I'm kinda in the process of donating my kidney (I have to decide between liver lobe and kidney donation since I can't do both. No one has done an analysis of this tradeoff, but conversations with the hospital make me lean towards kidney donation). I largely agree and even think we should extend this to all types of organ donations, but I don't agree with you when you say "I am convinced that if you investigated the bioethicists who are against compensating kidney donations, you would discover they’re funded by dialysis companies who don’t want to suddenly be cut off from the beautiful gushing flow of cash."
I've read some of those bioethicists and they strike me as genuinely concerned for the poor. One possible problem is that poor people are often forced to take deals that give them a bit of money now in exchange for having to pay a lot of money later (see e.g. the whole predatory lending landscape). I can easily see a similar dynamic happening here: the government gives a bit of money, but not enough to compensate the full recovery/long term effects, and poor people are forced to take that option because they need money now. This is especially dangerous in low-governance regions where I can see this leading to black organ markets (for a possible worst case scenario, see this story about "blood farms" in India: http://news.bbc.co.uk/2/hi/south_asia/7302649.stm)
Now I think that with very *very* careful law drafting we can craft a bill that minimizes these dangers while still saving those suffering from kidney failure, but I can't blame people for being skeptical about whether their lawmakers can pull that off.
I do think you could e.g. require kidney donors to be part of a household making at least the U.S. median household income, which would address a lot of these concerns.
Interesting idea, but that would exclude most of the population in poorer countries. On the upside, donating a kidney could become a status symbol if only wealthier members of society are able to do it... Would be interesting to try out.
While I definitely think the downsides here are minimal and a law simply setting up a regulated kidney exchange would be totally fine, you are still completely right that most bioethicists are well-meaning people who authentically worry about the issues, and themselves really aren't making a ton of money of these concerns! We can disagree on the merits without the character aspersions, so wanted to give you kudos on that front.
Thanks! I think it depends on the country, I'd fully endorse it for Norway and fully denounce it for Somalia, with all other countries falling somewhere in between.
I agree with the points you're making. Once you open the door to paid organ donation, it becomes potentially very open to various kinds of abuses, considering how valuable the service is to the patients.
The problem is that much if this stuff is already going on, and making it official might help rather than make things worse.
I think what lies behind this issue though is the same thing that makes paid (beyond cost) surrogacy or paid for adoption or even blood or gamete donations illegal (not sure if any of those are illegal in the US but they are in many jurisdictions) or causes ethical wrangling over sex work: the idea that certain goods related to physical body parts or body functions, typically ones that are not fully controlled by our conscious decision making, are not appropriate as objects of commercial transactions.
So ultimately it's at this level this needs to be argued, fundamentally.
But I do think that Ozy's immediate argument is also valid, and maybe it'd be easier to implement of it's framed as "compensating for costs incurred" rather than "work"?
Oh and as an example: I'd not donate kidney for free, unless it was to my child. But if I had a possibility of donating one for the, let's say, equivalent of annual cost of dialysis in the US, plus actual costs of recovery, I'd definitely consider it. I'm probably too old for it now, but in theory, absolutely.
And while I'm poor, I'm not "underclass in India" level poor, my life is fairly comfortable etc. But 45k USD would be life changing for me. Not because of the time discounting even, but because I'm not capable of saving that amount of money in the productive time I have left on this earth.
And I think bioethicists are uncomfortable with this kind of tradeoffs.
This if course assumes that my consent is so constrained by my needs that I'm effectively incapable of consenting. I disagree. But I can see the argument.
What I'd hoped to illustrate with the blood farm example is that we don't just need to worry about how poor people can be persuaded to harm their health through the subtle coercive influence of money, but also through literal physical coercion. Those people in the blood farm were captives and wouldn't see the 45k, it would end up being a life changing amount of money for people willing to capture and enslave poor people.
Yes. But that's going on ANYWAY. I don't think this is a main ethical concern over payments, because coercion and enslavement are illegal and morally bad anyway. We already condemn those.
I think the bioethicist concern IS often over subtle (or not subtle at all) influence of money on anyone who doesn't have a substantial trust fund, and the idea that poor people are powerless in the face of this influence.
