Instead of asking for self-sacrifice, why not allow poor people to sell their kidneys? There should be enough willing donors if compensation is high enough. Especially the affluent recipients should be able to leverage their wealth this way. In return, the global poor would have another income option.
Is this banned? If yes, then that means the current kidney shortage is a form of artificial scarcity.
Politically, it probably wouldn’t be feasible to allow organ sales, but there are a lot of intermediate policy alternatives likely sufficient to end the shortage by supporting donors better (just to start, you could pay lost wages and travel, but you could also provide health insurance, tax credits, or an annuity to donors). If you think that’s a good idea (we think it would save about 160K QALYs annually), donating your kidney gives you unique moral authority and power in advocating that policy.
But it’s a kind of moral authority that might disappear when you look at it too closely right? If the reason you’re donating is to get the moral authority, then it’s not clear that it’s a virtuous act anymore!
Another policy change is opt-out for (after-death) organ donation rather than opt-in. How do you feel about the likely effectiveness of that?
In terms of opt-out, I only know the data in the U.S. but basically while it might be a good idea, it’s unlikely to yield significant increases: it seems like such an attractive decision architecture/nudge type intervention, but when you dig in, it’s a much closer call (which is why Sunstein and Thaler don’t recommend it, for example).
The current American system is more of a hybrid than clear opt-in. Right now, about 75% of those who could become deceased donors ultimately consent to do so (about 40-50% are registered as organ donors and of the remainder, the family consents about 40-50% of the time). Thus even if an opt-out system worked as intended, the marginal upside isn’t so high (and the downside to it failing or being counterproductive would be quite severe). Spain, the country with the highest deceased donation rates in the world, ostensibly has an opt-out system, but the families are very empowered to say no to donation, and the actual difference between Spain and the U.S. is that in Spain a lot of their deceased donors are over 70 and here very few are.
There’d also be some risks of going to an opt-out system. So imagine what happens when someone is actually eligible to become a deceased donor—they’re brain dead, so their death is often sudden and unexpected to their family. Let’s say the donor didn’t choose to opt out. What do you tell the family who’s in the room with a brain-dead patient whose heart is still beating—“she’s dead. Now you have to leave the room so we can harvest her organs”? If they have no control over what happens to their loved ones body, you can imagine a lot of people becoming pretty upset, even people who might have been persuaded to say yes to donation. The deceased organ donation relies on the public’s support and good graces, so if you have repeated instances of grieving families publicly decrying the opt-out system, that creates a significant risk that the change will be counterproductive.
I haven’t studied organ donation, but I was under the impression that the current state of the (admittedly non-experimental) evidence suggested that switching to opt-out would likely yield significant (though not huge) increases in organ donation, e.g. see here and here.
Is it easy for you to explain, or link me to, the reasons for your skepticism?
The U.S. is third in the world for deceased donation per million persons. The difference between us and the #1 (Spain, which has a suite of good deceased donation policies, one of which is a version of presumed consent) can be explained by our generally not accepting deceased donors over 70 and Spain doing so. http://onlinelibrary.wiley.com/doi/10.1002/lt.23684/full
Also, the kidney shortfall is 20K/yr. Total deceased donor kidneys are about 12K per year. Opinions differ as to what percent of those eligible to be deceased donors donate, but the official government estimate is 75% (I think a range of 50-75% is probably credible), so even if all eligible deceased donors donated, there would still be an enormous shortfall in kidney transplants each year.
(re: political credibility) -- Ehhh, let’s say you become a doctor because you think healthcare is important. You want to help people and by being a doctor, you hope to have the status to advocate politically for expanding access to healthcare. I don’t see how your authority is impugned because of your desire for advocacy. I think what you’re going for is the loss of authority if you have an ulterior motive that cuts against the stated motive—e.g. if you join a church for political gain but don’t believe in god. As a kidney donor, though, your desire to give and desire to change policy are aligned.
I believe this is banned in many countries, including the US. I chatted to Alexander Berger of GiveWell (who’s donated a kidney) about it once, and if I recall the conversation correctly he said he thought it should be legal.
Instead of asking for self-sacrifice, why not allow poor people to sell their kidneys? There should be enough willing donors if compensation is high enough. Especially the affluent recipients should be able to leverage their wealth this way. In return, the global poor would have another income option.
