Photo: Magnus D
Some ideas are downright repugnant. Like … paying for human organs.
On the other hand, is it any less repugnant to let thousands of people die every year for want of a kidney that a lot of people might be willing to give up if they were able to be compensated?
Our new podcast ventures into the realm of repugnant ideas. (You can download/subscribe at iTunes, get the RSS feed or listen live via the link in box at right.) The fact is that the repugnance border shifts over time. Selling eggs or sperm, “renting” a womb — not long ago, all of this was considered way out of bounds. So was birth control and adoption. Go back a bit further in history: currency speculation, charging interest on loans, even selling life insurance — these practices, too, were almost universally felt to be repugnant.
Will the border shift for human organs as well? Should there be a legal market for organs? (At the moment, only Iran has one.) And if not, what should we be doing to help alleviate the massive world demand for transplantable organs, especially as the increase in diseases like diabetes continue to drive kidney failure?
Steve Levitt kicks off our journey through the repugnant by describing why economists can be useful in such conversations:
Economists are pretty much immune to repugnance. Either by birth or by training, economists have their mind open, or skewed in just such a way that instead of thinking about something in terms whether something it’s right or wrong, they think about it in terms of whether it’s efficient whether it makes sense…and many times the things that are most repugnant are the things that are quite efficient — but for other reasons, subtle reasons sometimes, are completely and utterly unacceptable.
The star of the podcast is Harvard economist Al Roth (the dean of repugnant ideas), who has thought a great deal about the organ problem. But more than that, he has actually done his part to help, helping to found the New England Program for Kidney Exchange. Here, from SuperFreakonomics Illustrated, is a look at how it works:
But Roth knows that, given the scope of the problem, a program like his doesn’t help all that much. Here’s how he puts it in the podcast:
There’s an enormous social cost that people pay personally when they’re ill, that we pay as a society to have them ill and dying, and that cost weighs very heavily on me as I see it. When I started thinking about kidney exchange, the waiting list was on the order of 50,000 people and now it’s getting near 90,000 people. So kidney exchange is a small but fast growing source of live donors, but it’s like trying to hold back the tide with a broom.
You’ll also hear from two doctors — one an Israeli transplant surgeon, the other a New York emergency-medicine specialist — who stare the existing organ-donor protocols in the face and spit on them. Because sometimes the best way to fight repugnance is with a little repugnance of your own.
Brilliant? Repugnant? Maybe … both?
Hope you enjoy the program.
[Female Voice 1]: Healthy 23-year-old female …
[Female Voice 2]: Healthy 23-year-old female …
[Female Voice 1]: No smoking, no drinking, no drugs …
[Female Voice 2]: No smoking, no drinking, no drugs …
[Female Voice 1]: No mental-health issues.
[Female Voice 2]: No mental-health issues.
[Female Voice 1]: Interested in becoming an egg donor.
[Female Voice 2]: Interested in becoming a kidney donor.
[Female Voice 1]: Let me help you start a new life.
[Female Voice 2]: Let me help you save your life.
[Female Voice 1]: Price negotiable.
[Female Voice 2]: Price negotiable.
Stephen J. DUBNER: One of these want ads is perfectly legitimate; the other might get you thrown in jail.
A young woman selling one of her eggs? An acceptable way to pay for college.
A young woman selling her kidney to raise cash? Well, that’s just repugnant.
Well, yeah, there are differences. Harvesting an egg is much easier than harvesting a kidney, and we have only one kidney to spare, but lots of eggs.
But it can be hard to find the border between what’s repugnant and what’s not. And that border changes over time. Selling eggs or sperm -- “renting” a womb: not long ago, all of this was considered way out of bounds. So was birth control and adoption. You go back a bit further in history: currency speculation, charging interest on loans, even selling life insurance -- these practices, too, almost universally felt to be repugnant.
Now, things move in the opposite direction, too. Slavery, polygamy, racial discrimination, the sale of indulgences -- all of them widely practiced at one time. Today: in most settings, repugnant.
How are we supposed to make sense of repugnance? Who can lead the way? Who is willing to march into the darkness, torch held high, to shed light on the solutions that society might want but can’t quite handle?
You know where I’m going with this one, don’t you?
