Controversial markets

I became interested in forbidden transactions by studying kidney transplantation

• Buying and selling organs for transplant is against the law almost everywhere.

• The only country I know of where there is a legal market for kidneys is the Islamic Republic of Iran.

Repugnant transactions

•Let’s call a transaction repugnant if some people would like to engage in it and others think they shouldn’t be allowed to, particularly if there aren’t easily measurable negative externalities to those who object.•E.g. even though the others can’t detect that the transaction has taken place unless someone tells them.

3

4

Why can’t you eat horse or dog meat in a restaurant in California?

1. Short answer: It’s against the law.• California Penal Code Section 598 states in part

“…horsemeat may not be offered for sale for human consumption.”

2. Longer answer: many Californians find it repugnant that anyone should eat a horse

• and this repugnance was enacted into law, by popular referendum (Prop. 6 in 1998)

Ancient repugnancies can change fast

•Consider same-sex marriage

1995https://twistedsifter.files.wordpress.com/2015/07/the-history-of-same-sex-marriage-in-the-us-in-a-single-gif-1.gif?w=850&h=800

Italy

• July 2016: Gay civil unions https://www.thelocal.it/20160729/gay-civil-

unions-finally-become-a-reality-in-italy

• Introduces civil unions •denies same sex couples equal adoption rights to their heterosexual counterparts.

•May 2018: Italians who marry their same-sex partner abroad cannot have their marriage recognized at home, Italy's top court has ruled. https://www.thelocal.it/20180515/same-sex-marriages-performed-abroad-wont-be-recognized-in-italy

14

CANADA (since 10/17/2018)

Marijuana laws in the U.S. (and Canada)

15

Money and repugnance

•Often x+$ is repugnant, even when x alone isn’t.

16

“We didn’t have time to pick up a bottle of wine, but this is what we would have spent.”(New Yorker)

17

Lending money for interest

• Once widely repugnant, now not (with the important exception of Islamic law).

Credit. Man’s Confidence in Man. “Commercial credit is the creation of modern times and belongs in its highest perfection only to the most enlightened and best governed nations. Credit is the vital air of the system of modern commerce. It has done more — a thousand times more — to enrich nations than all the mines of the world.” Daniel Webster, March 18, 1834.

18

Surrogacy laws in the U.S.

https://www.creativefamilyconnections.com/us-surrogacy-law-map/

Dark Green: fully legal, with birth certificates

Red: at least compensation is illegal

19

CANADA

Surrogacy debate in New York State

• “Women’s rights scholars have argued that paid surrogacy turns women’s bodies into commodities and is coercive to poor women given the sizable payments it can bring.”

• "But Senator Brad Hoylman, one of the bill’s sponsors, said the legislation showed “the importance of the L.G.B.T.Q. community to the State of New York.• “I think that’s a mark of progress for our community and

a mark of progress for human rights in general,” said Mr. Hoylman.

Italy: Medically Assisted Procreation Law (40/2004).(Moderated by subsequent court decisions)

• “This law prohibits research and reproductive cloning, the manipulation of embryos, the use of donated eggs or sperm for ART, and the cryopreservation of embryos (with the exception of severe injury/illness preventing embryo transfer). A maximum of three eggs can be fertilized and transferred per reproductive cycle. Sex-selection is only permitted through sperm sorting for

sex-lined genetic diseases. All forms of surrogacy are prohibited. The use of preimplantation genetic diagnosis for the selection of embryos is generally prohibited, but has been allowed through the courts on a case-by case basis. Genetic testing for non-medical purposes is prohibited. The use of ART is restricted to stable heterosexual couples who live together, are of reproductive age, are over the age of 18, have documented infertility, and have been first provided the opportunity for adoption.”

https://cbhd.org/content/g12-country-regulations-assisted-reproductive-technologies

Kidneys: Global incidence of (deceased and living donor) transplantation

The long wait for a kidney transplant

23

The U.S. National Organ Transplant Act of 1984

Pub. L. 98-507, Section 301

(a) Prohibition of organ purchases

It shall be unlawful for any person to knowingly acquire, receive, or

otherwise transfer any human organ for valuable consideration . . .

(b) Penalties

Any person who violates subsection (a) of this section shall be fined not

more than $50,000 or imprisoned not more than five years, or both

25

Article 21 of the Council of Europe’s (2002) Additional Protocol to the

Convention on Human Rights and Biomedicine, on Transplantation of

Organs and Tissues of Human Origin:

“The human body and its parts shall not, as such, give

rise to financial gain”

2017 Statement of the Pontifical Academy of Sciences Summit on Organ Trafficking and Transplant Tourism

• organ trafficking and human trafficking for the purpose of organ removal are “true crimes against humanity [that] need to be recognized as such by all religious, political and social leaders, and by national and international legislation…”

• Recommendations:

• 1. That all nations and all cultures recognize human trafficking for the purpose of organ removal and organ trafficking, which include the use of organs from executed prisoners and payments to donors or the next of kin of deceased donors, as crimes that should be condemned worldwide and legally prosecuted at the national and international level.

