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- [00:01]
Bloomberg Narrator
Some follow the noise. Bloomberg follows the money. Whether it's the funds fueling AI or crypto's trillion dollar swings, there's a money side to every story. Get the money side of the story. Subscribe now@bloomberg.com
- [00:18]
Alvin Roth
One of the thought experiments I talk about in my book is about why it's so easy to buy drugs and so hard to hire a hitman. And now the good fight with Jasia Monk.
- [00:37]
Host (possibly Jasia Monk)
Should we allow people to buy and sell kidneys? What about prostitution? Should that be legal or illegal? Is it a good idea to prohibit the sale of hard drugs like meth or heroin? Or should we legalize all drugs? How should we think about people who struggle with fertility and pay somebody to carry their child to term? Is surrogacy a good idea that empowers people to start a family? Or is it a form of exploitation of vulnerable women who are actually doing that work that should be outlawed? Well, the best person to talk to these questions is Alvin Roth. Al is a Nobel Prize winning economist at Stanford University who has pioneered the field of designing markets. If you were a resident after medical school, if you sent your kid to a public school in a big American city, Al probably helped to design the mechanism by which you were allocated or your child was allocated to a place in those institutions. And Al's new book is called Moral what Controversial Transactions Reveal About How Markets Work. And it is all about those topics. Drugs, organ sales, prostitution, and so on.
- [02:10]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
In the last part of this conversation, we talk about some of the most
- [02:14]
Host (possibly Jasia Monk)
interesting of these cases.
- [02:15]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
We talk about surrogacy, the case for it and the case against it. And we talk about various forms of sex work.
- [02:22]
Host (possibly Jasia Monk)
Why is it that Germany prohibits most
- [02:26]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
of these transactions we've been talking about, but allows prostitution, while the United States does exactly the inverse? And should we be worried about the rise of surrogacy in the world? Should be worried about the huge increase in the number of people who offer their sexual services on OnlyFans. To listen to that part of the conversation to support this podcast, to support the work we do here, to get two full episodes of a podcast into your inbox every week, please go to writing.hashemon.com listen. Writingto-monk.com listen.
- [03:05]
Host (possibly Jasia Monk)
Elroth welcome to a podcast.
- [03:07]
Alvin Roth
Well, thank you. Happy to be here.
- [03:09]
Host (possibly Jasia Monk)
So economists have a lot of influence on our lives, but a lot of the time that is less direct. As we're recording this, there was a decision by the Federal Reserve to keep the interest rates constant and that's going to influence the lives of people listening to this podcast in all kinds of complicated ways. But you have had influence on the world in a much more direct way. If some of the people listening to this are doctors in the United States, where they went to a residency was probably decided by a procedure that you help to put in place. If you have children who go to public school, there's a good chance that which public school your children ended up in was decided by a procedure, by a mechanism that you helped to put in place. Tell us about the class of problems that you started to tackle in your academic work and that then had this huge influence on the world of how to gifts gas goods to people under
- [04:05]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
particular kind of circumstances.
- [04:07]
Alvin Roth
Well, so economists study marketplaces, broadly defined, and game theory gave us a way to study the rules by which marketplaces are organized. And so that opened up the possibility that we economists could start studying the design of markets. And I'm using there the word design as a noun. That is, markets have designs and you can study them. And after I'd studied some markets designs, I started to get asked to help design and redesign some markets. Now, design is a verb, and that's part of a pretty new movement still in economics and academic economics called market design. But of course, market design itself is an ancient human activity. People have been creating markets of various sorts with or without money for a long time. So when we find stone tools distributed in the archaeological record far from where they were quarried, it means that our prehistoric ancestors knew something about trade, they knew something about markets. They could move goods far across the world. So markets are a little bit like languages. They're tools that human beings build to cooperate and coordinate and communicate and compete with each other. And often we treat markets as if we just received them. But of course, markets are built, and they can be fixed when they're broken.
- [05:45]
Host (possibly Jasia Monk)
And so tell us about some of these examples. How should we think about what good or bad design looks like? I mean, implicitly, even when we're not thinking about designing markets, as you're saying, laws, rules, cultural expectations, and habits effectively design a market. But when you're going about trying to design them in this more conscious, in this more explicit way, what kind of criteria should we apply and how should we assess whether they are doing a good job or a bad job?
