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Robert Kurzban

The Evolutionary Psychology Blog

By Robert Kurzban

Robert Kurzban is an Associate Professor at the University of Pennsylvania and author of Why Everyone (Else) Is A Hypocrite. Follow him on Twitter: @rkurzban

Some Things Money Can’t Buy. A Kidney, For Instance

Published 7 November, 2013

Speaking of moral dumbfounding, earlier this week my local paper, The Philadelphia Inquirer ran a piece about a paper by some even-more-local-to-me fellow members of the community of the University of Pennsylvania. The article, by Matthew Allen and Peter Reese, is entitled “Financial Incentives for Living Kidney Donation: Ethics and Evidence,” published in the well-known outlet, the Clinical Journal of the American Society of Nephrology.

The term “living kidney donation” does not refer to the kidney equivalent of the Monty Python live liver bit in Meaning of Life in which the organ is removed involuntarily and without anesthetic. Instead the distinction is between harvesting kidneys from live people as opposed to recently or about-to-be deceased people. At issue is the question of financial incentives. At present, it is illegal to sell your organs for transplant. As many have noted, organs, like sex, are fine to give away but not to sell. (Which does raise the question. It’s legal to get paid to have sex with someone if the sex is being recorded, and thus we have the porn industry. Suppose I filmed you selling your kidney for money… that would ok, right? And thus is born a new industry… “kidney porn”…)

An interesting feature of the Allen and Reese paper is that it reviews a number of objections to selling kidneys, and refutes all but one of them.

For example, one worry is that the possibility of getting money for kidneys will “crowd out” donations made out of purely selfless, altruistic motives. That is, it could be that if some people were getting paid to donate kidneys, the people who would otherwise give them away would choose not to. This is a perfectly reasonable concern. If the whole point of allowing payment for organs is to increase the supply of organs, then if crowding out occurred, then the whole point would be moot. Allen and Reese report, however, that the limited amount of empirical data that get at this issue suggest that crowding out doesn’t occur.

Allen and Reese discuss other objections to paying for kidneys, including the “unjust inducement” critique – that if kidneys can be sold poor people will “unjustly” differentially choose to sell their kidneys, in the same way that allowing people to sell their labor “unjustly induces” poorer people to do things like work for a living and allowing people to sell knick-knacks “unjustly induces” others to finally clean out the goddamn garage. And there’s the “undue inducement” critique – that if kidneys can be sold people won’t be able to consent properly, being overpowered by the lure of the cash for their vital organ, in the same way that the fact that Skyrim expansion packs are allowed to be sold unduly induces some of us to engage in a transaction that will simultaneously make us worse off financially and waste a shit-ton of our time. The authors (handily) address these two as well, leaving one, the commodification critique:

The commodification critique holds that  the human body has inestimable intrinsic value and allowing someone to sell the body, or part of it, degrades that person’s dignity. In short, the body is sacred and money is dirty.

Let’s hold aside the fact that human life can’t be inestimable insofar as apparently the EPA has helpfully estimated it. Anyway, my favorite line in the paper is that “the first three critiques could be verified through a trial of financial incentives for living kidney donation, but the commodification critique is not empirically testable.”

In some sense, they’ve run afoul of the issue I recently addressed, moral dumbfounding, though the issue also comes under other names such as “protected” or “sacred values.” The idea is that there are some things that people are unwilling to allow more or less independent of how much how many (other) people have to suffer to maintain the moral rule in question.

The psychological issue – or, really, issues – revolve around why there are such things as protected values at all – what a curious way to do evolutionary business. Really, I don’t care how much welfare is lost, but I won’t, in fine Meat Loaf fashion, under any circumstances, do that…? And of course there’s  the more specific question of the mixing of organs and money. The idea that the body is sacred and money is dirty doesn’t seem to quite do it. After all, the body, being sacred, can still be cut into, pillaged for organs, and sewn back up, if it’s all done for love. (Never mind the other things that are perfectly fine to do for, on, and to bodies if it’s for love.) And money doesn’t make just any old transaction treif. I mean, when you sell me your old stroller on Craigslist people find it positively charming. (Editor’s note: I do not want your old stroller.)

