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.


Since when was it decided that our organs are simply something for recyling into other people? I find it repugnant to suggest that I should part with something simply because someone, somewhere needs it. Should I also be forced to sell my house and donate the proceeds in order that someone else can have a heart transplant? What's the difference? I don't really "need" my home equity to sustain my life, do I?


Dan Ariely presented a graph at his TED talk, showing the percent of drivers donating organs in different countries.
Under 30%: Denmark, Netherlands, UK, Germany
Over 85%: Austria, Belgium, France, Hungary, Poland, Portugal, Sweden
The difference is whether the DMV form requires people to check a box to opt in or to opt out of donating organs.

I agree with Pavel that checking the "donor" box could make EMTs and the healthcare system give up on you sooner. Same with Do Not Resuscitate orders.


Now, the guy from "professional finance" a bill collector, can ask if you still have both kidneys and would you sign a lien against one or both at death.
The outrageous nature of the organ business is the content of the new film "Repo-Man" about foreclosing on that organ transplant or hip replacement. Humans are simply dangerous when money is involved.


What if I sell a kidney now and later develop renal failure? Should I be eligible to receive a kidney? Should I pay for it?

The best way to decrease the unmet need for kidneys to transplant is to improve the medical care of diabetics and hypertensives to prevent renal disease.

Robert Cohen

'Iran is the only country allowing sales of organs for transplant.'

Could a knowledgeable writer please inform readers re Iran, not reputed as a libertarian model a la Milton Friedman's Hong Kong.

Many/most readers are intererested as I am in how the Iranians are managing such.

Robin Batteau

Cool stuff. But here's some economics for you: if just 10% more people checked the donor box on their driver's license, the SUPPLY of transplants would go way up, exceeding DEMAND, driving the PRICE way down, lowering the cost of healthcare in general, lowering the cost of car insurance, paying back the donors-- and everyone else-- even lowering inflation by lowering everyone's insurance costs-- ahead of time. Problem solved.


The "paying for organs" thing still scaring people? The "exploitation" furphy still floating around.

How about this: the donor form is on driver's licenses. How about a 10% break on your comprehensive auto insurance if you check all the boxes on the back of your license? The fund could be paid for by the health insurance companies who will save money as keeping people on life support or dialysis is generally more expensive than transplants.


Actually, the best solution to the organ scarcity is simple: those who are organ donors themselves go to the top of the list if they ever need an organ. That is, there should be TWO lists for organ recipients (both sorted by need): one for people who had previous opted in to be a donor, and those who hadn't.

There should be minor exceptions for folks who are medically unable to donate (but NOT for religious or other voluntary reasons), allowing them to be put into the "donor" pool. And, as bad as it sounds, I'd INCLUDE kids in this scheme - more pressure on parents to have their kid be a potential donor.

I would expect that this solves a huge portion of the problem, as I can't imagine that any organ would ever go to anyone in the "didn't opt-in" pool. Pretty strong incentive to be a donor.

And, let's be honest, why should anyone who isn't willing to help someone else out by being a donor get a bump over someone who is willing?



I don't really care if people get compensated for donating organs, so long as they do not significantly imperil themselves by doing so. However I think there are important questions to ask about access.

Would all people have equal access to organs obtained in this way? This would seem to require public funding of such transplants. It would seem to require that donor compensation be set at a rate that meets the entire demand for organs. What would be the public cost and can we afford it?

Otherwise, it seems access would be limited to those who can afford it. I think part of what repels people from this idea is shifting terms of what is meant by income inequality. I'm happy to become an academic, as opposed to say a investment banker, because I presume the financial cost of my decision is things like luxury cars and beach homes and mansions and such. But if the cost is now whether I receive an much-needed organ or not, my decision takes on new implications, and I feel unfairly committed to it. Likewise, I presume many people are tolerant of income inequality, and in particular that which goes along with unequal access to opportunity and various circumstantial injustices, when the terms of this inequality is material things. But not so much when the stakes become life and death.


Baffled Observer

Being an organ donor is one way to make sure you won't be kept alive on life support if your case is utterly hopeless.


Re #30: "Being an organ donor is one way to make sure you won't be kept alive on life support..."

A good point, and one of the reasons I have the organ donor box checked. And yet another reason: the savings from NOT providing that life support when there's no real chance of a full recovery would more than cover the cost of the transplants, leaving anything paid for the organs as gravy.


Repugnant idea: Let people die when their bodies fail.

Why must we spend our resources trying to avoid death when it's time to die rather than spending to live when it's time to live?


Instead of having people check off that they want to be organ donors when getting their driver's licenses, the default should be that people are organ donors and they have to sign in order to be removed from the registry. I'm pretty sure Freakonomics has explored the choices people make in relation to the default (ex: the default on a menu is a smaller size, people will eat smaller portions, etc). It would be interesting to see how many people would opt OUT of organ donation, or how successful the program would be.

Tom G

Very surprising that nothing was mentioned about the fact that organs are bought and sold all the time

Heartless, But No Sucker

"....let's keep organ donation humane and socially incentivized, rather than economic and profitized..."

Get back to me when you see hospitals and doctors doing free organ transplants. Free, as in, no charge. To patients or insurance companies. Not accepting any privately raised donations. Because as it stands, organ donation is already an economic transaction, already profitized. It's just that doctors and hospitals are the ones benefiting economically. And as long as they can convince sap-minded donors to GIVE their organs away, it'll stay that way.


"Should there be a legal market for organs?"


Seattle expat

There is something strangely feudal about a system where everyone involved in a transplant--doctors, nurses, hospital admins, etc.--gets paid, except for the donor, who makes it possible.
How to avoid the problems many other comments have raised? And would these regulations be enforceable and followed? Similar to debates about legalizing prostituition.
Perhaps a government-set fee to someone who has already passed all other requirements for donation--not buying the organ, but a "transfer-tax" payable to the donor. SInce it could not be increased by the recipient, there would be no possibility of bidding wars.


Repugnant for who??

If you're healthy you might proliferate all sorts of points against it (right, wrong, not ethical, blabla).
You might reason about it with very clever points, debate about organ trafficking, and get really upset because it has become a real business.

Fine! For every good side, there will always be a bad side

If you're the one in need for an organ, i believe you are the happiest man in the world and might encourage people around you to donate organs as you're life's just been saved and anyone can save a life.

Our problem as human being is selfishness.

Selfishness is repugnant.


"Since when was it decided that our organs are simply something for recyling into other people? I find it repugnant to suggest that I should part with something simply because someone, somewhere needs it."

The only alternative is to give them to the worms for brunch. What have the worms done for you lately?

Would you burn all your money when you die? Would you have your dog shot when you die?

I just flew back from Asia and wound up sitting next to a guy who is a US medical professional who spent 2 months in a program to assist and teach heart operations in Vietnam. He told me of the last operation he participated in. I was a kid who got a heart valve replacement and would have died in short order otherwise. The valve came from a US kid who died in an accident - [Vietnam does not have the practical ability to preserve organs or parts thereof.] Your call.


Why base everything and value everything with money? Why not change the concept of money?