I've posted a new episode of the Taboo Trades podcast, this one featuring Pat Oglesby of the Center for New Revenue discussing marijuana legalization. From the show summary: "Pat discusses marijuana legalization and disses on the tax academe"
Pat has also done a blog post about the episode, in which he answers a few additional questions about legalization and drug policy posed by my seminar students.
You can listen to this episode (and others!) on spotify or apple, among other services.
Yeah, I know everyone has a podcast these days. But theirs aren’t about Taboo Trades and, therefore, are not as good as mine. :-)
As many readers know, I’ve taught a course on Taboo Trades for a number of years now. I’ve always been lucky to have interesting speakers, and this year decided to try to make lemonade out of the lemon that is zoom teaching. So I’m interviewing some of my favorite folks working in this area for the course and making it available to all of you as well.
You can access the podcast on both apple and spotify.
I’ve uploaded two episodes so far, and should have another posted this week.
I’ve so far interviewed Peter Jaworski about compensating plasma donors and Josh Morrison about paying kidney donors and purposely infecting volunteers with Covid-19 for a challenge trial.
If you’re interested listen to the full episodes on apple and spotify.
Next week I’ll be giving a keynote lecture and also participating in a panel discussion on “Allocation Problems in health care” at theMaCCI Law & Economics Conference on The Law and Economics of Market Design. From the conference website:
The conference will provide an international platform for exchange and discussion between academic researchers and practitioners in public authorities, legal counsel, and economic consultancies.
The MaCCI Law and Economics Conference is organized for the eighth time since the inaugural edition in 2011. It is our ambition to stimulate and disseminate research in the field of market design, competition, regulation, and innovation policy.
We gratefully acknowledge financial support from White & Case and the EPoS Collaborative Research Center for this year’s annual law and economics conference.
This year the topic is “The Law and Economics of Market Design”. The conference will consist of 4 panel discussions, two keynote lectures and will cover the following topics.
- Design of digital platforms
- Managing private and public procurement
- Designing infrastructure markets (telecom, traffic, energy)
- Allocation problems in health care (organ exchange)
Keynote Speakers
Duke Law School, Durham
University of Cologne and University of Maryland
For the keynote address, I’ll discuss repugnant transactions, or "taboo trades" (something I also recently discussed on Brian Frye’s Ipse Dixit podcast) and how the law responds to such transactions. I’ll focus on egg, sperm, and organ “donation” and, if I have time, briefly discuss blood, plasma, and bone marrow donation. (I’ve put “donation” in quotes because, consistent with common practice, I’m using the word donation to refer to transfers without regard to whether the donor was compensated).
For the health care allocation panel, I’ll discuss Global Kidney Exchange (prior blog posts on Global Kidney Exchange are collected here).
The full conference program is here.
The final version of the paper that I blogged about last week, Complete Chain of the First Global Kidney Exchange Transplant and 3-yr Follow-up, is now available online.
The publisher has created a Share Link providing 50 days' free access to the article. Anyone clicking on this link before October 27, 2018 will be taken directly to the final version of the article on ScienceDirect, which they are welcome to read or download.
After that, the paper will be behind a paywall, so enjoy!
Share Link:
https://authors.elsevier.com/c/1XhNI8Yy0L8qol
My co-authors and I recently published a paperthat provides more detail on the first Global Kidney Exchange (GKE), including a 3-year follow-up report on the Filipino pair that participated. We wrote this, in part, to respond to GKE critics who argued that the Filipino pair had been exploited or coerced into participating, or who argued that the pair had been disadvantaged in the swap or not received adequate follow-up care. Al Roth has more discussionover at his market design blog.
From the abstract:
Background
Global Kidney Exchange (GKE) offers an opportunity to expand living renal transplantation internationally to patients without financial means. These international pairs are entered into a US kidney exchange program that provides long-term financial support in an effort to identify opportunities for suitable exchanges for both these international pairs and US citizens.
Objective
While the promise of GKE is significant, it has been met with ethical criticism since its inception in 2015. This paper aims to demonstrate the selection process and provide >3 yr of follow-up on the first GKE donor and recipient from the Philippines.
Design, setting, and participants
The first GKE transplant occurred with a young Filipino husband and wife who were immunologically compatible, but lacked the financial means to continue hemodialysis or undergo a kidney transplant in their home country. The pair was enrolled in the Alliance for Paired Donation matching system, several alternative kidney exchanges were identified, and the pair subsequently underwent renal transplantation and donation in the USA financed by philanthropy. The resulting nonsimultaneous extended altruistic chain provided transplantation for the Filipino husband and 11 US patients.