That’s right: cue the economist:
Steven D. LEVITT: One of the easiest ways to differentiate an economist from almost anyone else in society is to test them with repugnant ideas.
DUBNER: That’s Steve Levitt, my Freakonomics co-author. He’s a research economist at the University of Chicago. He knows a thing or two about repugnance. His most infamous piece of work was a paper arguing that the massive drop in crime that began in the early 1990s was due in large part to … the legalization of abortion. Now, Levitt took no position on abortion per se; the paper was simply establishing cause and effect. But a lot of people thought that merely making the connection between abortion and crime was repugnant.
LEVITT: Economists are pretty much immune to repugnance. Either by birth or by training, economists have their mind open, or skewed in just such a way that instead of thinking about something in terms whether something it’s right or wrong, they think about whether it’s efficient, whether it makes sense...and many times the things that are most repugnant are the things that are quite efficient -- but for other reasons, subtle reasons sometimes, for reasons that are hard for people to understand, are completely and utterly unacceptable.
DUBNER: Ah, “completely and utterly unacceptable.” Now we’ve got ourselves a radio show.
DUBNER : From WNYC and American Public Media, this is Freakonomics Radio. Today, buying kidneys, transplanting hearts, and finding solutions to things that society just can’t stomach. Until it can.
ROTH: My name is Al Roth, and I’m an economist. I teach at Harvard University.
DUBNER: Which is impressive, to me at least, because you actually dropped out of high school. How did you get from there to here?
ROTH: Oh my. So that was a long time ago, and fortunately my children have now graduated from high school. But I woke up one morning in high school and thought that I hadn’t learned anything in a long time, and this distressed me so I stopped going so often. But very quickly thereafter I arranged to go to college, so I was never deeply at sea.
DUBNER: So you’re not what we think of as the typical high school dropout who worked on a freighter for ten years and got tattoos, and went to Singapore, and got thrown in jail, and then came back and miraculously got yourself in college.
ROTH: Right, that’s not the full list of things that I didn’t do, but I didn’t do any of those.
DUBNER: What Roth did do was study engineering and operations research. He was looking for ways to “make things work better.”
ROTH: What I ended up studying was game theory, which is meant to be a mathematics useful for talking about how people interact with each other. And so the things that I was attracted to trying to make work better were systems in which people interact with each other, markets and other kinds of interactions...and I’ve been particularly attracted to studying markets in which prices may not do the lion’s share of the work. So, economists have spent a lot of time studying markets in which prices do most of the work. If you want to buy a ton of coal, you can buy it if you can afford it, and the guys selling you the coal don’t care who buys it. And subject to making a commodity out of the coal, to describing its grade and its location, you don’t care really who you buy it from. But if you want to be admitted to college for example, you can’t just choose where you want to go, you also have to be chosen. So it’s a lot more like a marriage market. And labor markets are like that, and many things are like that. And I’ve been inclined to study those things, which often don’t work nearly as well as markets for commodities.
DUBNER: Roth is being a little bit humble here. He does more than study these markets. He actually designs them. He uses complex math to smooth out markets in which two sides need help in finding an optimal match. He’s helped hospitals and newly minted M.D.’s find each other. He’s done the same for high schools and incoming freshmen in New York City. Think of him as a very high-end matchmaker. Yente with a Ph.D. But it goes beyond that. It’s one thing to help arrange better matches for students and doctors; but Roth is willing to design better markets for things that people don’t even want to talk about.
DUBNER: When I think of Al Roth, I think of the Godfather of Repugnance. Is that a fair title?”
ROTH: Uhh. Hmm. Maybe we can replace ‘godfather’ with something else. But, but I have been interested not just in what markets we see and can build, but also in what markets people are reluctant to have seen or built. And so I have given a lot of thought to repugnant transactions, which are transactions that some people might want to engage in and other people think that they shouldn’t.
DUBNER: Transactions like … selling a kidney. Some economists -- including the Nobel laureate Gary Becker -- think we should have a market for kidneys. A strictly regulated market, to be sure. But under current U.S. law -- which is similar to the laws in most countries -- a person cannot be compensated for giving an organ, whether in life or death.
