I will lazily get an LLM to summarize it rather than rely on my imperfect memory:
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Titmuss's central argument is that a voluntary, altruistic system for blood donation is morally, socially, and often medically superior to a system that relies on commercial transactions or paid donors.
He contrasts the British system of voluntary, unpaid blood donation with the predominantly commercialized system in the United States at the time (the book was published in 1970).
Moral and Ethical Superiority:
1. Titmuss believed that allowing blood to be bought and sold commodifies a vital human tissue and devalues the act of giving.
* A voluntary system fosters altruism, social solidarity, and a sense of community responsibility. The act of giving blood freely is an expression of social cohesion.
* Commercialization erodes this altruistic spirit, not just for blood but potentially in other areas of social life. It replaces "the gift" with a transaction, diminishing the moral value.
2. Safety and Quality of Blood:
* He argued that voluntary donors are likely to provide safer blood. They have no financial incentive to lie about their health status or risk factors.
* Paid donors, especially those in desperate financial situations, might be more inclined to conceal health problems to receive payment, leading to a higher risk of transmitting diseases (like hepatitis, a major concern at the time).
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I remember it sounding a bit less supercilious when I first read it though, TBH, and I suspect the world has changed since 1970.
I'm curious what the truth is about Denmark and Italy and plasma - how come you thought they meet their need with altruistic donors and what is true instead?
> Case studies in countries such as Italy, Belgium and Denmark have shown that sustainable supply of blood products is realistic with only VNRDs [altruistic donors]
I simply over-interpreted this. The truth is they meet something like 2/3 of their needs that way, above the EU average but not self-sufficient.
Sorry for the Marxism or whatever this is (idk I've never read Marx):
Basically all of these examples come down to the unfairness of rich people buying out desperate poor people, which really is just societal coercion. The problem is obviously that this is possible. A single person having even 10 million dollars is _obscene_, from a wealth distribution perspective there really is no reason a single person deserves control of such a large part of society. That they can pay (coerce) a drug addict for their kidney is just a particularly striking example of what wealth _is_, namely your ability to coerce other people in society. It's all on a gradient or spectrum, everything from paying for groceries to getting paid for having a job. But obviously the main argument against capitalism viewed in this light is that above a certain point of wealth you can pay (coerce) people to get a bigger chunk of the wealth, and it snowballs from there into exponential growth for a smaller and smaller part of the population.
The obvious solution to this is to put a progressive wealth tax that caps out at 100% above, say 10 million. And to bring it back to the topic of this post, to flip the ethics the right way around again, instead of coercing a poor person to give up their kidney, the solution is simple: if you want a bigger part of society's collective resources than the 10 million cap I suggest, simply sell your kidney for a tax break. You can have an even bigger part of the pie, but you have to give up your kidney. The reason the current system is gross is that the wealthy person ends up with both the wealth _and_ the kidney.
For the Iran people, does not selling a kidney impact their "extreme poverty and financial desperation" situation? This feels a bit like the "if we don't have difficult conversations we leave it to worse people to have them" situation.
Also: Is it fair to ask the Iran kidney industry to pay the bill for issues much further up the chain?
How does normalising kidney sales impact future peoples' decision to donate a kidney? You implied that the plasma dontation system works better with the paid system as a backup.
> For the Iran people, does not selling a kidney impact their "extreme poverty and financial desperation" situation?
I find this a very difficult issue. The obvious answer, of course, is that if someone does something out of desperation, then you do them no favors by taking that option away from them.
On the other hand, I think most people share the intuition that "someone donates a kidney so their kids don't starve" seems bad in a way that "someone donates a kidney so they can have a nicer car."
At the end of the post, I was trying to steelman this intuition. The best argument I can make is that maybe higher-order effects of allowing kidney donation for desperate people are bad. E.g. maybe if Iran didn't allow people to sell organs there would be more political pressure to meet the needs of the population in other ways.
I don't really endorse that argument, because I'm on team incremental progress. But I guess I get it.
Does surrogacy get more or less bad for you depending on source of the genetic material? Some surrogate embryos are created with genetic material from one or two parents, some with a donor and a stranger, and others are full donor, where future parents can select for traits (race, religion, IQ, etc.) of both donors.
For better or for worse, it seems less gross to me if the genetic material comes from the people paying for the surrogacy. But I stress that I'm very confused about surrogacy and how to draw the line between that and "buying babies". (I'd hoped writing this post would clarify that for me but—nope.)
I was going back and forth about whether to comment here, because it's not clear to me that I have anything insightful to say; I mostly just wanted to register myself as a loud, angry pro-surrogacy voice who thinks (reasonably regulated) paid surrogacy is an enormous social good and people who oppose it are bad people. But since you say you are very confused--which is shocking to me--I figure I should speak up just to make sure you hear something from my side, which the rest of the comments don't seem to be providing. But I'm not sure what else to say because I don't really understand what I'm arguing against. Feel free to ask more probing questions if interested, I guess.
Hi! For what it's worth, my moral intuition is also that paid surrogacy should be legal and that paid surrogacy is probably good. I hold this view fairly weakly (as I don't consider myself that well informed on the topic) and I've heard a lot of anti-surrogacy views since publishing this post, but that's still where I tend to sit. When I said I was confused above, I didn't mean my feelings about surrogacy but rather this moral puzzle I raised in the post:
> 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.