- [06:17]
Alvin Roth
Sometimes markets are broken in a very obvious way. That is, the people trying to transact with each other are having trouble making connections. So that's often where market designers get called in.
- [06:28]
Host (possibly Jasia Monk)
So give me an example of that.
- [06:30]
Alvin Roth
Well, so the Market. So a lot of labor markets, like the market for new doctors once had all sorts of problems with the timing of offers. And people would get offers that they had to answer very quickly, exploding offers before they knew what other opportunities they had. And that market had in the first half of the last century had unraveled to the point where doctors were getting offers of their post graduation jobs very early in their education, too early for them to really know what kind of jobs they wanted, and too early for the places that had to hire doctors so early to be able to tell who was going to be a good doctor and who was not. So that was a problem that the medical establishment tried to solve in various ways. And today there's a centralized clearinghouse for how new doctors get their first jobs. And I was involved in redesigning that when it ran into some problems. So sometimes there are operational difficulties in the market that make it clear that it needs some help and redesign. But also, and this is part of the subject of my current book, markets need social support to work well. When you design a marketplace to operate in some big economic environment, people have other options. They could make their transactions not in the marketplace, they could make them elsewhere. So you have to attract people to participate in the market and come to the marketplace. And so that starts to involve questions of equity and transparency, making the market work well so that people want to support it and participate in it.
- [08:12]
Host (possibly Jasia Monk)
So I think this speaks to a broader confusion there is about the relationship between economics and ethics, economics and morality. Since its inception, economics has sometimes been known as the dismal science, the science that is amoral, perhaps even immoral. It is true that there was a time in which economists claimed that the principles that they followed were in some sense not involving moral choices. I don't think that is how most sophisticated economists think about these questions today.
- [08:47]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
But when you look at that, your disciplinary hat is that of an economist, not my disciplinary hat of that as a political theorist or as a moral philosopher or something like that. To what extent are you making normative choices? Where do those normative choices come in? How explicit are they? Perhaps you can tell us about a concrete system you were involved in designing or you were advising on in which there was a clear moral fork, and you had to explicitly choose one kind of market design that would serve one set of moral goods, or another kind of market design that might serve a different moral goods, and it wasn't obvious which one was preferable on purely economic grounds.
- [09:36]
Alvin Roth
One way to answer that is to say that this book on moral Economics that's just about to come out is my second popular book. My second book aimed at a general audience. And the first one was called who Gets what and why? And it was a sort of cheerful book about designing marketplaces where the questions were sort of straightforward, where they were technical, where it was about helping people make transactions that they wanted to make. And this book is about markets that are also broken, but that it's harder to fix them because we can't agree on what we want. These are morally contested markets where people have very different visions of how the market should work. So one thread that connects them is my work on kidney transplantation. So right now, There are about 130,000 cases of kidney failure a year in the United States. But we only do fewer than 30,000 transplants a year. And transplant patients is the treatment of choice for kidney failure. So most people who could profit from a transplant, whose lives could be saved and whose healthy lives could be made much longer, are going to die without getting a transplant. So one of the questions was how to help people get more transplants. Now, a topic that I talk about a lot in the current book, Moral Economics, is there's widespread feeling around the world and many laws that say it's illegal to pay a living donor to donate a kidney. Kidneys are a little bit special because healthy people have two kidneys and can remain healthy with one. So it's possible, if you love someone who had kidney failure, you might be able to save their life by donating a kidney to them. So that's something that happens 7,000 times a year in the United States. But if someone wanted to pay you for a kidney, then the two of you would be involved in a felony. So it's against the law for you to be paid, paid for a kidney, although you're allowed to give one. So what I've done with my economist colleagues and how we've helped our surgical colleagues is we helped make more efficient the idea of kidney exchange, which is maybe you want to give a kidney to someone you love and you're healthy enough to give someone a kidney, but you can't give it to the person you love because kidneys have to be well matched. And maybe your kidney is incompatible with your intended patient, and maybe I'm in the same situation. Well, it used to be that we, the two potential donors, would be sent home and they say, sorry, but no thank you, and that would deprive the world and our loved ones of living donor transplants. But now it might be that I can give a kidney to your patient, and you can give a kidney to my patient because. And that's a way in which each patient can get a compatible kidney from another patient's donor, intended donor, and that's called kidney exchange. And that's blossomed in the world in many ways. So a lot of transplants are now done that way that couldn't be done before. So that's a good thing. But an essential part of that, when you're talking about morally contested markets, is the donors are not paid. So it avoids the repugnance that much of the world feels towards the idea of paying for kidneys.
