Trading stuff for money

like kidneys or blood or babies

dynomight.net/money

Examples are good. Let’s start with some examples:

1. We all need kidneys, or at least one kidney. Donating a kidney sucks, but having zero working kidneys really sucks. Paying people for kidneys would increase the number available, but it seems gross to pay people for part of their body. Donating a kidney is low-risk, but not zero risk. If you pay for kidneys, the extra kidneys tend to come from poorer people. So we don’t pay, and every day people die for lack of a kidney.

2. Except for Iran. Yes, in Iran you can legally buy or sell a kidney for a few thousand dollars. There is no waiting list for transplants, but most sellers seem driven by desperation and overall it doesn’t sound super awesome.

3. We all need a heart. Paying someone for their heart would mean paying for suicide. If we were to auction off hearts from organ donors, they would tend to go to rich people. People die every day from lack of a heart, but you don’t hear much about trading hearts for money.

4. Many people need blood plasma. For some people (me) donating blood plasma is a psychological nightmare. For other people it’s fine. Not getting plasma when you need it is very bad. Paying people for plasma means more plasma, mostly from low-income people. Much of Europe has long prohibited paying for plasma. Denmark and Italy met their needs with altruistic donors, but overall Europe had a shortage of around 38%, which it met importing plasma from paid donors in the United States, where blood products account for 2% of all exports by value.

5. The EU recently legalized limited payments for blood donations. The French government opposed this change. The French government owns a company that runs paid plasma centers in the United States.

6. Some people want hair. Prohibiting people from selling their hair is stupid. You should be allowed to sell your hair.

7. We all need a liver. You can—amazingly—give away half your liver and re-grow the rest in a few months. This is pretty safe, but compared to donating a kidney is a more complex surgery with a longer recovery period and 3-10× the mortality risk.

8. Steve Jobs got pancreatic cancer in 2003. This was a rare form that often responds to treatment, but Jobs initially refused surgery and spent almost a year doing “alternative” treatments. Finally in 2004 he had surgery. In 2009, he had a liver transplant. This may have been needed as a consequence of Jobs’ decision to delay treatment in 2003. Tim Cook offered half his liver, but Jobs angrily refused. Most people in this situation would not have been eligible for a liver from the public donor registry, but Jobs was able to leverage his wealth and connections to both get classified as eligible and jump the queue. Jobs died two years later.

9. We all need food. Food that is healthier or tastier is often more expensive. Rich people get to eat more of it. Our for-profit food production system is really efficient and in rich countries the main problem is eating too much food.

10. We all need somewhere to live. Housing that is closer to high-paying jobs or larger/nicer is more expensive. Richer people get to live in nicer homes. The cost of housing means many people need to accept long commutes or live with lots of roommates or cities with worse job opportunities.

11. Buildings needs roofs. In North America, roofs are most often made of asphalt shingles, which need to be replaced every 10-30 years. Roofing work is exhausting and miserable and dangerous. People would rather not do roofing. Roofing is well-paid given the qualifications. We have the technology to make roofs that last for 100 years, at a lower long-term cost. Nobody suggests making it illegal to pay people to do roofing.

12. Large pink diamonds are rare. Only rich people get to have large pink diamonds. This is fine.

13. If there’s a sudden shortage of fuel, then you can either ration or let prices go up. If you let prices go up, then rich people get to drive more, but if you need fuel to drive grandma to the hospital, you can buy some.

14. Cars need to park. If there’s a shortage of parking, you can either raise prices or let people fight for spots. If you raise prices, then rich people get to park more, but if you need to park next to the hospital to drop off grandma, you can do so. If you don’t raise prices, people drive around endlessly looking for spots, wasting energy, creating pollution, and slowing traffic.

15. We all want to buy goods and services. People sell these to us for money. They do that because they can use the money to buy other stuff they want. If money didn’t provide any advantage, they wouldn’t do that.

16. Many people want babies. The idea of auctioning off babies is gross. Nobody wants to auction off babies.

17. Many people want babies, but can’t biologically carry a baby to term. Carrying a baby to term is hard on your body and deeply personal. In much of the world, it’s illegal to have someone else to do this for you. In most of the rest, it’s illegal to pay someone to do it. In a few places it’s legal to pay. (Contemplate this list: Arkansas, Belarus, California, Florida, Illinois, Kazakhstan, Maine, Nevada, New Hampshire, Russia, Ukraine, Vermont, Washington.) The people who purchase this service are usually richer than the women they buy it from. If you’re willing to pay a woman to be a surrogate, some third party might coerce her and steal the money. People who live in places where commercial surrogacy is illegal often buy it from places where it’s legal.

18. Most adults want sex. Some have difficulty accessing it. Paying for sex increases the supply of sex. Some people believe paid sex is degrading or has harmful cultural effects. If you’re willing to pay someone for sex, some third party might coerce them and steal the money. Paying for sex is illegal in most of the world. In places where it’s legal, organized brothels are often illegal. In a few places (Canada, France, Ireland, Norway, Sweden) it’s legal to sell sex but not buy it.

19. Sometimes on planes I think about offering the person in front of me some money to not recline their seat. I don’t do this because I’m pretty sure it would end with them either (A) refusing and thinking I’m a huge jerk or (B) doing it for free and thinking I’m a huge jerk.

