Organ transplants

Laws Banning Organ Markets Kill Even More People than Previously Thought

New analysis finds that thousands more die every year because the law forbids purchase of the kidneys they need to survive.

|The Volokh Conspiracy |

Many Americans die every year because they need kidney transplants, but cannot find one in time, in large part due to federal laws banning organ sales. A recently published article finds that the number of such deaths is likely to be much greater than previous estimates indicate. It finds that over the 30 years between 1988 and 2017, an average of over 30,000 Americans have died each year, because the ban on organ sales prevented them from getting transplants in time. Here is a summary of the conclusions, recently published in the Journal of the American Society of Nephrology (based in part on this article in the same journal):

[T]he death toll from ESRD [kidney failure] s very high in large part because of the severe shortage of transplant kidneys. Roughly speaking (all variables may not occur in exactly the same year), the incidence of treated ESRD is currently, about 126,000 patients per year, but only about 31,000 (25%) are added to the waiting list for a kidney from a deceased donor…. Moreover, only 20,000 (16%) actually receive a transplant kidney, of which 14,000 (11%) are from deceased donors and 6000 (5%) are from living donors. The approximately 106,000 (84%) who do not receive a transplant are fated to live an average of 5 years on dialysis therapy before dying prematurely….

Most of the focus of concern in the transplant community has been on the 25% of patients with ESRD who are added to the kidney waiting list, particularly how many receive a transplant, die, or are removed from the list because they become too sick to transplant. Little attention has been paid to the 75% who are not added to the list. But it is common knowledge that many of these patients with ESRD would medically benefit from a transplant, and if there was no kidney shortage would be recommended for the waiting list, would be accepted by a transplant center, and would receive a transplant….

What percentage of patients with ESRD fall into this category? No one knows for certain. However, to see the full extent of the harm done by the kidney shortage and the potential benefit from ending it, let us assume that 50% of those who are diagnosed with ESRD could medically benefit from a transplant. (This assumption is consistent with the findings of Schold et al….) Thus, half of the 126,000 patients who are currently diagnosed with ESRD each year 63,000 patients might medically benefit from a transplant. However, if only 20,000 patients per year receive a transplant, the remaining 43,000 would join the growing toll of those who die prematurely because of the kidney shortage…. We can extend this grim logic from the current time bac over thepast 30 years for which we have data….. The cumulative premature death toll…. from 1988 to 2017 was a horrendous 982,000…. Additionally, if we extrapolate the trend in ESRD diagnoses and transplants over the past 10 years forward to the next 10 years, the death toll would increase by an additional 465,000.

As the authors recognize, the estimate of 982,000 premature deaths over a thirty year period is very inexact. But even if the true figure is only, say, half as high, it still represents a vast amount of unnecessary suffering that could largely be prevented simply by allowing financial compensation for organ donors, thereby increasing the supply of available kidneys to the point where it can meet the demand.

By banning organ markets, the US government and other governments with similar policies thereby cause enormous needless suffering and death. It also deprives society of the productivity of the people who die prematurely and/or spend years in kidney dialysis that could have been avoided. Obviously, not everyone will want to become a kidney donor, even if monetary compensation were available. Some would not be willing to, and others are ineligible for medical reasons. But, if the authors' figures are correct we only need some 30,000 to 40,000 additional donors per year, out of a US population of over 300 million people. That should be a very feasible goal. In addition to offering payment to living donors, we can pay potential donors in advance for the "option" of harvesting organs after they pass away, a strategy that eliminates any negative health effects on donors, since, by definition, the option can only be exercised after they have died, and have no further use for the organ themselves.

The injustice of status quo policy is more than just a matter of failing to help people in need. It is the equivalent of actively killing them. Consider a situation where Bob needs to buy food in order to keep from starving. Producers are willing to sell him what he needs at market prices, but the federal government passes a law saying that it is illegal to sell food for a profit. Bob is only allowed to acquire such food as producers are willing to give him for free. If Bob starves as a result, the government is actively culpable for his death. It cannot claim that it was merely an innocent bystander who refused to help him in his time of need. The same point applies if the government (or anyone else) uses coercion to prevent people from selling organs that ESRD patients need to live.

Unlike in the case of food, it is unlikely that ESRD patients would buy what they need directly from sellers. Most likely, the actual purchases would be done by hospitals, health insurance companies, and other specialized enterprises, which could screen them for quality and then offer them to patients (as is the case with many other types of transplants and complex medical supplies). But that does not change the morality of the situation.

There are a variety of objections to legalizing organ markets. But to validate current law, they have to be compelling enough to justify killing thousands of innocent people every year. In my view, none of the standard arguments even come close to doing so. I address some of the most common ones here:

[M]any people oppose legalizing organ markets because they believe it would lead to exploitation of the poor. But most of them have no objection to letting poor people perform much more dangerous work, such as becoming lumberjacks or NFL players. If it is wrong to allow poor people to assume the risk of selling a kidney for money, surely it is even more wrong to allow them to take much greater risks in order to increase their income.

