Moral Economics: An Encyclopedia of Controversial Issues, by a Nobel Laureate Who Sold Kidneys
I recently picked up a hot-off-the-press copy of Moral Economics at the Songshan Cultural and Creative Park Eslite. The author is Alvin Roth, winner of the 2012 Nobel Prize in Economics — I’ll call him Al for short. He’s best known for designing the kidney matching mechanism that pairs dialysis patients with willing donors.
People have two kidneys and can function normally with just one. Patients who need dialysis have both kidneys failing — if someone is willing to donate one, the patient can be spared a lifetime of dialysis costs.
The book cites a figure: in the US, 90,000 people are on the waiting list for a kidney every year.
To economists, this is strange. Their minds work differently: they think anyone who needs a kidney should simply pay someone else for one. Globally speaking, kidneys aren’t actually scarce.
The reason so many people are stuck waiting is entirely because the market mechanism isn’t working — people who need kidneys and people with a spare kidney can’t reciprocally trade.
So why can’t they trade? Because of moral concerns — mainly, people worry that trading organs for money would harm the vulnerable.
Al is an activist economist. Since trading for money raises moral concerns, he first designed an improvement that doesn’t require money at all. Often a patient’s family member is willing to donate but can’t donate directly to the patient due to immune incompatibility. But maybe Family A’s relative can donate to Family B’s patient, and Family B’s relative can donate to Family A’s patient — this kind of matching can even extend across many families, producing far more matches.
Even though this design has already spared many people from death or dialysis, countries like Germany and Brazil, citing moral concerns, still only allow matching within a single family.
Al therefore made a specialty of studying this kind of transaction, and coined the term “repugnant transaction” — which I’ll loosely translate as “nauseating transaction”: a transaction both parties are willing to make, but that other people, for moral or religious reasons, don’t allow to happen — even when those other people are completely uninvolved and unaffected by it.
A repugnant transaction is a different matter from “does this transaction harm anyone” — economics already has a well-developed concept, externalities, for that latter question. But whether a repugnant transaction actually carries a negative externality is itself one of the central battlegrounds between the two sides.
The book accordingly covers all kinds of repugnant transactions: various forms of intimacy (sex work, pornography), reproduction (surrogacy, abortion), marriage (same-sex marriage, divorce), adoption, tobacco/alcohol/drugs, usury, all the way to euthanasia, vaccine trials, selling blood, selling kidneys — almost every issue that Taiwan and countries around the world have argued about at some point.
I can imagine a comedian in need of material flipping open this book to any page and finding something that toes the moral line; a politician in need of attention doing the same every day and finding fresh inspiration to throw onto the fire of public discourse.
This is an economics book that reads very differently from most — there’s actually very little economics in it. The author doesn’t have some winning formula he’s trying to hammer every controversial issue with. When I first saw “market design” mentioned early on, I expected a pile of auction-theory math. There’s none of that.
The book is more like a museum instead. Just laying these issues side by side is already interesting on its own. The whole book is under 300 pages, and the depth of discussion on each issue is roughly what you’d get from a museum tour guide. The author lays out both sides, along with empirical figures and trade-offs. On some issues you can tell where the author leans; most of the time you really can’t. It’s hard to come away from this book with any consistent mapping between left/right, progressive/conservative, or democratic/authoritarian and whether a given market “should” be opened up.
Almost every moral controversy in the book is being driven by technology — same-sex marriage and euthanasia are among the few exceptions. Sometimes a moral controversy persists precisely because the technology isn’t mature enough yet: the author hopes that, in the future, sufficiently advanced palliative care options will mean euthanasia is no longer an enviable choice; the kidney trade exists in the first place because we still can’t manufacture artificial kidneys and have to rely on donated transplants.
The economics in the book actually boils down to a fairly simple core logic: ban a market, and a black market appears — and black markets typically run on violence or other miserable means.
The governing instinct to “just ban it first” is remarkably common — banning something just takes an order, it’s easy; allowing a market and regulating it is usually the better approach, but it takes a lot more effort: you have to write rules, keep monitoring, keep researching, and keep enforcing.
That said, some markets really can be effectively suppressed. Both drugs and contract killing are illegal — so why are American prisons packed with people convicted of the former, while people convicted of the latter are almost nowhere to be found? Al gives an example: if he came to your place as a guest and, in passing, asked whether you had a connection to score some drugs, or to hire a hitman, you’d probably be unable to help with the former and not especially surprised — but hearing the latter, you’d probably call the police on the spot.
People’s moral revulsion toward “hiring a hitman” is far greater than their revulsion toward drugs, which makes it much harder for buyers and sellers of the former to ever find each other’s social networks.
By this point, you probably already have a feel for how provocative this book is.
A blurb on the back cover calls Al a “philosopher-economist.” With that title plus the Nobel halo, you’d probably picture a scholar sitting in an air-conditioned office writing papers.
But what impressed me most is how much of his own lived experience shows up in the book — I find it hard to imagine how he faces this kind of grief, day after day.
His blog constantly discusses these controversial issues, and getting blocked by a platform and then having to reapply to get unblocked is practically routine for him.
He also frequently travels the world to speak at conferences advocating for legal, compensated kidney exchange — and often gets his microphone cut, or has someone storm the stage screaming that he’s an “organ trafficker.”
Once, when he went to Azerbaijan to give a talk on repugnant transactions, a general came to meet him at the airport. On the drive to the hotel, the general asked whether there was anywhere in particular he’d like to visit.
Al had heard that a black market for kidneys existed in Azerbaijan, so he cautiously asked: “I’ve heard that here, people can arrange to buy a kidney. I’d like to learn more about it.”
The general answered mysteriously: “In Azerbaijan, selling kidneys is illegal. Customs intercepts kidney sellers and shuts this illegal market down.”
But the next day, on the way to the conference, the general suddenly ordered the driver to peel off from the motorcade, turn down a small alley, and stop in front of a hospital. The general said: “This is the place.”
In other words, the country’s own government both officially bans this market and quietly allows it to keep existing.
Does a philosopher who studies black markets like this end up, more often than not, in dangerous places, meeting dangerous people?
Wow, spooky~