The Kidney Opt-Out Revolution

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Economist Richard H. Thaler and law professor Cass R. Sunstein have a book out called Nudge: Improving Decisions About Health, Wealth, and Happiness in which they promote their theory of "libertarian paternalism." At the book's new blog, they mention Drew Carey's reason.tv bit about organ sales, and they seem to have come to some strange conclusions:

Reason, the libertarian magazine, has put together a video (hosted by comedian and libertarian advocate Drew Carey) on the virtues of organ donation.

The organ shortage in the U.S. is primarily due to default rules that require organ donors to formally register their wish to be a donor, known as explicit consent. In surveys, most Americans express a strong willingness to donate their organs upon death, but very few take the costly step of formally registering to become a donor. We tend to take people at their word that they do want to be an organ donor, and advocate switching the default rule from explicit to implicit consent, in which the minority of Americans (15-25 percent depending on polls) who do not want to be donors would fill out a form expressing those wishes.

As Virginia Postrel explains here, even if every one of us signs on as a potential donor, Americans will continue to die waiting. The circumstances under which deceased donor organs are usable remain quite limited, so abolishing the list entails incentivizing live donation. Only Iran has managed to find kidneys for everyone in need, and Iran has an imperfect, highly regulated system of organ sales.

Pointing out that presumed consent will not solve the problem is not exactly an argument against it, but the consent policy Thaler and Sunstein advocate is more complex than they seem to understand. It's an extremely delicate issue among minorities who are (with good reason) wary of the medical establishment, and it may be politically impossible in a society as heterogeneous as ours.

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  1. I’d love to see some libertarian commentary on this:

    The sting of poverty
    What bees and dented cars can teach about what it means to be poor – and the flaws of economics

    http://www.boston.com/bostonglobe/ideas/articles/2008/03/30/the_sting_of_poverty/?page=full

  2. And one other thing: fuck all of you. Fools.

  3. How is it costly to become an organ donor? They just asked me when I applied for my Washington drivers license.

  4. Iran has a kidney market?

    OMG! TEH ISLAMOFASCISTS WANT US TO WAKE UP IN A BATHTUB OF ICE WITH A CELL PHONE AND A NOTE TO CALL 911! I KNOW IT MUST BE TRUE BECAUSE THIS GUY AT A PARTY KNEW SOMEBODY WHOSE BOYFRIEND’S COLLEGE ROOMMATE’S MOM LOST A KIDNEY THAT WAY!

  5. minorities who are (with good reason) wary of the medical establishment

    What does that mean? Minorities are poor and therefore resentful? Minorities are stupid and therefore superstitious? Which minorities? Why “with good reason”? Anyone?

  6. Why “with good reason”? Anyone?

    The Tuskegee Experiment, perhaps?

  7. Hilarious, thoreau. With such comedy genius you should consider contributing to “Urkobold”.

  8. Only Iran has managed to find kidneys for everyone in need

    Does this spook the hell out of anyone else but me? Kind of like we found the justification for “We have no homosexuals in Iran” comments and the like.

  9. The Tuskegee Experiment, perhaps?

    Ah, so “minorites” necessarily means poor black retarded men? That’s too crude for Kerry.

  10. Cue Viking Douche with one of his wacky “Minion of Urkobold” posts.

  11. Good point, Other Matt, and putting the two together would explain where they get all the kidneys from.

  12. fwiw, Cato’s analysis of Iran’s kidney market here.

  13. Hey Edward, does your bitterness and resentment just sting, or does it really burn like a dump after eating Serrano peppers?

  14. Ah, so “minorites” necessarily means poor black retarded men?

    I’m not poor, black, or retarded, but the existence of that study still gives me pause.

  15. Instead of presumed consent, do this: If you register your wishes, you get $10 off your taxes. Doesn’t matter whether you say YES or NO. As long as you make a decision, you get the $10.

    So there can will be complaint from religious minorities. And even if half the population says YES, that’s still a lot more than are saying yes now.

    I’d add a few extra details: if you’re married, you have to get your spouse to sign off on your decision to get the $10 (to avoid arguments later). You can change your mind at any time. And if you and your spouse agree on a YES, no further consultation with family is necessary before they take your organs.

    If you like, and you feel like being sneaky, you can even add an extra hidden $10 increase to the next tax hike, to cover the cost. It’s like a $10 tax on the indecisive!!

  16. If you like, and you feel like being sneaky, you can even add an extra hidden $10 increase to the next tax hike, to cover the cost. It’s like a $10 tax on the indecisive!!

    Sounds like a plan to apply to alcohol, tobacco, fatty foods, fast foods, and give me a few min and I’ll think of some more.

    Y’all do realize you’re not really dead yet when they take the organs, right? Not that anyone would ever make a mistake or anything. This does give me a bit of pause, I will admit.

  17. People are prentending to be me again. I’m flattered.

  18. OK, she added a link to explain the “minorities” bit.

  19. “Sounds like a plan to apply to alcohol, tobacco, fatty foods, fast foods, and give me a few min and I’ll think of some more.”

    Actually, it’s not. Those things are paternalistic incentives to help only yourself. The organ-decision subsidy is an incentive to help other people.

  20. Reason is libertarian?

    ROFL.