> But that's going on ANYWAY. I don't think this is a main ethical concern over payments, because coercion and enslavement are illegal and morally bad anyway. We already condemn those.
Yes but something being immoral and illegal doesn’t stop it from existing. The fact that it’s already going on is not a good reason to financially incentivize it. The question is not “will it exist?”, the question is “will it become more prevalent?” and usually when it becomes easier to make money from something more people try to make money from it.
However, we also know that prohibitions on highly desirable activities rarely work unless enforced with very thorough state power/violence wielding apparatus, and that when a thing X is illegal, often more damage is caused by the fact that it's now provided by criminal networks (or individuals acting outside law), and abusive/coercive practices are harder to report, police and prevent.
From American alcohol prohibition to, again, sex work in jurisdictions that criminalise, decriminalise or legalise it, the effects are not obvious or easy to predict.
Legalising organ sales will increase the probability of people being coerced or forced into donating (maybe even hunted for?) their organs by criminals, but will also MOVE many such transactions “above board”. The outcomes are neither obvious nor easy to predict or model and would likely depend on many detailed factors related to the law on this and likely also location etc.
> I can easily see a similar dynamic happening here: the government gives a bit of money, but not enough to compensate the full recovery/long term effects, and poor people are forced to take that option because they need money now.
Plasma donation in the US is almost all desperate underclass, suggesting they are not exactly getting a great deal from Big Plasma. I agree, this is a valid concern and not a bioethicist fever dream.
in short: people in poverty are trapped in place that extract from them all legible resources, so making resources legible will not make their situation better by the amount of money they get, just make them have one organ less.
talking specifically to people who have already donated their kidneys for free whether, holding that fact about them fixed, they would rather be paid seems to be missing the point. *of course* there is a straightforward sense in which *these* donors would be better off! more money, with the same number of kidneys—things are better for them by precisely the amount they have been compensated in this envisaged scenario. maybe there is a sufficiently broad minded sense in which they would be worse off for their being exploited, but i can see easily why someone would overlook that in favour of the obvious benefits of cold hard cash.
the people for whom kidney markets pose a risk are those who do *not* donate without a market but would sell their kidneys on the market. the introduction of kidney markets is, effectively, levying a certain tax in opportunity costs on those who do not commodify their organs, thus coercing potential donors into selling them. its similar reasoning to other incursions on "freedom of contract" on anti-exploitative grounds, like bans on working more than a certain number of hours per week. maybe you disagree with this analysis, i certainly have not given a full throated defence of the position here, but it should be obvious that the victims being envisioned *arent the ones who have already donated absent market pressure to do so*.
something similar happens in how people talk about sex work and its abolition. opponents of abolition will point out how certain sex workers under a nordic system, say, are worse off than they would be if the system switched to full decriminalisation. idk, maybe, but thats sort of missing the point: sex work abolitionists want to use sex work regulation to *abolish sex work* on the grounds would be sex workers are better off in a world where they are not economically induced to sell their bodies for use. the ones currently selling sex services in this envisioned nordic regime are the ones for whom the regime has *failed* to abolish sex work. the real question is not how decriminalisation would affect them, but how it would affect other potential sex workers who would sell their services under the new regime—both in terms of how many there would be and how their circumstances would be affected. again, you can disagree with this line of thinking, many do, but the relevant questions are about those who *would* sell sex under decriminalisation but *not* under the abolitionist/nordic system, not about those who would sell it under *both*.
this probably makes it sound like my feelings on sex markets and organ markets are the same, which is not true. i am much more firm in opposing organ markets than in opposing sex markets—i have some sympathy to abolitionist arguments about sex work but would need to see more empirical evidence than i have. organ markets to me are an indication something has gone cataclysmically wrong politically.
I will donate my kidney for $50,000 in Krugerrands to anyone who’s interested. Was thinking of doing it anyway anonymously, but the inconvenience of it all has kept me from going through with it so far. It would be a no brained if there was a monetary justification.
I’m not poor, down on my luck, or making a bad decision either. The positives for me are basically zero and I have other things going on that take precedence, but $50k would easily justify it, as that’s like 5 full years of awesome skiing vacations.
