Altruism Exchange

There’s an interesting paper out by Choi, Gulati and Posner with the rather arresting title of “Altruism Exchanges and the Kidney Shortage”. This is a short summary of its central argument.

To quickly recap the issue at hand: around 90,000 Americans per year need a kidney transplant, but only 20,000 are supplied. In response to this, a common suggestion from economists is to create a market equilibrium by permitting people to sell their kidneys. For various moral reasons this suggestion is not terribly popular. 

The authors note that while the U.S. Congress has stringent laws forbidding organ transfer, they are willing to countenance exchange when the exchanges are driven by altruism. For example while the law states that you can’t sell your organs for anything of value (or ‘consideration’ in legal terminology), donations between family members or friends are of course tolerated and represent 70% of live kidney donations. There are instances when it would seem like consideration is involved, such as in paired exchanges. This is when I want to give my friend Joe my kidney, but it’s not a match. Steve wants to give his cousin Frank a kidney and they also don’t match. So we come to an arrangement where I give my kidney to Frank and Steve gives his to Joe. This mutual understanding we have could be construed as consideration and in fact hospitals originally refused to accept this kind of arrangement before new legislation defined it as acceptable. It appears moral revulsion at kidney exchange is only elicited when cash is involved, specifically revulsion at the motivation behind accepting money for organs.

The central proposal of the paper is to expand the scope of kidney donations beyond just paired exchanges. If the presence of altruism eliminates repugnance at the act of organ donation, why not open that up a little? What if, say, Steve’s cousin Frank is in perfect health and he has no incentive to donate his kidney to my friend Joe? Here the authors argue that it is morally equivalent for me to instead commit some act of charitable donation contingent upon Steve’s donation – it need not be the case that a kidney donation is repaid in kind. Instead let me donate money to a charity dear to Steve’s heart, or work in a soup kitchen for 6 months or teach English to children in Malawi. The broader goal is to create liquidity given that “there is a possibly large pool of people whose altruism takes other forms, who may be willing to donate a kidney in order to help a cause.”
 

The authors note many possible impediments that might prevent equilibrium being reached. In addition to those raised in the paper (see Figure 1), I think there are two points worth thinking about:
(1) the idea of a kidney for a kidney has a powerful simplicity that is lost when you’re calculating how many months of soup kitchen work is equivalent to a donation. Should each individual case be weighted and, say, 3 months extra added if the patient is especially young and vulnerable? (2) The authors central contention is that exchanges backed by altruism don’t attract the kind of opprobrium attached to selling a kidney, like exploitation of the poor or corrosion of human dignity. But the amount of administration required to enforce such an Altruism Exchange might very well undermine or crowd out the altruistic impulse anyway. If I donate my kidney contingent upon my working in a soup kitchen for 4 months, I can imagine any initial warm-glow utility diminishing by the banal bureaucracy necessary to ensure I held up my end of the bargain - filling out forms, check-ups to ensure I’m actually doing the work.

Altruism Exchange is an idea I’d like to learn more about. The success of websites like kiva.org, even Kickstarter to a certain extent, shows there is a market for altruistic exchange that is not rooted in financial compensation.