If you believe that organ markets must be banned because they exploit the poor, you must also argue that the poor should be forbidden to take jobs as lumberjacks and football players. If you believe that such considerations justify banning participation in organ markets even by the non-poor, than we must also categorically forbid monetary compensation for football players. Indeed, the case for banning the payment of football players is actually much stronger than that for banning organ markets. Unlike the ban on organ markets, a ban on professional football would not lead to the deaths of thousands of innocent people.

Other critics believe that organ markets must be banned because it is inherently wrong to "commodify" the human body. Yet most of them have no objection to letting a wide range of people profit from organ transplants, including doctors, insurance companies, hospital administrators, medical equipment suppliers, and so on. All of these people get paid (often handsomely) for helping transfer organs from one body to another.

Perversely, the only participant in the process forbidden to profit from the "commodification" of organs is the one who provided the organ in the first place. If you believe that people should be forbidden to sell kidneys because earning a profit from organs is immoral "commodification" of the body, you must either oppose paying all the other people who currently earn money from organ transplants, or explain why they, unlike the original owner of the kidney, are not also engaged in commodification…..

The same goes for people who argue that kidney markets should be banned because earning money from transactions involving body parts will somehow corrupt our morals. If the morals of doctors, nurses, and others are not corrupted as a result of repeatedly earning a large part of their livelihood from organ transplants, it is not clear why the morality of donors will be corrupted by earning money from selling a body part on just one or a few occasions.

I criticized the "exploitation of the poor" justification for banning organ markets in somewhat greater detail here, including pointing out that it cannot justify banning organ sales by donors who are not poor. The related argument that poor patients could not afford to buy kidneys in a market is also weak. The government can, if need be, subsidize the purchase of kidneys by poor patients, just as it currently subsidizes many other kinds of medical treatment for the poor. It would be far cheaper than the massive cost of paying for kidney dialysis, to say nothing of the cost of premature death, which deprives society of useful labor and the government of tax revenue. Even if we cannot get the subsidies completely right, that surely does not justify consigning thousands of people to death, any more than the absence of perfectly structured food subsidies justifies banning food markets and thereby causing large-scale starvation.

UPDATE: I think it is more accurate to describe the first piece quoted in this post as an "article" rather than a "study" (as I did originally), since it relies on data generated by previous publications, rather than its own original data. I have made the change accordingly.

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88 responses to “Laws Banning Organ Markets Kill Even More People than Previously Thought

  1. Wow, wonder what will be proposed next . . . one eye, one ear, one arm, or one leg perhaps?

    1. What’s your objection?

    2. WJack:

      To answer your hypothetical — if it were voluntary and the person received reasonable compensation, it should be legal. A lot is made about the necessity of allowing a person to control what happens with one’s own body. Should that not apply if one could actually profit monetarily from one’s decision, as well as profiting emotionally and morally? I doubt many people would be willing to part with one at almost any price.

      In any event, those parts are not necessary for life, whereas to a person with end-stage renal failure, a kidney is, while the donor can continue to live a normal life without the spare.

      1. Indeed. Everyone involved with organ transplantation benefits – except the donor. The recipient, of course, the various members of the medical team, the hospital(s), UNOS, the recipient’s family, arguably even society in general.

        Everyone but the donor, and the donors family. Not because what they offer is valueless, but because of arbitrary laws that prohibit the donor from benefiting from the donation. In terms of live donors, they in fact lose, not only because of the loss of the organ, but due to pain and time lost from work, etc. They also risk their own health to a degree, either from the surgical procedures they undergo, or the loss of an organ they may have need for in the future.

  2. I wonder what a kidney is worth? I’d give up one for $100k.

    1. Having seen some old folks with kidney problems late in life, I don’t think I would do it for a mere $100,000.

  3. But you don’t understand. People will begin to think they are in charge of their own bodies in areas that do not involve a baby dying.

  4. During the Cold War, the Soviet KGB and other progressives circulated stories in places like Guatemala that Americans paid to have vulnerable poor people kidnaped and murdered for their organs. That was a major reason we wanted nothing to do with a legal organ trade in the 1980s.

    1. “the Soviet KGB and other progressives”

      LOL

      1. There is no video replay review here; call ’em like you see ’em.

        1. I’m just glad he specified the Soviet KGB!

          1. I figured that 27 years after the Cold War ended, many readers might have no idea what the KGB was, without a little prompting.

            1. Heh. Well, this is the year that people born AFTER 9/11 start voting….

  5. To discuss this issue, we ought to discuss the difference, if any, between active and passive actions that predictably result in death.

    “The injustice of status quo policy is more than just a matter of failing to help people in need. It is the equivalent of actively killing them.”

    I don’t think that this is “more than” failing to help people in need. Whether a person allows someone to die out of inaction or action, the consequences are morally equivalent. Assuming, of course, equal knowledge of the consequences in both situations.

    Consider the following hypothetical. Migrants regularly cross some desert into some oasis and are in need of water. The oasis has unlimited water and the amount of energy that it would take to provide water for these migrants is negligible. Compare two situations. The governing authority of the oasis, fully knowing that N people will die without water (1) decides not to make provisions to provide people with water versus (2) decides to make it illegal to provide migrants with water in exchange for money. If N people die under either policy, they are both essentially equally bad. That in one case people are knowingly allowed to die of neglect versus in another knowingly being prevented from being able to buy water does not change the main problem in both scenarios, mainly N people dying. To put it another way, a person dying of thirst is the primary problem. Whether the means by which they are killed is passive or active is secondary.