But some growing discussion…

27

28

Transactions between consenting adults

•Test yourself for repugnance: are you willing to contemplate carefully regulated, sales of live:

•Kidneys?

•Hearts?

Poll on repugnance of kidney sales, AST CEOT Feb 2016

are you willing to contemplate carefully regulated, sales of live: Kidneys? Hearts?

29

Description and boundary testing

Leider, Stephen and Alvin E. Roth, “Kidneys for sale: Who disapproves, and why?” American Journal of Transplantation, 10 (May), 2010, 1221-1227.

• Representative (American) sample survey of four market scenarios:• Individual versus government payers, for deceased versus living-

donor kidneys

• “We find that a majority of our respondents approve of each of the four kidney markets we describe, while a substantial minority disapproves of at least one potential market. A similar majority favors the legality of having the government and/or insurance companies give a standard payment to donors; a plurality also would like an individual market to be legal, but nearly as many want such markets to be illegal.”

31

Segev, D.L and S.E. Gentry “Kidneys for Sale: Whose Attitudes Matter?” American Journal of Transplantation, 10 (May), 2010

•“Should we devote resources to investigatingthe nuances of public attitudes toward these markets? Probably not…”

•“…nothing else is relevant until physicians support organ sales.”

32

Money and repugnance

•There seem to be three principal lines of argument about how adding money makes a non-repugnant transaction (like kidney transplantation) repugnant:•Objectification (“commodification”)•Coercion (“exploitation”)•Slippery Slope

33

“Coercion” Can high payments harm recipients?

34

“benefits … raise … the danger that … some prospective participants enroll … when it might be against their better judgment and when otherwise

they would not do so”

- National Bioethics Advisory Commission, 2001

“payments … should be … not so substantial that they … will lead donors to discount risks”

- American Society for Reproductive Medicine35

36

More Money, More Problems? Can High Pay be Coercive and Repugnant? By Sandro Ambuehl, Muriel Niederle and Alvin E. Roth, American Economic Review, Papers & Proceedings, 2015

• We presented 1445 subjects on Amazon Mechanical Turk with a hypothetical medical trial that compensates participants with $50, $1,000, or $10,000. The trial was described as a test for side-effects of a vaccine that requires a total of 40 hours of a participant’s time and was characterized as low but non-zero risk.

• We asked our survey participants, as third parties, to evaluate the trial (as hypothetical IRB members).

37

Third party evaluations, divided into two patterns(covering the majority of respondents)

38

Tradeoffs…

Paying for heroism…

•Niederle, Muriel and Alvin E. Roth, “Philanthropically Funded Heroism Awards for Kidney Donors?, Law & Contemporary Problems, 77:3, 2014, 131-144.

40

SurveyOn a scale of 1 (strongly disapprove) to 10 (strongly approve) evaluate the following proposals.

1. Federal compensation for American Kidney Heroes by an Act of Congress:Congress will authorize the federal government to recognize all non-directed donors with a ceremony in Washington D.C., a medal and a payment of $50,000.

…5. American Heroes Foundation, a private non-profit philanthropy: The Foundation will establish some generally recognized criteria for exceptional heroism, and each year will recognize qualifying American Heroes, who will be celebrated with a ceremony in Washington D.C. and will each receive a medal and a prize of $50,000. While the kinds of heroism celebrated may vary from year to year, the Foundation’s criteria will include particularly deserving policemen, firefighters, and non-directed kidney donors. The goal will be to recognize five American Heroes each year. The Foundation expects to be able to include a non-directed kidney donor every year.

41

Fed 50K has a lower approval rating than any other proposal

•

38

An Offer You Can’t Refuse?Incentives Change How We Think

Sandro Ambuehl

University of Toronto

Subjects are presented with a lottery

Lottery

lose $3.50, prior probability ½

lose nothing, prior probability ½

Incentive

• Get $3 and take the lottery, or don’t participate

• Get $0.50 and take the lottery, or don’t participate

Information

Examine picture however you like

• If state = good: 50 G, 40 B

• If state = bad: 50 B, 40 G

(Similar to Caplin & Dean, 2014)

Treatments: 2x2 design

Incentive Informed of incentive

High / low Before/after examining state

Control: Prevent skewed information search

Learn incentive amount only after examining picture, but before any decision. (Similar to Babcock & Loewenstein, 2007)

• Cannot skew information search according to incentive

• Other channels can still matter (e.g. optimistic prior for high incentives, Brunnermeier & Parker, 2005)

Change in participation rate if search can be skewed

Average increase for high incentives 11.62%** (s.e. 4.25%). Increase in bad state for high incentives 15.49%** (s.e.7.50%). Remaining effects are not statistically significant.