Super essay! The End Kidney Deaths Act (HR 9275) is a ten year pilot program to provide a refundable tax credit of $10,000 each year for five years ($50,000 total) to living kidney donors who donate a kidney to a stranger, which will go to those who have been waiting longest on the kidney waitlist. By the 10th year after the passage of the EKDA, up to 100,000 Americans who had been dying on the waitlist will instead have healthy kidneys, and taxpayers will have saved $10-$37 billion. While initially qualified to be on the waitlist, 100,000 Americans died due to the long wait times between 2010-2021. In the decade after the passage of the EKDA, up to 100,000 waitlisted Americans will receive a life-saving living kidney transplant that will on average last twice as long as a deceased donor kidney.
Because we have no shortage of surrogate parents and plasma donors due to the compensation, I believe that the End Kidney Deaths Act will end the kidney shortage. It's a win for kidney failure patients, donors, taxpayers (we will save up to $37 billion) and hospitals who make money on living kidney transplants and lose money on deceased donor transplants.
The question is, should we offer a tax credit to encourage more people to donate kidneys, knowing only 2% complete the process, or let Americans continue to die from kidney failure due to the kidney shortage?
As Ozy Brennan states in his essay, kidney donation is time consuming, painful and stressful work. It's morally important to pay people for difficult work.
Very few Americans are healthy enough to be kidney donors. The transplant centers' evaluations are rigorous. Only the healthiest are selected, and living kidney donors live longer than the general population. Potential donors to strangers usually have to see two to three mental health experts in order to be approved. Kidneys that are donated by strangers go to those at the top of the kidney waitlist, those most likely to join the 9,000 Americans who die on the waitlist each year.
The 100,000 lives the End Kidney Deaths Act will save in the next decade will definitely be lost without the bill's passage. Most of those people will be low income Americans because high income people list at multiple centers, put up billboards and hire teams to help them get kidneys.
I just spoke with my friend Doug this week who waited on the waitlist so long that he has now been removed from the waitlist due to a pulmonary edema. If we had no kidney shortage, Doug would be thriving now instead of withering away due to the kidney shortage.
Half of the 90,000 Americans waiting for a kidney will die before they get a kidney due to the shortage.
Let's save the lives of all of those who are dying from preventable deaths.This is within reach because this problem (unlike so many others) is solvable! Go to EndKidneyDeaths.org and join our team to help us get this legislation to the finish line. Questions? Email ElainePerlman@modifynota.org
Dialysis should have become obsolete two decades ago, when I published how to prevent 90% of it (1). But nobody in healthcare wants to eliminate it: it pays the salaries of too many people, beginning with Medicare bureaucrats. For those who think Medicare-for-All is the solution, think again (2).
I think the big fear is poor people selling their kidneys for money--it just has that 'ick factor' for a lot of people. There's still that old Judeo-Christian idea of the sanctity of the body, I'm guessing. These things persist in a lot of ways even after the religion's faded.
Under my model, paid kidney donors come in two types (completely made up based on very little data):
1. People who make absurdly bad decisions to the point where they accrue insane amounts of debt/expenses, and then try to donate their kidneys to solve these money losses, but failing to realize that one can't fix a leaky bucket by pouring in more water.
2. People who were making reasonable decisions but living in an economically precarious situation, and who eventually got hit by some big external factor that required a lot of immediate money to handle, and who thus essentially used their kidney as insurance against that sort of stuff.
From a utilitarian perspective, it's hard to argue that the world is better of permitting kidney donors to be paid. However, especially the first of these two types seems definitely exploitative.
Meanwhile, in a system with unpaid kidney donors, I think the people who donate are entirely different:
3. People who personally care about the person who needs a kidney.
4. People who feel an unbounded desire to give charity to everyone.
By bringing down the queues, I think paying kidney donors would mostly remove the need for these two groups to donate and move it to the other groups.
One potential downside of this is that group 3 generates an implicit prioritization, where hopefully good people would be more likely to receive kidneys.
How is it exploitative? You're essentially denying agency -- but only over certain kind of decisions pertaining to some body functions or parts -- to people based on their material situation.
