Kieran Healy, Last Best Gifts, University of Chicago Press, 2006.
Gary Becker and Julio Elias, Introducing Incentives in the Market for Live and Cadaveric Organ Donation, (working paper).
The
distinguished theoretical chemist John Murrell wrote that physicists like to solve simple models exactly, while
chemists like to solve detailed models approximately. There are
benefits to both approaches. Take the study of solid state electronic
and magnetic properties, where the early work of physicists was to
compute, using very sophisticated techniques, the properties of highly
simplified models such as a free-electron gas with a uniform background
of positive charge. Chemists, on the other hand, were busy studying
complex materials with intricate structures, but didn’t have the theory
to do more than classify the kind of observations they made. As a
result, physicists gave theories for superconductivity and other exotic
phenomena, but because their theories had so little information about
the specifics of molecular structure they couldn’t predict the kind of
material where superconductivity would be found. The discovery of
high-temperature superconductors in the 1980’s had physicists as well
as chemists scratching their heads. The empiricism of chemistry (where
theorists form about 10% of the population) compared to physics (where
the number is, I think, more like 30%) forces theoretical chemists to
deal with the messy and specific problems that their discipline’s vast
body of observation and experiment demands.
Economists are to
sociologists as physicists are to chemists. Whenever you see a
discussion of scientific method and rigour in the social sciences, the
comparison is always made to physics. This is not surprising, because
physics remains the archetypal science, but it’s a bad thing because
the social sciences — like chemistry — have to stay grounded in the
empirical side of what they study. The details of any particular
problem are so often crucial to the outcome that you can’t use "the
light touch of the physicist" and expect to come out with predictions.
It’s all very well to talk in the abstract of markets, but when reality
hits it’s the details that often matter. Sociologists spend their lives
looking at those details, like chemists they tease out conclusions from
the structure and dynamics of particular circumstances and events. And
like chemists, they get less respect than their more formal, more
model-driven, and less empirical siblings.
These different
proclivities are on show when sociologist Kieran Healy looks at blood
and organ donation in his new book Last Best Gifts and when economists
Gary Becker and Julio Elias look at organ donations in their widely
discussed working paper, and my ex-chemist self is glad to say that
Healy comes out looking better.
The basic problem is simple.
Advances in surgery and in immuno-suppressing drugs have made organ
transplants safer and cheaper since the 1980’s. The number of organ
donors (whether live or dead) has grown, but not nearly enough to keep
up with the demand, and the result is a growing shortage of organs.
People who could be saved are dying while waiting for "donor" organs.
What can be done?
Becker takes, as anyone who has read any of
his writings would expect, a forthright and straightforward approach.
Shortages mean that supply and demand don’t match. As he says in a blog essay on this issue:
To an economist, the major reason for the imbalance between demand
and supply of organs is that the United States and practically all
other countries forbid the purchase and sale of organs. This means that
under present laws, people give their organs to be used after they die,
or with kidneys and livers also while they are alive, only out of
altruism and similar motives. In fact, practically all transplants of
kidneys and livers with live donors are from one family member to
another member. With live liver transplants, only a portion of the
liver of a donor is use, and this grows over time in the donee, while
the remaining portion regenerates over time in the donor.
If laws were changed so that organs could be purchased and sold,
some people would give not out of altruism, but for the financial gain.
The result would be an increased supply of organs. In a free market,
the prices of organs for transplants would settle at the levels that
would eliminate the excess demand for each type of organ.
You
make supply match demand by introducing a market — paying people for
their organs (eg, kidneys) or for the organs of their family members
after death — because that’s what markets do. So he and Elias do some
rough calculations on what would be needed ($32,000 per liver, while
the current cost of a liver transplant is $175,000), and say "let’s do
it". Becker is under no illusion that this proposal will be adopted
soon, but believes that there is a real chance that it may be taken
increasingly seriously over the coming years, and serious discussions
are increasingly (so I’m told) including markets as possibilities, as
in a recent issue of Kidney International.
There
are no details in Becker and Elias’s sketch of the form that the market
would take. Of course, Becker is aware of many of the arguments against markets
(many coming from Richard Titmuss’s influential 1971 book The Gift Relationship)
and returns to them in his later blog posting to address them: that
"commodification" of body parts is immoral; that payment may drive out
altruistic donations and so not yield the bumper crop he predicts; that
organs may be removed mainly from the poor and installed mainly in the
rich; that organs may be removed forcefully from people (as Falun Gong
supporters are claiming is happening in China now) in order to be sold;
that people may regret an impulsive and irreversible decision to sell;
that payment may lead to people lying about their medical health and so
lead to infected organs entering the system. He doesn’t so much argue
these issues as dismiss them. Tellingly, he uses the passive voice: the
quality of blood "can be maintained at a high level", the source of
organs "could be determined in most cases without great difficulty";
the number of impulsive donors "could be sharply reduced by having a
month or longer cooling off waiting period". It isn’t quite clear who
has the incentive to maintain all these standards, or carry out these checks, or how
much it would cost to persuade someone to do so. And yet in markets for experience goods
(and organs, surely, are experience goods of a visceral kind)
information issues are at the heart of the problem. The cavalier
brushing aside of issues of trust, fair dealing, and asymmetric
information makes Becker’s case unconvincing to this reader.