    1. (cont.)

      Somin must agree with this on some level. He even advocates for coercion in order to save lives in the case where he suggests that poor people might have their purchase of kidney transplants subsidized. Where are these subsidies going to come from? From taxes. So, the bigger problem is someone dying, not whether or not it takes coercive taxation to prevent this bad outcome.

      If we want to address this kidney donation problem, we can start by allowing people (while they are alive) or their estates (after they die) to be compensated to transplant their kidney after they are dead. There is no real moral objection to this, since to take an organ from a dead person in order to save a life is a clear win for society. In contrast, taking organs from living people (whether they are paid or not) is another problem altogether, since this permanently lowers the health of the donor. Yes, a kidney donor can survive. But the surgery itself has risk and there is a significant chance that the donor would need that kidney for their own health later on. We ought to start by trying to get all of the kidneys we need from those who are deceased rather than incentivizing the living to provide kidneys.

      1. “Yes, a kidney donor can survive. But the surgery itself has risk and there is a significant chance that the donor would need that kidney for their own health later on.”

        If we will allow people to give their kidney away for free, why is it morally impermissible, or socially/civilly bad, to let them do it for money? Do people who accept money to give their kidneys away suffer more negative health effects than people who give them away for free? I would think the opposite is the case. And as to the risk, we allow people to do risky things all the time for money. Is the likelihood of being injured in a kidney surgery materially different than the likelihood of being injured as a residential roofer? Pizza delivery driver? Cop? Marine infantry?

        The whole purpose of allowing the sale of organs is to increase the availability of healthy organs. If the donor needs a kidney later, he’s more likely to get it. The reality is that the overwhelming majority of human beings live their entire lives with more kidneys than they need.

        “We ought to start by trying to get all of the kidneys we need from those who are deceased …”

        I think that’s the proposal in the OP.

        1. When we allow sales of kidneys from living donors, we are creating incentives for healthy living people to donate their kidney that would not otherwise exist. In contrast, if there is no market, no incentive is created.

          That is the difference. We should not be creating market incentives for people to take such a risk. In contrast, if a person wants to take such a risk because of a relationship, well, they need to have the liberty and freedom to do that.

          To the extent that the proposal is limited to incentivizing the use of kidney’s from people who are already dead, I do not think there is a serious moral objection. That person is already dead and cannot use the kidney either now or in the future. The problem comes when we create incentives and, in reality, economic pressure, for living people to make organ donations.

          1. “…we are creating incentives for healthy living people to donate their kidney that would not otherwise exist.”

            Of course, that’s the point. The purpose is to encourage people to give their kidneys away. Because we have a shortage of kidneys for people who need them on the one hand, and a surplus of kidney of people who don’t on the other.

            “We should not be creating market incentives for people to take such a risk.”

            But we already do. We enforce contracts for cops, roofers, and marine infantry. By allowing people to engage in those activities.

            1. First of all, there is a major difference between selling an organ (which is a one-off transaction) and engaging in a career as a police officer, roofer, or soldier.

              Second of all, our goal is to make these jobs safer, not expose more people to similar risks. Your argument goes something like this. N people die from dangerous jobs each year. Therefore, it is just fine if 2*N die instead. Obviously, that logic doesn’t work. Rather than 2*N people dying, we would rather it be N/2 and so on all the way to zero.

              Third, most police officers, roofers, and marine infantry members do not lose anything from engaging in their professions. They take a calculated risk. But every single organ donor loses an organ no matter what. This is a serious physical injury that is guaranteed to happen.

              Fourth, we have an alternative to harvesting organs from the living, which you seem so excited to do. We can get them from the dead. So, there is no reason to expose the living to this risk.

              I could go on. But that is enough for now.

              1. “First of all, there is a major difference between selling an organ (which is a one-off transaction) and engaging in a career as a police officer, roofer, or soldier.”

                We allow people to engage in one-off services for any of those things. A roofer is not obligated to roof for his entire life.

                “N people die from dangerous jobs each year. Therefore, it is just fine if 2*N die instead.”

                Wrong, the argument is that if we allow people to engage in activity in which N die, it is logically inconsistent to refuse to allow people to engage in activity in which

                1. Rest of my comment was cut off. The issue is that if kidney transplantation is safer than pizza delivery, I assume even you would agree it should be legal, since your rebuttal depends on 2*N rather than N/2.

                  “Third, most police officers, roofers, and marine infantry members do not lose anything from engaging in their professions.”

                  Of course they do. Sometimes they die. Sometimes they even lose kidneys.

                  “We can get them from the dead.”

                  There are not enough dead donors supplying kidneys for those in need, and you can’t legally pay a living person to donate in death.

                  1. “Of course they do. Sometimes they die. Sometimes they even lose kidneys.”

                    My point stands. Sometimes is not equivalent to most.

                    “There are not enough dead donors supplying kidneys for those in need, and you can’t legally pay a living person to donate in death.”

                    As I said earlier, I am fully in support of incentivizing people to donate their kidneys after they die anyway. A dead person has no need for a kidney. If you can pay a person or their estate in life to agree to give up their organs in death, I don’t see any problem with that. My opposition is to incentivizing people to give away their kidneys while they are still alive.