. . .
Conclusions
While criticisms of GKE highlight concerns for possible exploitation of financially disadvantaged groups, these results demonstrate that these concerns did not come to fruition, and the outcome experienced by the GKE donor and recipient (and other US participants) was successful.
Patient summary
The first Filipino Global Kidney Exchange (GKE) donor-recipient pair continues to be followed by both US and Filipino transplant centers. Both are in good health, support the GKE program, and advocate for its expansion.
Related posts:
GKE Debate in The Latest Issue of the American Journal of Transplantation
GKE Debate in Current Issue of The American Journal of Transplantation
Global Kidney Exchange (GKE) to Overcome Financial Barriers to Kidney Transplantation
Reverse Transplant Tourism (cont.)
Over at Market Design Blog, Al Roth posts part of an incredibly moving email conversation with a donor who became part of a kidney paired exchange after hearing what I think is one of the best Freakonomics episodes of all time. As the donor describes it:
Then I heard a follow up episode that united a donor with his recipient. Stephen Dubner was crying... I was crying... I called Mayo Clinic the next morning and signed up for testing.
You should definitely read the entire exchange here. And if you have not yet listened to the pair of Freakonomics podcasts that led to the donation, you should do so, but only if you’re in a setting where it’s okay to cry. The second podcast is the one the donor is referring to, in which a donor is reunited with his recipient.
Freakonomics podcast: Make Me a Match (Rebroadcast)
Freakonomics podcast: Ask Not What Your Podcast Can Do For You
I found this part of the exchange particularly interesting:
"The rest is a long story and I know you are a busy man so I'll skip most of it. I ended up being part of a pair, instead of an altruistic donor. There was a man who worked with my wife that needed a kidney. He once saved her life with the Heimlich maneuver so it was pretty poetic that I could save his. He received his kidney from a bridge donor and I gave mine to someone on the diseased donor list. So I got to save two lives! I'm doing great. I went back to work a couple of weeks ago. I have no regrets and I hope I can inspire others to do something selfless and extraordinary in their lifetime. (emphasis added)
This ability to help more people, through a chain or paired exchange, rather than a single recipient, as through a donation to the waitlist, seems to be something that (understandably, I think) provides kidney donors with a lot of satisfaction. More generally, it's important to hear these personal stories from kidney donors.
I’ve blogged a few times about kidney exchange, for example:
Custom, Contract, and Kidney Exchange
Global Kidney Exchange (GKE) to Overcome Financial Barriers to Kidney Transplantation
GKE Debate in Current Issue of The American Journal of Transplantation
The latest Law & Contemporary Problems volume -- Altruism, Community, and Markets -- is now available! The entire volume is free online here. From the Foreword:
That human motivations can be complicated and that the concerns of individuals for both self and others shape communities—local, national, and global—are simple observations. It is much harder to grasp the complexities of a rapidly changing world in which human beings with their varying commitments continually interact. Our desire to better understand how and in what ways the forces of self-interest and altruism intersect—and at times collide—in the early twenty-first century inspired us to organize a symposium on “Altruism, Community, and Markets.” The proceedings of that conclave are published in this issue. Held in Washington, D.C. in October 2017 and sponsored by the American Enterprise Institute, Duke Law School, and the University of Virginia School of Law, the symposium brought together scholars in law, public policy, economics, medicine, and related fields to examine the institutions5 that promote and restrict market and nonmarket interactions. The group also explored how the powers of altruism and self-interest are (and have the potential to be) harnessed to create and distribute goods and services.
The articles produced for the symposium cover a wide range of subjects and are of exceptional depth and intellectual ambition. All address topics of current importance while situating their analyses in the broader context of the symposium’s theme. Taken together, the articles contained in this issue provide a snapshot of a world grappling with the challenges of “institutionalizing”6 human cooperation in the face of evolving social attitudes and technological advances.
As they say, download it while it's hot!
I’m a signatory (along with a number of economists and ethicists) to this letter to the Expert Panel on Immune Globulin Product Supply and Related Impacts in Canada. The letter argues that Canada, which imports most of its plasma from the United States (which, in turn, collects plasma from paid donors), should not ban compensation to plasma donors.
The genesis of the letter is that the Provinces of Québec, Ontario, and Alberta prohibit compensation for plasma donations for purposes of further processing into plasma-derived medicinal products (PDMPs). Currently, Nova Scotia and British Columbia are contemplating similar bans. The detailed letter, for which Peter Jaworski deserves primary credit, addresses, among other issues, wrongful exploitation, commodification, and crowding out. But the most interesting issue, in my view, is the purported safety rationale behind the ban.