Ah, I was hoping for a rephrasing of your confusion because I didn't really understand what you meant by "auctioning off babies", but maybe I should just take a guess and you should say if I'm wrong. My guess at the scenario: you are pregnant, or have recently given birth, and are considering adopting the baby out instead of raising them yourself. In our world, you would contact an adoption agency who would match you with prospective adoptive parents. You might be compensated for travel expenses, and the prospective parents might treat you to dinner or something to convince you that they would be good parents, but they wouldn't say "we will pay you $X if you choose us". In the "auctioning off babies" world, they would.
If that's indeed the comparison you're thinking of, to me, one key distinction with paid surrogacy is that in the above scenario, at the time of your pregnancy, you are legally and socially considered--for lack of plausible alternatives--the parent of that particular future child. Thus, at that time, it is expected that you act in the future child's best interest, not yours. It would feel selfish and irresponsible to choose their adoptive parents based on how much they will pay you (whereas choosing them based on, e.g., how fat a trust fund they can leave to the future child seems much more reasonable). And it would feel wrong to encourage selfishness and irresponsibility in others by trying to bribe them to choose you as an adoptive parent.
On the other hand, if you enter into a surrogacy contract and then get pregnant according to the terms of the contract, there is no point in the existence of the embryo/fetus/baby where you are ever legally or socially its parent. The actual legal and social parents are right there in the contract. That makes the best interest of the future child their responsibility, not yours, from the moment of fertilization. Similarly for egg/sperm donors, etc.
(As an unrelated aside, I find it deeply sexist that anti-surrogacy types consider a woman less of a "real" parent if she doesn't gestate the fetus in her own body. All my husband ever did to construct our kid was dump his genetic material in someone else [me] and make sympathetic noises while it parasitized me for 9 months, and nobody thinks that makes him less of a real parent. But if *I* did that it would be gross baby-buying? Suspicious.)
Thank you, I think this is insightful. I think that the distinction you point may well explain my moral intuitions. (Or at least some of them—it's hard to introspect about these things!)
I think that perhaps another part of my intuition is that, just like I have a ton of sympathy for people who need kidneys, I also have a ton of sympathy for people who want children but can't gestate a fetus themselves. For whatever reason, once a baby already exists, this doesn't feel as strong.
Most of all I'd like to stress that I don't pretend to have all the answers. I don't think I've resolved all of population ethics, and I definitely didn't write this trying to convince anyone in either direction. (I'm squishy I tell you—squishy!)
Some of the "grossness" might come from implicit externalities or second-order/third-order incentives. Let's say you can "sell your heart" : you get a bunch of money up front, but when you die, your heart goes straight to the corporation that paid you (that company in turn sells the heart to rich donors in need for profit). Unfortunately, the second-order consequence is that the company now has a direct incentive for wanting you to die (like a tontine, which are illegal pretty much everywhere) and the patients-in-waiting do as well. That's gross!
Selling babies creates hugely problematic incentives. Some women might get extorted into becoming Factory Wombs, just so they can churn out babies for demanding buyers. The third-order consequences of this could get extremely ugly, so the subconscious ick factor kicks in strongly. Surrogacy, because it involves direct 3rd party control over the production, cannot be as directly subverted by potential extorters, so subconsciously we experience less ick.
Sex work- well, I think a lot of the social ick comes from the history of venereal disease. Condoms and modern antibiotics suppress a lot of this risk, which is why sex work has become more accepted in some places. Historical acceptability has varied a lot by time and culture, which suggests this one is extremely malleable and we might be exiting a local minima.
Totally agree, I think a lot of our moral instincts are shaped to win at games that involve these kinds of higher-order consequences. It's an interesting theory that the risk of coercion might be why many people find commercial surrogacy gross. I certainly agree that's the biggest problem in practice with commercial surrogacy.
I've always wanted a system in which you can sign-up for kidney donation, and donated kidneys go to other signed-up people. This seems to me to be much, much fairer than "rich people get kidneys", "almost nobody gets a kidney", and "it becomes routine for all low-income people to donate a kidney in order to afford a car/housing deposit/wedding/whatever": those willing to help others are prioritised when they themselves need help.
It might not maximise our QUALYs (eg. if 60-year-old Doris is a registered donor but 30-year-old Gary isn't and now they both need a kidney, Doris gets priority so the kidney only gives us 10-20 years of service inside Doris rather than potentially 50+ years inside Gary) but I think it maximises the fairness of the system and gets kidneys to where they're most needed: to me, Doris who has, her whole life, been willing to donate a kidney to a stranger, now that she needs one herself she's much more deserving of it than Gary who, though young and fit, is uninterested in helping others. Similarly, by refusing to donate a kidney, Gary is essentially saying "I don't consider kidney donation to be morally important or necessary" so it seems fair that he isn't eligible to receive one.
Moreover, I say "might" not maximise our QUALYS deliberately: it might actually do so, by incentivising many more people to sign-up for kidney donation - and doing so without costing the health service however much money it would cost to pay everybody for their kidneys, thus leaving money free for other interventions.