- [12:51]
Host (possibly Jasia Monk)
Now, it sidesteps the moral issue. And so this is obviously an amazing win win solution, as you're saying. It means that a lot more kidney transplants are facilitated every year through this process. And by and large, the people who have moral objections about the buying and selling of kidneys are perfectly fine with this because it still operates as part of a kind of gift economy. Right? It's still part of people basically saying, I want to donate a kidney without financial reward. There's just a more complicated chain of kind of transactions, which means that I can thereby assure that my loved one survives, even if I'm not directly giving my loved one the kidney.
- [13:30]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
What about the underlying question?
- [13:32]
Host (possibly Jasia Monk)
What about whether or not we should
- [13:34]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
in fact allow the buying and selling of kidneys? Because even though this mechanism, which you were involved with, which is saving thousands of lives in the United States every
- [13:42]
Host (possibly Jasia Monk)
year, which is a fantastic thing, I
- [13:44]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
don't often have distinguished podcast guests over time, but not often ones that I think can with some confidence, say that they help to save thousands of lives in the United States and around the world every year. But there's, as you're saying, still a lot of people who pass away from kidney disease not having received a kidney. A lot of these people would be able to pay for the kidney, perhaps, if we collectively decided that we should be allowed to buy and sell kidneys and health insurance covered, that even people who don't have a lot of means who now die would be able to survive. How should we think about that moral question?
- [14:25]
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- [15:25]
Alvin Roth
So I think that's a question we
- [15:28]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
have to think about.
- [15:29]
Alvin Roth
And I have a chapter in my book, my current book devoted to that. Because although, as you say, we've had some good achievements in increasing the number of kidney transplants, these are victories in a war that we're losing, right? There are more people who need kidney transplants today, and the gap between how many transplants we can produce and how
- [15:52]
Guest or Commentator (possibly another expert or co-author)
many people need them is growing.
- [15:54]
Alvin Roth
So a natural thing to think about is can we increase the supply of kidneys so that there won't be almost 100,000 people on the waiting list for a deceased donor kidney as there are today? And as you point out, when economists see a long queue of people waiting for a scarce resource, they wonder if prices could increase the supply so it wouldn't be so scarce anymore. And kidney exchange increased the supply, but not enough to solve the problem. We have this terrible shortage. So on the other hand, one of
- [16:28]
Guest or Commentator (possibly another expert or co-author)
the things that people worry about is
- [16:30]
Alvin Roth
we might not want or be able
- [16:35]
Guest or Commentator (possibly another expert or co-author)
to get support for a market in which only rich people could get transplants
- [16:39]
Alvin Roth
and they would buy kidneys from poor people. So a lot of the designs that have been proposed get away from that
- [16:47]
Guest or Commentator (possibly another expert or co-author)
by, for instance, proposing that only the federal government could pay for kidneys and that we'd continue to allocate kidneys based on need the way we now allocate deceased donor kidneys. Not that that's a perfect process either.
- [17:02]
Alvin Roth
So I talk about things like that, and often there is legislation being proposed in Congress that would allow at least a Small experiment in that direction. So this year the particular legislation that's trying to get some hearing is called the End Kidney Deaths act. And it proposes simply to give a tax credit over a period of time to non directed donors, to people who donate a kidney anonymously to someone who they don't know rather than have a particular patient in mind. And those people are, they help do a lot of kidney exchange transplants because as you alluded to, they allow long chains of transplants to, to be effectuated. So there are about 500 of them a year in the United States at the moment. People who give a kidney, who want to give a kidney to someone are healthy enough to give it.