It's really similar to arguments over sex work, actually: you either do it "for love" or "because you're extremely forced to".
You're not leaving room for at least approximately rational decision making of the "if I can make xyz money in few months max by selling an organ or providing a use if my body for other purposes -- eg medical trial, surrogacy etc, and saving the same amount of money would take me 10 years of my life of souls destroying or body damaging labour, this seems like a very reasonable tradeoff".
A person can LITERALLY sign up to a trade/profession that involves killing and a risk of being purposefully killed, but they cannot legally sell a kidney, hire out their uterus or vagina (the latter only in some jurisdictions) or get payment for blood they donate. Weird.
Oops, ESL error. When I said "From a utilitarian perspective, it's hard to argue that the world is better of permitting kidney donors to be paid.", I meant "From a utilitarian perspective, it's hard to argue with the point that the world is better of permitting kidney donors to be paid.". As in, I see the point Ozy is making and agree at least within a certain range of considerations. "It's exploitation" was meant descriptively, and I'm not sure to what extent the concerns I raise overrule the utilitarian advantage.
As for sex work, a major difference is that one can keep doing sex work for years, thus making it suitable as a persistent source of income. (In that case, the main worry I have is that a young sex worker might underestimate the loss of income that would likely come with age, or overestimate the opportunities to leave. I've heard multiple stories of women entering sex work with the dream of being swept away by a rich man, but I'm not sure how well that works in practice, and I could imagine it working terribly.)
I'm certainly open to the possibility that there can be a good income made by selling kidneys, but it depends on the market conditions, and the vibe I got from Ozy's post as well as from a quick research on it was not that good. I would love to see some estimates of how many % fit in each of the categories we've come up with. This is also one of the major factors of uncertainty that makes me not have a very definitive opinion on the topic.
But your argument remains the same, doesn't it? Something along the lines of “we should maybe protect people who tend to make bad decisions from being tempted to make certain kinds of decisions with long term potentially catastrophic consequences”? Or maybe you're simply assigning a very high value to the kidney and assuming the people in groups 1 and 2 are desperate? So group 1 would be selling a kidney in a VAIN hope of solving their long standing problems, not for example to put a deposit down for a mortgage or to do up a house to operate a b&b out of it or to travel round the world or whatever reason would seem justified and rational?
A focus on protecting people from the bad decisions seems to lead to too much obstructionistic bureaucracy and opaqueness to me. I would rather say that there's a need to solve whatever root causes lead people to act like this. The question of compensated kidney donation then becomes less a question of protection and more a question of, should we rush to extract as much value as possible from people who act self-destructively before we cure their self-destructiveness? And obviously as Ozy points out there's a clear utilitarian argument in favor of doing so, but I feel like the impulse to harvest people's organs is hard to have in the same mindset as the impulse to stop people from leaking so many resources that even their organs get harvested.
I still feel that you see the loss of kidney as disproportionally huge / extreme here and consequently the people who'd sell kidney as necessarily desperate in weirdly uncommon ways. But if selling kidneys was normalised, you'd get way more non desperate, rational people making those decisions. And ESPECIALLY if the pay was high!!
So maybe the argument is less about whether to pay and more about how much is an organ worth?
Apparently a surrogate can earn between $50,000 and $90,000 in the US (not sure if it's legally framed as pay). I'd expect a kidney to be at least that (tho kidney donation likely entails shorter loss of earnings periods), probably more.
What I heard is that when they stopped paying blood donors, the quality of the blood supply improved, because when you don't pay people for blood, then people don't have an incentive to lie about things like whether or not they use illegal IV drugs...
I'm kinda in the process of donating my kidney (I have to decide between liver lobe and kidney donation since I can't do both. No one has done an analysis of this tradeoff, but conversations with the hospital make me lean towards kidney donation). I largely agree and even think we should extend this to all types of organ donations, but I don't agree with you when you say "I am convinced that if you investigated the bioethicists who are against compensating kidney donations, you would discover they’re funded by dialysis companies who don’t want to suddenly be cut off from the beautiful gushing flow of cash."