                    Please note, that incentivizing organ donations in death has a lot of use way beyond just kidneys.

                    I wonder why advocates of incentivizing kidney transplants in life don’t make a similar argument for eyes. After all, you only “need” one. And, in fact, if you are willing to live your life as a blind person, you don’t need any.

                    How do you feel about that? Should people have a “right” to donate their eyes in exchange for money? What could go wrong?

                2. There is more of a reason to stop someone from doing a one-off transaction that involves a high amount of risk than engage in an entire profession that involves a high amount of risk.

                  The former decision has a high probability of being driven by a desperate situation rather than true desire, whereas, the latter may very well be a thoughtful career goal.

                  The problem with organ donation is not just the risk, it is the economic pressure to engage in that risk for short-term and often illusory gain.

        2. “materially different than the likelihood of being injured as a residential roofer”

          Ideally, we would develop robots to do this dangerous job instead of exposing people to the risk of falling off a roof.

          You are saying that one bad thing (a risk of falling off a roof) justifies another bad thing (the risk of a surgery and the risk of not having enough kidney function later in life). No.

          Actually, the reasoning flows the other way. Since we want to protect people as illustrated by the example of deciding to not incentivize organ donations from living people, we actually want to reduce the risk to roofers through technological advance. Indeed, one of the major arguments for investing in self-driving cars is the number of lives that would be saved each year. More risk of serious bodily harm is bad; less risk is good. These things flow in the same direction.

          1. You are flipping the presumption. We don’t have to get the government’s permission to buy and sell things. Including personal services and including even personal services that can harm us, like demanding physical labor.

            I accept that transactions can and should be banned if they are truly unsafe, but that’s the government’s burden and the burden of those who support a ban.

            1. Dilan:

              I disagree. The status quo is that selling organs is illegal. You want to change the status quo? The burden is on you to prove that people who donate kidney will not ever die during surgery and won’t need that kidney later. You also have to prove that this policy will not harm lower-income people disproportionately.

              I am not a huge fan of burden shifting arguments, since, ideally, it is best to win an argument based on evidence rather than lack of evidence. But since you want to go there, I say the burden is on you.

              As far as buying personal services, we have laws that require safe workplaces for a reason. It is, in fact, forbidden to have excessively unsafe workplaces. And that is a good thing, because in so-called “free markets” people lacking freedom would get themselves into all sorts of unnecessarily dangerous situations.

              1. Being able to sell my property is a basic human right.

                My body is my property. It’s literally none of your business if I want to sell it, unless you can prove that there is some very strong reason to prevent the sale.

                The status quo is irrelevant.

                1. “Being able to sell my property is a basic human right.”

                  No. Just no.

                  Being able to defend yourself is a basic human right. Being able to earn a living is a basic human right. Free speech is a basic human right.

                  Being able to sell your organs? No. Just no.

                  “My body is my property. It’s literally none of your business if I want to sell it, unless you can prove that there is some very strong reason to prevent the sale.”

                  No. Your body is not property. It is much more significant and important than mere property. I believe that people should be able to do what they want with their bodies, but when it comes to selling organs, it is really not what people want to do with their own bodies, it is what OTHER PEOPLE want to do with the bodies of OTHER PEOPLE. By creating a market, we are creating economic pressure on people to sell their organs. Many people will be much worse off having done so.

                  “The status quo is irrelevant.”

                  You are the one that wants to engage in burden shifting. So, traditionally, a person who wants to change the status quo has the burden. Like I said, I prefer arguments based on evidence rather than lack of evidence (like burden shifting). But you decided to go there.

                  1. The term “totalitarianism” is thrown around too often.

                    But if you believe I do not own my body, you are a dangerous totalitarian whose views have no place in any free society.

                    1. To reduce the human body to a mere item of property is the insult.

                      Based on that theory, you ought to be able to sell yourself into slavery. After, all, your body is only property and therefore you ought to be able to sell it.

                      You are the one with a dangerous theory, not me.

                    2. That’s…not very utilitarian of you.

            2. The freedom to sell off one’s warm body parts for cold cash is outweighed by the public interest in protecting idiots* from exploitation by dishonest brokers.

              ________________________
              *in its original legal meaning

    2. “Whether a person allows someone to die out of inaction or action, the consequences are morally equivalent”

      How many kidneys are in your abdomen right now; in all likelihood both.
      You argue that failure to donate is the moral equivalent of murder. And worse, it is only because someone has not yet met your strike price.

      1. Gasman:

        Let us say that you killed someone in order to prevent them from stealing your kidney. You would be justified in doing so under the law, because stealing your kidney would be considered serious bodily harm. If you were locked in a room with a surgeon who was planning to knock you out with anesthesia and going to take your kidney with only the ordinary risks of such a surgery, you would be justified in using deadly force to stop that outcome if there was no other way for you to escape.

        That is not murder. The is justified homicide.

        Morally, when you decide to not give your kidney to someone when you know they could use it, it is morally equivalent to justified homicide, not murder. You are not obligated to undergo a serious bodily injury in order to save the life of another.