To me this seems like a good, Rawlsian solution - but it didn't even seem to feature on Dynomight's list of options? Might this be because there's some obvious flaw in it that I'm not seeing? Or because it's so alien/unpalatable to D's way of thinking (possibly as a result of D's being afflicted with libertarian leanings)?
[Obvs. there are complexities with my system: what happens if you sign-up but then refuse to donate when called-upon? Do you get a fixed fine (perhaps to the tune of however much it costs the health-service to supply a lifetime of dialysis)? Or a means-tested fine (to prevent rich people from routinely reneging on their donation)? Or do you simply get charged with manslaughter? And what happens if you aren't eligible to donate a kidney? Do people need to decide whether or not they sign up before they're screened for eligibility, to preserve Rawls' veil? Or are some/all ineligible people (maybe children?) made eligible to receive a kidney by default? But - I think all these complexities are eminently soluble, so if there's some other problem with the system that I haven't seen I would suspect it to be something more fundamental..]
> Many people need blood plasma. For some people (me) donating blood plasma is a psychological nightmare.
The first time I donated blood I literally passed out from the anxiety. Normally I can do things that scare most people without batting an eye, skydiving, cave diving, etc. and I assume I had a negative experience as a child with needles that turned into a phobia.
I now donate regularly and while it’s not super comfortable, I don’t dread doing so anymore. Definitely makes you feel psychologically capable when you overcome a phobia, so I can’t recommend it more to anyone who has serious fear of donating.
Alternatively we can wait until we get old or injured, and need some serious needling, or an artificial organ or something, and then we get to experience all that same anxiety of a machine sucking your blood out at a time we are already going to be very anxious.
> Alternatively we can wait until we get old or injured
You know I've contemplated this, and my guess was that the anxiety would sort of stack sub-linearly? (That said, I'm sure you're right that this is something that can be overcome.)
I'd assume the same. Needle phobia, or more broadly sucking your blood out phobia can't be that uncommon, but you don't hear about people in their 70s going in for a major operation and going absolutely insane from the anxiety of the operation + an untreated phobia they are forced to contend with.
I'm not saying it's a good thing (i can think of many reasons why it would be bad), but although directly paying a kid for every A-grade they get is strange, it's not at all bizarre for parents to give their kids an allowance that is tied to a specific achievement in grades. Like "You get five bucks a week as long as you keep getting 85% in your math class."
I don't think it's anywhere near as common now as it was like 30 years ago, though.
I was thinking that fairly large amounts would be needed to move the needle on children's behavior. (Like $100 per A? More?) I've seen a lot of theorizing about ethics and "intrinsic reward" etc, but I haven't been able to find a good experiment that actually tried this!
Slightly off topic but I don't think it's true that metal roofs are cheaper. I did some research in the past and I remember coming away thinking they were more durable but more expensive.
They're definitely more expensive up-front, but Wikipedia claims they're cheaper long-term: https://en.wikipedia.org/wiki/Metal_roof (Of course, that's over a scale of ~50 years, given that shingle roofs last ~25 years and you need a couple cycles for the savings to show up.)
This seems like Moloch at work, to me. If shingle rooves last 25 years but houses change owners on average every 20 years, you'd still all be better off with metal rooves but without a coordination mechanism you're still all going to fit shingle ones.
(When I say "you" I mean "Americans"; my country seems to be slowly transitioning from ceramic tile rooves to entirely plastic ones. Not sure where these might fit into the cost-lifespan spectrum..)
I think money should be an adequate coordination mechanism. I mean, some companies and governments issue 100 year bonds. People buy them because they know that when there's 90 years left, they can sell them, which works because *they* can sell them when there's 80 years left, etc.
More prosaically, people complain about the cost of replacing roofs all the time. I suspect it's a lack of information. (Or, possibly, that people thing it would be better to buy a cheap roof, invest the rest of the money in stocks or whatever, and then use the earnings to replace the roof 4 times?)
I think you're probably right that it's lack of information - but I do nevertheless think there are some aspects to house husbandry where money fails to work as a coordination mechanism: sometimes it's very difficult for the buyer to determine whether the thing will last for two years more or fifty years more (plumbing, wiring). Sometimes the competition is sufficiently intense (houses near the right school/Tube station/whatever) that things below a certain threshold can't move the price much. Sometimes the benefit is sufficiently far in the future that buyers can't bring themselves to care even though they should ("hyperbolic time discounting"?) Sometimes the up-front cost is unaffordable for most people even though it would make them money in the long-run. (I think EV charger, heat pump, and solar panel installations might fall into these last two categories)
I don't entirely rule these out as possible explanations!
But honestly, I think we're both missing the obvious factor: Metal roofs look really weird! (I personally think they're a clear improvement over asphalt shingles, but not everyone agrees, and not everyone want to be "weird".)
I actually suspect this probably isn't a significant factor! I can't imagine the price or service life of a roof being unimportant enough to a homeowner that it's outweighed by "weirdness" concerns. Possibly this is just a failure-of-imagination on my part, of course.
(P.S. I suppose the word "rooves" looks as weird to you as the word "roofs" does to me! Fortunately both words have the same installation cost - but, mine being Victorian and yours being contemporary, it does seem that yours has the longer service life..)