Increase in participation when search can be skewed is entirelydue to increase in false positive rate (additional participation in bad

state)

Some subjects made objectively worse decisions when faced with “high incentives”

• Something similar happened in a related experiment, also reported in the same paper.

How much would you have to be paid to eat an edible (prepared) insect?

Or this?

Is eating an insect (for pay) a repugnant transaction?

52

Kidney exchange--background

•Many more people need kidney transplants than there are available organs.

•The waiting list in the US has more than 100,000 people •The wait can be years, and many die while waiting.

•Recently about 14,000 transplants/year from deceased donors

Living donation, and exchange

•Transplantable organs can also come from living donors.• In recent years we’ve had about 6,500 transplants a year from living donors in the U.S.

•Sometimes donors are incompatible with their intended recipient.

•This opens the possibility of exchange .53

Simple two-pair kidney exchange

Donor 1Blood type

A

Recipient 1

Blood type B

Recipient 2

Blood type A

Donor 2Blood type

B

54

Charlie W. Norwood Living Organ Donation Act

Public Law 110-144, 110th Congress, 2007

• Section 301 of the National Organ Transplant Act (42 U.S.C. 274e) is amended-- (1) in subsection (a), by adding at the end the following: ``The preceding sentence does not apply with respect to human organ paired donation.''

55

56

Congestion: 2-way exchange involves 4 simultaneoussurgeries (January, 2006)

56

57

58

O O A A B A A A A A

1Jul 2007

AZ

2Jul 2007

OH

3Sep 2007

OH

4Sep 2007

OH

5Feb 2008

MD

6Feb 2008

MD

7Feb 2008

MD

8Feb 2008

NC

9Mar 2008

MD

10Mar 2008

OH

62%

Cauc

Wife

Husband

0%

Cauc

Daughter

Mother

23%

Cauc

Mother

Daughter

0%

Cauc

Brother

Sister

82%

Cauc

Husband

Wife

78%

Hispanic

Daughter

Father

64%

Cauc

Wife

Husband

100%

Cauc

Brother

Brother

46%

AA

Mother

Daughter

3%

Cauc

Friend

Friend

Transplant Date:

Recipient's State:

Recipient's PRA:

Recipient's Ethnicity:

Recipient-to-Donor

Relationship:

1 The initiating donor was an unpaired altruistic donor from Michigan.2 The recipient of Transplant 6 required desensitization to HLA DSA by T and B cell flow cytometry.3 The recipient of Transplant 9 required desensitization to blood group (AHG titer of 1:8).

Recipient's Sex

and ABO type:

Donor's Sex

and ABO type: AO AO B A A A AB A AB1

2 3

58

Feb 2012, NKR: a NDD chain with

60 people (30 transplants)

59

• Cycle bound constraint is added only iteratively to speed up the computation• The running time of the algorithm is below 20 min for most instances (most are solved within seconds)

• Anderson, Ross, Itai Ashlagi, David Gamarnik and Alvin E. Roth, “Finding long chains in kidney exchange using the traveling salesmen problem,” Proceedings of the National Academy of Sciences of the United States of America (PNAS), January 20, 2015 | 663–668.

Matching algorithms have had to get more powerful to find optimal matchings involving

cycles and chains in sparse graphsInteger Programming based algorithm for finding optimal cycle and chain based exchanges.

Formulation I:

60

Why are long chains needed? (transplant center directors have big strategy sets…)

• We are seeing some hospitals withhold internal matches, and contribute only hard-to-match pairs to a centralized clearinghouse.

• “Market Failure in Kidney Exchange,” by Nikhil Agarwal,Itai Ashlagi,Eduardo Azevedo, Clayton Featherstone,and Ömer Karaduman, American Economic Review, forthcoming.• “most transplants are arranged by hospitals instead of

national platforms”61

Graph induced by pairs with A patients and A donors. 38 pairs (30 high PRA). Dashed edges are parts of cycles.

No cycle contains only high PRA patients.Only one cycle includes a high PRA patient

62

Kidney exchange in Europe

65

Kidneys Transplanted per million population

U.S.A.

(Global Observatory on Donation & Transplantation)

Spain and Portugal

Philippines

66

Mexico

Germany

Netherlands France

Canada

Italy

Kidneys Transplanted per million population

U.S.A.

(Global Observatory on Donation & Transplantation)

Mexico

Philippines

67

Global kidney exchange: a possibility of mutual aid

Developing World

United States

Transplants unavailable

68

Two-way exchange

First global kidney exchange, with a pair from the Philippines—January 2015, Alliance for Paired Donation (Rees et al.)

