In a 2020 Proceedings of the National Academy of Sciences article, Alvin Roth and Stephanie Wang observe that both markets and bans on markets require social support to be effective. For example, if a particular transaction is banned but a sufficient share of the population does not find it “repugnant,” a black market might develop or people might travel to other jurisdictions or countries where the exchange is legal.

Roth and Wang study popular attitudes in Germany, Spain, the Philippines, and the United States toward three morally controversial markets: prostitution, surrogacy, and Global Kidney Exchange (GKE). In some cases, they find a disconnect between popular opinions and regulation: support for commercial surrogacy and GKE is above 60% in all four countries, including those where the law prohibits the practices. In contrast, popular support for legalized prostitution is strong where the practice is legal (Germany) and weak in the countries studied without legal prostitution.

The examination of attitudes about a particular issue is helpful because it can give a sense of the type of pressure the public might exert on policymakers, and how that might shape future legislative or regulatory changes. Based on their survey results, Roth and Wang suggest that for surrogacy and kidney exchange, we are likely to see more (and more successful) efforts to remove restrictions where they are currently illegal.

Americans and kidney donation compensation / The National Organ Transplant Act (NOTA) of 1984 prohibits donors from receiving “valuable consideration” for organs to be used for transplantation. But what do Americans think about paying organ donors? Julio Elias of Argentina’s Universidad del CEMA, Nicola Lacetera of the University of Toronto, and I investigated this question in a 2019 study published in the American Economic Review. In our research, we assessed the attitude of Americans toward different forms of compensation for living kidney donors under various institutional arrangements and hypotheses regarding their effects on the availability of kidneys for transplant (and thus on lives saved). We conducted an experimental survey with more than 2,500 participants whose main demographic characteristics matched, on average, those of the overall U.S. population.

We find that:

  • Attitudes toward compensating kidney donors depend on both ethical considerations and the effect on reducing the nation’s kidney shortage.
  • Support for compensated-donor systems increases with the hypothesized effect on the number of annual transplants performed.
  • Respondents showed little support for systems where patients must pay for organs. Many people think that a “free market” in organs would be exploitative of the poor and violate principles of fairness because wealthy patients would be able to obtain life-saving organs whereas poor patients would not.
  • Yet, more than 60% of respondents would support a system where a public agency provides compensation to kidney donors and allocates kidneys based on objective criteria such as medical urgency, blood and tissue match, and time on the waiting list.

These results suggest that a majority of Americans would support compensating organ donors if the system were governed by a public agency ensuring transparency and fairness. The system with the highest support was one with non-cash compensation (such as contributions to a retirement account) provided by a public agency. Support for such a system ranged from 64% to 77%, depending on its hypothesized effect on lives saved.

Reform efforts / In line with popular opinions about this issue, recent regulatory changes and proposed legislation go some distance toward expanding allowable compensation to organ donors. In September 2020, the Health Resources and Services Administration (HRSA) issued a new rule that amends regulations to remove financial barriers to organ donation by expanding the scope of reimbursable expenses incurred by living organ donors to include lost wages and child-care and elder-care expenses incurred by a caregiver. Previously, the federally funded National Living Donor Assistance Center could only reimburse eligible living organ donors for travel and subsistence expenses.

In June 2021, Congressmen Matt Cartwright (D–PA) and Joe Wilson (R–SC) introduced the Organ Donation Clarification Act. This bipartisan bill would clarify that certain payments are not “valuable consideration,” which NOTA forbids, but reimbursements for expenses a donor incurs. The legislation would also authorize government-run pilot programs to test the effectiveness of providing non-cash benefits to promote organ donation.

The latter provision would allow the United States to obtain important empirical evidence on the effectiveness of compensation. Our findings indicate that many Americans are not simply “in favor” or “against” paying living organ donors: the opinion of a significant share of the population depends on precisely what results would follow (in terms of additional lives saved) from compensating donors. That is, people’s opinions are affected by evidence.

However, in the absence of evidence, ideological considerations prevail. When that happens, the debate can become highly polarized, and reaching a compromise becomes difficult if not impossible. By authorizing government-run pilot studies, Cartwright and Wilson’s bill would inform the debate by allowing evidence to be collected on both the desired outcomes and possible unintended consequences.

It bears noting that efforts to induce more organ donation are not limited to the federal level. In New York, two bills currently being debated in the state legislature would fully remove financial disincentives to living organ donation.

Readings

  • “Paying for Kidneys? A Randomized Survey and Choice Experiment,” by Julio J. Elias, Nicola Lacetera, and Mario Macis. American Economic Review 109(8): 2855–2888 (2019).
  • “Popular Repugnance Contrasts with Legal Bans on Controversial Markets,” by Alvin E. Roth and Stephanie W. Wang. Proceedings of the National Academy of Sciences 117(33): 19792–19798 (2020).
  • “Removing All Financial Disincentives to Living Kidney Donation,” by Mario Macis. In 1% Steps for Health Care Reform, edited by Zack Cooper and Fiona Scott Morton; online publication: oneper​centsteps​.com, 2022.
  • “Removing Disincentives to Kidney Donation: A Quantitative Analysis,” by Frank McCormick, Philip J. Held, Glenn M. Chertow, et al. Journal of the American Society of Nephrology 30(8): 1349–1357 (2019).
  • “Removing Financial Disincentives to Living Organ Donation,” produced by the U.S. Health Resources Services Administration. September 2020.