Is this banned? If yes, then that means the current kidney shortage is a form of artificial scarcity.
Politically, it probably wouldn’t be feasible to allow organ sales, but there are a lot of intermediate policy alternatives likely sufficient to end the shortage by supporting donors better (just to start, you could pay lost wages and travel, but you could also provide health insurance, tax credits, or an annuity to donors). If you think that’s a good idea (we think it would save about 160K QALYs annually), donating your kidney gives you unique moral authority and power in advocating that policy.
Also you might be interested in signing this open letter if you support benefit for donors—http://www.ustransplantopenletter.org/home.html
But it’s a kind of moral authority that might disappear when you look at it too closely right? If the reason you’re donating is to get the moral authority, then it’s not clear that it’s a virtuous act anymore!
Another policy change is opt-out for (after-death) organ donation rather than opt-in. How do you feel about the likely effectiveness of that?
In terms of opt-out, I only know the data in the U.S. but basically while it might be a good idea, it’s unlikely to yield significant increases: it seems like such an attractive decision architecture/nudge type intervention, but when you dig in, it’s a much closer call (which is why Sunstein and Thaler don’t recommend it, for example).
The current American system is more of a hybrid than clear opt-in. Right now, about 75% of those who could become deceased donors ultimately consent to do so (about 40-50% are registered as organ donors and of the remainder, the family consents about 40-50% of the time). Thus even if an opt-out system worked as intended, the marginal upside isn’t so high (and the downside to it failing or being counterproductive would be quite severe). Spain, the country with the highest deceased donation rates in the world, ostensibly has an opt-out system, but the families are very empowered to say no to donation, and the actual difference between Spain and the U.S. is that in Spain a lot of their deceased donors are over 70 and here very few are.
There’d also be some risks of going to an opt-out system. So imagine what happens when someone is actually eligible to become a deceased donor—they’re brain dead, so their death is often sudden and unexpected to their family. Let’s say the donor didn’t choose to opt out. What do you tell the family who’s in the room with a brain-dead patient whose heart is still beating—“she’s dead. Now you have to leave the room so we can harvest her organs”? If they have no control over what happens to their loved ones body, you can imagine a lot of people becoming pretty upset, even people who might have been persuaded to say yes to donation. The deceased organ donation relies on the public’s support and good graces, so if you have repeated instances of grieving families publicly decrying the opt-out system, that creates a significant risk that the change will be counterproductive.
I haven’t studied organ donation, but I was under the impression that the current state of the (admittedly non-experimental) evidence suggested that switching to opt-out would likely yield significant (though not huge) increases in organ donation, e.g. see here and here.
Is it easy for you to explain, or link me to, the reasons for your skepticism?
The U.S. is third in the world for deceased donation per million persons. The difference between us and the #1 (Spain, which has a suite of good deceased donation policies, one of which is a version of presumed consent) can be explained by our generally not accepting deceased donors over 70 and Spain doing so. http://onlinelibrary.wiley.com/doi/10.1002/lt.23684/full
Also, the kidney shortfall is 20K/yr. Total deceased donor kidneys are about 12K per year. Opinions differ as to what percent of those eligible to be deceased donors donate, but the official government estimate is 75% (I think a range of 50-75% is probably credible), so even if all eligible deceased donors donated, there would still be an enormous shortfall in kidney transplants each year.
(re: political credibility) -- Ehhh, let’s say you become a doctor because you think healthcare is important. You want to help people and by being a doctor, you hope to have the status to advocate politically for expanding access to healthcare. I don’t see how your authority is impugned because of your desire for advocacy. I think what you’re going for is the loss of authority if you have an ulterior motive that cuts against the stated motive—e.g. if you join a church for political gain but don’t believe in god. As a kidney donor, though, your desire to give and desire to change policy are aligned.
I believe this is banned in many countries, including the US. I chatted to Alexander Berger of GiveWell (who’s donated a kidney) about it once, and if I recall the conversation correctly he said he thought it should be legal.
Yes, kidney selling is officially banned in nearly every country. My preference, at least in the U.S. context, would be to have the government offer benefits to donors to ensure high quality and fair allocation: http://www.nytimes.com/2011/12/06/opinion/why-selling-kidneys-should-be-legal.html