Now, to someone like Becker, the idea of being compensated for a kidney -- whether it’s cash or a tax break or an interest-free college loan -- that’s far less repugnant than the current situation. Every year, thousands of sick people die for want of a kidney while millions of people are walking around with a second, spare kidney. And think of all the bodies that are buried or cremated every year with perfectly reusable organs -- life-giving organs -- all because the incentives for people to donate them aren’t very strong. If you’re an economist, this represents a massive inefficiency, a massive failure of supply to meet demand.
Al Roth is not 100 percent in favor of an organ market. He’s sympathetic to the repugnance issue:
ROTH: The late Pope John Paul wrote about this and he objects strongly to the sale of kidneys but thinks the donation of kidneys is a very good thing, though if we do it for money is a very bad thing...I think his feeling is that it turns people from ends into means which is a bad thing in itself. So that’s one nature of objection. Another kind of objection is that it might be OK if I offered to buy your kidney because you’d be a hard guy to exploit, you’re a successful, financially solvent person, but pretty soon we’d start seeing the desperately poor and maybe they would in some sense be acting against their self interest, they would be being exploited or coerced even, by the temptation of the money in ways that if they could use their better judgement they wouldn’t want to be. So that’s sort of a coercion argument. And then there’s a slippery slope argument that says if we started allowing people to sell their kidneys, it would be primarily poor people who would sell their kidneys, and pretty soon we would start hearing political discussion that said, ‘you know, we don’t really need unemployment benefits, we don’t really need aid to families with dependent children because after all, everyone’s got two kidneys and they can take care of themselves by selling a kidney if they need to’...and that makes us a much less desirable society to live in.
DUBNER: So Roth gets the repugnance factor; but he also gets the supply-and-demand failure. That’s why, several years ago, he helped found the New England Kidney Exchange Program. [Correction: The New England Program for Kidney Exchange] Here’s how it works.
Imagine there’s a man in Boston who needs a kidney, and his wife is willing to be the donor but she’s not compatible -- because of blood type or tissue type or some other medical issue.
Now, imagine another couple forty miles away in Gloucester, Mass., in the same fix -- husband needs a kidney, wife is willing to give one, but they are also incompatible.
Okay, but what if the Boston wife is compatible with the Gloucester husband -- and the Gloucester wife is compatible with the Boston husband? Voila! A ‘matched pair’ of kidney donors. As long as there’s a way for them to find each other.
That’s how a kidney exchange works. It’s an unrepugnant way for one person to give a stranger a kidney and get something in return.
Clever, yeah? But Roth knows this is a tiny solution to a big problem. Since 2006, the New England Kidney Exchange is responsible for 71 transplants. Roth is the first to admit it’s not enough:
ROTH: There’s an enormous social cost that people pay personally when they’re ill, that we pay as a society to have them ill and dying, and that cost weighs very heavily on me as I see it. When I started thinking about kidney exchange, the waiting list was on the order of 50,000 people and now it’s getting near 90,000 people. So kidney exchange is a small but fast growing source of live donors, but it’s like trying to hold back the tide with a broom.
DUBNER: So how do you stem that tide? With a grim forecast for diabetes and other causes of kidney failure, how can that demand be met?
There’s currently one country in the world with a formal system for buying and selling kidneys: Iran. The people who’ve studied this system don’t know all the details, and from what we do know, the system isn’t perfect. That said, it appears that Iran is the only country in the world where sick people do not routinely die for want of a kidney that no one is willing to donate.
And how would something like this Iranian system go over here, in the U.S.?
Al Roth and a colleague recently conducted a survey to measure Americans’ feelings about repugnant transactions like selling human organs -- or paying for sex, also known as prostitution:
ROTH: We didn’t find an aversion to kidney sales at anything like the aversion to prostitution... the vast majority, found prostitution repugnant, and a large minority...found...had some objection to compensating kidney donors in various ways.
DUBNER: So if your survey is believable and representative to some degree, then we might be led to believe that we’ll see sales of kidneys legalized before prostitution is legalized in this country at least, yeah?
ROTH: Well there’s also the question of how many people are interested on both sides.
DUBNER: And which kind of people, like politicians for instance. I’m guessing that just as legalizing prostitution is an issue that most politicians won’t go near. I’m guessing that legalizing kidney sales is a bit of a third rail for a lot of politicians, yes?
ROTH: I think it looks unlikely to be a winning campaign slogan.