- [18:02]
Host (possibly Jasia Monk)
To be clear, you know, a much more common case is my parent, my, my child, my spouse needs a kidney, I happen to be a match, or perhaps as part of this kidney exchange, I'm willing to give somebody else a kidney if it means, if it causes, results in my loved one getting, getting a kidney. The rarer case is I have two kidneys, I'm a healthy person, I don't need those two kidneys. I can save the life of a stranger by going to the hospital and having that organ removed. And so that obviously is a very altruistic act. And the number of people you're saying
- [18:37]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
would do that is about 500 a year.
- [18:39]
Guest or Commentator (possibly another expert or co-author)
Yes.
- [18:40]
Alvin Roth
And so there's a proposal to experiment whether that number might be increased if we were more generous to them, if we were more, if we were more grateful nation to them through the tax system. So it's an incremental proposal. On the other hand, if it substantially increased the number of non directed donors, it would not only increase transplants, but it would be an indicator that maybe we could start to think more generally about being more generous to donors than we now are.
- [19:10]
Host (possibly Jasia Monk)
So should we do that? What is your answer? Should we allow. You know, and I think this kind of proposal is interesting, but it's quite limited. I think the broader question remains very urgent. Right. Even if we do this, and perhaps it means that 700 rather than 500 people a year given undirected kidney, that doesn't seem to actually grapple with the most fundamental problem, which is the tens of thousands of people who don't get a kidney every year.
- [19:32]
Alvin Roth
Absolutely.
- [19:33]
Host (possibly Jasia Monk)
So should we abolish any limit?
- [19:36]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
I mean, obviously it needs to be
- [19:37]
Host (possibly Jasia Monk)
regulated, et cetera, et cetera. But should we in principle allow the
- [19:40]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
buying and selling of kidneys?
- [19:42]
Alvin Roth
I think that if an experiment like the one proposed by the current legislation works, well, then we'll be able to garner support for broader programs of generosity to donors. But I think as a practical matter, even small legislative steps like this have failed in the past. So I think it's probably necessary, as a matter of fact, practical public policy to start small with these very generous undirected donors to see if we can express our gratitude to them for all they do. And if that doesn't lead to terrible things happening, which is what the opponents of paying kidneys, they worry that it'll lead to exploitation of poor people in ways that we would regret. But if it doesn't do that, then, then I think I would certainly then be in favor of, of pursuing a much broader program. Incidentally, there's a parallel issue in the world about donating blood plasma.
- [20:47]
Host (possibly Jasia Monk)
So, so let me, and I'd love to get to the question of blood plasma in a moment, but let me go through some of the obvious objections to this scheme and I'd love to hear your, your reactions to, to each of them. So one you just mentioned, which is the exploitation of the poor. Presumably you could also imagine terrible cases of exploitation in a system where you can't buy and sell kidneys. Which is to say that one of the things that a free market often does is to alleviate scarcity. At the moment we have this artificial scarcity in kidneys because it is impossible
- [21:18]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
to pay people for it.
- [21:19]
Host (possibly Jasia Monk)
Presumably if we had a liquid market in kidneys, it would also be much less dangerous to donate a kidney. One of the things is, well, what if I donate a kidney and there's some outsized chance that my other kidney becomes diseased, I'm going to have trouble
- [21:32]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
getting a kidney myself. Well, you know, in a world in
- [21:35]
Host (possibly Jasia Monk)
which the buying and selling of kidneys
- [21:36]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
is allowed and in which if you're poor, then the state steps in and ensures that you're able to get access to a kidney, that danger would be much lower because I could in that circumstance myself receive a kidney. And you could imagine there being case of expectation precisely because there's such a scarcity. Right. If you have a loved one saying I'm going to die unless you donate your kidney, there can be enormous forms of pressure exerted on people who are in a life and death situation, on those of whom they might have some power or influence in their lives because it's a life out of question. You would circumnavigate that again if you had a liquid market in those organs.
- [22:16]
Guest or Commentator (possibly another expert or co-author)
Absolutely.
