Default Effect

Some Background

The first successful organ transplant took place in 1954 when a man offered his twin brother a kidney. The first transplant of a kidney from a deceased donor occurred eight years later. As they say, the rest is history.

For the period from 1988 to the time of their account, the authors report more than 819,000 US organ transplants, with nearly 80 percent from deceased donors.2 Unfortunately, the demand for organs greatly exceeds the supply, which means that a lot of lives could be saved if we could find a way to make more organs available. As of November 2020, there were more than 108,000 patients waiting for an organ transplant, mostly for kidneys, in the United States alone, and hundreds of thousands more worldwide.3 Many (possibly as many as 60 percent) will die while on the list, and although the number of people on the waiting list had declined in the period described, the number of transplants continues to be much lower than the demand. Almost thirty-five thousand people on the waiting list described by the authors had waited more than three years for an organ transplant. The authors cite a U.S. government estimate of seventeen deaths each day among people waiting for a transplant.4

The primary sources of organs are patients who have been declared brain-dead, meaning that they have suffered an irreversible loss of all brain function but are being maintained temporarily on ventilators. In the United States, roughly twelve thousand to fifteen thousand potential donors are in this category each year, but fewer than two-thirds become donors, either because of medical conditions like cancer or infection that rule out a transplant, or because the transplant has not been authorized.5

Living donors are another source of kidneys, which is possible since we each have two. The authors describe a prohibition on payments to living donors, alongside illicit markets in some countries. Nevertheless, people do donate their kidneys and might be promised priority on the waiting list if they are ever in need. Often these live donors are friends or relatives of the patient getting the kidney. But if the donor isn’t a match for the donee, a hospital may be able to set up a matching system—the closest thing to a market that exists. In the simplest of these deals, if there is a patient with blood type A who has a willing donor who is type B, the matching organization looks for a patient who is type B and has a donor who is type A. The organization then arranges simultaneous operations. However, these kinds of bilateral trades can be hard to organize, especially for rarer blood types. Economists, most notably Alvin Roth, have helped solve this problem by creating mechanisms to facilitate more elaborate chains of multiple donors and patients.6 There are also a few Good Samaritans who donate kidneys just because they think it is the right thing to do. Unfortunately, there are not enough of them to meet demand.

When demand exceeds supply, as in this case, economists usually recommend using prices to eliminate the shortage. Gary Becker and Julio Jorge Elías, for instance, have advocated creating markets in kidneys.7 Such markets would work by allocating available kidneys to those patients who are willing to pay the most, the same way we allocate Maseratis and Saint-Tropez villas. The more patients are willing to pay, the more people would supply their kidneys. It is not only economists who have this view. Some philosophers have vigorously defended the view that people should be able to buy and sell kidneys.8

Nevertheless, this policy has not gone very far. The authors identify Iran as the only country allowing a legal kidney market at the time of their account.9 As Roth correctly notes, most people find the very idea of such markets to be “repugnant.”10 People do not think that kidneys should be allocated strictly (or even partially) on the basis of willingness (and ability) to pay. It may be fine for luxury goods to be limited to the rich, but most people believe that life-saving operations should not be. Countries have decided instead that priority on the waiting lists for kidneys (and other organs) should be determined by medical factors, such as how urgent it is for the patient to get a kidney, how long the patient can be expected to live, as well as how long he has been waiting.

Meeting demand requires deceased donors as well as living donors. Some organs, such as hearts, cannot come from living donors; a portion of a liver can be donated by a living person. Because each donor can provide as many as eight organs for transplant, every extra donor is quite valuable.11 Actions by both potential donors and their families, who are often consulted, are important in determining how many organs are obtained. This is where default rules come in. When a potential organ donor is declared dead, what should the policy be? There are numerous options to consider.