with which readers are likely to operate.
This argument doesn’t hold up to scrutiny. Is AMF hurting because by distributing bednets and preventing people from getting malaria, you are reducing the incentive to create a malaria vaccine since it would now be less good to create this vaccine.
I would potentially make this argument, I think many people would, but not because AMF is hurting the development of a malaria vaccine.
Most countries /w malaria got rid of it and they did it through other means, I’d leave it as an exercise to you for how AMF distributing malaria nets could prevent that from happening.
However, the important bit with AMF distributing malaria nets is that the cost to the individual is low and not permanent, on the whole most people working on the malaria nets projects probably came out of it better off in terms of their potential to engage with the world.
“Just do good” is an easy heuristic up until it runs against “just kill yourself” at which point I think we should actually do the utility calculation beyond the 1st degree effects, yes.
Hate to be that guy, but I’d love a TLDR at the top as a way of gauging the substance of the post before committing X minutes to learning more. No biggie though, you do you.
I’ve really liked the EA Forum summary bot, and it’d be cool if that could be used here (or just be a standard thing for any post beyond a certain length)
Kidneys are important, and having fewer of them leads to a severe downgrade in markers associated with health and quality of life. Donating a kidney results in an over 1300% increase in the risk of kidney disease. A risk-averse interpretation of the data puts the increase in year-to-year mortality after donation upwards of 240%.
While through a certain lens, you can claim kidney donation is not that big a deal, this perception stems mainly from comparing a (very healthy) donor population with your average American or European (prediabetic, overweight, almost never exercises, and classifies fruits as cake decoration as opposed to stand-alone food).
Furthermore, when research evidence is mixed due to the difficulty of the studied area, lack of data, and complete lack of open data, we should fall back to our theories about human physiology, as well as common sense, both of which paint a very bleak picture.
You should not donate a kidney if you aren’t prepared to live the rest of your life with significantly decreased cognitive and physical capacity.
Well, it’s only the summary of a single section—the post is essentially an introduction to the chapters and then this summary so I think it does a good enough job for 2+ paragraph readers.
I wanted to write briefly to say a sincere thanks for writing this. I wrote a previous EA forum piece on kidney donation (which I think was linked here), have worked on the issue for a number of years, and answered some questions about kidney donation for Scott Alexander (whose post I believe prompted this one). I haven’t been working on kidney donation for my day job for a while, and I wish I had the time to comment on this piece more thoughtfully. But I did just want to chime in and say I really appreciate your writing this. I don’t agree with all the points, but I believe many of them are cogent and are worth serious consideration by people exploring kidney donation. I know it’s not easy to publicly critique arguments made my influential people in the EA community, and I think it’s a very valuable thing and you should be commended for it.
“Donating a kidney results in an over 1300% increase in the risk of kidney disease. A risk-averse interpretation of the data puts the increase in year-to-year mortality after donation upwards of 240%.”
Could you provide these in absolute terms as relative terms are pretty meaningless and rhetoric
Thank you for writing this! I think most people considering kidney donation should read something like this. That being said, I would hesitate to recommend this piece to a prospective donor, at least in its current form. I can’t respond in-depth, but maybe the most succinct way to explain why is that I think it has some elements of a soldier mindset. I’ll use the skin in the game sub-section as an example:
Why is Harvard in scare quotes? That’s just the name of the school. I noticed this throughout the piece, including in the title of section 1c. I don’t think this adds to your argument, and I worry it’s just a rhetorical attack against all medical and professional establishment.
Is believing that the entire medical establishment is “evil or insane” actually the most parsimonious explanation for one of many stated-revealed preference gaps in the world? I think I should exercise for 60 minutes a day, but I often fail to do that. Does that make me insane? Of course, I think your actual goal is to hint at medical professionals not even endorsing donation in theory:
Nephrologists spill a lot of ink discussing the risks of kidney donation (which I take it you’ve read much of). Why can’t we just trust the things they say about what they think the risk is?
