In their column Elias, Lacetera and Macis note that certain 'repugnant' transactions, such as the sale of organs, are prohibited on moral grounds, despite there being substantial potential efficiency gains from having such transactions. Their column uses a survey-based experiment to explore public perceptions of the morality–efficiency trade-off in the context of the kidney procurement system in the USA. Respondents are found to accept higher levels of repugnance for higher levels of efficiency. These results suggest room for efficiency concerns alongside moral and ethical considerations.
Elias, Lacetera and Macis use a survey-based choice experiment to address questions about the morality--efficiency trade-off and quantify the trade-off between the morality and the efficiency of alternative kidney procurement systems. They find that although systems that allow for payments to donors do raise stronger moral concerns than a system with no payments, a majority of individuals would be willing to accept a more repugnant system provided that it produced a sufficiently large additional number of transplants.
The repugnance-efficiency trade-offThe author's conclusion is,
We recruited 2,918 US residents through Amazon Mechanical Turk. After providing an overview of the state of organ procurement and allocation in the US, we asked the participants to consider three alternative procurement systems to increase living undirected kidney donations:
After receiving this information, respondents expressed their opinion about these systems related to their morality in terms of ethical concerns emphasised in philosophy and bioethics studies (e.g. Delmonico et al. 2002). We asked the subjects how coercive, exploitative, unfair to the patients, unfair to the donors, and against human dignity they thought each system was, and an overall assessment of how much a system was in contrast with the respondent’s values
- A system based on unpaid donors with allocation based on priority rules determined by the patients’ medical situation, age, time on the waiting list, etc. (corresponding to the current system).
- A system where donors would receive $20,000 from a public agency, with allocation based on the same priority algorithm.
- A system of individual, private transactions, where donors would receive $20,000 from the organ recipient (out of pocket or through privately purchased insurance, for example).
Respondents were then asked to assume that each system would result in a given efficiency in terms of the kidneys for transplantation procured, and to choose their preferred system. The efficiency levels were randomly determined, and each participant was presented with three choice opportunities, in a sequential manner.
The unpaid-donor system received low repugnance ratings – that is, individuals, for the most part, did not express moral concerns about this system. The two paid-donor systems received, in general, higher repugnance ratings than the unpaid-donor system. However, there was a large difference according to whether the system contemplated payments by a public agency or by the recipients in private transactions, with the latter resulting as the most repugnant system.
Looking at choices, the results show that the likelihood of respondents choosing a particular combination of repugnance and efficiency increased with the level of efficiency and decreased with repugnance. Respondents thus preferred options with higher efficiency and those considered less repugnant, but also acknowledged, through their choices, a general trade-off between these two characteristics.
We estimated the size of these trade-offs employing discrete choice models. The median respondent would favour payments to organ donors made by a public agency if it increased the annual supply of kidneys by about 6 percentage points; this corresponds to about 2,000 additional kidneys, which would reduce the shortage by around 11% and would result in $250 million saved annually by taxpayers.
However, to accept a system based on private transactions, the median respondent would require about a 30 percentage point increase in supply, corresponding to 10,000 extra kidneys procured (which would reduce the shortage by more than 50%), and $1.26 billion in savings for taxpayers. This difference in the estimated trade-offs appears to derive from the fact that the public agency paid-donor system was considered less repugnant than the private transactions system along all of the morality features that we included. In particular, participants rated the public agency system as being equally ‘fair to the patients’ as the unpaid donor system (these two systems allocated organs to patients based on the same priority rules), whereas private transactions (in which the allocation is purely market-based) were considered highly unfair.
There was heterogeneity in the population, ranging from respondents with ‘deontological’ preferences who were not willing to allow payments, irrespective of the expected number of lives saved, to ‘consequentialist’ individuals who placed a large weight on efficiency over moral concerns. This heterogeneity did not generally relate to the respondents’ socio-demographic characteristics, but was correlated to broader attitudes as measured by a set of moral dilemmas typically used in psychology, thus providing further evidence that ethical views in these choices are central.
Alvin Roth stresses that “we need to understand better and engage more with the phenomenon of ‘repugnant transactions’, which often serves as an important constraint on markets and market design.” The prohibition on payments to kidney donors is one important example of this phenomenon. Our research suggests that individual choices based on repugnance considerations respond in a predictable ways to efficiency information, but also that ethical views play a crucial role in these preferences.
Supplying evidence and promoting studies on such sensitive topics might therefore lead to greater awareness and improved policy design based on the actual preferences of a population. In the case of introducing regulated payments for organ donors and their families in particular, the evidence is particularly strong that informing society about the potential benefits of economic incentives does impact the acceptability of this transaction.
Because individual preferences appear to depend on expected efficiency in addition to ethical considerations, pilot trials testing the outcomes of different arrangements may enhance the ability of a population to determine the preferred organ procurement and allocation system.