    3. “Whether a person allows someone to die out of inaction or action, the consequences are morally equivalent”

      How many kidneys are in your abdomen right now; in all likelihood both.
      You argue that failure to donate is the moral equivalent of murder. And worse, it is only because someone has not yet met your strike price.

    4. “Whether a person allows someone to die out of inaction or action, the consequences are morally equivalent”

      How many kidneys are in your abdomen right now; in all likelihood both.
      You argue that failure to donate is the moral equivalent of murder. And worse, it is only because someone has not yet met your strike price.

    5. “Whether a person allows someone to die out of inaction or action, the consequences are morally equivalent”

      How many kidneys are in your abdomen right now; in all likelihood both.
      You argue that failure to donate is the moral equivalent of murder. And worse, it is only because someone has not yet met your strike price.

    6. “Whether a person allows someone to die out of inaction or action, the consequences are morally equivalent”

      How many kidneys are in your abdomen right now; in all likelihood both.
      You argue that failure to donate is the moral equivalent of murder. And worse, it is only because someone has not yet met your strike price.

    7. “Whether a person allows someone to die out of inaction or action, the consequences are morally equivalent”

      How many kidneys are in your abdomen right now; in all likelihood both.
      You argue that failure to donate is the moral equivalent of murder. And worse, it is only because someone has not yet met your strike price.

    8. “Whether a person allows someone to die out of inaction or action, the consequences are morally equivalent”

      How many kidneys are in your abdomen right now; in all likelihood both.
      You argue that failure to donate is the moral equivalent of murder. And worse, it is only because someone has not yet met your strike price.

    9. “Whether a person allows someone to die out of inaction or action, the consequences are morally equivalent”

      How many kidneys are in your abdomen right now; in all likelihood both.
      You argue that failure to donate is the moral equivalent of murder. And worse, it is only because someone has not yet met your strike price.

    10. “Whether a person allows someone to die out of inaction or action, the consequences are morally equivalent”

      How many kidneys are in your abdomen right now; in all likelihood both.
      You argue that failure to donate is the moral equivalent of murder. And worse, it is only because someone has not yet met your strike price.

      1. If both means two, I count 18.

        1. You greedy pig. You could save 17 lives!

  6. Well, it appears from remarks here that Judeo – Christian Western values have pretty much run their historical course. Money is to rule – yea!

    1. Nothing in Somin’s proposal prevents anyone from donating a kidney.

  7. There is a reason so many movie villians make utilitarian arguments. It’s the same reason this argument won’t work – our morality is not utilitarian.

    If I had to guess, I’d say we’re Kantian more than anything – whether liberal or conservative, instrumentalizing other individuals or groups is more what you accuse the other side of doing than what you think you’re doing.

    1. “…our morality is not utilitarian.”

      Speak for yourself!

      “If I had to guess, I’d say we’re Kantian more than anything…”

      I don’t know any Kantians. I told my grandmother that I went to church, and sometimes I even tell my wife she looks great in an outfit that I don’t love. If a bleeding person runs by me screaming, shortly followed by a person with a knife asking me if I saw a bleeding person walk by, I’m going to lie to them and say the bleeding person went the other way.

    2. I think that all serious moral arguments are utilitarian.

      The argument for a deontological morality over a utilitarian morality only could be that adoption of the deontological morality makes the world a better place (that is, adoption of the deontological morality has positive consequences). But, this is an argument about consequences, isn’t it. Which deontology claims to not consider.

      Let us say we were forced to argue for deontology without respect to consequences. The only argument we could make for it is that deontology is better than utilitarianism because it just is. I am not an expert, but there is non-arbititrary and non-utilitarian argument for deontology that I have run into. “It just is” isn’t an argument based on reason.

      Further, utilitarianism doesn’t imply a lack of respect for rights. We don’t murder people and harvest their organs because a system that allowed the arbitrary murder of individuals would imply a corresponding power in another individual or group (and ultimately, really, an individual that had influence over the group) to order that murder. The power to murder would never only be used for good. No human can be trusted with that kind of power. We don’t need to resort to deontology to forbid throwing Christians to the lions for the entertainment of thousands of Roman spectators.

      1. (cont.)

        I have not found a situation where utilitarianism, properly interpreted to concern both short-term and long-term as well as physical, mental, relational, and distributional consequences does not suffice. I am not sure what deontology ever has to add. Deontological arguments only seem persuasive in contrast to BAD utilitarian arguments. But when we have sophisticated utilitarian arguments, deontological arguments are not needed. And if they were, how would we say they are better?

        Are we saying that we shouldn’t throw Christians to the lions EVEN THOUGH this is a good outcome? I think, at the end of the day, the so-called deontological arguments against throwing Christians to the lions has something to do with the belief that throwing Christians to the lions is a bad consequence. If it wasn’t a bad outcome, there would be no problem with it. What if being eaten by a lion REALLY was the ONLY way to get to heaven? Would it be bad even then? No, because consequences.

      2. @David Welker: “It just is” isn’t an argument based on reason.

        Of course it’s not. So what? All arguments based on reason have to go back, ultimately, to some “It just is”, i.e. some axiom, some given, some a priori. In fact, your commitment to “reason” is an “It just is”. You can’t defend it using reason since that would be a tautology and tautologies are not rational. If you argue with someone who doesn’t agree with the principles of “reason,” you have no common ground from which to reason them into agreeing.