Many opponents of compensating Canadian plasma donors raise safety issues. This really makes no sense to me (or the other signatories) for a number of reasons. First, some opponents conflate blood donors for transfusion purposes with plasma donors for PDMPs. As we explain in the letter, these are two very separate issues. Second, the scientific consensus is that compensating donors does not compromise the safety of PDMPs. As stated by Dr. Graham Sher, the CEO of Canadian Blood Services:
“It is categorically untrue to say, in 2015 or 2016, that plasma-protein products from paid donors are less safe or unsafe. They are not. They are as safe as the products that are manufactured from our unremunerated or unpaid donors.”
Finally, and perhaps most importantly, Canada imports PDMPs from the United States, where donors are compensated. There is no reason to believe that PDMPs made from compensated Canadian donors would be any less safe than PDMPs made from compensated United States donors. Instead, the opponents’ position seems to reflect a type of NIMBYism that fellow letter signatories Nico Lacetera (Rotman School of Management, University of Toronto) and Mario Macis (Johns Hopkins, Carey Business School) discuss in an article forthcoming in a Law & Contemporary Problems volume, Altruism, Community, and Markets, edited by me, Julia Mahoney (UVA), and Sally Satel (AEI). A draft doesn’t appear to be available online yet, but I’ll blog more about it when it is.
Fellow signatories Al Roth and Alex Tabarrok also blog about the letter here and here, respectively. The letter is very informative and can be read in full here.
In this series of posts, I’ve discussed a new draft that Phil Cook and I are circulating, If We Allow Football Players and Boxers to Be Paid for Entertaining the Public, Why Don't We Allow Kidney Donors to Be Paid for Saving Lives?. Our claim, which I laid out in my first post, is that there is a stronger case for compensating kidney donors than for compensating participants in violent sports. If this proposition is accepted, one implication is that there are only three logically consistent positions: allow compensation for both kidney donation and for violent sports; allow compensation for kidney donation but not for violent sports; or allow compensation for neither. Our current law and practice is perverse in endorsing a fourth regime, allowing compensation for violent sports but not kidney donation.
A common argument in support of the ban on kidney donation is that if people were offered the temptation of substantial compensation, some would volunteer to donate against their own “true” best interests. This argument is often coupled with a social justice concern, namely that if kidney donors were paid, a large percentage of volunteers would be poor and financially stressed, and for them the offer of a substantial financial inducement would be coercive. In sum, a system of compensated donation would provide an undue temptation, and end up exploiting the poor.
To these arguments we offer both a direct response, and a response by analogy with violent sport. My posts have touched on a few key points. First, the medical risks to a professional career in football, boxing, and other violent sports are much greater both in the near and long term than the risks of donating a kidney. On the other hand, the consent and screening process in professional sports is not as developed as in kidney donation. The social justice concerns stem from the fact that most players are black and some come from impoverished backgrounds.
Note that these arguments focus on the donors’ welfare, and ignore the welfare of people in need of a kidney. A comprehensive evaluation of amending NOTA to allow compensation requires that both groups be considered. Such an evaluation, conducted by Philip Held and colleagues, reached the following conclusion about a regime in which living donors were offered enough compensation ($45,000) to end the kidney shortage: “From the viewpoint of society, the net benefit from saving thousands of lives each year and reducing the suffering of 100,000 more receiving dialysis would be about $46 billion per year, with the benefits exceeding the costs by a factor of 3. In addition, it would save taxpayers about $12 billion each year.”
As stated by Held et. al., “dialysis is not only an inferior therapy for end-stage renal disease (ESRD), it is also almost 4 times as expensive per quality-adjusted life-year (QALY) gained as a transplant.” This means that the Medicare (which pays for the bulk of ESRD treatments) dollars currently spent on dialysis could be reallocated to compensating kidney donors, saving lives and tax dollars in the process.
As I said, even a series of posts gives only an introduction to our arguments and evidence, so download the full paper here.
Prior related posts:
If You Oppose Paying Kidney Donors, You Should Oppose Paying Football Players And Boxers Too
Paying Kidney Donors, Football Players, And Boxers: Medical Risks
Paying Kidney Donors, Football Players, And Boxers: Informed Consent And It’s Limits
Paying Kidney Donors, Football Players, And Boxers: Exploitation, Race, Class
In prior posts, I introduced the question, If We Allow Football Players and Boxers to Be Paid for Entertaining the Public, Why Don't We Allow Kidney Donors to Be Paid for Saving Lives?, and argued that the medical risks to a professional career in football, boxing, and other violent sports are greater than the risks of donating a kidney and that the consent and screening process in professional sports is not as developed as in kidney donation.
