Related: GiveWell's Increasing the Supply of Organs for Transplantation in the U.S.

(Content warning: organs, organ trade, transplantation. Help me flesh this out! My intention is to present the arguments I've seen in a way that is, at a minimum, non-boring. In particular, moral intuitions conflicting or otherwise are welcome.)

“Now arriving at Objection from Human Dignity,” proclaimed the intercom in a euphonious female voice. Aleph shot Kappa and Lambda a dirty look farewell and disembarked from the train.

Kappa: “Okay, so maybe there’s a possibility that legal organ markets aren’t completely, obviously bad. I can at least quell my sense of disgust for the length of this train ride, if it really might save a lot more lives than what we’re doing right now. But I’m not even close to being convinced that that’s the case.”

Lambda nodded.

Kappa: “First: a clarification. Why kidneys? Why not livers or skin or corneas?”

Lambda: “I’m trying to be conservative. For one, we can eliminate a lot of organs from consideration in the case of live donors because only a few organs can be donated without killing the donor in the process. Not considering tissues, but just organs, this narrows it down to kidneys, livers, and lungs. Liver transplants have … undesirable side effects that complicate-”

Kappa: “Uh, ‘undesirable side effects?’ Like what?”

Lambda: “Er, well it turns out that recovering from a liver donation is excruciatingly painful, and that seems like it might make the whole issue … harder to think about. Anyway, for that reason; and because most organ trade including legal donations is in kidneys; and because most people who die on waitlists are waiting for kidneys; and because letting people sell their organs after they're dead doesn't seem like it would increase the supply that much; for all of these reasons, focusing on kidneys from live donors seems to simplify the analysis without tossing out a whole lot of the original problem. Paying kidney donors looks like it’s a lot closer to being an obvious improvement in hindsight than paying people to donate other organs and tissues. If you wanted to talk about non-kidneys, you would have to go further than I have.”

Kappa: “Okay, so just kidneys then, unless I see a good reason to argue otherwise. The first big problem I see is that surgery is dangerous. So how are you not arguing that we should pay a bunch of people to take a bunch of deadly risks?”

Lambda: “As with any surgery, patients are at greater risk than usual immediately after having such a serious operation. The standard response is, "The risk of death from a kidney transplant in the form of a natural frequency is merely 1 in 3000, which is about the same as the risk of death from a liposuction operation." But to my knowledge there are only four studies that have looked at this, some finding little risk, others finding greater risk, some finding no increased risk of end stage renal disease, others finding increased risk of end stage renal disease. Both sides have been the target of methodological criticisms. I'm currently of the opinion that the evidence is too ambiguous for me to make any confident conclusions. I'm thus inclined to point out that we already incentivize people to do risky things with social benefits, such as military service, medical experimentation, and surrogate pregnancy. So saying that it's immoral to incentivize people to donate kidneys seems to imply that it's immoral to incentivize people to do at least some of those other things.”

Kappa: “Fine. Let’s assume that incentivizing people to take the personal risk is morally acceptable, just for the sake of argument. What makes you think that a market would improve things? How do I know you’re not the sort of person who thinks a market improves anything?”

Lambda: “Suppose you have a family member who needs a kidney transplant, and you’re not compatible. Suppose further that a stranger approaches you at the hospital and explains that they have a family member who needs a kidney and that they also aren’t compatible with their family member. However, claims the stranger, the two of you are compatible with one another’s family members. They will donate their kidney to your family member only if you will donate your kidney to their family member. Ideally, we would like this trade to take place. Would you donate your kidney? If not, why not?”

Kappa: “First I would want to know how the stranger accessed my medical records. At any rate, I don’t think I would. What if I donate first, and they back out after I donate? What if their family member dies before or during surgery and they no longer have an incentive to donate their kidney to my family member?”

Lambda: “Indeed, what if? In more than one way, it’s risky to trade kidneys as things are today. On the other hand, if you could reliably sell your kidney and buy another, you wouldn’t have to worry about being left out in the cold. Your kidney may be gone, but no one can take your revenue unless you make a big mistake. If the seller backs out, you can always try to buy another one.”

