Organ transplants

A Vivid Description of the Needless Suffering Caused by Laws Banning Organ Markets

A recent Canadian Broadcasting Corporation article describes the travails of a man and his family who have waited eight years for a kidney transplant. Such needless pain could be eliminated by legalizing organ markets.

|The Volokh Conspiracy |

Every year, thousands of people in need of kidney transplants endure greatly suffering because there are not enough organs available to satisfy the demand.  They can survive—for a time—only by going through the difficult and time-consuming process of kidney dialysis A recent Canadian Broadcasting Corporation article effectively conveys the pain involved:

Blair Waldvogel wishes he didn't have to spend so much time in his basement. But if he doesn't, he'll die.

The 52-year-old Winnipeg father has been on Manitoba's kidney transplant list for the past eight years. His Type O blood means Blair can only receive a kidney from a Type O donor and he hasn't been able to find a match.

So, four days a week, Blair Waldvogel goes downstairs to the guest bedroom, hooks himself up to his home dialysis machine, and sits there for four hours while the machine cleans his blood.

"I never imagined I'd get to eight years," said Blair…..

If you include the time it takes to set up the machine and to clean up afterwards, Blair has spent the equivalent of 348 days in his basement on dialysis.

"There have been some scary, scary times along the way," said [Blair's wife] Irene. She has had to call paramedics more than once after Blair passed out in his dialysis room because his blood pressure dropped too low.

As the article describes, kidney dialysis makes it extremely difficult to continue to live a normal life. Blair Waldvogel, for example, has had to quit his job as the president of the North American recycling program for an international steel company. The article also correctly notes that many dialysis patients endure even greater suffering than the Waldvogel family. And, every year, thousands die because organs do not become available in time to save them. Indeed, Mr. Waldvogel is somewhat fortunate to have survived for eight years on kidney dialysis, because the average life expectancy of dialysis patients who cannot get a transplant is only 5-10 years. The case described in the CBC article is in Canada. But the situation in the United States is no better.

In addition to the pain endured by patients and their families, society loses as well, due to patients' reduced productivity and the enormous expense of dialysis treatment (much of it subsidized by federal and state governments).

Nearly all of this death, suffering, and waste could be eliminated if only the US and Canadian governments would legalize organ markets, thereby increasing the supply of kidneys. For reasons I summarized here, laws banning organ markets are the moral equivalent of actively killing innocent people:

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.

In the same post and elsewhere, I also addressed various standard objections to organ markets, such as claims that they will corrupt our morals by "commodifying" the body, and lead to unjust exploitation of the poor.

By legalizing organ markets, we can save thousands of lives and greatly curtail the kind of suffering now needlessly endured by the Waldvogel family and thousands of others. As an extra bonus, we can also increase economic productivity and reduce health care costs in the process. Few if any other policy reforms can achieve such enormous gains at so little cost.

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  1. We’ve been told it’s immoral. Money, that is. Profit especially. Nasty, dirty, evil incarnate. Anything you do for money is tainted by association. Marime to be blunt. Polluted, evil, dirty money. And profit.

    And how dare you, Mr. Somin, pretend that lost “productivity” matters? There you go again, caring about money. And profit. Nasty, evil, polluted filthy lucre.

  2. Everyone involved in the transplant process benefits from it, except the donor… The recipient (obviously), the hospital(s) performing the procedures, the surgical teams, society as a whole, the insurance companies…

    Not the donor, or his estate…

    Why is that equitable? What sort of busy-body meddling jerk in government decided this was a law they needed to write? What kind of socialist scum decided that the altruism of the donor was the only reward they could receive?

    1. The type that wanted to prevent debt collectors from forcibly “persuading” poor people to give up their kidneys.

      1. There is a very simple solution to the issue that you raise. Simply make the proceeds from the sale of an organ exempt from all creditors’ claims. States could handle this very easily through their own exemption laws, and the Federal government could take it even further by exempting those proceeds from attachment by the IRS and all other federal government creditors.