I've read some of those bioethicists and they strike me as genuinely concerned for the poor. One possible problem is that poor people are often forced to take deals that give them a bit of money now in exchange for having to pay a lot of money later (see e.g. the whole predatory lending landscape). I can easily see a similar dynamic happening here: the government gives a bit of money, but not enough to compensate the full recovery/long term effects, and poor people are forced to take that option because they need money now. This is especially dangerous in low-governance regions where I can see this leading to black organ markets (for a possible worst case scenario, see this story about "blood farms" in India: http://news.bbc.co.uk/2/hi/south_asia/7302649.stm)
Now I think that with very *very* careful law drafting we can craft a bill that minimizes these dangers while still saving those suffering from kidney failure, but I can't blame people for being skeptical about whether their lawmakers can pull that off.
I do think you could e.g. require kidney donors to be part of a household making at least the U.S. median household income, which would address a lot of these concerns.
My troll proposal is that we start by only allowing accredited investors. This probably wouldn't get us that many kidneys, though.
Interesting idea, but that would exclude most of the population in poorer countries. On the upside, donating a kidney could become a status symbol if only wealthier members of society are able to do it... Would be interesting to try out.
Ozy is specifically talking about US law
While I definitely think the downsides here are minimal and a law simply setting up a regulated kidney exchange would be totally fine, you are still completely right that most bioethicists are well-meaning people who authentically worry about the issues, and themselves really aren't making a ton of money of these concerns! We can disagree on the merits without the character aspersions, so wanted to give you kudos on that front.
Thanks! I think it depends on the country, I'd fully endorse it for Norway and fully denounce it for Somalia, with all other countries falling somewhere in between.
I agree with the points you're making. Once you open the door to paid organ donation, it becomes potentially very open to various kinds of abuses, considering how valuable the service is to the patients.
The problem is that much if this stuff is already going on, and making it official might help rather than make things worse.
I think what lies behind this issue though is the same thing that makes paid (beyond cost) surrogacy or paid for adoption or even blood or gamete donations illegal (not sure if any of those are illegal in the US but they are in many jurisdictions) or causes ethical wrangling over sex work: the idea that certain goods related to physical body parts or body functions, typically ones that are not fully controlled by our conscious decision making, are not appropriate as objects of commercial transactions.
So ultimately it's at this level this needs to be argued, fundamentally.
But I do think that Ozy's immediate argument is also valid, and maybe it'd be easier to implement of it's framed as "compensating for costs incurred" rather than "work"?
Oh and as an example: I'd not donate kidney for free, unless it was to my child. But if I had a possibility of donating one for the, let's say, equivalent of annual cost of dialysis in the US, plus actual costs of recovery, I'd definitely consider it. I'm probably too old for it now, but in theory, absolutely.
And while I'm poor, I'm not "underclass in India" level poor, my life is fairly comfortable etc. But 45k USD would be life changing for me. Not because of the time discounting even, but because I'm not capable of saving that amount of money in the productive time I have left on this earth.
And I think bioethicists are uncomfortable with this kind of tradeoffs.
This if course assumes that my consent is so constrained by my needs that I'm effectively incapable of consenting. I disagree. But I can see the argument.
What I'd hoped to illustrate with the blood farm example is that we don't just need to worry about how poor people can be persuaded to harm their health through the subtle coercive influence of money, but also through literal physical coercion. Those people in the blood farm were captives and wouldn't see the 45k, it would end up being a life changing amount of money for people willing to capture and enslave poor people.
Yes. But that's going on ANYWAY. I don't think this is a main ethical concern over payments, because coercion and enslavement are illegal and morally bad anyway. We already condemn those.
I think the bioethicist concern IS often over subtle (or not subtle at all) influence of money on anyone who doesn't have a substantial trust fund, and the idea that poor people are powerless in the face of this influence.
> But that's going on ANYWAY. I don't think this is a main ethical concern over payments, because coercion and enslavement are illegal and morally bad anyway. We already condemn those.
Yes but something being immoral and illegal doesn’t stop it from existing. The fact that it’s already going on is not a good reason to financially incentivize it. The question is not “will it exist?”, the question is “will it become more prevalent?” and usually when it becomes easier to make money from something more people try to make money from it.
Very valid point in that last line.
