You Say Repugnant, I Say … Let’s Do It! (Ep. 15)

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(photo: Magnus D)

You Say Repugnant, I Say … Let’s Do It!: What happens when the most disturbing ideas are also the best?

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, read the transcript, 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:

The Harvard economist Alvin E. Roth, a specialist in market design, helped invent a “paired donation” organ exchange that finds matches for compatible organ donors. Here’s how it works: A willing donor enters the exchange along with a person she wants to give an organ to (her husband, for instance) but with whom she is biologically incompatible. This pair is matched with a similar pair of people so that each pair’s donor is compatible with the other pair’s recipient. Although this organ-for-organ transaction is in fact a sort of market, it doesn’t provoke the repugnance of a cash exchange.

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.

In Israel, Jacob Lavee was so outraged by the low organ-donor rates that he pushed for a law that gives medical preference to people who sign up to be organ donors. It’s called Give Life, Get Life.

And in New York, we spoke with Lewis Goldfrank, the driving force behind a new Organ Preservation Unit — whose goal is to increase organ donation by making house calls.

Brilliant? Repugnant? Maybe … both?

Hope you enjoy the program.

DESCRIPTIONFDNY New York’s new Organ Preservation Unit, making house calls.

bruce stasiuk

we are frozen in place by pretending to live up to the ethical standards we boast about.
it does us more harm than good.


the irony here is that our entire health care for profit system is repugnant- the kidney stuff is a drop in the bucket- making money off of someone because they are sick creates inhumane incentives to keep people sick, just as monetizing organ donation turns a noble gesture into an exploitable one, presumably along stratified lines- the movie 'the island' heightens this moral repugnance, as an ethical end game scenario for monetizing organ donation- im with the social solutions above- let's keep organ donation humane and socially incentivized, rather than economic and profitized


this just in!:

Joseph Hale

People are going to start asking, "You're still $22,000 in debt; why not just sell off all your usable organs?"

That's right, never say you're broke while you have both kidneys.


When did currency speculation stop being repugnant?

Drill-Baby-Drill Drill Team

Repugnant Ideas

Ban all languages, and unify all people with the logical ESPERANTO modern superlanguage--Only 10 rules of grammar. NO irregular verbs. No 100 verb conjugations. Spelling is phonetic.

Ban all religions. Unify believers with a single monotheistic superreligion based on peace, love and cooperation. Call it " Double Rainbows All the Way.'

Allow study of holy books like the Bible or Koran or Book of Mormon to be equivalent to literature--no different than chick lit, bromance novels, or Playboy. No you cannot base your life on camels and life in the desert.

Ban all food restrictions and food intolerances: everyone will enjoy vegan high protein biscuits and Velveeta cheese.

Allow the harvesting of human fat from liposuction clinics to be used as biodiesel. Its homegrown, it reduces our foreign oil addiction, and it slenderizes the populace. It's Win-Win!

Jon Webb

Look, just donate a kidney. I have done it, and it's not that big a deal. You are essentially giving someone a life (life on dialysis is a half life at best) and risking very, very little (something like 1 in 5000 risk of death). All care related to the transplant will be covered and, should you someday need a kidney yourself, you will go to the front of the list. Should you do this you may well find that it is the best single thing you have done with your life (as I have).


Repugnant to whom? Not me.

Lev Brostein

That organ donor van looks a little scary, especially if you've seen the "Live Organ Transplants" sketch from Monty Python's "The Meaning of Life".


"Economists are pretty much immune to repugnance."

That's pretty much why the economy has tanked and why the wealthy have already recovered while the middle class continues to get hit.


It is a nice gesture, but after speaking to many EMTs over the years, when they see that "donor" box checked, they are more likely to let you become a donor...

Eric M. Jones


There are some things that are great for a society but terrible for an individual.

I want the emergency room medical personnel to say (over my still warm body), "Well, we'd better see if we can save him...and the rich guy's kid will just have to wait for kidneys; Eric has no organ donor card."

But more generally (Freakonomically*) the appeal to people's good nature instead of coming up with something that make economic sense is a losing game.

Consider: We could pay an amount for blood that would cause people to actually give blood because it is in their economic best interest. What a refreshing idea: no more donated blood. Now we might have a market that demanded "quality" blood as well, not that "questionable" blood.

If someone wanted to pay me now for donating my organs at some future date-- when the time came, they're yours!. But for now all I get is some sort of weird semipatriotic appeal for my important inner parts.

Makes no sense! I'll keep the parts, thank you.

*Hey, I invented a word!


Justin Caron

The problem is that this will end up exploiting poor and desperate people who need to make some cash. I doubt many rich people would line up to do this for even a couple thousand bucks. But homeless people, drug addicts, and the growing ranks of unemployed people will line up.