- [22:17]
Alvin Roth
The whole point of making kidney transplants more available is to make kidney disease less deadly and Therefore, as you say,
- [22:27]
Guest or Commentator (possibly another expert or co-author)
reduce the danger of this life or death decision. And of course, given that it's illegal almost everywhere in the world, with the
- [22:36]
Alvin Roth
single exception of the Islamic Republic of
- [22:39]
Guest or Commentator (possibly another expert or co-author)
Iran, that it's illegal everywhere else for a donor to be paid for a kidney. There are black markets. And because it's illegal to be paid for a kidney, these black markets often operate as outside of the traditional medical establishment. So there are surgeries being done, not in hospitals. So that means very low quality of medicine, very dangerous, both to the donors and to the recipients in some of these black markets. So one of the ways to. One of the ways to fight black markets is with legal markets. You know, one of the examples I use in, in my book, Moral Economics, is prohibition. When we had prohibition of selling alcohol in the United States, there were lots of black markets, and organized crime grew up to mediate those black markets. And so we ended prohibition in the early 1930s. And of course, alcohol is still problematic. There's still alcoholism and drunk driving and things like that. But you can no longer buy moonshine whiskey from gangsters.
- [23:45]
Alvin Roth
Right.
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Guest or Commentator (possibly another expert or co-author)
We've eliminated the organized crime black market part of prohibition. So I think that's exactly right. If we want to fight black markets and make kidneys more available, those two things go together. Many of the opponents mistakenly, I think, believe otherwise. They look at the black markets and they say these black markets are very bad, and they're very bad because donors are being paid for their kidneys.
- [24:14]
Alvin Roth
But really they're very bad because they're
- [24:15]
Guest or Commentator (possibly another expert or co-author)
giving very low quality medicine in very inequitable ways. And if we could design an acceptable market where we could pay donors for kidneys, then I think kidney disease would be much less a cause of death and criminality.
- [24:36]
Host (possibly Jasia Monk)
What about another objection that people might make, which comes downstream from a book that I think is fun and interesting and insightful, but that has perhaps overly influenced people's understanding of economics, which is freakonomics. A Freakonomics style argument that you could make about this, and I've heard moral
- [24:51]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
philosophers make similar arguments, is sometimes when
- [24:54]
Host (possibly Jasia Monk)
you pay people for stuff, they stop
- [24:55]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
giving it for free.
- [24:56]
Host (possibly Jasia Monk)
That if there's 500 people who think,
- [25:00]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
I'm a moral person, I want to give a kidney in order to save somebody's life, and I'm doing this out of altruism. If suddenly you give them especially these minor tax incentives, or perhaps even though you paid them a lot of money, they might say, you know, I'm not the kind of person who's going to sell a part of my own body for money. Right. Like, that seems like a very different kind of moral act than donating a part of my body so that somebody else may live. So, you know, how sure can we be that this would actually help to alleviate this casting?
- [25:32]
Alvin Roth
Well, so that's an empirical question. But, you know, there's vast evidence from the world's economies for centuries that while paying for things might stop people giving them away for free, that's more than compensated for by the fact that if you pay enough, people are willing to give them to be paid. There's a famous phrase, a famous paragraph in Adam Smith that says, it's not through the generosity of the butcher and the baker that you get your food. That's how they earn their living, they sell food. And by and large, we're not short of food. We have some trouble still distributing it around the world. So I think that, again, blood plasma is a good example. I was an early adopter of COVID and so when I recovered, I went to Stanford Blood center, where you can donate blood plasma without being paid because there was a demand for convalescent plasma. But once my antibody levels fell below some threshold, they fired me, and. And I no longer. I still give whole blood because we do that for free in the United States, and that's how we get whole blood. But I no longer donate plasma because there's plenty of plasma in the United States. We pay plasma donors, and there's no shortage of plasma. In fact, the United states exports about 70% of the world's plasma. So because it's in short supply in the many countries that think it's immoral to. To pay plasma donors, but of course, you don't have to pay plasma donors. You can always buy plasma from the United States. So you're right. I've been crowded out of the plasma market. It's awkward and not so much fun to give plasma. And I don't need the $70, and I don't want to take that option away from people who are supplementing their income by donating plasma, which is plentiful here.
- [27:32]
Host (possibly Jasia Monk)
So one other kind of argument that a number of moral philosophers have made is that there's a way that we should value our bodies, and there's a way that we should value organs. And to make it the kind of thing that can be bought and sold is to dishonor what our bodies are. What this organ is. It is simply valuing it in the wrong kind of way. My doctoral advisor made this argument, among others. How would you respond to that?