Jose Mamaril received a kidney from a non-directed American donor in Georgia. His wife, Kristine, donated one of her kidneys to an American recipient in Minnesota, whose donor continued the chain by donating to a patient in Seattle.THE BLADE/JETTA FRASER 69

•

Jose Kristine

D2R2

…

Non-directed

donor

The chain

70

Safely home…

• $50,000 escrow fund for post-surgical care

71

Global Kidney Exchange

72

The GKE proposal is “self-financing”.

• Back of the envelope calculation:

• cost of hemodialysis ≈ $90, 000 per year • average time under dialysis ≈ 5 years• cost of transplant ≈ $120, 000 per surgery

(plus $20,000 in maintenance therapy costs per patient per year)

Why is GKE Special?

• Medical care in rich countries is better than in poor countries

• There are limits to how much we can help the poor in poor countries

• But the fact that kidney exchange exists in rich countries with lots of highly sensitized patients allows us to help some poor patients at no cost.

73

The medical logistics may not be the hard part

74

Repugnance constraints

• Living donors• From poor countries

• As a first reaction, many people are going to conflate global kidney exchange with buying kidneys (which is illegal everywhere except Iran—a ‘repugnant transaction’)

75

GKE in the AJT

76

Abstract: Engaging compatible kidney donor–recipient pairs from other countries for participation in a paired kidney exchange program in the United States poses a number of ethical challenges that deserve close scrutiny…77

Repugnance1. “the plan is really not about the international recipient (nor…about the international donor), but only about getting organs for US citizens. So it is exploitative."

2. “Lets solve problems at home first…We should encourage programs that allow Americans to help Americans."

78

Support for GKE

79

GKE in Mexico

80

GKE in Mexico: A Bridge of Life

81

“Just as US President Donald Trump is seeking to build a wall of thousands of miles on the border with Mexico, a tireless surgeon and a renowned economist join forces to exchange organs between citizens of both countries"

Robot assisted transplant in Amedabad, May 2019

82

U.S., Spain, Germanyrepresentative sample survey on

repugance of: Global Kidney Exchange, Surrogacy, and Prostitution

Al Roth and Stephanie Wang

Surrogacy Global kidney exchangeA surrogate mother is a woman who bears a child for another woman, often for pay, through in vitro fertilization (IVF).

Consider the following situation:

James and Erica are a married couple in [Spain]. They want to have a child, but Erica does not want to become pregnant due to the demands of her career as a model. Maria is a married mother in the Philippines. Maria’s husband is out of work, and Maria has decided to become a surrogate mother to earn additional income. James and Erica hire Maria to carry and give birth to a child from James and Erica’s sperm and egg. James and Erica pay Maria a year’s average income in the Philippines, and everyone signs a contract making it clear that James and Erica are the child’s biological parents and will have custody after the child is born.

A kidney for transplant must be compatible with the recipient’s blood type and immunological system. A kidney can come from a compatible deceased donor, or from a healthy compatible living donor. In case a living donor wishes to give a kidney to a particular patient but is incompatible, kidney exchange is another possibility, in which two patient-donor pairs exchange kidneys, so that each patient receives a compatible kidney from the other patient’s donor.

Consider the following situation: James and Erica are a married couple in [Spain]. James needs a kidney, but Erica is an incompatible donor. There isn’t a compatible match for him anywhere in Spain. Maria is a married mother in the Philippines whose husband needs a kidney transplant but cannot afford one. Maria and her husband can do a kidney exchange with James and Erica. It would save the Spanish insurance enough money so they could pay for the surgery for the Filipino pair, who could then get postoperative care back home.

84

Prostitution

• Consider the following situation:

• James is an unmarried man in [Spain]. Maria is a married mother in the Philippines. Maria’s husband is out of work, and Maria has decided to become a prostitute to earn additional income. James visits the Philippines regularly for work, and regularly hires Maria for her services. James pays Maria a year’s average income in the Philippines.

85

Proportion who support legality

Country Surrogacy Prostitution Global Kidney Exchange

N

Germany 60.56 65.79 79.44 535

Spain 64.04 50.77 74.23 648

USA 81.47 44.23 86.58 529

Some market design/repugnance challenges

87

Drug related deaths around the world (pmp)

88

Refugee and migrant resettlement"no one puts their children in a boat unless the water is safer than the land"--from "Home" by Warsan Shire

89

Prostitution

• Scott Cunningham and Manisha Shah, “Decriminalizing Prostitution: Surprising Implications for Sexual Violence and Public Health” Review of Economic Studies, Forthcoming

• Paul Bisschop, Stephen Kastoryano, and Bas van der Klaauw, Street Prostitution Zones and Crime , American Economic Journal: Economic Policy 2017, 9(4): 28–63