Becker also commits what Tyler Cowen of Marginal Revolution calls the libertarian vice:
assuming that the quality of government is fixed. In this case, that
means assuming that if altruism isn’t working now, then it won’t work
in the future. "If altruism were sufficiently powerful, the supply of
organs would be large enough to satisfy demand, and there would be no
need to change the present system. But this is not the case…"
Kieran Healy spends most of Last Best Gifts
exploring the very things that Becker skates over so casually, and argues
that they are the heart of the matter. Altruism is not a fixed
quantity, but depends crucially on "the cultural contexts and
organizational mechanisms that provide people with reasons and
opportunities to give" (p2). Those unspecified actors who are the passive
voices of Becker’s arguments are, Healy argues, the key to success or
failure when it comes to blood and organ donation. For example, organ
donation from the newly dead is, in practice, dependent on approval
from the relatives and the rate of approval depends in turn, it turns
out, on who asks them. If the person who is helping them come to turns
with the death is the one who asks them to approve donation of the
organs, they are more likely to refuse than if somebody else (even from the
same organization) asks them. Establishing protocols and practices,
managing logistics, establishing trust — all these matter. It is,
Healy is arguing, not useful to talk about the issue or organ transplants without
addressing the specifics of questions such as whether relatives of dead
organ donors have the right to meet the recipient (as justone example), because these are
the kind of decisions that can have big consequences.
The book is
academically written, with all the costs and benefits that implies. It
was originally a PhD thesis, so unsurprisingly it favours logic and
cautious language over passion, footnotes everything, and tends to wrap
conclusions in qualifiers. The empirical middle chapters in particular
(3 and 4) are a bit dry. But the book is an important contribution; it identifies a whole range of
important issues when it comes to organ donation, and may move the
debate away from the market/altruism dichotomy to a more nuanced and realistic debate
over coping with large-scale enterprises. That would be valuable. I definitely recommend it if you
want to learn about the issues involved, and want some ideas for
healthy ways forward.
(A minor quibble before moving on. He discusses the US and a bunch of European countries, but not Canada. This is common in American/European comparisons — The Economist seems prone to it — but it is still irritating to this Anglo-Canadian reader.)
Healy looks at both the blood system and
the organ system, and his analysis of the failure of the blood system
in the US and in Europe to handle HIV and Hepatitis C infection makes
his reality-based approach uncomfortable reading for market enthusiasts
and market sceptics alike. In some cases, the market-based blood plasma
system in the US did better than the donation-based mainstream blood
system in responding to the potential for infection, even as both sets
of organizations had the same information at the same time. That they
too failed at the hurdle of throwing out blood plasma that was already
taken is no comfort. In fact, one of the more interesting conclusions
that Healy seems to come to is that there may be dependencies among the
different parts of the system (the collection agency, the donors, the
recipients, the hospitals) that are more important than the presence of
absence of payment in the determination of success or failure. The
issue may be more one of industrialization of the system than the
commodification of organs. This makes sense, once he points it out,
because any market-based approach is going to involve local monopsonies
and a few big players in any given region. There’s not going to be a
whole lot of competition going on among agencies, offering higher and
lower prices for kidneys, and so the outcome will depend on the
detailed interactions that take place. And if the shortage is to be
tackled (there were 50,000 people on the waiting list for kidneys in
the USA in 2000) then this is going to be a large-scale, industrial
effort whether or not payment is made to "donors" or not. Money will
be involved because big organizations – private industry or not – have
lots of money flowing through them. People will make or break their
careers based on what decisions are to be made, and as the
HIV/hepatitis case proved, a public or not-for-profit agency is no
proof against tragedy.
Much of the discussion is handled in
terms of literature on the "gift relationship". It’s not something I
know much about (the literature, not the relationship, although I am a
bit cheap), but it seems to handle what sociology is best at. There are
layers of meaning that influence our decisions and attitudes to issues
such as organ transplants. Healy reminds us that life insurance was
once a controversial industry, with its connotations of payment for
death, that had to overcome cultural resistance and find ways to stake
a position that is both morally acceptable and profitable. The life
insurance industry was, of course, one of the last havens of
large-scale mutual co-operative organizations, and in some countries
the movement away from that model to a shareholder model is one that
has not yet played out. But I digress.
The nature of the gift
relationship is subtle. If payment is made to a funeral home rather
than directly to family members, then does that mean the organs of a
just-deceased loved one have been donated (with an acknowledgement made
in honour of the gesture) or have the family been paid? If a live
kidney donor is compensated for their time and discomfort, but not for
their kidney, have they been paid? There are more subtleties in the
book, both involving payment and not. It seems that we all agree that
organ donation is good in the abstract, but not so much when it comes
to the crunch. Attempts to narrow this gap between abstract approval
and on-the-spot reluctance may be seen as delicate and considerate
diplomacy, or may be seen as cynical manipulation (Healy compares parts
of the process to the con-man’s efforts to "cool the mark" meaning to
make the object of a scam accept his/her position as loser in a
resigned manner rather than in anger, so that they don’t report it to
the authorities).
My guess is that the systems developed in
different countries will involve some forms of payment but will steer
clear of the obvious payment that Becker appears to advocate. Any
agency, public or private, will have to be monitored (oops – there’s
that passive voice), and that monitoring will cost money. Issues like
deciding on how to determine death (and debates are going on about this
now, of course) are vulnerable to all kinds of incentives I’d rather
not think about; but someone has to, and it shouldn’t be someone with a
direct monetary stake in the outcome.
Healy convinced me that the big
issue is not the economists’ issue — of markets versus altruism —
but is the sociologists’ issue of coping with complex incentives in
large-scale industrial organizations, and that alone was worth the price of the book. Recommended.
