15. You Say Repugnant, I Say … Let's Do It!

Episode Summary

Executive Summary: The episode examines "repugnant" markets—especially organ sales, organ donation, and related incentives—through economist Al Roth’s work. It argues that markets and policies rejected on moral grounds can still save lives if designed carefully, while also showing how fear of exploitation and social backlash shape what’s politically feasible.

Main Topics: Repugnance as a barrier to markets (Priority: 5/5): The episode introduces the idea that some transactions feel morally unacceptable even when they may be efficient, and shows how that boundary changes over time across issues like eggs, kidneys, interest, and slavery. Al Roth and market design (Priority: 5/5): Roth explains his work on matching markets where prices don’t clear supply and demand, including schools, doctors, and transplant systems, and frames organ allocation as a market-design problem. Kidney shortage and exchange programs (Priority: 5/5): The transcript explores the shortage of kidneys, the ethics of compensation, and the New England Kidney Exchange as a non-cash workaround that pairs incompatible donor-recipient couples. Ethical objections to organ markets (Priority: 4/5): The discussion covers objections to selling kidneys, including commodifying people, coercion of the poor, and slippery-slope concerns that social supports might be weakened if organs become a fallback income source. Israel’s donor-priority law (Priority: 4/5): Israeli transplant surgeon Jacob Levy describes a law that gives priority to people who register as organ donors, a controversial but effective incentive to increase donor sign-ups. U.S. organ preservation efforts (Priority: 4/5): New York’s Louis Goldfrank describes an emergency-response pilot that brings organ-preservation expertise into the field after unsuccessful resuscitation, highlighting how bureaucracy and public distrust constrain innovation. Future alternatives: artificial or animal organs (Priority: 3/5): The episode closes by asking whether artificial organs or xenotransplantation, such as pig kidneys, will solve the shortage before a formal organ market does.

Key Arguments: Some transactions are labeled repugnant not because they are impossible, but because moral intuitions and social norms block markets that could be efficient. Economists are trained to evaluate whether arrangements work and reduce inefficiency, even when those arrangements offend common sensibilities. The current kidney system fails because demand far exceeds supply and many viable organs are buried or cremated unused. Compensation for organs could increase supply, but risks exploitation of poorer people and political arguments against social welfare programs. Kidney exchange programs create value without cash by matching incompatible donor-recipient pairs, but they only address a small fraction of the shortage. Giving organ-donor priority to registered donors can increase registrations by making contribution and benefit more directly linked. Presumed consent and field preservation protocols used in parts of Europe show that system design can improve organ availability, though public trust is crucial. A society’s willingness to adopt a solution depends not only on its efficiency but on whether it is perceived as morally acceptable and politically survivable.

Data Points: New England Kidney Exchange transplants: 71 - Number of transplants the program had completed since 2006 at the time of the episode. Kidney waiting list, earlier period: about 50,000 - Approximate size of the U.S. kidney waiting list when Roth first began thinking about kidney exchange. Kidney waiting list, later period: near 90,000 - Approximate size of the waiting list by the time of the interview. Organ donor registration in the U.S.: about 40% of adults - Share of American adults who had signed up to be organ donors. Viable organ recovery after death: less than 1% - Share of people who die and leave behind organs suitable for transplantation. Organ donor registration in Israel before policy change: about 10% - Share of Israelis carrying an organ donor card before the donor-priority law. Post-campaign donor sign-ups in Israel: 20,000 additional Israelis - Increase after one month of public relations for the new donor-priority program. Prior sign-up rate in Israel: about 1,000 per month - Baseline monthly donor-card sign-ups before the campaign. New York organ preservation pilot constraints: one ambulance; Manhattan only; 4 p.m. to midnight; six-month trial; ages 18-60 - Operational limits imposed to get the pilot approved.

Pivotal Quotes: "The economists have their mind open or skewed in just such a way that instead of thinking about whether something is right or wrong, they think about whether it's sufficient, whether it makes sense." — Narrator quoting Steve Levitt: Explains why economists are drawn to repugnant ideas and efficiency-based analysis. "I have given a lot of thought to what I call repugnant transactions, which are transactions that some people might want to engage in and other people think that they shouldn't." — Al Roth: Roth defines the central concept behind his work on organ markets and other controversial exchanges. "It's a pretty strange culture where you have people dying every day who want to give organs and we don't put something together to do it." — Louis Goldfrank: Goldfrank defends an aggressive organ-preservation pilot despite criticism.

Implications: The episode suggests that solving organ shortages will require not just better technology, but also smarter incentives and political courage. It also warns that moral discomfort can block life-saving reforms long after the public’s views have shifted.