However, we also know that prohibitions on highly desirable activities rarely work unless enforced with very thorough state power/violence wielding apparatus, and that when a thing X is illegal, often more damage is caused by the fact that it's now provided by criminal networks (or individuals acting outside law), and abusive/coercive practices are harder to report, police and prevent.
From American alcohol prohibition to, again, sex work in jurisdictions that criminalise, decriminalise or legalise it, the effects are not obvious or easy to predict.
Legalising organ sales will increase the probability of people being coerced or forced into donating (maybe even hunted for?) their organs by criminals, but will also MOVE many such transactions “above board”. The outcomes are neither obvious nor easy to predict or model and would likely depend on many detailed factors related to the law on this and likely also location etc.
> I can easily see a similar dynamic happening here: the government gives a bit of money, but not enough to compensate the full recovery/long term effects, and poor people are forced to take that option because they need money now.
Plasma donation in the US is almost all desperate underclass, suggesting they are not exactly getting a great deal from Big Plasma. I agree, this is a valid concern and not a bioethicist fever dream.
I was bewildered by the opposition to selling organs, until i encountered the model of extraction. i actually read it in facebook, but there is a LessWrong post now: https://www.lesswrong.com/posts/fPvssZk3AoDzXwfwJ/universal-basic-income-and-poverty
there was discussions about selling organs somewhere, but i wasn't able to find it, so here a post about that from facebook that is not the one i want to link, but one from the same category: https://www.facebook.com/yudkowsky/posts/pfbid044c1JKDsvK2Q85vMsWtBKqVpqxbWPkBJY2RKbFEm64REzegCcR9mQT8nLC4FkVfGl
in short: people in poverty are trapped in place that extract from them all legible resources, so making resources legible will not make their situation better by the amount of money they get, just make them have one organ less.
talking specifically to people who have already donated their kidneys for free whether, holding that fact about them fixed, they would rather be paid seems to be missing the point. *of course* there is a straightforward sense in which *these* donors would be better off! more money, with the same number of kidneys—things are better for them by precisely the amount they have been compensated in this envisaged scenario. maybe there is a sufficiently broad minded sense in which they would be worse off for their being exploited, but i can see easily why someone would overlook that in favour of the obvious benefits of cold hard cash.
the people for whom kidney markets pose a risk are those who do *not* donate without a market but would sell their kidneys on the market. the introduction of kidney markets is, effectively, levying a certain tax in opportunity costs on those who do not commodify their organs, thus coercing potential donors into selling them. its similar reasoning to other incursions on "freedom of contract" on anti-exploitative grounds, like bans on working more than a certain number of hours per week. maybe you disagree with this analysis, i certainly have not given a full throated defence of the position here, but it should be obvious that the victims being envisioned *arent the ones who have already donated absent market pressure to do so*.
something similar happens in how people talk about sex work and its abolition. opponents of abolition will point out how certain sex workers under a nordic system, say, are worse off than they would be if the system switched to full decriminalisation. idk, maybe, but thats sort of missing the point: sex work abolitionists want to use sex work regulation to *abolish sex work* on the grounds would be sex workers are better off in a world where they are not economically induced to sell their bodies for use. the ones currently selling sex services in this envisioned nordic regime are the ones for whom the regime has *failed* to abolish sex work. the real question is not how decriminalisation would affect them, but how it would affect other potential sex workers who would sell their services under the new regime—both in terms of how many there would be and how their circumstances would be affected. again, you can disagree with this line of thinking, many do, but the relevant questions are about those who *would* sell sex under decriminalisation but *not* under the abolitionist/nordic system, not about those who would sell it under *both*.
this probably makes it sound like my feelings on sex markets and organ markets are the same, which is not true. i am much more firm in opposing organ markets than in opposing sex markets—i have some sympathy to abolitionist arguments about sex work but would need to see more empirical evidence than i have. organ markets to me are an indication something has gone cataclysmically wrong politically.
I will donate my kidney for $50,000 in Krugerrands to anyone who’s interested. Was thinking of doing it anyway anonymously, but the inconvenience of it all has kept me from going through with it so far. It would be a no brained if there was a monetary justification.