        1. Except that money is fungible. And money that doesn’t go to paying off the loans can go to paying for the car, mortgage, food or drug dealer. Meanwhile, the money that went towards the car, mortgage, and food can now make its way to the debt collector.

          1. So your solution to helping the poor is to deny them any choice in the matter. Sounds pretty arrogant (“I know better than the poor what’s good for them”) and authoritarian (“because I’m smarter than the poor I should tell them what they can and can’t do”) to me.

            1. 1. Not just the poor. Everyone should be “denied the choice”.

              2. To understand why, you need to understand exactly what is being commoditized here. Human life. People are buying life from one person in order to transfer it to another. And that is what organ “selling” is. This commoditization of human life is bad for society in the same way that slavery is bad for society. Both involve the buying of human lives. In doing so, it makes people unequal. Some people become “worth less” and others become “worth more,” and doesn’t it just make sense for those people who are “worth less” to give up some of their life to those who are more “worthy?”

              3. Now, we all make our judgements about what society should be. You think a more fully “libertarian” prospective should be imparted. I prefer one where slavery and other items which sell people’s lives doesn’t occur.

              1. Not necessarily life…not even quality of life. People can do quite well with one kidney or lung, or missing part of their liver…. People donate blood, and bone marrow, all the time with no consequence.

                I agree that commoditizing suicide is wrong, because I think life has intrinsic value…but that adults of normal ability have ultimate control over their bodies…

          2. Why should debt collection be demonized in this way?
            The money was loaned in good faith.

            Also: what’s the moral difference between selling a kidney to pay a bill vs. taking a dangerous unhealthy job like coal mining to pay the same bill.

            1. The moral difference is because the risk scenarios are totally different. Take a dangerous job, and be paid well for it, knowing that there is a small risk of death: this is something millions do every day because the risk is small and usually avoidable with careful preparation (though there is always bad luck). Selling a kidney to pay off a debt is 100% certainty, not just a risk.

              The moral equivalence to selling a kidney to pay off debt is much more like taking steroids to win a body building or athletic contest.

          3. RE: “Money is fungible”

            “Fungible” means “tasty in mushroom sauce”. The root is fung, as in “fungus”. The Italian for “spaghetti with mushrooms” is “spaghetti con i funghi“.

      2. Why is that anyone’s decision but the donors?

        1. That is of course, the ultimate libertarian argument. Let’s extend this. Why shouldn’t a healthy young person be able to donate their own heart for money? Do you see any problems with it? Aside from the whole death issue…

          1. Donating your own heart would be suicide…which society should, generally, dissuade.

            However, if people indeed ‘own their bodies’, then they should have that right…I would gladly donate my heart if doing so allowed by wife or children to live: I’ve lived a good long life at this point and while I have a few more decades ahead of me, my kids have more.

            1. But why should society dissuade, as oppose to encourage, suicide? What’s the rationale?

              1. To protect family, to gain additional benefits to society, to keep people who may be distraught from ending their lives for trivial reasons (suicide is almost always a permanent solution to a temporary problem).

                But, if people want to commit suicide, many states allow it. Some nations do it for you.

          2. People commit suicide for life insurance every day.
            If you want to make it all but impossible to donate one’s heart, that might be good policy, but an absolute blanket ban is a denial of moral agency.

            1. A prohibition on donating anything that would result in the death of the donor (heart, both kidneys, full liver, etc) might be acceptable…

              But, I would willingly donate my heart to save my children…or wife. Even if it is suicide.

              Why is it the government’s role to deny me that right, to save my family?

              1. It’s the government’s role to deny protect its citizens, sometimes from themselves, and sometimes from each other.

                This is the moral and social and cultural backing for laws for banning prostitution, dueling, and legal drinking under 21. We should be able to make a case by case decision of where the trade-off are in each case.

                1. “It’s the government’s role to deny protect its citizens, sometimes from themselves, and sometimes from each other.”