I'll bite the bullet and say surrogacy is bad actually - though I think cases where it is done with the surrogates genetic material are definitely significantly worse than those where it is the material of the people buying the baby.
Just to clarify: When you see you'll bite the bullet, does that mean that you take this position not because of an independent moral instinct about surrogacy, but rather because you feel that you *have* to say to be consistent with other moral instincts for other scenarios (e.g. "selling babies")?
My independent moral instincts align in saying that both surrogacy and selling babies is bad because surrogacy is selling babies? The source of the genetic material somewhat fuzzes how much it is selling babies, but it's pretty clearly selling a baby from the mom it has known.
In adoption you obscure the selling by preventing the sell-ee from seeing any material gain from selling another person.
Selling a baby from the mom it has known - this is the main reason I oppose surrogacy.
Surrogacy has all the usual organ donation coercion issues. This is not necessarily a dealbreaker for me. But it should give policymakers pause.
Surrogacy additionally has the emotional issues and moral injury of selling sex, but much more so: labor and birth evolved to make mothers fall in love with their babies, among other goals. There are ways to deaden this feeling, but heartbreak is still a risk. And yet, consenting adults can make their own choices, etc. Maybe some mothers notice they haven't felt that attachment with their prior babies, so can accurately predict it won't be a problem with a surrogate baby? I don't like it, but I can't confidently rule out such cases, so the emotional issue may not be a dealbreaker.
What is a dealbreaker for me regarding surrogacy is that there's another person harmed who cannot consent: the baby. Babies are synced up with their mother and are used to hearing her heartbeat and voice, feeling her gait, and even tasting and smelling her, before they are born. Human babies are born so prematurely compared to other species that they evolved to want to be close to their mother all the time. Mother-baby separation is traumatic not just for the mother but especially for the baby. I've had three babies myself, and this science was all very obviously reflected in their behaviors. In infant adoption, the trauma of separation still happens. Adoptees are increasingly speaking out about this. But it's nevertheless understood to be the least bad option. In surrogacy, this trauma is made to order. I find this unethical.
There's also a concern for the baby inasmuch as current surrogacy laws are much less stringent in vetting adoptive parents than for regular adoption. A random dude can order a baby, fly in from another country the day after it's born, never meet the mother, and whisk the baby away on a plane with no follow-up. That seems like a clear risk for human trafficking of the worst kinds. However, the solution to that is to enforce normal adoption vetting rules. So that is more a critique of our current system than a dealbreaker for surrogacy in general.
Soooooort of, yes. But there isn't a (legal?) website where people upload pictures of different babies with their stats and genetics and they're auctioned off. It's all a matter of degree!
I'm sure you've heard this argument before, but it's more convincing (to me) in favor of allowing a market for kidneys than the point that a lot of people needlessly die for lack of a kidney, and I didn't see it in the article:
We currently allow poor people to do jobs for money which are more dangerous than donating a kidney. If we allow coal mining / ice road trucking / crab fishing in small boats / fighting in wars* for money, how do we justify a ban on kidney sales?
* I don't know the stats for these particular examples off-hand, I just picked dangerous-seeming jobs. I remember reading that there definitely are many jobs more dangerous than kidney donation though.
> In other situations, we pay people to do difficult work. Paid heroes like police officers and firefighters engage in difficult work that involves risks to save lives. The choice to not pay kidney donors for their generosity and heroism is arbitrary and resulting thousands of preventable deaths.
(I sort of alluded to it by analogy to roofing. It's odd that roofing is OK but not kidney donation, given that we have the technology to greatly reduce the need for roofing work, but not to reduce the need for kidney donations.)
If people’s basic needs are met, the supply of kidneys would go down and the price of kidneys would go up. I’m sure a lot of people whose needs are met have a price at which they would sell their kidney. Would you refuse a billion dollars? Maybe the total quantity traded would be zero but it could be positive.
I don’t think allowing kidneys to be sold “calcifies the current system,” rather it makes some of the system’s features more visible and harder to ignore. That can make it easier to tackle undesirable features since we would have a clearer picture.
I totally agree with your first paragraph. Well, I'm sure the quantity would still be non-zero if only because of altruistic donors, but this seems unimportant.
But I'm not totally sure that allowing kidneys to be sold makes the system's features more visible. It seems to me that most people have no idea that scale of paid blood plasma donation in the US. There's a not-totally-crazy argument that if paid plasma donation were forbidden, this would create political pressure to address poverty in other ways. (To be clear, I don't agree with that argument, for various reasons.)
There is a classic problem (maybe outdated) with selling things that we haven't mentioned yet, which is Titmuss' Gift of Blood model: https://archive.org/details/giftrelationship00titm
I will lazily get an LLM to summarize it rather than rely on my imperfect memory:
---
Titmuss's central argument is that a voluntary, altruistic system for blood donation is morally, socially, and often medically superior to a system that relies on commercial transactions or paid donors.
He contrasts the British system of voluntary, unpaid blood donation with the predominantly commercialized system in the United States at the time (the book was published in 1970).
Moral and Ethical Superiority:
1. Titmuss believed that allowing blood to be bought and sold commodifies a vital human tissue and devalues the act of giving.