I’m not poor, down on my luck, or making a bad decision either. The positives for me are basically zero and I have other things going on that take precedence, but $50k would easily justify it, as that’s like 5 full years of awesome skiing vacations.
Super essay! The End Kidney Deaths Act (HR 9275) is a ten year pilot program to provide a refundable tax credit of $10,000 each year for five years ($50,000 total) to living kidney donors who donate a kidney to a stranger, which will go to those who have been waiting longest on the kidney waitlist. By the 10th year after the passage of the EKDA, up to 100,000 Americans who had been dying on the waitlist will instead have healthy kidneys, and taxpayers will have saved $10-$37 billion. While initially qualified to be on the waitlist, 100,000 Americans died due to the long wait times between 2010-2021. In the decade after the passage of the EKDA, up to 100,000 waitlisted Americans will receive a life-saving living kidney transplant that will on average last twice as long as a deceased donor kidney.
Because we have no shortage of surrogate parents and plasma donors due to the compensation, I believe that the End Kidney Deaths Act will end the kidney shortage. It's a win for kidney failure patients, donors, taxpayers (we will save up to $37 billion) and hospitals who make money on living kidney transplants and lose money on deceased donor transplants.
The question is, should we offer a tax credit to encourage more people to donate kidneys, knowing only 2% complete the process, or let Americans continue to die from kidney failure due to the kidney shortage?
As Ozy Brennan states in his essay, kidney donation is time consuming, painful and stressful work. It's morally important to pay people for difficult work.
Very few Americans are healthy enough to be kidney donors. The transplant centers' evaluations are rigorous. Only the healthiest are selected, and living kidney donors live longer than the general population. Potential donors to strangers usually have to see two to three mental health experts in order to be approved. Kidneys that are donated by strangers go to those at the top of the kidney waitlist, those most likely to join the 9,000 Americans who die on the waitlist each year.
The 100,000 lives the End Kidney Deaths Act will save in the next decade will definitely be lost without the bill's passage. Most of those people will be low income Americans because high income people list at multiple centers, put up billboards and hire teams to help them get kidneys.
I just spoke with my friend Doug this week who waited on the waitlist so long that he has now been removed from the waitlist due to a pulmonary edema. If we had no kidney shortage, Doug would be thriving now instead of withering away due to the kidney shortage.
Half of the 90,000 Americans waiting for a kidney will die before they get a kidney due to the shortage.
Let's save the lives of all of those who are dying from preventable deaths.This is within reach because this problem (unlike so many others) is solvable! Go to EndKidneyDeaths.org and join our team to help us get this legislation to the finish line. Questions? Email ElainePerlman@modifynota.org
Dialysis should have become obsolete two decades ago, when I published how to prevent 90% of it (1). But nobody in healthcare wants to eliminate it: it pays the salaries of too many people, beginning with Medicare bureaucrats. For those who think Medicare-for-All is the solution, think again (2).
1. https://www.bmj.com/content/363/bmj.k4303/rr
2. https://www.opednews.com/populum/page.php?f=An-elegant-solution-to-the-by-David-Moskowitz-Access_DIALYSIS_Equality-Inequity_Innovation-190804-167.html
A lot of people who end up on dialysis don't realize they have a kidney problem at all until it's already far too late. :(
I always thought this made sense.
I think the big fear is poor people selling their kidneys for money--it just has that 'ick factor' for a lot of people. There's still that old Judeo-Christian idea of the sanctity of the body, I'm guessing. These things persist in a lot of ways even after the religion's faded.
Under my model, paid kidney donors come in two types (completely made up based on very little data):
1. People who make absurdly bad decisions to the point where they accrue insane amounts of debt/expenses, and then try to donate their kidneys to solve these money losses, but failing to realize that one can't fix a leaky bucket by pouring in more water.
2. People who were making reasonable decisions but living in an economically precarious situation, and who eventually got hit by some big external factor that required a lot of immediate money to handle, and who thus essentially used their kidney as insurance against that sort of stuff.
From a utilitarian perspective, it's hard to argue that the world is better of permitting kidney donors to be paid. However, especially the first of these two types seems definitely exploitative.