I might have some motivated reasoning here since I donated a kidney. But, for what it’s worth, my experience of the kidney donor evaluation process was basically a bunch of professionals trying to convince me that risks are real and non-negligible, that there are limits to what we can infer about them from the existing literature, that if I have any doubts I shouldn’t donate, etc.
But it wasn’t a screed against it by any means. It seems like the overall take that the vast majority of nephrologists and experts in the field have landed on is something like: “kidney donation is sufficiently safe for the healthy donor, and it provides such significant benefits for the average recipient, that we can, in good faith, devote much of our careers to facilitating it.” [1] And hospitals, notorious for taking overly conservative approaches to care as to avoid legal liability, at least in the US, have agreed with that assessment.
I still think it’s worth critically scrutinizing the purported risks, but I don’t think it’s necessary to postulate that medical professionals secretly think the operation isn’t worth it, nor that they are all “evil and/or insane.”
They also seem to think it’s a terrific thing for someone to choose to do, and they tend to hold donors in very high regard.
The “active harm by donating” argument is very unconvincing for me. Specifically, the analogy to blood donation does not strike me as adequate. It’s just not true that “the existence of altruistic blood donors means that ruthless capitalists are not going to invest in creating artificial blood” — a quick Google search shows that there have been numerous startups that have sought to do so and are seeking to do so. That very poorly attested $7.6 billion number is huge, especially considering that number is just for US sales! That’s about the value of US sales of Ozempic generated in 2022 — a drug that has resulted in such enormous flows of money to its Danish producers that it’s impacting the country’s monetary policy.
So that analogy really does not hold, and I think it doesn’t hold in the same ways it does not hold for kidney donation — even with altruistic kidney donors, thousands die every year waiting for a kidney, and there is enormous demand for organs in general (again, a casual Google search for “artificial organ market” suggests it’d be in the tens of billions of dollars per year). A single person donating their kidney could save someone’s life; it is very unclear how that marginal donation and life saved sets back artificial organ research.
Interesting that you’re referring here, as a counterfactual, to a drug that was put on hold for a very long time because weight loss was not a large enough market—only managed to be developed with diabetes as the focus target, and got repurposed for weight loss later.
Also, GLP-1 agonists were a thing for cca 16 years, but the tweaks and research necessary to make them suitable enough for mass-market weight loss only came about in the last 6, and the approval process and scaleup of production took a long time.
Do you believe this would have been faster had weight loss been a 10x bigger market for whatever reasons?
I don’t think so, no, in part because I don’t think that there’s a linear relationship between hypothesized market size and the like likelihood of a product being developed. A breast cancer vaccine could be worth like a hundred billion dollars, but of course, there are real scientific obstacles there. Maybe we can get something like a universal breast cancer vaccine some day, but in the mean time, it seems rather absurd to argue that chemotherapy is net harmful because it suppresses the need for vaccine development.
Weight loss represents an enormous industry in the US. This has been true for decades. (Not devoting a lot of time to research, I found this figure cited in an FTC report based on research by the Atlanta Business Chronicle: ” consumers spent an estimated $34.7 billion in 2000 on weight-loss products and programs.”) But development of obesity drugs has been extremely difficult — historically, “a bottomless pit into which people shove money and time,” according to one journalist. In other words, there’s far more than market size at play.
That a relatively small number of kidney donors somehow suppress (tens of?) billions of dollars worth of value does not seem plausible to me, and moreover, I still don’t think that extra hypothetical market size is likely to substantially influence whether artificial organ transplants are developed faster.
Executive summary: The post argues against donating a kidney to a stranger, cautioning that kidney donations cause harm to donors, have unclear ethics, and stem from misguided motivations.
Key points:
Kidney donations severely downgrade health and quality of life, increasing risks of kidney disease, mortality, and loss of physical and cognitive capacity.
The long-term impact is negative, as more donors today reduces incentives to develop better solutions like organ growth.
Psychological biases make kidney donation seem more altruistic than other acts that help more with less harm.