- [28:05]
Alvin Roth
Idea, well, millions of people are dying of kidney disease. I would want to at least weigh that idea against the cost of having all these deaths. And you'd have to be very sure that it was, you know, this aesthetic judgment was more important than millions of deaths a year around the world. Right. In most places, kidney disease is among the top 10 causes of death. And it's growing. So it's growing as we beat back infectious disease as a cause of death and things like that. So I think that you have to be very sure that you don't like to think of having people sell their kidneys before you condemn so many people to death.
- [28:54]
Host (possibly Jasia Monk)
To show my hands, I want to make sure that I run through the devil's advocates arguments in a fair way. And I think these are some of the main arguments that people make against these kinds of transactions. I agree with you that there is something queasy about buying and selling of organs. I absolutely understand why a lot of people, probably a lot of my listeners have a deeper version against it. But one of the fundamental things in politics is that you always have to think in trade offs and you always have to understand what's on the other
- [29:23]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
side of a trade off.
- [29:24]
Host (possibly Jasia Monk)
And in cases like this, where the trade off, not in some theoretical way, not in some distant way, but in a very immediate everyday sense, is people needlessly dying, you need to be really sure that the moral arguments you make against a practice that could alleviate this untold suffering is sufficiently weighty to allow you to persist in that. And just to make a kind of meta ethical point, which I try to refrain from usually doing on the podcast,
- [29:55]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
I think this is actually a kind
- [29:56]
Host (possibly Jasia Monk)
of insightful way of thinking about utilitarianism. So in the broader debate, moral philosophy, between consequentialist moral outlooks that really measure actions and rules by the consequences they have, of which utilitarianism is the most
- [30:16]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
prominent one, evaluating a policy and action in terms of whether it increases the balance of happiness over pain in the world, and the ontological notions, notions that
- [30:28]
Host (possibly Jasia Monk)
certain things are in themselves wrong, that
- [30:31]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
there are certain rights that obtain and apply irrespective of consequences they may bring in the world. I am not a straightforward consequentialist. I don't think that in every realm of our lives it is obviously true that we should simply look at what, for example, increases the balance of happiness over pain. But I do think that when the consequences of a rule or an action are very obviously very bad, as they obviously are in the case of prohibiting the buying and the selling of organs leading to tens of thousands of people needlessly dying in the United States and many more around the world. You better have really weighty arguments on the other side of that.
- [31:17]
Host (possibly Jasia Monk)
And so consequentialism is not necessarily the right philosophy in every context, but I do think it makes a sensible default in policy situations. You need to have really weighty moral arguments on the other side of the ledger when the consequences of a rule are as disastrous as I believe the consequences of not allowing the buying and selling of of kidneys in particular.
- [31:44]
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- [32:13]
Alvin Roth
I agree, but of course the market design question is we also will have to be very careful to make sure that bad things don't happen to anyone aid donors. So that's a thing of high importance in the design of the eventual market that might relieve the shortage of kidneys.
- [32:32]
Host (possibly Jasia Monk)
And that's going to be my next question, in fact. So let's imagine that Congress finally changes its mind and it says we're going to allow the buying and selling of kidneys, but Al Roth come in and help us design this market. How would you go about doing that?
- [32:48]
Alvin Roth
So I would think of a first way to so I would think that any market you design would have to be constantly monitored. And if bad things were happening, you would want to change, you know, change the rules to try to avoid those bad things. But I would think a good way to start would be to say we're not going to have a laissez faire market for kidneys. Rather, we're just going to amend the law so that the federal government can pay for kidneys. And the kidneys obtained in this way will be regarded as the same kind of national resource that we now regard deceased donor kidneys and will be allocated according to need. And, you know, Medicare will pay for the cost so that the rich and the poor alike will now be able to get the suddenly more abundant kidneys. And that will maybe some of the payment to donors will involve coming back for annual checkups for the next 10 years because we'd like to be really sure that the donors are doing well and if there's something that can be fixed about the way we're dealing with donors we should fix it. One of the problems now is that it's a little bit hard to keep track of the donors because they're healthy. You would like them to come back for annual checkups, but they are off skiing somewhere. So I would try to incentivize the donors not just to be grateful, not just to show that we're grateful for them providing a kidney, but to make sure that they continue to allow their health to be monitored so that we can make sure that it becomes very desirable to become a kidney donor.