Meanwhile, in a system with unpaid kidney donors, I think the people who donate are entirely different:
3. People who personally care about the person who needs a kidney.
4. People who feel an unbounded desire to give charity to everyone.
By bringing down the queues, I think paying kidney donors would mostly remove the need for these two groups to donate and move it to the other groups.
One potential downside of this is that group 3 generates an implicit prioritization, where hopefully good people would be more likely to receive kidneys.
How is it exploitative? You're essentially denying agency -- but only over certain kind of decisions pertaining to some body functions or parts -- to people based on their material situation.
It's really similar to arguments over sex work, actually: you either do it "for love" or "because you're extremely forced to".
You're not leaving room for at least approximately rational decision making of the "if I can make xyz money in few months max by selling an organ or providing a use if my body for other purposes -- eg medical trial, surrogacy etc, and saving the same amount of money would take me 10 years of my life of souls destroying or body damaging labour, this seems like a very reasonable tradeoff".
A person can LITERALLY sign up to a trade/profession that involves killing and a risk of being purposefully killed, but they cannot legally sell a kidney, hire out their uterus or vagina (the latter only in some jurisdictions) or get payment for blood they donate. Weird.
Oops, ESL error. When I said "From a utilitarian perspective, it's hard to argue that the world is better of permitting kidney donors to be paid.", I meant "From a utilitarian perspective, it's hard to argue with the point that the world is better of permitting kidney donors to be paid.". As in, I see the point Ozy is making and agree at least within a certain range of considerations. "It's exploitation" was meant descriptively, and I'm not sure to what extent the concerns I raise overrule the utilitarian advantage.
As for sex work, a major difference is that one can keep doing sex work for years, thus making it suitable as a persistent source of income. (In that case, the main worry I have is that a young sex worker might underestimate the loss of income that would likely come with age, or overestimate the opportunities to leave. I've heard multiple stories of women entering sex work with the dream of being swept away by a rich man, but I'm not sure how well that works in practice, and I could imagine it working terribly.)
I'm certainly open to the possibility that there can be a good income made by selling kidneys, but it depends on the market conditions, and the vibe I got from Ozy's post as well as from a quick research on it was not that good. I would love to see some estimates of how many % fit in each of the categories we've come up with. This is also one of the major factors of uncertainty that makes me not have a very definitive opinion on the topic.
Ah, then it fits together better.
But your argument remains the same, doesn't it? Something along the lines of “we should maybe protect people who tend to make bad decisions from being tempted to make certain kinds of decisions with long term potentially catastrophic consequences”? Or maybe you're simply assigning a very high value to the kidney and assuming the people in groups 1 and 2 are desperate? So group 1 would be selling a kidney in a VAIN hope of solving their long standing problems, not for example to put a deposit down for a mortgage or to do up a house to operate a b&b out of it or to travel round the world or whatever reason would seem justified and rational?
A focus on protecting people from the bad decisions seems to lead to too much obstructionistic bureaucracy and opaqueness to me. I would rather say that there's a need to solve whatever root causes lead people to act like this. The question of compensated kidney donation then becomes less a question of protection and more a question of, should we rush to extract as much value as possible from people who act self-destructively before we cure their self-destructiveness? And obviously as Ozy points out there's a clear utilitarian argument in favor of doing so, but I feel like the impulse to harvest people's organs is hard to have in the same mindset as the impulse to stop people from leaking so many resources that even their organs get harvested.
I still feel that you see the loss of kidney as disproportionally huge / extreme here and consequently the people who'd sell kidney as necessarily desperate in weirdly uncommon ways. But if selling kidneys was normalised, you'd get way more non desperate, rational people making those decisions. And ESPECIALLY if the pay was high!!
So maybe the argument is less about whether to pay and more about how much is an organ worth?
Apparently a surrogate can earn between $50,000 and $90,000 in the US (not sure if it's legally framed as pay). I'd expect a kidney to be at least that (tho kidney donation likely entails shorter loss of earnings periods), probably more.
What I heard is that when they stopped paying blood donors, the quality of the blood supply improved, because when you don't pay people for blood, then people don't have an incentive to lie about things like whether or not they use illegal IV drugs...