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.
Just finished the book & am catching up with the background bloggage. Really interesting stuff - thanks for doing it like this.
Tangentially, have you come across the 'Survival Lottery'? I blogged about it here:
http://gapingsilence.wordpress.com/2007/07/18/a-tree-in-paradise/
Posted by: Phil | August 16, 2007 at 05:51 PM
I appreciate the depth of your review of a work that is a great example of how sociology, with economic quantifications, can approach "science". I also like the previous review by VIRGINIA POSTREL, January 28, 2007. She starts from the "what a miracle" point of view and is frustrated that organ transplantation is so problemmatic -- and with 94,000 Americans on a waiting list. She also values Healy's contribution.
I love the way you compare economists (physicists - simple model with precise numbers): and sociologists (chemists - complex empirical model with approximations). Just as Healy himself shows that the "gift of life” story is useful but oversimplified. Fables hag-ride the market. We seem to be left with only the "con-men" which Healy points out remain to nurse the fable of humanitarian motives, so soften the pain of loss. Many kidney sellers would still have humanitarian motives. “The idea that markets inevitably corrupt,” Healy writes, “is not tenable precisely because they are embedded within social relations, cultural categories and institutional routines.” And also those con-men.
Posted by: Tom Key | May 28, 2009 at 09:51 PM
Thanks for clarifying about it.
Posted by: Joy | October 31, 2009 at 04:48 AM