        1. I certainly agree with you to an extent. We have to start somewhere. But, the advantage of reason is that it allows people to go back to axioms that have wide agreement as being true. So, if you build your reasoning on a set of assumptions that people agree with you one, they ought to agree with your conclusions as well. That is the entire advantage of reasoning. Obviously, if someone does not agree with your premise, then there is no reason for them to agree with your conclusions.

          It is better if premises are limited to less ambitious objects. If I say you should worship the god Zed, just because I said so, this seems arbitrary. But if I say to you, notice how whenever you see an X, it seems like Y follows, and you agree with me on that because you have seen the same thing with your own senses. And then I say, hey, don’t you think that A is an X? And then you agree with that too, I can then go on with my conclusion, well, I bet that we are going to have a Y soon, just like with all the other X’s.

          We could assume Y. But that is not as convincing as reasoning to Y. When we should how our belief in Y is related to other things (through reasoning), then we increase our confidence in the truth of Y. So, reasoning to conclude Y is better than assuming Y.

  8. This blog is more of a poverty issue than a donor issue.

    Only someone in a dire financial situation would consider selling an organ.

    If we addressed poverty, then we wouldn’t have this discussion.

    1. Nah, while it would be mostly the poor selling organs it wouldn’t be only the poor. Iran allows the organ trade (highly regulated) and 20-30% of the sellers aren’t poor.

      1. “20-30% of the sellers aren’t poor”

        So, 70-80% of the sellers are poor. I think you have just illustrated one of the problems.

    2. The trick is getting people to consider the idea in the first place, which most people don’t unless it’s someone they have a connection to who needs the transplant. Offering money for it would get more people to consider the idea, even if it’s not someone you’d call poor. A lot of people could use extra money for something that isn’t strictly necessary.

    3. “If we addressed poverty, then we wouldn’t have this discussion.”

      That’s right. And if we addressed mortality, we wouldn’t have this discussion, either.

  9. Who pays for the kidney?

    How about we reduce an inmate’s sentence if they donate a kidney?

    Criminal does something useful.

    1. That is China’s approach, except the “criminal” does not get to make the decision. And some of the PRC’s ideas of “crimes” would not pass muster here.

      1. Also, although they get an early release, doesn’t it tend to be feet-first (assuming they still have their feet)?

    2. You know, since we are viewing the kidney as an asset to be traded, how about asset forfeiture?

      There is only one problem with trading a sentence for a kidney. It creates an incentive to create more criminal laws so that society can harvest more kidneys.

      We already have too many criminal laws. And people are in jail that should not be.

      Imagine, for a moment, that someone was really dangerous to society and likely to recommit a crime. Would you release them merely because they donated a kidney? How would their next victim feel about that?

  10. Might not need a full market solution if the donor were absolved of all of the costs of nephrectomy. There are substantial barriers to donation for anyone not living on a fixed income:

    -full income replacement. Typically 4-6 weeks return to work just for an office job, longer if you lift stuff.
    -support for family members who take time off work. If you have ever experienced an illness or surgery, it is clear that there are people other than just the patient who loose work.
    -term life policy purchased for the donor, should anything really bad occur.
    -lifetime health insurance for renal related care. This covers the newly acquired ‘pre-existing’ condition of solitary kidney. People with one kidney are harder/more expensive to insure.
    -disability insurance to cover renal related loss of income later in life. Donors experience renal failure at higher rates than non-donors, because of less reserve renal capacity. Disability from renal failure begins years before one is a transplant candidate.
    -Finally, donors who later require transplant go to the head of the line.

    1. “Might not need a full market solution if the donor were absolved of all of the costs of nephrectomy.”

      Why wouldn’t the costs you describe just be dealt with as part of the sale?

      1. And why don’t kids always wait for another marshmallow? See Wikipedia: Stanford marshmallow experiment.

        Why do people make mistakes with their finances when it is in their best interest to avoid such mistakes?

        “Why wouldn’t the costs you describe just be dealt with as part of the sale?”

        If you really think that all of these costs are going to be “dealt with” as a part of the sale, the burden is on you to prove it. Here is a hint. You can’t.

        1. “See Wikipedia: Stanford marshmallow experiment.”

          The Stanford marshmallow experiment may be a fraud.

          “Why do people make mistakes with their finances when it is in their best interest to avoid such mistakes?”

          Because they make bad decisions. I’m not suggesting seize peoples’ finances so the government (also run by people) can decide for them how to spend their money, though.

          “Here is a hint. You can’t.”

          Haha right, because it’s illegal. Great argument. Of course I can prove it. The price to perform dangerous activities everywhere, in history, is higher than the price to perform equivalent but safe work. It’s hazard pay and it’s ubiquitous in the market, even unregulated markets.

          1. The conclusions of the Stanford marshmallow experiment for later in life are not relevant here. The experiment did show that some kids waited for a second marshmallow and others did not. That was a direct observation of the experiment. So, whether that has any meaning for later in life, that observation was still existent.

            “Because they make bad decisions.”

            If some people sometimes make bad decisions, then we should not expect them to deal with all contingencies as part of a sale.

            “Of course I can prove it.”