* A voluntary system fosters altruism, social solidarity, and a sense of community responsibility. The act of giving blood freely is an expression of social cohesion.
* Commercialization erodes this altruistic spirit, not just for blood but potentially in other areas of social life. It replaces "the gift" with a transaction, diminishing the moral value.
2. Safety and Quality of Blood:
* He argued that voluntary donors are likely to provide safer blood. They have no financial incentive to lie about their health status or risk factors.
* Paid donors, especially those in desperate financial situations, might be more inclined to conceal health problems to receive payment, leading to a higher risk of transmitting diseases (like hepatitis, a major concern at the time).
---
I remember it sounding a bit less supercilious when I first read it though, TBH, and I suspect the world has changed since 1970.
This makes me feel that maybe Australia is strange? Here sex work is a gray market but only faintly gray. Brothels have web pages advertising their specialties (e.g. "only wives!"), there is a sex work union ( https://scarletalliance.org.au ) and relatively mild social ick around sex work. Maybe this is correlated with the universal health care lowering contagion risk? If all that sounds exotic to you, you might enjoy some documentaries about sex work in Australia. Here are some: https://soundcloud.com/eury99/the-only-hooker-in-the-village https://iview.abc.net.au/show/you-can-t-ask-that/series/1/video/LE1517H009S00
I'm curious what the truth is about Denmark and Italy and plasma - how come you thought they meet their need with altruistic donors and what is true instead?
In short, this paper: https://doi.org/10.1111/vox.13540 says:
> Case studies in countries such as Italy, Belgium and Denmark have shown that sustainable supply of blood products is realistic with only VNRDs [altruistic donors]
I simply over-interpreted this. The truth is they meet something like 2/3 of their needs that way, above the EU average but not self-sufficient.
Sorry for the Marxism or whatever this is (idk I've never read Marx):
Basically all of these examples come down to the unfairness of rich people buying out desperate poor people, which really is just societal coercion. The problem is obviously that this is possible. A single person having even 10 million dollars is _obscene_, from a wealth distribution perspective there really is no reason a single person deserves control of such a large part of society. That they can pay (coerce) a drug addict for their kidney is just a particularly striking example of what wealth _is_, namely your ability to coerce other people in society. It's all on a gradient or spectrum, everything from paying for groceries to getting paid for having a job. But obviously the main argument against capitalism viewed in this light is that above a certain point of wealth you can pay (coerce) people to get a bigger chunk of the wealth, and it snowballs from there into exponential growth for a smaller and smaller part of the population.
The obvious solution to this is to put a progressive wealth tax that caps out at 100% above, say 10 million. And to bring it back to the topic of this post, to flip the ethics the right way around again, instead of coercing a poor person to give up their kidney, the solution is simple: if you want a bigger part of society's collective resources than the 10 million cap I suggest, simply sell your kidney for a tax break. You can have an even bigger part of the pie, but you have to give up your kidney. The reason the current system is gross is that the wealthy person ends up with both the wealth _and_ the kidney.
could you donate some autism to me?
i need it more than you
For the Iran people, does not selling a kidney impact their "extreme poverty and financial desperation" situation? This feels a bit like the "if we don't have difficult conversations we leave it to worse people to have them" situation.
Also: Is it fair to ask the Iran kidney industry to pay the bill for issues much further up the chain?
How does normalising kidney sales impact future peoples' decision to donate a kidney? You implied that the plasma dontation system works better with the paid system as a backup.
Agree: Squishy...
> For the Iran people, does not selling a kidney impact their "extreme poverty and financial desperation" situation?
I find this a very difficult issue. The obvious answer, of course, is that if someone does something out of desperation, then you do them no favors by taking that option away from them.
On the other hand, I think most people share the intuition that "someone donates a kidney so their kids don't starve" seems bad in a way that "someone donates a kidney so they can have a nicer car."
At the end of the post, I was trying to steelman this intuition. The best argument I can make is that maybe higher-order effects of allowing kidney donation for desperate people are bad. E.g. maybe if Iran didn't allow people to sell organs there would be more political pressure to meet the needs of the population in other ways.
I don't really endorse that argument, because I'm on team incremental progress. But I guess I get it.
Does surrogacy get more or less bad for you depending on source of the genetic material? Some surrogate embryos are created with genetic material from one or two parents, some with a donor and a stranger, and others are full donor, where future parents can select for traits (race, religion, IQ, etc.) of both donors.
For better or for worse, it seems less gross to me if the genetic material comes from the people paying for the surrogacy. But I stress that I'm very confused about surrogacy and how to draw the line between that and "buying babies". (I'd hoped writing this post would clarify that for me but—nope.)
I was going back and forth about whether to comment here, because it's not clear to me that I have anything insightful to say; I mostly just wanted to register myself as a loud, angry pro-surrogacy voice who thinks (reasonably regulated) paid surrogacy is an enormous social good and people who oppose it are bad people. But since you say you are very confused--which is shocking to me--I figure I should speak up just to make sure you hear something from my side, which the rest of the comments don't seem to be providing. But I'm not sure what else to say because I don't really understand what I'm arguing against. Feel free to ask more probing questions if interested, I guess.