                  You state that as if it is self-evident. It is not. Far, far, far too often government coercion is justified as necessary to “protect people from themselves. “

                  But that justification proves too much. Slavery is justified if we assume that a certain group of people are simply incapable of caring for themselves, making their own decisions what is best for them. So, just how far are you willing to extend that arrogant belief that government knows best; are you willing to reinstitute slavery?

                  1. What is the purpose of government? Please think about that for a few moments before your next response. If we are talking about governments, then it is self-evident.

                    And yes, slavery was justified with this same reasoning, which is why, as I said, we should be able to make a case by case decision based on the trade-offs. Your reducto ad absurdum doesn’t get you anywhere.

                    1. The purpose of government is to protect people from others who would interfere with their freedom, including foreign invaders and domestic criminals. It is NOT to “protect them from their own actions/decisions.” That is arrogant and tyrannical.

                    2. Wrong. The purpose of government is to protect people from external threats, and to provide for internal rules. Every government ever, even if it does this poorly, does these to things. That’s why governments are either created or perpetuated.

                      Tyrannical? Ha! All governments exist to wield power, that is their purpose. We just soften the edges with rights and elections. Arrogant? Don’t make me laugh. An answer you don’t like to hear doesn’t make it arrogant.

                    3. “What is the purpose of government?”

                      The purpose of government is self-evidently to secure the rights with which men are endowed by their creator. You know, life, liberty, the pursuit of happiness…

                    4. And it does these things, “life, liberty, pursuit of property (ahem) happiness,” by internal rules. Rules which are enforced with power. After all, a right is an obligation on another. Your right to your life means I can’t hit you over the head and take your stuff. Your liberty means we set up internal rules so I can’t have slaves (thus the contradiction at the founding). etc.

                      This is a mistake that libertarians and even conservatives sometimes make. The purpose of government isn’t to protect liberty, per se. We are all actually more free when the government hos some power to enforce our internal rules, because we can go to a 3rd party as arbitrator. Without it, it is only the strongest or most numerous who wins.

                    5. “Tyrannical? Ha! All governments exist to wield power, that is their purpose. We just soften the edges with rights and elections. Arrogant? Don’t make me laugh. An answer you don’t like to hear doesn’t make it arrogant.”

                      mad_kalak, you are a master at missing the point. It isn’t an answer that I don’t like which makes it arrogant, it is a position which implicitly assumes that government knows better than the individuals directly affected by the decision which is arrogant. And tyrannical includes the assumption of the power to force those decisions down the throats of the people. When Obama, who didn’t have a clue as to the state of my health or my finances, decided that he knew better than me precisely what kind of health insurance I needed, what coverages, what exclusions, what co-pays, and what premiums, THAT was arrogant. And when he decided to force me to accept his control over my health insurance, a matter deeply personal to my own wants, needs, and preferences, THAT was tyrannical. If you don’t understand that, then you are being willfully obtuse.

                    6. And DJ, you are a master at not understanding first principles.

                      Indeed, Obamacare was a disaster. I agree. It was arrogant of Obama. Again, I agree. But aside from the unconstitutionality of it and the fact that it was a bad policy, it was still normal for the government to express its power that way. Morally, it was not much different from the draft.

                      While preventing a market in kidney’s may be a good or bad thing (I think it is a good thing) your inability to realize that a law preventing a market in kidneys is perfectly normal within what governments are for, and further no different than what we ask government to do NOW already (i.e. prostitution being illegal) as an expression of the government protecting the people from either themselves or others by the enforcement of agreed up on internal rules.

                2. It is my moral, cultural, role to protect my family. Why does the state think it has the right to stop me from doing that?

                  1. I need to provide for my family by selling drugs because there is no economic opportunity in my area and I am an ex-felon, and further, I have to protect them with an illegally obtained pistol since I can’t buy one legally.

                    The state has quite the right.