            By proof, I do not mean absolute proof. I just mean simply to give strong and persuasive reasons to think it would be true. I do not think you can do that. In fact, I do not even think you can make an argument that would make your view even plausible, much less persuasive.

            My experience is that most people are not calculators. So, the complicated calculations that Gasman proposes are probably not going to be performed by most people.

            1. “…then we should not expect them to deal with all contingencies as part of a sale.”

              Why not just extend this to any sale? Why don’t we just have government committees decide the terms of all peoples’ private agreements?

              “My experience is that most people are not calculators.”

              So why do dangerous jobs pay more than their non-dangerous equivalents? Anyway, it doesn’t make any difference since you don’t have to require that people be calculators. You could condition the sale of organs on disclosure of the risks. Just like we do for living volunteers who donate but are not paid.

              1. “Why not just extend this to any sale?”

                I would extent it to any sale. In fact, people are not calculators. At least, not really very good ones.

                “Why don’t we just have government committees decide the terms of all peoples’ private agreements?”

                This is an easy question. Because, in most case, that would be even worse. That this a bad solution does not mean that problem of people not being calculators is not a real one.

                “So why do dangerous jobs pay more than their non-dangerous equivalents?”

                A lot of this comes down to simple ignorance. Dangerous jobs may pay more, but that is often because dangerous jobs are often simply less pleasant in other ways. For example, one of the most dangerous jobs is logging. Well, it turns out that this job involves a lot of really hard physical labor.

                Here is another dangerous job. Driving a taxi. But, since the working conditions are pretty pleasant, it does not provide very high premiums in terms of pay.

                Guess what, people actually are not aware of how dangerous or safe jobs are. Many people think that being a police officer is one of the most dangerous jobs. But it isn’t even in the top ten. Like, I said, people are not calculators.

                There is no reason to think that people negotiate for what they do not calculate.

              2. “Why not just extend this to any sale?”

                I would extent it to any sale. In fact, people are not calculators. At least, not really very good ones.

                “Why don’t we just have government committees decide the terms of all peoples’ private agreements?”

                This is an easy question. Because, in most case, that would be even worse. That this a bad solution does not mean that problem of people not being calculators is not a real one.

                “So why do dangerous jobs pay more than their non-dangerous equivalents?”

                A lot of this comes down to simple ignorance. Dangerous jobs may pay more, but that is often because dangerous jobs are often simply less pleasant in other ways. For example, one of the most dangerous jobs is logging. Well, it turns out that this job involves a lot of really hard physical labor.

                Here is another dangerous job. Driving a taxi. But, since the working conditions are pretty pleasant, it does not provide very high premiums in terms of pay.

                Guess what, people actually are not aware of how dangerous or safe jobs are. Many people think that being a police officer is one of the most dangerous jobs. But it isn’t even in the top ten. Like, I said, people are not calculators.

                There is no reason to think that people negotiate for what they do not calculate.

  11. The first rule of medicine is not to do harm – first, above all, do no harm.

    It is inevitable that someone who takes that rule seriously will sometimes fail to do good, and this fact shouldn’t deter anybody.

    We already have a society in which the 1% control most of the world’s resources. Do we want them buying up people’s organs too?

    I think most poor people would laugh, if not scream in agony, at folks like Professor Somin’s claims that their economic choices are purely voluntary and they act as equals with the rich and powerful in making contracts.

    It’s one thing for the children of the rich to have incentives to hasten their parents’ deaths and refuse treatment so they can inherit faster. It’s another for the children of the poor to have these incentives so they can acquire valuable organs to sell. Same with institutions if costly unclaimed patients can be made into valuable unclaimed bodies.

    The potential for harm is enormous. Professor Somin is being willfully ignorant, deliberately indifferent, by simply pretending it isn’t there.

    1. “Do we want them buying up people’s organs too?”

      Yes, if it means freeing up kidneys for the poor who are also on the waiting list.

      “I think most poor people would laugh, if not scream in agony…”

      Why don’t we legalize the market and see what poor people would prefer? Do you think poor people who prostitute themselves are really happy the government is looking out for their interest by criminalizing prostitution?

      “The potential for harm is enormous.”

      If that’s true, you have a moral obligation to tell us about this potential harm.

      1. “Do you think poor people who prostitute themselves are really happy the government is looking out for their interest by criminalizing prostitution?”

        That we as a society treat poor people so badly that they reasonably think they will improve their lives by resorting to prostitution is the REAL problem.

        I personally think IF we are going to make this trade illegal, we ought to target the buyers, not the sellers. Maybe making the trade illegal causes more harm than good, even if we reformed enforcement practices to target buyers rather than sellers, but that is a complicated question.

        “If that’s true, you have a moral obligation to tell us about this potential harm.”

        Easy.

        The harm from donating organs includes death, serious injury, as well as pain and suffering. Those are bad things.

        1. “That we as a society treat poor people so badly that they reasonably think they will improve their lives by resorting to prostitution is the REAL problem.”

          Not poor people do it, too. But the point of freeing up kidneys is to improve the lot of people, including poor people.

          “The harm from donating organs includes death, serious injury, as well as pain and suffering.”