20. Lots of people want to move to rich countries. Some rich countries let people based on employment, some based on family, and some on “points”. If you auctioned off the right to move to a rich country, you’d get a mixture of people who (A) have lots of money, and (B) would economically benefit from moving. A few places—including arguably the United States—do this already.

21. Lots of people want their kids to get better grades. Lots of people pay for tutors or extra after-school education. You could directly pay your kids to get good grades. This seems strange and possibly bad, though I’m not sure why.

OK, but how do you feel?

After working through these kinds of cases, I feel: Squishy.

I’m attracted to simple rules that can rise to tame the complexity of the real world. But the more I think about these cases, the less optimistic I feel about such rules.

Like every rationalist-adjacent blogger, I lean vaguely libertarian and consequentialist. (I wish I was more unique and interesting.) So I sometimes find myself thinking in high-handed slogans. Things like, “The government should not intrude in arrangements between consenting adults”, or “The right policy is whatever makes the outcome as good as possible.” I like how those words sound. But are they actually useful?

For example: Paid sex is not my thing. But there are some scenarios (e.g. people with certain disabilities) where prohibiting it seems downright cruel and providing this service downright noble.

On the other hand, when you talk about “arrangements between consenting adults”, it seems to call to mind a sort of theoretical idealized society. Like most people, I like to blithely imagine the Netherlands are such a society. After formally legalizing sex work in 2000, they’ve been creative and tenacious in trying to address organized crime and coercion. It sounds like it’s going OK, but not exactly great? I guess almost every other country has lower state capacity and would do somewhat worse.

Or take kidneys again. Say we had a total free market libertarian utopia/dystopia: If a rich person wants a kidney, they can go find a drug addict, hustle them into a clinic, get them to sign some forms, hand them some cash, and then take their kidney. That sounds gross. I’m not 100% confident I could win a debate arguing from first-principles that it’s grosser than our current system in which thousands of people die every year for lack of a kidney. But I’m not too worried about that, because it has zero chance of happening.

The Coalition to modify the National Organ Transplant Act wants to pay people to donate kidneys. They suggest a months-long screening process that only the 10% of people at lowest risk would pass. Donors would get no money up front, but would get $10,000 per year when they file their taxes for the next five years. This seems less gross than the libertarian {u,dys}topia because people couldn’t donate if they were high risk, because there’s a long waiting period, and because the resulting kidneys would be given out according to the current (non-market) system based on need and potential benefit.

The Coalition points also out that lower-income people would benefit the most from extra kidneys, since rich people tend to have healthy friends and family who are willing and able to give a directed donation. They also point out that the lowest-income people are the least likely to qualify as low-risk donors. But common sense still says the extra donors you get by paying people will tend to be lower income.

I don’t love that. But I think it’s silly to look at the flaws of one system without comparing to the flaws of the alternatives. As far as I can tell, those are: (1) Do nothing and let thousands of people continue to die every year. (2) Pay rich people extra when they donate. (3) Force everyone to register for some kind of kidney donation “lottery”. (4) Reeducation campaigns. (5) Marxism. Maybe the Coalition’s proposal is the “worst system other than all the other systems”.

In both cases (paid sex and paid kidneys) rules and slogans are weak. The action is in details.

The grossness spectrum

What makes some things seem grosser than others? There seem to be many factors. Do some people need the stuff more than others? Will trading for money get the stuff to the people who need it more? Will money increase production? Do we want more production?

Here’s a case I find particularly confounding: Why does paying a surrogate mother seem not-that-bad (at worst), but auctioning off a baby seem horrific? Sure, surrogate mothers usually use genetic material from the clients, but even with an embryo from third parties, it still seems OK. Yet, if I buy an embryo and then pay a surrogate mother, haven’t I just bought a baby in advance? I can’t find any clear distinction, but I also can’t get myself to bite the bullet and say the two are equivalent.

But I do have one theory.

In terms of how gross it is to sell body parts like normal market products, I think everyone agrees the order is hair < blood ≪ kidney < liver ≪ heart.

I don’t think that order is controversial. The main way people differ is in terms of where they’d draw the line.

As you’ve surely surmised, I lean somewhere right of “kidney”. While this is a minority view in the world, I suspect it’s a majority view among people reading this. So I thought I should make the case for drawing the line near the left end of the spectrum.

Here goes: When I picture paying someone for a kidney, I picture someone who is healthy and hearty. They’re thriving in life and don’t need money, but they drive a Honda and they really want an Acura, so they sell a kidney and buy an Acura and live happily ever after. When I think of paid surrogates, I picture a woman who loves being pregnant so much she’d almost do it for fun.

Lovely. But in the existing organ industry in Iran sounds grim. Many sellers seem motivated by extreme poverty and financial desperation.

If someone does something out of desperation, you can argue that—almost by definition—this means it helps them, and removing the option would hurt them.

But suppose that if everyone had their basic needs met, then almost no one would donate their kidneys for money. Then you can argue that paying for kidneys is a step in the wrong direction. We should be moving towards a society where no one is desperate and people donate out of altruism. Paying for donations calcifies the current systems and papers over our problems instead of correcting them.

I don’t really agree, because I like incremental progress and I’m allergic to anything that verges on “the worse the better”. But I see where it’s coming from.