    I’m more anti-state than the psuedo-libertarian clowns at Reason, and I don’t even consider myself libertarian.

  21. What does this mean: “The circumstances under which decreased donor organs are usable remain quite limited . . .” ? Typo?

    I don’t think they’re trying to come up with a complete solution to the problem of shortages. But as a step in the right direction, whatever its practical shortcomings, doesn’t the concept make a lot of sense?

  22. Step 1: Assume that I implied consent with having my organs used after I die.
    Step 2: By extension, assume that my organs belong to the State(TM).
    Step 2.5: Make it illegal to abuse state property by leading an unhealthy lifestyle.
    Step 3: Profit!!!

  23. Reason is libertarian?

    DRINK!

  24. I’m still waiting for these two to come up with any other viable examples of “libertarian paternalism” besides (1) presumed organ donation and (2) opt-out rather than opt-in for 401(k)s.

    Sometimes the exception proves the rule (i.e., that “libertarian paternalism” is indeed an insolent oxymoron 99.99% of the time and is best relegated to a footnote in the encyclopedia of political philosophy).

  25. Kip, you think they even rate a footnote?

  26. Regarding the boston.com link posted by Edward, it’s interesting to note that

    a) Tyler Cowen has some good things to say about it.

    b) The central insight of the book is essentially an expression of marginal utility.

    In the end, it really does not discredit free-market theories in any way, since a free market is what you get when you eliminate violence from a society. It essentially supports something that I suspect which is that the solution to poverty is increasing human productivity until even the poorest can afford the necessities of life.

  27. So someone claiming to be a libertarian supports the idea that we should have to explicitly say we do NOT want our body parts yielded up to the state and its medical establishment, and Reason’s big argument against the idea is that it won’t fix the organ shortage problem and that it’s “politically impossible”?

    Is this really what passes for libertarianism around here?

  28. They can have my kidneys when they pry them from my cold, dead, lower back.

  29. What about having a free organ market instead of this astute by small “fix”. You could get a lump sum, or an annuity for agreeing to give your organs to a company at your death, and that company would sell them on the market. Everyone would be better off.

  30. The one thing that concerns me about opt-out policies are that the incentives would encourage making opting out unduly burdensome so that people either don’t realize they have have the option or so it becomes so burdensome that people who otherwise would don’t exercise it.

    If it’s a matter changing “Check this box to participate” to “Check this box not to participate”, it’s not an issue for me, but I’m not sure how long politicians would fight the temptation to switch it over to something along the lines of “Apendix M: If you wish to apply for a license without joining the program, submit a notarized copy of Form 4568-A (see schedule 1347 to determine proper recipient) and $20 processing fee no later than 7 days after recieving your license or the first business day of the month, whichever comes first.” to bolster enrollment rates.

  31. Sunstein is not an economist.

  32. Only Iran has managed to find kidneys for everyone in need,

    According to who? The mullahs?

    How many kidney transplant programs do they have in Iran? How many nephorologists who can diagnose “everyone in need”?

    Skepticism doesn’t begin to describe my reaction to that assertion.

    And the whole notion of “presumed” consent gives me the willies.

  33. What does this mean: “The circumstances under which decreased donor organs are usable remain quite limited . . .” ? Typo?

    Probably should be “deceased donor organs”.

  34. According to who? The mullahs?

    No, actually. according to a U.S. doctor working for Cato:

    If a decade’s worth of reports in the transplant literature are to be believed, only one country in the world does not suffer from an organ shortage: Iran. Although Iran clearly does not serve as a model for solving most of the world’s problems, its method for solving its organ shortage is well worth examining. Organ donation is ubiquitous throughout the world, but Iran is the only country that legally permits kidney vending, the sale of one individual’s kidney to another suffering from kidney failure.

    Paper here

    In fact, Iran is a popular destination for Middle-Easterners wanting to get good medical care. They even dominate the market for sex-change operations. Getting a sex change is legal in Iran, it was blessed by the Ayatollah Khomeni himself.

  35. Getting a sex change is legal in Iran, it was blessed by the Ayatollah Khomeni himself.

    Yeah, I still can’t wrap my mind around that one.

  36. Human organ donation will eventually be irrelevant once Bush is out and science is legal and funded once again.

  37. That’s a pretty big “if” there in the Cato article, tarran.

    I really, really find it hard to believe that there aren’t any Iranians who go without needed kidney transplants.

    I mean, I’m all in favor of organ vending, but I suspect there’s somebody playing fast and loose with definitions or numbers here somewhere.

  38. OTOH, R C, should we really be shocked if allowing people to buy and sell something reduced the wait times for the product in question?

  39. It’s sad that Jonah Goldberg over at his Liberal Fascism blog was faster to point out the un-libertarian implications of implicit donation system: that the state has first right to your organs and that it’s the individual’s job to take positive action to have their body left alone. I’m a little disappointed that Reason would discuss the utilitarian implications rather than the philosophical, when the proposal is so repugnant ideologically.

  40. Why should there be a presumption that you want to “keep” your organs after they’re put with you in the ground, any more than that you want to keep your excrement after flushing it down the toilet?

  41. And, I could’ve added, for the gov’t to make money off sludge made from your excrement. Why is the case with organs more repugnant than that?

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