But: Miami/Dade County just shut down a former Holiday Inn that was doing trials on undocumented immigrants, paying them bargain basement fees. The place was shut down largely because the physical building had become so run-down.

In the 1990s, pharma Co Lily ran a similar operation in Indianapolis that catered to the homeless. Word of this got around, to the point that homeless were traveling from all parts of the country to avail themselves.

Part of the problem is oversight: or lack thereof. There are for-profit Institutional Review Boards (IRBs) that will approve conditions of such testing. Of course, one wonders if the payment of the fee might not prejudice the IRB’s willingness to police the trial.

Nah. Couldn’t happen. The “invisible hand” will prevent such abuses.

Except that’s exactly what happened with Arthur Anderson and their “oversight” of Enron’s financial dealings.

My point is that, when enough money is involved, the system will become corrupted. After all, if you aren’t cheating, you aren’t really trying. The solution is rigorous oversight–by the gov’t. The problem becomes one of funding. If the appropriate board doesn’t have the funding, it doesn’t have the personnel to provide proper oversight. Then you get ‘for-profit’ proxies, and the fun really begins.

Sometimes I get wrapped a little too tight, and the issue of economic fairness is very near and dear to my heart.

So, we’ll need to work on the details.

And, universal health care would be a great start.

I agree with you that it would be better to just pay people straight cash for kidneys. That would allow average Joe and Jane to benefit from the exchange. The proposals for med students, etc. are introduced purely as second-best or third-best alternatives to overcome various political and ideological objections. I am most worried about the potential recipients, who are the ones needlessly suffering and dying every hour of every day, so if there is some inter-donor inequity but we can get people to accept payment for kidneys, I’m willing to accept the second or third best solution.

ninjanurse: My understanding is that Healy’s point (in his book) about HIV in the blood supply is historical. When HIV was new, collectors of plasma for hemophiliacs who relied on voluntary donations were very concerned about not asking too many questions or turning away their donors, many of whom were gay. Paid collectors were more worried about market acceptance of their product and tried harder to screen their donors. At the time, unfortunately, there was no HIV test so they tried to use hepatitis as a proxy, which wasn’t correlated enough to protect a population receiving such a large number of transfusions. The point is about incentives, not results.

In general, the WHO point of view about blood supplies is contested by many people who have studied the question. With modern testing of blood and questioning of donors, it is not clear that the limiting factor on blood quality is the quality of the donor pool as much as it is the willingness to rigorously apply the tests and disqualify high-risk donors. (I believe that the cost of blood is going up, but suspect that has to do with the application of these more rigorous screening practices.)

There is nothing wrong with government oversight of the blood supply, provided that they don’t create unnecessary shortages; to date, I have not heard of any problems in that regard. You can’t say that about the rabidly anti-market kidney policy with which we have been saddled. If we could get kidney policy to the level of rationality of current blood policy, I’d celebrate.

The market did not prevent predatory lending practices. In fact, the market sought out sub-standard lenders and gave them loans that were unlikely to be paid off. Why? Because the loan originator sold the mortgage and had no reason to care whether the borrower could pay. That is the sort of distortion that free markets create.

And you would have us beleive that selling a kidney is a less complex transaction than taking out a mortgage? That is your implication.

With profit to be made, people will try to game the system. If trying to prevent such abuse is, as you sneeringly call it, ‘paternalistic,’ then by all means, let’s be paternalistic. The term is, I believe, ‘regulation.’ Or don’t you believe in medical regulation?

The point wasn’t that selling kidneys is more complex than CDOs. It’s that if ‘sophisticated’ ivestors can be taken to the cleaners, then some level of ‘paternalism’ is necessary to protect individuals who aren’t quite so ‘sophisticated.’

Which brings us to asymetrical information. For a free market to work per the theory, both sides of the transaction have to have approximately equal amounts of knowledge. To assume that both sides of a kidney sale will have anything approaching equal levels of knowledge, except in rare instances, is theoretical to the point of fantasy.