                    1. Well, if that’s the best you can do.. Provide a product others are willing to exchange money for.

                      As far as the firearm, there is no felon exception in the second amendment.

                      Criminal laws do not exist to protect the law abiding: They exist to protect the criminals from society. The punishment you as a felon might meet attempting (say) to rob my home would be FAR, FAR more serious from me, than from the state. Do you feel lucky tonight?

                3. Well, I can find no stipulation in the Constitution that gives government control over dueling, drinking, or prostitution.

                  And I think that the decision to give alcohol to anyone should be up to the responsibility of the person providing it. Likewise, dueling would also settle a number of problems.

                  As for prostitution, if people ‘own’ their bodies, then why is government involved?

            2. They do, and it’s a tragedy. It also tends to be rather discouraged by society. The insurance companies hate it, and won’t pay out in the first year typically, if its a suicide.

              A market place that existed to sell organs from people who “voluntarily” sold them would encourage suicide.

      3. Professor Somin has addressed the issue of undue pressure on the poor by asking his classes whether they’d be OK with legalizing organ sales only above a certain level of financial security.

        Here’s what he hears when he asks:
        “In my experience, those who raise the exploitation argument almost never endorse this proposal – despite the fact that it would eliminate any possible exploitation of the poor caused by legal organ markets without killing thousands of innocent people (as today’s categorical ban on organ markets does). Few of them raise any technical policy objection to it. They simply seem find the idea intrinsically distasteful. Nonetheless, if your main objection to organ markets really is the fear of exploitation of the poor, you should at least give the idea some serious thought. If, on the other hand, the exploitation argument is just a rationale for some other objection such as intuitive repugnance at the mere thought of organ sales, then we would have a better discussion if you admit that and focus on the real object of your concern.”

        This is a pretty clear indication that we’re dealing with emotional moral intuition, as described by Jonathan Haidt in “The Righteous Mind: Why Good People Are Divided by Politics and Religion”. That kind of “intuitive repugnance” runs deep and is very hard to counter with reason.

        1. And what level of financial security is “sufficient”? $20K a year? $50K a year? $100K a year? $250K a year. I’ve seen proposals where people making $250K a year just “isn’t enough”, and they need help to pay off their student loans.

        2. What Somin, and Haidt, don’t seem to get, is that in a Republic, our innate moral squeamishness with creating a marketplace for the sale of organs is a perfectly valid enough reason for a law being in place.

          Most people have an innate moral squeamishness about bestiality, cannibalism, or necrophilia all well. There are utilitarian arguments that can be made that it is not worthwhile to ban bestiality, and if someone can donate their body to science they should also be able to donate their body to a chef, and if someone wants to put it in their will that their body can be used for sex, why not? People legally get paid for sex in front of the camera while alive, so why not make some $$ for an heir while dead, for those that get off on such things.

      4. The moral hazard is real – and indistinguishable from many other moral hazards that courts and less restrictive laws somehow manage to successfully mitigate.

  3. If anyone is worried that there won’t be enough safeguards to prevent bad things from happening, then just add more safeguards. Add a hundred safeguards.

    How many forms would you fill out not to be on dialysis for years?

    Even a stupidly cumbersome bureaucratic nightmare of a transaction would be better.

    1. “Safeguards” can be bypassed by sufficient interest and money.

      1. So can bans.

        1. It’s significantly harder

      2. Just add more safeguards then.

  4. You need to talk more about how this policy change would effect potential donors, both individually and collectively.
    That’s where the social concern lies – where the poor sell their kidneys just as some nowadays sell their blood. If you think that they should be so free, make that argument.
    Otherwise you have a utilitarian argument looking only at the benefits and not the costs, and that’s suspicious on at least two levels.

  5. “If you think that they should be so free, make that argument.”

    I’m pretty sure he just did.

    1. My point is that he’s making the argument from the recipient side, not the donor side.

      1. As I said, the donor has the only thing of value to everyone else involved (without the donor organ, NOBODY gets NOTHIN’). But the law is structured to prevent the donor from realizing any benefit from that which has value.