Hi! For what it's worth, my moral intuition is also that paid surrogacy should be legal and that paid surrogacy is probably good. I hold this view fairly weakly (as I don't consider myself that well informed on the topic) and I've heard a lot of anti-surrogacy views since publishing this post, but that's still where I tend to sit. When I said I was confused above, I didn't mean my feelings about surrogacy but rather this moral puzzle I raised in the post:
> 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.
Ah, I was hoping for a rephrasing of your confusion because I didn't really understand what you meant by "auctioning off babies", but maybe I should just take a guess and you should say if I'm wrong. My guess at the scenario: you are pregnant, or have recently given birth, and are considering adopting the baby out instead of raising them yourself. In our world, you would contact an adoption agency who would match you with prospective adoptive parents. You might be compensated for travel expenses, and the prospective parents might treat you to dinner or something to convince you that they would be good parents, but they wouldn't say "we will pay you $X if you choose us". In the "auctioning off babies" world, they would.
If that's indeed the comparison you're thinking of, to me, one key distinction with paid surrogacy is that in the above scenario, at the time of your pregnancy, you are legally and socially considered--for lack of plausible alternatives--the parent of that particular future child. Thus, at that time, it is expected that you act in the future child's best interest, not yours. It would feel selfish and irresponsible to choose their adoptive parents based on how much they will pay you (whereas choosing them based on, e.g., how fat a trust fund they can leave to the future child seems much more reasonable). And it would feel wrong to encourage selfishness and irresponsibility in others by trying to bribe them to choose you as an adoptive parent.
On the other hand, if you enter into a surrogacy contract and then get pregnant according to the terms of the contract, there is no point in the existence of the embryo/fetus/baby where you are ever legally or socially its parent. The actual legal and social parents are right there in the contract. That makes the best interest of the future child their responsibility, not yours, from the moment of fertilization. Similarly for egg/sperm donors, etc.
(As an unrelated aside, I find it deeply sexist that anti-surrogacy types consider a woman less of a "real" parent if she doesn't gestate the fetus in her own body. All my husband ever did to construct our kid was dump his genetic material in someone else [me] and make sympathetic noises while it parasitized me for 9 months, and nobody thinks that makes him less of a real parent. But if *I* did that it would be gross baby-buying? Suspicious.)
Thank you, I think this is insightful. I think that the distinction you point may well explain my moral intuitions. (Or at least some of them—it's hard to introspect about these things!)
I think that perhaps another part of my intuition is that, just like I have a ton of sympathy for people who need kidneys, I also have a ton of sympathy for people who want children but can't gestate a fetus themselves. For whatever reason, once a baby already exists, this doesn't feel as strong.
Most of all I'd like to stress that I don't pretend to have all the answers. I don't think I've resolved all of population ethics, and I definitely didn't write this trying to convince anyone in either direction. (I'm squishy I tell you—squishy!)
I agree, I often say that my husband already outsourced pregnancy - to me!
Some of the "grossness" might come from implicit externalities or second-order/third-order incentives. Let's say you can "sell your heart" : you get a bunch of money up front, but when you die, your heart goes straight to the corporation that paid you (that company in turn sells the heart to rich donors in need for profit). Unfortunately, the second-order consequence is that the company now has a direct incentive for wanting you to die (like a tontine, which are illegal pretty much everywhere) and the patients-in-waiting do as well. That's gross!
Selling babies creates hugely problematic incentives. Some women might get extorted into becoming Factory Wombs, just so they can churn out babies for demanding buyers. The third-order consequences of this could get extremely ugly, so the subconscious ick factor kicks in strongly. Surrogacy, because it involves direct 3rd party control over the production, cannot be as directly subverted by potential extorters, so subconsciously we experience less ick.
Sex work- well, I think a lot of the social ick comes from the history of venereal disease. Condoms and modern antibiotics suppress a lot of this risk, which is why sex work has become more accepted in some places. Historical acceptability has varied a lot by time and culture, which suggests this one is extremely malleable and we might be exiting a local minima.
Totally agree, I think a lot of our moral instincts are shaped to win at games that involve these kinds of higher-order consequences. It's an interesting theory that the risk of coercion might be why many people find commercial surrogacy gross. I certainly agree that's the biggest problem in practice with commercial surrogacy.
I've always wanted a system in which you can sign-up for kidney donation, and donated kidneys go to other signed-up people. This seems to me to be much, much fairer than "rich people get kidneys", "almost nobody gets a kidney", and "it becomes routine for all low-income people to donate a kidney in order to afford a car/housing deposit/wedding/whatever": those willing to help others are prioritised when they themselves need help.
It might not maximise our QUALYs (eg. if 60-year-old Doris is a registered donor but 30-year-old Gary isn't and now they both need a kidney, Doris gets priority so the kidney only gives us 10-20 years of service inside Doris rather than potentially 50+ years inside Gary) but I think it maximises the fairness of the system and gets kidneys to where they're most needed: to me, Doris who has, her whole life, been willing to donate a kidney to a stranger, now that she needs one herself she's much more deserving of it than Gary who, though young and fit, is uninterested in helping others. Similarly, by refusing to donate a kidney, Gary is essentially saying "I don't consider kidney donation to be morally important or necessary" so it seems fair that he isn't eligible to receive one.