DUBNER: Coming up … a pair of doctors, one in New York and one in Israel, stare their existing organ-donor protocols in the face -- and spit on them. Because sometimes the best way to fight repugnance … is with a little repugnance of your own.
DUBNER: From WNYC and American Public Media, this is Freakonomics Radio.
Jacob LAVEE: It all started five years ago, when a patient of mine, who was hospitalized in my department for many months waiting for a heart ...
DUBNER: That’s Professor Jacob Lavee - he’s a transplant surgeon at Sheba Medical Center, near Tel Aviv, in Israel.
LAVEE: …and he was a very religious orthodox Jew, [he] told me very frankly that although he himself is waiting for a family to give their permission for organ donation of their deceased beloved one, if the situation he told me would have been reversed and he had been asked to give his own permission for organ donation of one of his relatives he would have said no because...because of the religious issues. This I could not accept. I can accept, and I appreciate and I respect the person who says I do not believe in brain death but then please, if you need an organ, do not become an organ candidate. I mean, that cannot be.
DUBNER: In the U.S., about 40 percent of adults have signed up to be organ donors. But that number isn’t as helpful as it might sound. Only a very small share of people who die -- less than one percent -- actually leave behind organs that are viable for transplantation.
Now let’s look at Israel. Only 10 percent of Israelis carry an organ-donor card. Why? Jewish law - or, at least, how some people interpret Jewish law.
Some ultra-Orthodox Jews maintain that death happens not when the brain stops functioning, as modern medicine holds, but only when the heart stops beating. Harvesting organs, however, becomes immensely more difficult if you wait that long.
And so, while most Jewish religious leaders actually encourage people to become organ donors, a lot of Israelis fail to do so -- a sort of ‘better-safe-than-sorry’ take on Jewish law.
So Jacob Lavee came up with a work-around. He pushed for a new law that’s just gone into effect, and it pokes a sharp stick in the eye of all the free riders like the heart patient who inspired Lavee. The law is called “Give Life, Get Life.” Which means that if you sign up to be an organ donor, then you get preference if you ever need an organ yourself.
LAVEE: I’m fully aware of the fact that it’s a very drastic law. It’s a very drastic law and it had to be drastic because the situation is drastic. As the Israeli law...is a world precedent. There is no other precedent in the world, there is no other country, no other society has adopted a similar law.
DUBNER: Think about what’s happening here: a factor other than medical need is being used to determine who goes to the top of the list for an organ transplant. This is, simply put, not how doctors are trained to think. But desperate times call for repugnant measures.
Now there’s some nuance here. Lavee says that the preference for organ donors only comes into effect when two or more transplant candidates have the same medical priority. Still, he says that’s a common scenario with something like the heart transplants he performs. So from now on, the patient who had the foresight to become an organ donor himself will move to the top of the list.
Brilliant? Repugnant? Maybe … both?
It seems to be working. Lavee says that after one month of a public-relations push for the program, 20,000 additional Israelis have signed a donor card. Before that, only about a 1,000 people a month were signing up.
DUBNER: So: you’ve signed up to be an organ donor. Great! Now, while we’re on the subject: if you do happen to meet an untimely demise, please be extra considerate and die in such a way -- from a brain aneurysm or gunshot to the head maybe -- that the doctors have a clear shot to harvest the healthiest organs.
Oh, and also -- please make sure to die in a hospital, not at home. In a hospital, a respirator can help keep your body functioning after brain death; without that, your organs have a much shorter shelf life. Which means that your organs, instead of saving someone’s life, just get sent to the cemetery.
How’s that for repugnant?
All that supply, all that demand, never meeting up.
Lewis GOLDFRANK: My name is Lewis Goldfrank, I’m the chairman of emergency medicine at New York University and director of the emergency department at Bellevue Hospital Center.
DUBNER: Not long ago, Goldfrank was asked by the Institute of Medicine, the health arm of the National Academy of Sciences, to find new ways to improve organ donation in the U.S. He started reading medical journals from France and Spain. Many European countries practice “presumed consent,” which means that unless your family specifically opts out, it is presumed that you have consented to donate your organs upon death:
GOLDFRANK: But the big thing they do - - is that they would say if someone dies in the street, someone has cardiac arrest or someone is stabbed or shot they take that person and try to resuscitate that person and after they’ve failed...whether they’ve failed or succeeded, they’re going to bring that person back to the hospital. And in the hospital, they decide whether someone is going to be good for preservation and organ donation … so they showed that those transplantations of organs taken in the field after the heart had stopped, when the person was dead, became quality organs... for function a year later, and many years later.