        So, the donor should be able to treat it as any other thing of value. For those who believe that women ‘own’ their bodies, well not really: They cannot sell a kidney (say).

        Not equitable, and a market distortion that damages society as a whole.

        1. Providing value creates incentives. The issue is what those incentives will lead to.

          We don’t let women sell their abortions either.

          1. We do, sorta, in that the parts of aborted fetuses are sold by Planned Parenthood.

          2. But the abortion issue revolves around who owns (controls?) the womans’ body.

            How is that different?

          3. We don’t let women sell their abortions either.

            I’m not aware of any law or regulation that says that a woman can’t say, “If you pay me $10,000 I’ll have an abortion.”

            1. Indeed:
              “Get an abortion, and you get to keep your $5000 a day job as a model”.

  6. Comparing this to food sale is not correct.

    These are organ sales. Organs that cannot be regrown. Organs that come from people. The proper comparison is more akin to slavery, with the corresponding severe social issues.

    The pressure that would be brought upon people to “just sell a kidney (or 2…)” to get through their fiscal issues would be intense, and disproportionately affect the poor. That’s before you get into the international issues that could potentially arise. The potential regulations don’t necessarily fix the social issues and the ways around them.

    Mr. Waldvogel may get his kidney. Mr. Jones may lose his due to the debt collectors and the pressure they bring.

    1. You completely gloss over the benefit that Jones accrued that caused him to be in debt.

  7. This neither rebuts nor supports Professor Somin’s arguments, but it’s an intriguing example of how human ingenuity can create some of the benefits of a market even without the lubrication of money.

    I recently discovered that there are entire networks of people who have agreed to donate to some tissue-compatible stranger in return for getting a donation from the stranger’s family to one of their own relatives. Long and intricate chains of donation swaps have formed.

    The effect has been to increase, by some amount, the supply of donations.

    Here’s my pet idea, which I haven’t pushed because I suspect it’s unethical. Repeal motorcycle helmet laws for and only for motorcycle operators who have checked the box to be organ donors. Hospital people already call those machines “donorcycles”.

    1. I would say repeal helmet laws, with the understanding that any rider who does not wear a helmet is an automatic donor, AND is not eligible for society-provided health care..

  8. Everything Professor Simon describes could with equal reason be attributed to lack of compulsory organ transplants. Moreover, all lack of care for failure to afford it could be attributed to lack of compulsory universal health care.

    Professor Somin is hardly in a position to throw stones.

    1. Most of us have two hands, arms, legs, and feet – there ought to be a legal market for these eight parts as well as the hearts and lungs etc., of those contemplating suicide. Yea!

    2. Compulsory organ donation? Who owns your body?

      I would also recommend a short, science fiction story called ‘Lipidleggin’, by F. Paul Wilson… https://web.archive.org/web/20150224140101/http://www.billstclair.com/DoingFreedom/000623/df.0600.fa.lipidleggin.html

      1. I apologize: Lipidleggin is not the story I thought it was…and I can’t recall the name of the one I did have in mind..

        Still, it’s a good story.

        1. And the one I was thinking of is Jigsaw Man, by Niven

  9. Most of us have two hands, arms, legs, and feet – there ought to be a legal market for these eight parts as well as the hearts and lungs etc., of those contemplating suicide. Yea!

    1. If it were possible to take someone’s limbs and put them on another’s body, fully functioning, there would be calls for a market in it.

      1. That has been done…full arm, and even face transplants have been done.

        1. When nerves can be regenerated, though, is that I was getting at. Meaning that the guy who lost an arm can get a new arm from someone else that works as well as the replacement, more akin to a heart transplant.

          1. The arm, hand and face grafts show real promise, and a surprising degree of functionality…

  10. People commit suicide for life insurance every day.
    If you want to make it all but impossible to donate one’s heart, that might be good policy, but an absolute blanket ban is a denial of moral agency.

