The Cost of Non-Cash Incentives for Organs

The Times newspaper featured an editorial proposing changes in the organ procurement system last week by Sally Satel, a scholar from the American Enterprise Institute, a conservative think tank. I thought the first few lines were especially revealing about Satel’s attitude to market transactions – she reports that she desperately needed a kidney herself, but dreaded “the constricting obligation that would surely come with accepting” an altruistic donation. She therefore “wished [she] could buy a kidney just to avert the emotional debt.”

Satel goes on to argue that because the altruistic system we now have does not provide enough organs to meet public health needs, we should offer “donor benefits”. These might include cash, and Satel claims that her libertarian colleagues “make a compelling argument for a traditional market arrangement” based on the idea that needy patients who could afford it would remove themselves from the pool for free organs, leaving more for others. But she fails to mention the strong evidence that the development of a parallel market system in such things tends to supplant rather than supplement the altruistic system, and may even reduce overall availability.

More interestingly, Satel accepts that “some people are uneasy about offering lump-sum cash payments” because “cash is too much of a lure for the economically strapped,” and then argues that the answer is to provide in-kind rewards because these “would not attract desperate people who might otherwise rush to donate for a large sum of instant cash”. Some examples Satel offers are “a contribution to a retirement fund, an offer of lifetime health insurance, a tuition voucher or a large charitable contribution in [the donor’s] name”.

As I’ve argued previously on this blog, my concerns about a free market for organs arise from the worry that an opportunity to sell an organ can all-too-easily be transformed into an obligation to sell one. And I think there is significant intrinsic value in not being subject to such obligations. So a free market in organs would fundamentally and detrimentally change our relationships toward each other.

Does Satel’s suggestion to offer in-kind benefits then circumvent my objection to cash transactions? This depends on precisely what the in-kind benefits are, I think. But the risk is that the in-kind benefits proposed would either be ineffective at increasing donation rates, because they would fail to motivate people who are already unwilling to donate altruistically to save a life, or else they would be significant enough that we could effectively be obligated to do whatever is necessary to acquire them – including donating our organs. Taking Satel’s examples – it is hard to imagine how the  offer of a “large charitable contribution” in the donor’s name would incentivize a donor who is not already motivated altruistically to give a life-saving gift. On the other hand, things like tuition vouchers, lifetime health insurance, or retirement funds could obviously motivate self-interested people. But the opportunity to acquire these things by donating one’s organs could all-too-easily turn into the obligation to do so. Health care, education, and security in retirement could be provided free by the state through general taxation. If they are not, then we must decide on attitudes to take toward individuals in need of them. One attitude is the sympathetic attitude that the individual lacks the means necessary as a result of misfortune, and perhaps we will see some obligation or moral value in assisting in such cases, to provide for these important needs in the person’s life. An alternative, less sympathetic attitude is that the individual either possesses the means necessary, or if he lacks them, it is his just desert, perhaps because of to a lack of effort on his part. A system in which organs could be exchanged to meet our needs for health care, education, or security in retirement would make it difficult to maintain sympathetic attitudes towards those who lack these things if they possess viable organs they could sell. So providing in-kind benefits of these kinds to organ donors would significantly change our social relationships, and do so in detrimental ways.

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