- [34:22]
Host (possibly Jasia Monk)
I think kidneys is a super interesting case. You write about many more things than that, but it's allowing us to kind of make concrete a lot of these questions that arise. So let me ask you a different question about this. So what should we do about kidneys today when they remain scarce? Or let's say that we've solved the kidney problem, but obviously there's still going to be a scarcity, probably of livers, of hearts, of other organs that might be transplanted. How should we think about the best algorithms, the best decision making procedures for which patients should get those in which order? Obviously we likely don't want the richest person to get that first or for that to be discriminatory criteria that somebody
- [35:05]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
gets in the base of a race, et cetera, that's sort of taken for granted. But how should we think beyond that
- [35:11]
Host (possibly Jasia Monk)
about the design of how to distribute
- [35:14]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
those very scarce goods?
- [35:16]
Alvin Roth
So that, I think gets squarely into the area where we're talking about technical difficulties in allocating deceased donors. Because there won't be. You can't do living donation of hearts. Livers are different. You can donate a lobe of liver. But hearts, let's use hearts as an example. That's always going to be a deceased donation thing. And the thing about deceased donation is first you have to decide when the patient is dead, the donor is dead. And that's a little bit controversial because we have two criteria that in ancient times were the same. One is brain death and one is circulatory death. And the reason those used to be the same is once you, once you stop breathing or your heart stops beating, your brain very quickly dies and you're very dead. But the special thing about transplantation is that death isn't exactly binary. You can be dead, but some of your organs are still alive enough to be transplanted. So you have to work very quickly after a death. And so there's some question about what it means to be dead, but then the organ doesn't stay viable for all that long. Outside of the body. So organs have to be allocated quite quickly, and there's some difficulty in doing that because there are many more people who need a heart transplant than there are hearts and similarly for other organs. So some of the questions involve efficiency and how it relates to equity. So think of there being a waiting list for hearts. That depends on how long you've been waiting or that depends on how sick you are. There are different ways to prioritize patients. And the way we think about it in the United States is for different organs, there are different priorities. But the idea is that a deceased donor organ should be offered first to the highest priority person on the list, then to the next highest priority, and so forth with. With priorities depending on many things, including location and other things. But the problem is it takes a little while for an offer to be considered and accepted or rejected. And if it's rejected, the heart has a little less chance of reaching someone who will take it in time while it's still transplantable. So sometimes you have to think about, this is a hard organ to find. A, a person will take. It's a marginal organ, it'll save somebody's life. But many people who have high priority are going to try to wait for a better organ. Can I skip over people with higher priority and offer it to someone who I think will take it? Now, because some organs are unused, they are offered too many times and rejected, and then they're not usable anymore. So among the things we have to think about is how to balance efficiency and equity in this question of how strictly do you have to follow predetermined priority list in making the offers, or can you say we need to expedite this organ doing some different thing? That's a matter of current debate right now.
- [38:34]
Host (possibly Jasia Monk)
So, you know, there's obviously a black market for organs, and that is significant. But by and large, transplanting an organ requires a lot of attention, right? Like you have lots of people involved, you need a lot of infrastructure in order to do it. And so therefore, the prohibition on paying people to buy and sell organs has
- [38:57]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
not been perfectly enforced.
- [38:58]
Host (possibly Jasia Monk)
Nothing is imperfectly enforced, but it has had a very, very real effect in suppressing those transactions. There are other areas where the extent to which the state's ability to suppress transactions is much more in doubt. And drugs and other substances that are rendered illegal are probably prime examples. I don't know how many times every year somebody buys and sells meth or cocaine or heroin in the United States, but there must be many, many, many, many of those transactions. Many More than there are of people
- [39:32]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
buying and selling organs.