Moreover, I say "might" not maximise our QUALYS deliberately: it might actually do so, by incentivising many more people to sign-up for kidney donation - and doing so without costing the health service however much money it would cost to pay everybody for their kidneys, thus leaving money free for other interventions.
To me this seems like a good, Rawlsian solution - but it didn't even seem to feature on Dynomight's list of options? Might this be because there's some obvious flaw in it that I'm not seeing? Or because it's so alien/unpalatable to D's way of thinking (possibly as a result of D's being afflicted with libertarian leanings)?
[Obvs. there are complexities with my system: what happens if you sign-up but then refuse to donate when called-upon? Do you get a fixed fine (perhaps to the tune of however much it costs the health-service to supply a lifetime of dialysis)? Or a means-tested fine (to prevent rich people from routinely reneging on their donation)? Or do you simply get charged with manslaughter? And what happens if you aren't eligible to donate a kidney? Do people need to decide whether or not they sign up before they're screened for eligibility, to preserve Rawls' veil? Or are some/all ineligible people (maybe children?) made eligible to receive a kidney by default? But - I think all these complexities are eminently soluble, so if there's some other problem with the system that I haven't seen I would suspect it to be something more fundamental..]
> Many people need blood plasma. For some people (me) donating blood plasma is a psychological nightmare.
The first time I donated blood I literally passed out from the anxiety. Normally I can do things that scare most people without batting an eye, skydiving, cave diving, etc. and I assume I had a negative experience as a child with needles that turned into a phobia.
I now donate regularly and while it’s not super comfortable, I don’t dread doing so anymore. Definitely makes you feel psychologically capable when you overcome a phobia, so I can’t recommend it more to anyone who has serious fear of donating.
Alternatively we can wait until we get old or injured, and need some serious needling, or an artificial organ or something, and then we get to experience all that same anxiety of a machine sucking your blood out at a time we are already going to be very anxious.
> Alternatively we can wait until we get old or injured
You know I've contemplated this, and my guess was that the anxiety would sort of stack sub-linearly? (That said, I'm sure you're right that this is something that can be overcome.)
I'd assume the same. Needle phobia, or more broadly sucking your blood out phobia can't be that uncommon, but you don't hear about people in their 70s going in for a major operation and going absolutely insane from the anxiety of the operation + an untreated phobia they are forced to contend with.
I'm not saying it's a good thing (i can think of many reasons why it would be bad), but although directly paying a kid for every A-grade they get is strange, it's not at all bizarre for parents to give their kids an allowance that is tied to a specific achievement in grades. Like "You get five bucks a week as long as you keep getting 85% in your math class."
I don't think it's anywhere near as common now as it was like 30 years ago, though.
I was thinking that fairly large amounts would be needed to move the needle on children's behavior. (Like $100 per A? More?) I've seen a lot of theorizing about ethics and "intrinsic reward" etc, but I haven't been able to find a good experiment that actually tried this!
Slightly off topic but I don't think it's true that metal roofs are cheaper. I did some research in the past and I remember coming away thinking they were more durable but more expensive.
They're definitely more expensive up-front, but Wikipedia claims they're cheaper long-term: https://en.wikipedia.org/wiki/Metal_roof (Of course, that's over a scale of ~50 years, given that shingle roofs last ~25 years and you need a couple cycles for the savings to show up.)
Ah okay great! I think I just misunderstood what you meant. Yes I agree they are cheaper long-term!
This seems like Moloch at work, to me. If shingle rooves last 25 years but houses change owners on average every 20 years, you'd still all be better off with metal rooves but without a coordination mechanism you're still all going to fit shingle ones.
(When I say "you" I mean "Americans"; my country seems to be slowly transitioning from ceramic tile rooves to entirely plastic ones. Not sure where these might fit into the cost-lifespan spectrum..)
I think money should be an adequate coordination mechanism. I mean, some companies and governments issue 100 year bonds. People buy them because they know that when there's 90 years left, they can sell them, which works because *they* can sell them when there's 80 years left, etc.
More prosaically, people complain about the cost of replacing roofs all the time. I suspect it's a lack of information. (Or, possibly, that people thing it would be better to buy a cheap roof, invest the rest of the money in stocks or whatever, and then use the earnings to replace the roof 4 times?)
I think you're probably right that it's lack of information - but I do nevertheless think there are some aspects to house husbandry where money fails to work as a coordination mechanism: sometimes it's very difficult for the buyer to determine whether the thing will last for two years more or fifty years more (plumbing, wiring). Sometimes the competition is sufficiently intense (houses near the right school/Tube station/whatever) that things below a certain threshold can't move the price much. Sometimes the benefit is sufficiently far in the future that buyers can't bring themselves to care even though they should ("hyperbolic time discounting"?) Sometimes the up-front cost is unaffordable for most people even though it would make them money in the long-run. (I think EV charger, heat pump, and solar panel installations might fall into these last two categories)
I don't entirely rule these out as possible explanations!
Agreed, those are probably factors.
