The Cost of Banning Kidney Sales: 130,000 New Cases a Year, Fewer Than 30,000 Transplants
The US sees about 130,000 new cases of kidney failure a year and performs fewer than 30,000 transplants. Al Roth takes apart where the repugnance toward organ markets comes from, and argues that regulated compensation could save lives without exploitation.
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90,000 people wait for a kidney and the ban cannot say whom it protects
The episode opens with a brutal number: roughly 90,000 people are on the US kidney transplant waiting list. Most of them will not get a kidney, and some will die waiting. The solution may already exist — plenty of healthy people would give up one kidney for payment, if the law allowed it. Society has chosen to forbid it. That sets up the question the whole conversation turns on: "When we say this is not allowed, what exactly are we protecting?" It also establishes the frame of the repugnant transaction: both parties consent, and the people who object may have no way of even knowing the transaction took place.
— Brian WalshOnly bans with an identifiable victim actually get enforced
Al Roth uses a pair of comparisons to show what gives a market ban its social footing. Buying heroin and hiring a hitman are both illegal transactions, but society enforces them with wildly different intensity. Ask someone where to buy heroin and they may just be startled; ask where to hire a hitman and they may call the police, who will then set up an undercover operation. Both are serious felonies, yet prisons are full of drug dealers and hold almost no hitmen. Why? Because a contract killing has a clear victim, while the drug user entered the transaction willingly. Whether a ban is strictly enforced depends on society's shared judgment about harm.
— Al RothThe organ shortage is not a technical problem but a supply arrangement problem
Kidney failure is one of the ten leading causes of death in the US, with about 130,000 new cases a year, while the country performs fewer than 30,000 transplants annually. Dialysis is no ideal substitute: half of patients die within five years, and the treatment itself is close to torture — three times a week, four hours a session, exhausting people past the point where they can hold a job. Al Roth stresses that transplantation is the treatment of choice, yet it is scarce to a tragic degree. These numbers explain why the organ shortage is not a technical problem but a problem of how supply is arranged.
— Al RothSeventy percent of kidney sellers are poor, which still does not condemn the market
Iran is the only country in the world where paying for a kidney is legal. Akbarpour, a colleague of Al Roth's, found that between 2012 and 2017 about 70% of Iranian kidney sellers were below median wealth, while among the patients that share was only 41% — and sellers were generally unwilling to be publicly identified. But Al Roth refuses to treat this as the market's original sin: poor people work in coal mines and rich people use the electricity, and an uneven income distribution does not by itself condemn a market. What matters is how to keep vulnerable people from being exploited, not rejecting compensation itself because the distribution is unequal.
— Al RothExploitation risk can be managed by design rather than by prohibition
Market design can defuse the worry that the rich will buy kidneys and the poor will sell them. Al Roth proposes amending the National Organ Transplant Act so that only the federal government may pay for a kidney, with a bureaucratized allocation system then distributing organs by medical need and paying no attention to income. It would also need very robust informed consent, so that no one sells a kidney on impulse because their car broke down or the rent is due and then regrets it. He concedes the risk of exploitation cannot be eliminated entirely, but he thinks these risks can be controlled through design rather than settled with a ban.
— Al RothTwo hundred more donors a year would prove compensation works
Al Roth says the death toll has weighed on him throughout: when he began his research there were 40,000 people waiting for a deceased-donor kidney, and today it is close to 100,000. He supports an experimental bill called the End Kidney Deaths Act, which would give non-directed donors — people who donate a kidney anonymously and start a transplant chain — a refundable tax credit over five years. There are currently about 500 such donors a year; if that rose to 700, it would demonstrate that compensation really does expand supply. And because transplantation is cheaper than dialysis, taxpayers would not spend more.
— Al RothAddiction destroys consent, so drugs cannot copy the organ solution
Drugs are not like organs: addiction strips the buyer of any real basis for consent, so the market solution cannot simply be transplanted. Al Roth grants that we are losing the war on drugs, but insists the problem cannot be solved by surrender or by force alone. He argues for treating cities as laboratories of democracy and running more experiments: clean needle exchanges have already been shown to reduce transmission of hepatitis and AIDS, and safe injection sites are worth trying too. And if an addict is also mentally ill and homeless, then prisons have to offer treatment that actually works, not just talk about it.
— Al RothWe will fight over AI's limits before asking whether it deserves moral concern
Al Roth thinks AI will be the next source of repugnant-transaction controversies. We chose pigs rather than chimpanzees as a source of transplant organs because chimps feel almost human to us; in the future we may come to feel the same kind of moral obligation toward silicon-based intelligence. His prediction is that before we get to the question of whether AI deserves moral concern, we will first argue about the limits on using it — restrictions on facial recognition by the San Francisco police, for instance, and how privacy rights get redefined in an environment saturated with cameras. All of this will test the boundaries we currently draw between the natural and the disgusting.
— Al RothIn their own words · checked verbatim
There's no law in California against selling cockroaches for human consumption, but there is a law against selling horse meat for human consumption
Al Roth5:00
Just as markets need social support to work well. So do bans on markets.
Al Roth6:46
We have about 130000 new cases of kidney failure each year. But we do fewer than 30000 transplants each year
Al Roth9:28
There were 40,000 Americans on the waiting list for a deceased donor kidney. And today, they were closer to 100,000.
Al Roth29:49
We're losing the war on drugs. But it doesn't accept our surrender either
Al Roth36:28
we think about markets as human artifacts, tools that we build
Al Roth45:26
Figures
| People on the US kidney transplant waiting list | about 90,000 | 0:00 |
| New US cases of kidney failure per year | about 130,000 | 9:28 |
| Kidney transplants performed in the US per year | fewer than 30,000 | 9:28 |
| Five-year mortality for dialysis patients | about 50% | 9:28 |
| Share of Iranian kidney sellers below median wealth | about 70% | 15:00 |
| Share of Iranian patients below median wealth | about 41% | 15:00 |
| Medicare spending on kidney failure treatment per year | more than $55 billion | 19:02 |
| People on the US kidney waiting list (when Al Roth began his research) | about 40,000 | 29:49 |
| People on the US kidney waiting list (now) | close to 100,000 | 29:49 |
| Non-directed kidney donors in the US per year | about 500 | 29:49 |
Glossary
- repugnant transaction
- A transaction both parties enter willingly that bystanders believe should not be permitted.
- market design
- The branch of economics that treats markets as buildable tools and improves allocation outcomes by designing their rules.
- non-directed donor
- A living donor who gives a kidney anonymously, without knowing who receives it.
How to listen
Policy researchers, healthcare founders, transplant surgeons, and anyone who has to choose between banning a market and saving lives.