There’s something special about adding otherwise-not-so-dirty money to the otherwise perfectly-defilable-body-in-the-privacy-of-your-own-home that is specifically and narrowly morally horrible. And before you say that it’s just something WEIRD about decadent Americans, in almost no country in the world is it legally permissible to sell your organs.
So what the heck? What sort of value is being protected keeping kidney-needing people on a lengthy donor’s list, and money-needing people in want of money while in possession of twice as many kidneys as anyone really needs?

Proposals now being accepted. The only requirement is that the proposal has to potentially explain the phenomenon. “Bodies are sacred” is a super motto for a health spa (and “bodies are scared” would be a good motto for a horror film maybe), but it’s not an explanation for why combining money and surgery equals morally horrible. Placebo explanations need not apply.

Postscript: I know posts have been coming infrequently recently. I have some pretty good excuses reasons, but I can’t promise I’ll be able to speed up in the very near future. Still, thank you for visiting, and I hope you’ll check back from time to time.

  • Chris Martin

    Have you had a look at Proscribed Forms of Social Cognition: Taboo Trade-offs, Blocked Exchanges, Forbidden Base Rates, and Heretical Counterfactuals.by Tetlock, McGraw, & Kristel? That’s a book chapter, so if you want a journal article, there are other Tetlock papers on the topic of blocked exchanges.

    • rkurzban

      As it happens, Phil Tetlock’s office is three doors down from mine… as you note, I probably should have linked to his work. Thanks for the comment.

  • http://popsych.org/ Jesse Marczyk

    Moral condemnation of homosexuality is to sexual strategy, as moral condemnation of selling organs is to….

  • Peter Rothman

    A note from the future:

    Organ transplantation may be obsolete soon and very likely by the end of this century. Transplantation from a human donor will be entirely replaced by grown and/or “3D printed” organ replacements developed using the person’s own stem cells or other techniques that do not require donors at all.

    There are already a number of exciting developments in these areas. One can also imagine that it might be possible to develop “improved” organs down the line, say a liver that is cirrhosis resistant or better able to process certain medications.

    So, IMO, not very long from now, human body parts and organs will commonly be “purchased” at first in the guise of a paying for a medical treatment that produces a needed organ. e.g. http://www.telegraph.co.uk/science/science-news/10157885/Tiny-livers-grown-from-stem-cells-could-repair-damaged-organs.html

    Down the line “designer organs” will be created and widely used in medical procedures. And of course man made artificial organs are already available for purchase. See the recent FDA approved artificial pancreas for example.

  • cbranch

    Speaking entirely as an interested amateur here, and I admit I didn’t read the actual paper since apparently you need a subscription to CJASN – probably would have been over my head anyway. 😉 But having said that…

    I’m not convinced that the “unjust inducement” critique is necessarily dealt with. It’s easy to make fun of it by saying that the poor (in fact, all the non-independently-wealthy) are “unjustly induced” to work for a living, but in fact that’s true – if by “just” we mean that no one deserves a life that is any worse than any other member of the human race, it is indeed unjust that most of us have to work, some much harder than others.

    Organ selling has two things going against it – one: it involves intentionally damaging one’s own body, which for most of our history would have likely resulted in death, and thus is probably evolutionarily discouraged. Two: it’s new – the inducement to work is something that’s been true for almost everyone in history, so we’ve gotten used to it. The relatively novel inducement to sell ones organs sparks us to recognize it as a potential injustice.

    Not that I’m necessarily against it, by the way, only trying to explain the moral dumbfounding.

    Also, great job on the blog, Robert; maybe not as prolific as some, but every post is well worth reading.

  • Mookie Tenembaum

    In only two countries, the sale of organs is legal: Saudi Arabia and Iran, two bullwarks of tirany, but there is no shortage of organsm and that is a fact. The State ilussion will sacrifice the life of real individuals in the name of “morals”.

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