Although the primary focus of our paper is on the medical risk associated with living kidney donation, we also briefly discuss concerns about exploitation, coercion, race, and class, again with an analogy to violent sports. Living kidney donors in the United States have above-average incomes (after adjusting for sex and age). In a new regime in which donors were paid a substantial fee, it is predictable that the influx of volunteers would have below-average incomes. The prospect of financially stressed individuals attempting to make ends meet by “selling” a kidney raises a red flag for some ethicists. A compensation regime would expand the choice set for those in comfortable circumstances, but those in desperate circumstances might feel compelled to sell a kidney; in that sense, the option of selling could be seen as “coercive.” Furthermore, a system that in part depended on the poor to supply kidneys could be seen as “exploiting” the poor.
We believe that using words like “coercion” and “exploitation” to characterize the introduction of a new option by which poor people (and others) could earn a substantial amount of money provides more heat than light on this situation. The legitimate ethical concern is that so many Americans are poor, with inequality increasing over time. But that observation does not support a ban on compensation, which in fact limits the options available to the poor and thereby makes a bad situation (their lack of marketable assets) worse. But for anyone not persuaded by this argument, we note that these social-justice concerns apply with at least equal force to compensating boxers; most American professional boxers were raised in lower-income neighborhoods, and are either black or Hispanic.
As more has become known about the dangers of the repeated head trauma, similar arguments regarding football have become more prominent. About 70% of NFL players are black, and Pacific Islanders are also overrepresented as compared to the American population. Accordingly, much attention has been paid to the concussion crisis as a race and class problem. As one observer recently noted, “What’s a little permanent brain damage when you’re facing a life of debilitating poverty?” In reality, NFL players are better educated themselves, and come from better educated homes, than is average for Americans, in part because the NFL typically recruits college students. Still, some NFL players, like some would-be kidney donors, come from poverty.
Of course, this is only a taste of our arguments and evidence, so read the full paper here. In my next post, I’ll recap and wrap up.
Prior related posts:
If You Oppose Paying Kidney Donors, You Should Oppose Paying Football Players And Boxers Too
Paying Kidney Donors, Football Players, And Boxers: Medical Risks
Paying Kidney Donors, Football Players, And Boxers: Informed Consent And It’s Limits
In prior posts, I introduced the question, If We Allow Football Players and Boxers to Be Paid for Entertaining the Public, Why Don't We Allow Kidney Donors to Be Paid for Saving Lives?, and argued that the ban against paying kidney donors cannot rest on the basis of medical risk when we pay professional athletes to incur far greater risks. Today, I will talk about the consent process and the extent to which we might expect the system to protect participants – whether organ donors or professional athletes – from making bad choices against their own interests in exchange for the lure of money.
We believe that if NOTA were amended to allow payments to donors, potential kidney donors could be protected against being unduly tempted through the existing structure of screening, counseling, and delay, perhaps with some additional protections to prevent hasty decisions. On the other hand, it is not clear that NFL recruits have such protections in place.
Whether and when sane, sober, well-informed, adults should be banned by government authority from choosing to engage in an activity that risks their own life and limb is an ancient point of contention. There are a variety of hazardous activities that are permitted with no legal bar to receiving compensation. Included on this list are such occupations as logging, roofing, commercial fishing, and military service. Also included are violent sports such as football, boxing, and mixed martial arts (MMA). These examples illustrate a broad endorsement of the principle that consenting adults should be allowed to exchange (in a probabilistic sense) their physical health and safety for financial compensation, even in some instances where the ultimate product is simply providing a public entertainment.
One potentially distinguishing feature of kidney donation is that the harm is not the result of an accident, but rather of the deliberate action (of the surgeon and medical team). But this is also the case with fighting sports and with egg donors, who are compensated.
It is helpful to deconstruct the decision to donate a kidney under both the current regime (no compensation) and a hypothetical regime (in which the donor would be financially compensated). A well-developed organ procurement process in the American system seeks to ensure that potential donors are fully capable of making a good decision. Potential kidney donors are not only provided with full information, but also screened for mental and physical disability. While there is the possibility of “mistakes” (a decision to donate against the true best interests of the individual) under both a compensated and uncompensated system, the screening, consent process, and delays should minimize the chance for the kind of errors that behavioral economics has demonstrated are common. There is nothing intrinsically irrational about a willingness to assume medical risk in exchange for a substantial amount of money. But the quality of the choice may be influenced by a variety of factors, and we recommend some “nudges” designed to overcome the most common causes of faulty decision-making under such circumstances.