    1. No. They don’t. Many insurance plans don’t cover suicide and if they do there is typically a waiting period. And “need the life insurance for x” doesn’t break into the top ten reasons people commit suicide.

      And even if it did – it remains an idiotic argument for allowing a market on organs.

  11. Yet another iteration of the notion that liberals don’t care what you do as long as it’s mandatory.

    1. Please stop calling people who want to control what others may or may not do “liberal”. Don’t be complicit in this deceitful debasement of the English language.

      1. Just because you are ashamed of the people whose side you are taking, doesn’t mean we have to massage our language to make you feel better.
        The left is known to everyone (supporters and detractors alike) as “liberal”. This has been true for decades.

        1. But the left is the polar opposite of liberal. The left is a bunch of authoritarian statists hiding behind a false flag which they inaccurately call “liberalism.”

      2. What term would you prefer? Progressive? Statist? Totalitarian? Fascist? All work for me.

  12. I would like to see some protection of the price of a kidney become a race to the bottom.
    Add up the quality adjusted years of life saved from transplantation versus ongoing dialysis. Current calculation of a QALY in that paper is $200,000. So lets compensate at minimum the donor with at least the cash value of one QALY, or 200,000.
    Insufficient donors yet? increase the price.
    Too many willing donors? 200,000 still the base price, but now there is the luxury of medical screening from a larger pool of potential donors, to ensure that there is a better HLA match, or other improved transplant metric.

    But let’s not see folks giving up a vital organ for a pittance. The health care system is making a mint on renal transplantation, and is itself not subject to market forces of competition to drive down prices. So too should donor reimbursement not suffer from market competition.

    1. You honestly think that you are smart enough, with sufficient knowledge of the individual wants, needs, preferences, and risk tolerances of others to set the price, without any regard to what individual sellers might prefer? I suggest that you need a remedial course in price theory and a careful examination of Hayek’s work on the knowledge problem (you can start with Hayek’s acceptance speech when he was granted the Nobel Memorial Prize in economics).

    2. It isn’t even a matter of people selling their own kidneys: With sufficient financial motivation, the number of cadaveric donors would increase. For $200k, a lot of delays or rejections, for whatever reason, by family members would likely dissipate….

  13. Create a legal market for human organs, with the government and the health care industry collaborating on its regulation – what could possibly go wrong?

  14. People should be allowed to do anything for money that they’re allowed to do for free.

    1. Anything, whatsoever? Could there be a marketplace for interesting suicides or deadly actions? If we pool enough money for people, kind of like a GoFundMe page for the $ to go to next of kin, would you still support people taking money to take their own lives? I can also imagine someone getting millions to risk certain death by an unusual means, say a recreation of a Roman gladiator battle of a lone man against 6 hungry lions.

      Anyway, point is, be careful with universal statements.

      1. “say a recreation of a Roman gladiator battle of a lone man against 6 hungry lions.”

        Hmmm. How much would you do it for?

        1. Only if you’d be there next to me, bub. Alone, I might do it (provided I had the right armor/weapons) for a couple million and sufficient training time.

      2. Johnny Depp did an art-house movie about that called The Brave, about an (American) Indian in desperate poverty that agreed to be killed in a snuff flick to earn money for his family.

        1. Well, murder is generally strongly opposed by society…

          But what if technology existed to (say) allow someone to donate their heart, and receive a mechanical heart that is perhaps only 30% as effective to keep them alive? Should it be their decision to accept a reduction in quality of life for a hefty payout?

      3. Can people perform interesting suicides for show and not charge money? I don’t think so. Not to mention that suicide and attempted suicide have been and in some places still are illegal.

        The point is that if people shouldn’t be doing something, then they shouldn’t be doing it whether they get paid for it or not.

  15. It’s had to imagine a useful principled context for a discussion shaping up as ideologues vs. utilitarians—with each group insisting the issue be contested according to its own premises.

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