Better ways to help include donating money, tackling solvable problems directly, or waiting until older to donate with less personal risk.
The fuzzy ethics and low impact mean donating now is unwise given the high personal risks and potential to damage your ability to do good later.
Address other inconsistencies first before assuming such a high-risk, low-upside act is the best way to contribute.
This comment was auto-generated by the EA Forum Team. Feel free to point out issues with this summary by replying to the comment, and contact us if you have feedback.
This argument doesn’t hold up to scrutiny. Is AMF hurting because by distributing bednets and preventing people from getting malaria, you are reducing the incentive to create a malaria vaccine since it would now be less good to create this vaccine.
I can make a million different versions of this. In a nutshell, yes, helping solve a problem makes it smaller and thus less good can be done by others since the problem is now smaller.
Also, allow me to make a small reversal test. You say there is a small market for kidney organs disincentivizing the capital markets from coming in and investing in solutions. If we could, should we be trying to increase the prevalence of kidney disease to increase the potential size of the market for forming kidneys from the recipient’s own cells so that there is a larger reward pool to motivate investors to solve the problem? After all, there are also positive externalities, since growing kidneys is similar to growing any other organ. So advances in this field could be extrapolated and lead to the curing of many other conditions.
To quote my other comment:
My claim is that we shouldn’t be using utilitarian ethics to judge this and instead do the heuristically obvious things, that’s what EA <sometimes> does.
But those heuristics have boundaries which are usually set at harming self and others.
The reason I make this argument is because self-harm is only justified in a very naive utilitarian framework, I believe a mature framework of ethics avoids it in other ways. And I am making this argument primarily for young naive people (like myself) who might not have that fully developed frame of ethics. Some of which might still be utilitarians.
In other words, I would not do the reverse and I don’t think that the “makes the market less efficient” argument stands up to scrutiny in any sensible framework of ethics. But neither does altruistic kidney donation, so I am trying, to the best of my abilities, to showcase the fallacy in the ethical framework with which readers are likely to operate.
I would potentially make this argument, I think many people would, but not because AMF is hurting the development of a malaria vaccine.
Most countries /w malaria got rid of it and they did it through other means, I’d leave it as an exercise to you for how AMF distributing malaria nets could prevent that from happening.
However, the important bit with AMF distributing malaria nets is that the cost to the individual is low and not permanent, on the whole most people working on the malaria nets projects probably came out of it better off in terms of their potential to engage with the world.
“Just do good” is an easy heuristic up until it runs against “just kill yourself” at which point I think we should actually do the utility calculation beyond the 1st degree effects, yes.
Hate to be that guy, but I’d love a TLDR at the top as a way of gauging the substance of the post before committing X minutes to learning more. No biggie though, you do you.
I’ve really liked the EA Forum summary bot, and it’d be cool if that could be used here (or just be a standard thing for any post beyond a certain length)
Summary
Kidneys are important, and having fewer of them leads to a severe downgrade in markers associated with health and quality of life. Donating a kidney results in an over 1300% increase in the risk of kidney disease. A risk-averse interpretation of the data puts the increase in year-to-year mortality after donation upwards of 240%.
While through a certain lens, you can claim kidney donation is not that big a deal, this perception stems mainly from comparing a (very healthy) donor population with your average American or European (prediabetic, overweight, almost never exercises, and classifies fruits as cake decoration as opposed to stand-alone food).
Furthermore, when research evidence is mixed due to the difficulty of the studied area, lack of data, and complete lack of open data, we should fall back to our theories about human physiology, as well as common sense, both of which paint a very bleak picture.
You should not donate a kidney if you aren’t prepared to live the rest of your life with significantly decreased cognitive and physical capacity.
This is probably the most important bit.
Thanks! Might be good to also edit your post to put this summary at the top so that readers immediately see it.
Well, it’s only the summary of a single section—the post is essentially an introduction to the chapters and then this summary so I think it does a good enough job for 2+ paragraph readers.