The same concerns that apply to the quality of kidney donor decisions also apply, and more obviously, to the decision to sign a contract to play in the NFL. Yet the consent and screening process in professional sports is not as developed as in kidney donation. Players are provided with little information about the risks, and indeed, the longer-term risks (including the risk of CTE in middle age) have not been well quantified, but appear to be far higher than for kidney donation. The payoff in both financial terms and status is also very high, and in part conveyed immediately. Any counseling or screening that might occur is up to the player to pursue.
In short, to the extent that the ban on compensated kidney donation is grounded in a concern that the lure of money may cause donors to disregard the risks of the procedure and subsequent long-term effects, that concern applies with even more force to participation in violent sport.
This, of course, is just a taste of our analysis and evidence, so read the full paper for more.
Prior related posts:
If You Oppose Paying Kidney Donors, You Should Oppose Paying Football Players And Boxers Too
Paying Kidney Donors, Football Players, And Boxers: Medical Risks
Yesterday, in If You Oppose Paying Kidney Donors, You Should Oppose Paying Football Players And Boxers Too, I introduced a new paper, written by Phil Cook and me, arguing that the case for paying kidney donors is much stronger than the case for paying participants in football, boxing, and other violent sports, and promising to follow up with subsequent posts outlining our arguments and evidence.
Today, I’ll discuss the central argument in our paper: the medical risks to a professional career in football, boxing, and other violent sports are much greater both in the near and long term than the risks of donating a kidney. Injuries in such sports are common, and retired players are very often disabled by the long-term effects of these injuries as well the cumulative effect of thousands of blows to the body.
One challenge in making a meaningful comparison between the risks entailed in kidney donation and the risks entailed in participation in contact sports is that the latter may stretch out for many years and involve not one choice (donate or not) but rather a series of choices regarding participation. While it is difficult to quantify these effects in a way that provides a natural comparison with kidney donation, we provide some statistics that suggest that, for example, a man who signs a contract to play in the NFL for a year is consenting to be exposed to far greater medical risks than someone who volunteers to donate a kidney.
We focus our analysis on football, because the epidemiology of injury and disability is better developed than for fighting sports. It is worth noting, however, that there has always been concern about the risk posed by fighting sports, and that concern has accelerated in recent years, due to a better understanding of the long-term effects of head trauma. As a result of these risks, medical associations around the world, including the American Medical Association and various state medical associations, have called for limitations or bans on boxing and MMA.
As to kidney donation, we analyze both the post-operative risk from surgery and the post-recovery chance of death or disability resulting from loss of function of the remaining kidney. Both risks – while greater than zero -- are quite low, both in an absolute sense and in comparison to the typical risks of participation in violent sport. For example, post-operative complications (most of them minor, such as bleeding or wound infection) are present in 7.3% of cases, and donors face a higher cumulative incidence of end stage renal disease than nondonors – 0.31% versus 0.04%. While that risk is thus significantly elevated for donors, it remains very low in an absolute sense, representing an increased chance of about 1 in 400.
With respect to football, we discuss injury rates at the youth, high school, collegiate, and professional level. While that data is far too extensive to fully discuss here, I’ll provide a few highlights:
This last point requires some explanation, because the findings do not imply that 99% of former NFL players will have CTE. The brains in the study were voluntarily submitted for examination by family members who were often motivated by a desire to know the cause of their loved ones dementia or other neurological problems. But the 111 brains do represent 8.5% of the 1300 former NFL players who died during the period that these brains were donated. That places something of a logical lower bound on the prevalence of CTE. Presumably the true prevalence is much higher than 8.5%.
While it is not possible to do a precise “apples to apples” comparison of the medical risks associated with kidney donation` and the risks associated with a professional football career, it seems clear that the acute risk of injury and of long-term disability are far higher for the football player. As discussed above, most NFL veterans live out their lives following retirement with serious physical and mental disabilities. The vast majority of kidney donors lead entirely normal lives following recovery from the initial operation.
In other words, the ban against paying kidney donors cannot rest on the basis of medical risk when we pay professional athletes to incur far greater risks. This is just a short preview of the evidence on medical risk, so read the whole paper, If We Allow Football Players and Boxers to Be Paid for Entertaining the Public, Why Don't We Allow Kidney Donors to Be Paid for Saving Lives?
Prior related posts:
If You Oppose Paying Kidney Donors, You Should Oppose Paying Football Players And Boxers Too
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