          These are the sorts of things that will happen if we don’t increase the availability of organs. But as we’ve pointed out up thread, not everything that leads to “death, serious injury, as well as pain and suffering” is illegal. Residential roofing is a job that people can perform for money.

          1. “Not poor people do it, too. But the point of freeing up kidneys is to improve the lot of people, including poor people.”

            There are alternatives to living donors. For example, dead donors. I am in favor of incentivizing people (whether in life or as part of their estate) to give not just kidneys, but other organs after they are dead. The dead have no need for organs. It is one thing to decrease the suffering of the living at the “expense” of the dead. It is another thing to do so at the expense of the living.

            “These are the sorts of things that will happen if we don’t increase the availability of organs. But as we’ve pointed out up thread, not everything that leads to ‘death, serious injury, as well as pain and suffering’ is illegal.”

            Not everything that leads to “death, serious injury, as well as pain and suffering is legal either.

            “Residential roofing is a job that people can perform for money.”

            And it is a bad thing that this job is as dangerous as it is. We ought to seek to make it safer through better technology. That bad things happen in the world to roofers is not an argument for increasing the number of bad things that happen in the world to other people. I don’t know why you would think it is.

            1. “That bad things happen in the world to roofers is not an argument for increasing the number of bad things that happen in the world to other people.”

              I cannot tell if you are incapable or unwilling to understand the argument. If we allow X which is Y dangerous, it makes no sense to criminalize P which is less than Y dangerous. Sillier still, it doesn’t make sense to make it illegal to do P if you are paid, but legal to do P for free, regardless of risk Y.

              1. I understand your bad argument. It is an argument by analogy. If we tolerate X, we should tolerate Y. But it is still a bad argument. My logic goes in the opposite direction. Instead of tolerating X, we should make X better.

                Hey, if roofers sometimes fall off roofs and injure themselves, what is wrong with risks of causing injuries in other people?

                Yeah, but what you fail to “get” is that one bad thing does not justify another.

                I understand your argument. And I reject it.

        2. I’m surprised a pure utilitarian like yourself sees prostitution as a negative.

          1. I think most criticisms of utilitarianism are based on a misunderstanding of what utilitarianism is. I do not agree that there is a right that is distinct from that which is good. Things are right because they are good. To put it another way, nothing that is evil (taken as a whole, not merely in part) is also right.

            1. I don’t think I’m the one confused about utilitarianism. But under your theory of utilitarianism, what’s bad about prostitution?

              1. Prostitution creates a situation where people are unhappy. And it also makes miserable situations seem sustainable. It is a false solution to real problems.

                That is the problem with it.

                The reason that prostitution is bad is because of its real world effects on real people. Not because, you know, it “just is.” To me, that is not an argument.

                1. “The reason that prostitution is bad is because of its real world effects on real people. Not because, you know, it “just is.” To me, that is not an argument.”

                  But that’s all you are doing. You are saying that it makes people unhappy. Who? Not the customers. Many sex workers also disagree that prostitution itself, rather than the dangers exacerbated by its illegality in most states, makes prostitutes unhappy.

                  “And it also makes miserable situations seem sustainable. It is a false solution to real problems.”

                  How so? What makes it different than other kinds of work? Unless you start from the premise that casual sex is somehow inherently wrong, I have a hard time seeing why it is different than other types of selling your body, like manual labor.

  12. Also agree with those who point out that if we take Professor Somin’s rhetoric seriously – that the “do no harm” principal is nonsense, and failure to do good is equivalent to doing harm – then we also have to accept that a person who refuses to sell because a prospective buyer doesn’t meet the strike price should be treated the same as a contract killer.

    In other words, under Professor Somin’s own professed moral principals, the sale of organs (which is a refusal to donate unless people are paid money) cannot be justified as a refusal to donate until one is paid is no more moral than an unconditional refusal to donate. What Professor Somin’s principals logically justify is the proposition that the state should require involuntary organ harvesting and it shouldn’t be a matter of personal choice. If refusal to donate is truly equivalent to murder, this is the only possible moral result.

    This is not, of course, a particularly libertarian result. It is indeed a reform in the opposite direction of what Professor Simon proposes. But it would at least be consistent with Professor Somin’s stated principals. Professor Somin’s proposed reform is not.

    Only if we accept a principal like not doing harm trumps doing good (at least sometimes) can allowing personal choice of any kind in organ donation be justified at all.

  13. About your update, you weren’t necessarily wrong. Although they’re rather stupid in most cases, articles that review the state of the literature overall are called “metastudies.”

  14. Oddly enough, this video parody by Remy from Reason is a good summation of Somin’s argument:

    Remy People Will Die!

  15. In most states, you have to “opt in” to organ donation in case of death through your driver’s license. Suppose instead you have to “opt out” if you don’t want to donate your organs. Otherwise your organs are fair game. Surely that would produce enough organs to satisfy the need.

  16. Apologies if the point has already been made in the comments, but the original objection to the sale of organs for transplantation was not addressed by Ilya Somin: the fear that a market for organs would only benefit wealthy buyers. I’m not sure that is any better or worse an argument for or against the sale/purchase of organs, but as the first argument it deserves to be addressed. (I suspect, however, that it is a surrogate for larger personal philosophies about whether health is a right or a privilege.)

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