OK, let’s split the difference and call it $25k per kidney. And yet, you’re going to offer half of med-school tuition in exchange? So, for the run-of-the-mill donor, it’s $25k. But, for a future member of the financial elite, we’ll fork over tuition reimbursement which could run $100k or more?

What’s wrong with this picture? Sounds like the game is already rigged in favor of those who have–or will have–more money, because you want to pay them 4 times market rate. How is that a free market?

Look, I’m not saying that you’re completely wrong, or that the market cannot be made to work to solve this problem. I’m saying your proposal, as it stands, is simplistic, to the point of naive. The devil is in the details. You need something much more structured, including a lot of regulation, to make this work, and to prevent the exploitation of the less-sophisitcated parties in this proposed exchange. $25k will probably not entice someone who is financially comfortable. So who’s left?

However, you are right, but only up to a point.

First, there was no animosity towards the well-to-do. Ninjanurse said that financially comfortable people aren’t likely to sign up, and I agree. The problem comes with the level of compensation. Set it too high, and the system doesn’t work because it’s too expensive. Set it too low, and you decrease the pool of people willing to “donate for money.”

When you talk about halving the cost of med school: how much is that, exactly? $100k? (my apologies, but I’m not up on current med school tuition). Can you be sure that the system can support $100k kidneys, in addition to the other attendent costs?

If the compensation is lower than that, the incentive diminishes, especially for more affluent “donors.” Which leads us back to lower income people selling their organs.

Which brings us to the other problem. You also fall into the trap that all free-marketers do by assuming that the buyer and the seller have equal amounts of knowledge and power, and this is simply not true when dealing with less educated or less affluent people.

And as an example of asymetric information, I need only point out the current sub-prime financial mess. Some very sophisticated people paid a lot of money for CDOs and SIVs that weren’t worth nearly as much as they thought. If the CEO of Morgan Stanley can get taken to the cleaners, then what chance is there that someone with a HS diploma can deal on equal terms?

And if there aren’t equal terms, then you set the table for exploitation.

And let’s face it: there are fewer affluent people than lower income people. So the pool is smaller to start with. So, what percentage of the affluent can you entice with $50k? 10%? But if you can entice 10% of the lowest income quintile, then you’ve enticed a lot of people.

In other words, your plan is based on that rarest of individuals: the “rational economic agent” that neo-classical economists are fond of discussing. The problem is, this person is a myth. In our society, nothing is more fraught with emotional baggage than money. Nothing is harder to be rational about. What is the single biggest cause of marital disputes? Money.

I don’t mean to be disparaging. It’s just that I’m really tired of the whole “free markets will solve everything” diatribe. They won’t. They can’t. They don’t, and they never have. They just introduce a different set of problems. And the problems free markets introduce are the sort that the well-off can handle easily, leaving the rest of the world to twist in the wind.

Your plan sounds wonderful in theory. And that’s where it will work: in theory. In the real world, the people who will be selling kidneys are those at the bottom of the income scale. That’s not class-animus; it’s simply an observation based on experience.

I am going to run your suggestion that medical students will jump at the chance to sell their kidneys by some of the doctors and nurses I know. It will be an unscientific survey, but it should be interesting.

I meet people every day who are suffering from preventable or curable diseases, but are getting no or inadequate care because they can’t afford primary care. Like you say, the poor suffer from kidney disease, often as a direct result of untreated diabetes or exposure to pollutants. Our system of accepting people into the emergency room, sending them a huge bill, and not investing in prevention is not only inhumane, it’s wasteful. I would love to see us begin to construct a system that rewards doctors for keeping people healthy. It would cost more in the short term and pay us back in the long term.

I’m guessing that you have health insurance. Do you feel that this is the heavy hand of paternalism?

Finally, some of my best friends are rich. Good for them. Some of my best friends are poor. A good number of the people I work with in the less well-paying areas of health care have no insurance themselves. It makes it very hard to save and strive to get ahead when you know that a minor accident or illness could wipe out all your savings. Some of the people in this situation are the young, and small business owners, and people a few years from medicare. Seeing this every day I am convinced that basic health insurance for all is something we should provide as an affluent and civilized society.