Kappa: “But there are already organizations with matchmaking programs that allow such trades to take place. They solve the trust problem with social prestige and verification procedures and other things. What more would a market get you, and how much does it matter after considering the additional problems that a market might cause? What are you really suggesting, when you can't use words like 'market'?”

Lambda: "The ban prevents the use of money in organ trades, so what do you use in its place, and what have you lost? In the place of money, you use promises that you'll donate your kidney. The first way that promises are worse than money is that they're a poor store of value. If I trade my promise for a stranger's promise, and the stranger loses their incentive to donate, then the promise loses its value. Even if I only want to use the money to buy a kidney, I would prefer receiving money because I can be confident that I can later retrieve it and exchange it for a kidney as long as someone is selling one that I want. The second way that promises are worse than money is that they're a poor medium of exchange. Because each individual promise has associated with it some specific conditions for donation, promises aren't widely acceptable in trade. At the moment, we have to set up what are essentially incredibly elaborate barters to make trades that are more complex than simple donations from one donor to one recipient. It seems like both of these factors might prevent a number of trades that could be realized even given the currently low supply, particularly trades that might occur across time."

Kappa: “Right, but like I said, what about the additional problems that markets cause? Tissues sold by corporations in the U.S. in 2000 were more expensive than tissues sold by public institutions in the EU in 2010. And some of their products aren’t even demonstrably more useful than public alternatives; they deceive consumers! How is that supposed to make things better?”

Lambda: “This is a case where I would argue that there isn’t enough regulation. It’s true that with the wrong laws you can get situations like, say, the one where corporations encourage new parents to harvest and privately store autologous cord blood for large sums even though there’s no evidence that it’s more effective than the allogenic cord blood that's stored in public banks. But is an unqualified ban the only way to stop the rent-seeking? Why couldn’t you throw that part out but keep the trust, all via regulation? Remember also that you can store cord blood in a bank, but at the moment you can only store kidneys inside of a living human body. It seems like that would make it a lot harder to arbitrage."

Kappa: "What about egalitarian concerns? Wouldn't these incentives disproportionately encourage the poor to sell their organs?"

Lambda: "Whether lifting the ban makes things more egalitarian or less depends on your reference frame. The poor will have a greater incentive to sell their organs than the rich just like the poor usually have a greater incentive to sell other things than the rich. The idea behind the egalitarian objection is that the ban prevents this and it's more egalitarian if no one can legally sell their organs at all. But illegal organs already tend to flow from the poorest countries to the richest countries for the very reasons that you fear lifting the ban, and lifting the ban decreases U.S. demand for foreign organs by increasing domestic supply. In this reference frame, lifting the ban is more egalitarian, replacing the current sellers who receive little to no compensation, high risks, and poor post-operative care, with U.S. sellers who would receive more compensation, have lower risks, and receive better post-operative care."

Kappa: “In a market, I would guess that the average recipient wants to receive a kidney a lot more than the average donor wants to donate one. This could spell disaster for a market solution. What makes you think this wouldn’t happen with a kidney market?”

Lambda: “Empirically, the Iranian organ market has eliminated kidney waitlists in that country. The U.S. and Iran may be quite different, but they'd have to be different in the particular way that makes markets work there and markets not work here for that argument to follow. Besides, the U.S. spends about $72,000 per patient per year on dialysis, whereas the U.S. only spends about $106,000 on transplant patients in the first year, and about $24,000 per transplant patient per year, so the government should be willing to subsidize kidney suppliers in the case of market failure without intervention.”

Kappa: "Geez. Uh... what about impulsive donations? You'd be encouraging irresponsibility."

Lambda: "That seems like a weak one. Legislate waiting periods. And this isn't exactly a problem particular to legal kidney markets."

Kappa: "I have you now, Lambda! Even if all of these things are true, the fact remains that most people, including me, are disgusted by the very idea of exchanging our organs for money! How ever would you overcome our repulsion?"

Lambda: "You do have me, Kappa."

Kappa: "I'll grant you that, but no politician can lose by being against- I mean, what?"

Lambda stood up and walked solemnly to the window.

"How ever would I overcome your repulsion?"