But honestly, I think we're both missing the obvious factor: Metal roofs look really weird! (I personally think they're a clear improvement over asphalt shingles, but not everyone agrees, and not everyone want to be "weird".)
I actually suspect this probably isn't a significant factor! I can't imagine the price or service life of a roof being unimportant enough to a homeowner that it's outweighed by "weirdness" concerns. Possibly this is just a failure-of-imagination on my part, of course.
(P.S. I suppose the word "rooves" looks as weird to you as the word "roofs" does to me! Fortunately both words have the same installation cost - but, mine being Victorian and yours being contemporary, it does seem that yours has the longer service life..)
I'll bite the bullet and say surrogacy is bad actually - though I think cases where it is done with the surrogates genetic material are definitely significantly worse than those where it is the material of the people buying the baby.
Just to clarify: When you see you'll bite the bullet, does that mean that you take this position not because of an independent moral instinct about surrogacy, but rather because you feel that you *have* to say to be consistent with other moral instincts for other scenarios (e.g. "selling babies")?
My independent moral instincts align in saying that both surrogacy and selling babies is bad because surrogacy is selling babies? The source of the genetic material somewhat fuzzes how much it is selling babies, but it's pretty clearly selling a baby from the mom it has known.
In adoption you obscure the selling by preventing the sell-ee from seeing any material gain from selling another person.
Selling a baby from the mom it has known - this is the main reason I oppose surrogacy.
Surrogacy has all the usual organ donation coercion issues. This is not necessarily a dealbreaker for me. But it should give policymakers pause.
Surrogacy additionally has the emotional issues and moral injury of selling sex, but much more so: labor and birth evolved to make mothers fall in love with their babies, among other goals. There are ways to deaden this feeling, but heartbreak is still a risk. And yet, consenting adults can make their own choices, etc. Maybe some mothers notice they haven't felt that attachment with their prior babies, so can accurately predict it won't be a problem with a surrogate baby? I don't like it, but I can't confidently rule out such cases, so the emotional issue may not be a dealbreaker.
What is a dealbreaker for me regarding surrogacy is that there's another person harmed who cannot consent: the baby. Babies are synced up with their mother and are used to hearing her heartbeat and voice, feeling her gait, and even tasting and smelling her, before they are born. Human babies are born so prematurely compared to other species that they evolved to want to be close to their mother all the time. Mother-baby separation is traumatic not just for the mother but especially for the baby. I've had three babies myself, and this science was all very obviously reflected in their behaviors. In infant adoption, the trauma of separation still happens. Adoptees are increasingly speaking out about this. But it's nevertheless understood to be the least bad option. In surrogacy, this trauma is made to order. I find this unethical.
There's also a concern for the baby inasmuch as current surrogacy laws are much less stringent in vetting adoptive parents than for regular adoption. A random dude can order a baby, fly in from another country the day after it's born, never meet the mother, and whisk the baby away on a plane with no follow-up. That seems like a clear risk for human trafficking of the worst kinds. However, the solution to that is to enforce normal adoption vetting rules. So that is more a critique of our current system than a dealbreaker for surrogacy in general.
What about adoption? Buying and selling babies. It's just not worded that way.
Soooooort of, yes. But there isn't a (legal?) website where people upload pictures of different babies with their stats and genetics and they're auctioned off. It's all a matter of degree!
Ok, no there's isn't anything like that on the good side of the web.
I'm sure you've heard this argument before, but it's more convincing (to me) in favor of allowing a market for kidneys than the point that a lot of people needlessly die for lack of a kidney, and I didn't see it in the article:
We currently allow poor people to do jobs for money which are more dangerous than donating a kidney. If we allow coal mining / ice road trucking / crab fishing in small boats / fighting in wars* for money, how do we justify a ban on kidney sales?
* I don't know the stats for these particular examples off-hand, I just picked dangerous-seeming jobs. I remember reading that there definitely are many jobs more dangerous than kidney donation though.
The Coalition does make exactly this argument!
> In other situations, we pay people to do difficult work. Paid heroes like police officers and firefighters engage in difficult work that involves risks to save lives. The choice to not pay kidney donors for their generosity and heroism is arbitrary and resulting thousands of preventable deaths.
(I sort of alluded to it by analogy to roofing. It's odd that roofing is OK but not kidney donation, given that we have the technology to greatly reduce the need for roofing work, but not to reduce the need for kidney donations.)
If people’s basic needs are met, the supply of kidneys would go down and the price of kidneys would go up. I’m sure a lot of people whose needs are met have a price at which they would sell their kidney. Would you refuse a billion dollars? Maybe the total quantity traded would be zero but it could be positive.
I don’t think allowing kidneys to be sold “calcifies the current system,” rather it makes some of the system’s features more visible and harder to ignore. That can make it easier to tackle undesirable features since we would have a clearer picture.
I totally agree with your first paragraph. Well, I'm sure the quantity would still be non-zero if only because of altruistic donors, but this seems unimportant.
But I'm not totally sure that allowing kidneys to be sold makes the system's features more visible. It seems to me that most people have no idea that scale of paid blood plasma donation in the US. There's a not-totally-crazy argument that if paid plasma donation were forbidden, this would create political pressure to address poverty in other ways. (To be clear, I don't agree with that argument, for various reasons.)