And in reply to Mr. Jones, the blood supply for medical use in this country is entirely from volunteer donors to avoid risky donors. This is the best way to get "quality blood." Look at all the shady people at plasma collection centers (for research and cosmetic use, not medical). Drug users will be first in line to sell blood because its a quick buck.


The huge increase in kidney failure patients due to TYPE 2 diabetes should not be a major contributor to the demand for kidney transplants (exception would be children whose parents are responsible for their condition). Even a very compliant Type 1 diabetic is likely to suffer kidney damage during their life but they are born with this disease which is unfortunate and I think they have every right to be considered for transplant. The number of Type 1's is vastly overshadowed by the millions with type 2.

All adults may not be nutritionally literate but let's be realistic, they dam sure know that fast food isn't a healthy choice. Type 2 diabetes is almost always a result of abuse of the human body due to lack of exercise and poor diet/ food choices. Similar behaviors are seen in people addicted to alcohol and who aren't willing to admit they need to curb their alcohol intake. Even if alcoholism is an addiction and the patient works to stop drinking, they are rarely considered for transplant, although those with wealthy probably have ways of getting around this.

Regardless of the socioeconomic class, we don't give liver transplants to alcoholics, should we really even consider giving kidney tranplants to Type 2 diabetics when there are people with kidney damage due to diseases that couldn't have been prevented?



I have a very strong opinion on this issue but I prefer the "stick" approach to motivate tissue/organ/blood donation.

If you do not contribute or plan to contribute to the pool of organs than you should not be able to draw from the pool of organs. Certainly there are exceptions for age, health, ect. Pair this rule with an "opt-out" method and countless additional lives are saved daily.

An ex-girlfriend once told me she did not have the donation box checked because the whole idea sounded gross.


Northwestern's Transplant Center has been doing paired donations since 2006, including what are called "domino paired exchanges," where many related donations and transplants are accomplished simulataneously. See, e.g., this link:

There are so many health and compatability issues that have to be worked through, even with willing and able donors, that this has become a dynamic area in transplant medicine.

I rather doubt that in the US we will ever get to a point where the field will be any less regulated. The notion that organs will go to the highest bidder neglects to account for the fact that there are multiple highly sophisticated parties involved in these transactions (UNOS, hospitals, transplant centers, physicians) that are required to effectuate the procdure and the many layers of testing that are required in approving a match. For cadaveric grafts, still the majority of transplants, this is absolutely the case. Whether a person may attempt to solict a living donor via some promise of remuneration, that is really the issue. I suspect it goes on. It doesn't bother me. This is a side agreeement, though, between two adults, outsde of the purview of hospital and docters, that may not be legally enforceable should one party breach the contract.


richard schumacher

The paired donation arrangement is better than nothing, but it's just barter, with all the clumsiness of any bartering system. A market would be more effective. Are we serious about saving lives or are we not?


All of this clumsiness in organ donation, which still doesn't address the problem, as even Dr. Roth admits.

The real solution - the one that is the least "repugnant" - is simply to massively fund stem cell research so scientists can grow everyone a new kidney/liver/pancreas from their own adult stem cells.

It's already been shown to be possible: and

That no one pushes for what is clearly the best solution shows in fact those who claim "to care" are just interested in shocking as many people as possible - reveling in their "repugnance" as a form of counter-signaling.


Decades ago, I proudly marked the organ donor box on my license and it's stayed that way ever since. I have zero concern that the medical community will try to harvest my organs prematurely. To the contrary, I think most medical personnel would make more of an effort to preserve the life of someone who's trying to help other people with chronic medical conditions; I'd guess that many more people in medical positions have checked the 'organ donor' box than any other profession. These people have their feet on the ground and truly understand the need, where people like you and me are free to stand far back and speculate.

That said, I'm not too terribly concerned with putting an actual price on what is, after all, a very valuable item. But I have an EXTREMELY STRONG concern that if we do it, rich people will buy all the organs and poor people will be left with none. I strongly suspect that's precisely why Iran has established an actual market for them, and in my mind, it's precisely why it's repugnant to do so. Rich people can afford better cars than the rest of us, better houses, better food, better lifestyles, and I have no problem with any of that. But when they're allowed to, say, destroy their liver by drinking excessively, then simply buy another, while a much less reckless poor person with a liver disease dies because he can't afford another one....well, that's a line we can't cross, as far as I'm concerned.

Regarding the position that economists are immune to repugnance, my view is more along the lines that economists place most or all value on money and little or no value on anything else. They're not repulsed by the idea that rich people should be entitled to everything they can afford to buy, while people who are unable to buy anything deserve nothing. Many of the rest of us, like this EE, find that idea as repugnant as any.



Passive consent. Instead of making people opt in to being organ donors, make that the default, and if people want, they can opt out. Easy solution. Not repugnant. The current status quo deserves to be spat upon.