DUBNER: So let’s say you live in Madrid and late one night, something terrible happens to you. Someone calls an ambulance. It arrives. The emergency team fights to save your life. That doesn’t work. So they quickly transition to preserving your precious organs and rushing you to the hospital, where the transplant process can begin.
Pretty efficient, right? Or … maybe you see a potential conflict of interest here. Would an EMT maybe work a little less hard to save your life if he knew that your death might provide life-saving organs for a bunch of other people?
When Goldfrank began talking about a similar plan for New York, sending organ-harvesting units into the field, the reaction wasn’t so warm:
GOLDFRANK: We had a host of individuals who said that this is a vulture bus - these people are ghouls - they’re not concerned about us any longer - they’re doing this transplant. And so, we couldn’t really afford that, to move the project forward. And we thought there were so many positives things that we became restrictive in what we did. Excessively restrictive.
DUBNER: “Restrictive” meaning that: in order to satisfy the New York Organ Donor Network, the hospitals, the police and fire department and any number of other departments, boards, and commissions, Goldfrank had to whittle down his ambitious European-style organ-harvesting program into a single ambulance that will operate only in Manhattan, only between the hours of 4 p.m. and midnight, only for a six-month trial period, and will accept only kidneys from people between 18 and 60 years old.
But he got it done. And just a few weeks ago, the Organ Preservation Unit hit the streets.
When a regular ambulance goes out an emergency call that sounds as if it might yield an organ donor, the organ ambulance heads for the same address, and parks around the corner. The idea is that the EMT workers in the rescue ambulance shouldn’t be influenced by the presence of the organ-harvesting ambulance.
But then: if the patient dies, and if that patient had expressed his wishes to be an organ donor -- then the Organ Preservation Unit knocks on the door. There’s a doctor, two EMT’s, and a family-services specialist -- that is, a person trained to have a very delicate talk with a grieving, shocked family, while the body is still warm. And if, if, if, everything goes right, one person’s death saves someone else’s life.
GOLDFRANK: We gerrymandered our project to get through every barrier we could find. And so we’re left with very few human beings that really fit the process.
DUBNER: In fact, there’s a good chance this new program won’t yield a single life-saving kidney during its six-month pilot. But Goldfrank hopes the trial will lead to a fuller program, with fewer restrictions.
GOLDFRANK: I think we’re trying to limit the level of controversy - people have said really nasty things and I think, some of it I can understand. On the other hand, I would say it’s a pretty strange culture where you have people dying every day who want to give organs and we don’t put something together to do it.
DUBNER: So that’s what happens when a particular topic makes us squeamish -- whether it’s organ transplantation or paying for sex or making money off of other people’s misfortunes. There are bound to be a lot of unintended inefficiencies -- opportunities missed; lives lost.
Just look at all the constituencies that had to be placated for Lewis Goldfrank’s plan to even get a shot -- and it may not save a single life! Sometimes it doesn’t matter what smart people like Goldfrank and Al Roth and Jacob Lavee dream up. Sometimes, the repugnance factor is just too much. At least for the time being. Without question, too many people around the world will die for want of an organ transplant. But maybe this problem will end up being solved by some other means, a different kind of idea entirely. I asked Al Roth about it …
DUBNER: One last organ question for you. What do you think will come first in the U.S., some kind of a market for organs, or artificial organs?
ROTH: So that’s a good question, and I think it’s well posed in the sense that both of those are hard things. If we talk about will it be possible to do xenotransplantation, to have pig organs transplanted and function inside human beings, everyone recognizes that that’s a very difficult problem. People are working on it. And your immune system reacts violently and fatally to a foreign organ like a pig organ, but it might be possible to modify the proteins in the pig, or the pig kidney so that you’d be able to use a pig organ, and that would be a great thing. That would presumably completely satisfy the need for kidneys if it worked for everyone because we could grow lots of pigs and use their organs.
DUBNER: So now you just have to ask yourself if you can imagine walking down the street one day with a pig’s kidney inside of you. Or do you find that idea too … repugnant?