In my last few posts, I’ve been discussing the controversy generated by Gary Becker and Julio Elias’s recent essay advocating for kidney markets, Cash for Kidneys: The Case for a Market for Organs. Because Phil Cook and I are currently circulating a paper on the same topic, this is an issue that’s been on my mind lately.
In my first post I demonstrated that, when properly measured, the gap between kidney need and supply is even larger than typically assumed and there is little reason to expect that trend to abate under current conditions. The prospects are dim for increasing kidney donation rates under the current system: donation levels have been static overall since 2006, and donations from living kidney donors have actually declined from their 2003 peak. In my next post, I showed that most kidneys from suitable deceased donors are already procured -- even a perfect deceased organ consent and allocation system would not yield nearly enough kidneys to cover the amount needed per year to satisfy unmet demand.
Moreover, an increase in the number of living kidney donors would improve health outcomes for those with ESRD and reduce the annual cost per patient, while imposing relatively little donor risk. However, as shown above right (figure 8 from our paper), living kidney donations are currently nearly all directed, usually to family members. Perhaps with sufficient education and public outreach the number of altruistic donors could be increased. But the fact that there were only 182 nondirected donors in 2012, combined with the recent downward trend in living donations – despite current education and outreach efforts – are not encouraging in that regard. It is for all of these reasons that so many observers, including Becker and Elias, conclude that the time is ripe to reconsider financial incentives for kidney donation.
In response to the Becker and Elias essay, Al Roth notes that these arguments for kidney markets have made no headway over the years and questions whether repetition of the basic facts will move the ball forward. As many Loungers know, Roth has written about Repugnance as a Constraint on Markets, and has often argued that a better understanding of the precise nature of the repugnance toward financial incentives is essential to making progress on this issue.
I suspect Al is right that pure “cash for kidneys” arguments are unlikely to have much practical impact at this juncture, as evidenced by the HHS reaction to incentives for bone marrow donations that Michelle Meyer has blogged about. Instead, any successful incentive system would likely need to build on the existing transplant frameworks and methods that already enjoy widespread acceptance.
What I would like to see in the near future are innovations in, for example, contracts and NEAD chains, or incentives to participate in kidney swaps. The former is a topic I have addressed with Kieran Healy and the latter is one I take on in forthcoming work with Mike Rees, that I plan to blog about in more detail in the next few weeks.
Innovations such as these have several advantages. First, given the ambiguity in NOTA’s text and legislative history concerning the meaning of the term “valuable consideration,” these innovations, if properly structured, arguably pass master under NOTA, thus obviating the need for legislative action. Second, although these proposals undoubtedly would move kidney donation further toward “markets” along the gift-markets spectrum, they are a far cry from the “cash for kidneys” envisioned by Becker and Elias – a proposal that (predictably) prompted immediate outrage from the bulk of WSJ commenters.
In short, thoughtful commenters have proposed a rich array of incentive structures that are designed to address objections to organ markets while still incentivizing donation. Some of those proposals are featured in the forthcoming Law & Contemporary problems issue on Organs & Inducements, including a paper by keynote speaker, Al Roth, with Muriel Niederle.
I’m looing forward to blogging in more detail about the volume as the papers are made available. There are some excellent pieces worth reading by authors in law, economics, medicine, and other fields.
In the meantime, you can read the volume’s accompanying primer here.