- [39:35]
Host (possibly Jasia Monk)
What about that case? The harms from drug prohibition are straightforward and obvious. Lots of people going to jail, lots of money spent on chasing them, potentially users of drugs being criminalized in various
- [39:49]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
ways, not being able to access help and so on, for that is rather improved in the last decades. But the dangers of completely opening up those markets, of potentially having very sophisticated corporations advertisements and sell the use of drugs in ways that can have hugely damaging consequences to individuals, is also very, very hard. I'll also say that I think from my philosophical perspective, which is that of a philosophical liberal, it also seems to push against the boundaries of how I think about the world. More organs. You can talk about the harm principle and say it's unclear that anybody's harmed by allowing buying and selling of organs. As long as we have some side conditions where you can't put pressure on people, People in general in society aren't so destitute that that's the only way that they don't starve and so on, right? In the case of drugs, you know, from a strict harm principle point of view, you could say, well, you know,
- [40:55]
Host (possibly Jasia Monk)
if an adult wants to choose to shoot up heroin, the person the harming is themselves. Why, why, why, why should we care? But it can lead to a huge rise in crime in neighborhoods. You know, it probably imposes huge costs on society at large. Yesterday I'm at a conference at the moment in Boston and walking back from above a few conference participants. We came past a gentleman who was crying for help who had some kind of drug addiction problem. And we stayed around and called 911 and the ambulance arrived and the EMTs, as soon as he saw this person said, oh, that's so and so his first name. And he clearly was a frequent user of that service. So that's. I'm very glad that he got help. And he seemed to be a very decent person in a very desperate situation. But it's also obvious that that imposes costs on the broader community. So you can try and make that case and say, well, perhaps even on the harm principle, you can outlaw drugs. But it's not clear to me how clean that is, because really the main harm is on the individual. So this is a topic where I have to say I'm very torn about what to think. How do we puzzle through this with more clarity than I just have in the last 90 seconds?
- [42:11]
Alvin Roth
Well, so one thing I say in the conclusion to my book is I think that when we think about the things we're morally obligated to do. They have to be things that we can do. And even if we feel morally obligated to prevent heroin, we have to recognize that there's still a lot of heroin, a lot of fentanyl and a lot of crystal meth, A lot of dangerous drugs. Even though we send people to prison all the time for selling them. As you say, our prisons are full of drug offenders. One of the thought experiments I talk about in my book is to think about why it's so easy to buy drugs and so hard to hire a hitman. And I think it has to do with the social attitude towards drugs and towards killing for hire. But we treat those two crimes, selling drugs and selling murder.
- [43:08]
Host (possibly Jasia Monk)
And also every time, sorry, I'm just gonna suggest a much more obvious explanation and perhaps that is somehow missing the mark. But every time I shoot up a drug, I may be breaking the law, but it both doesn't immediately have an external victim, which is the point that I was getting at with the harm principle. And it's not like the state immediately realizes this, right? Every time I'm hired as a hitman and I go out and kill somebody, A, I'm harming this other person and B, it's likely that somebody is going to say they're missing and the state kicks into gear trying to investigate it, right? So part of it is that it's quite easy to get away with drug crime, at least at a low level or if you're the user, right, like you can can violate a drug law. And it's hard for the state to know that you have done that. It's quite difficult to violate the prohibition of murder without the person who's perpetrated the murder going to jail.
- [43:58]
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- [44:30]
Alvin Roth
I think that's largely true. But of course we've had years when there were more than 100,000 opioid overdose deaths in a year. And that vastly exceeds the number of homicides from any cause that we have in the United States, right, Which is I think fewer than 20,000. So it's not that drugs don't kill a lot more people than are murdered. But murder for hire is so rare in the United States that it doesn't even make it into the national crime statistics. And part of there are lots of reasons why.
- [45:06]
Host (possibly Jasia Monk)
And if you think that you've successfully hired a hitman, 99 out of 100 times, it's an FBI agent who's about to arrest you.
- [45:14]
Alvin Roth
And that's because if I told you I wanted to hire a hitman, you might call the police and they would say to you, why don't you get back to Professor Roth and tell him, you know, where he can, you know, some bar he can go to where he can hire a hitman?
- [45:26]
Guest or Commentator (possibly another expert or co-author)
And that's where I'd try to hire the FBI agent.
- [45:28]
Alvin Roth
Whereas if you called them and said, you know, professor Roth is thinking that he wants to try heroin and wanted my advice on where he could get it, they would say, why are you calling us? We're a busy police department, you know,
- [45:40]
Host (possibly Jasia Monk)
so tell Professor Roth if it's a bad idea.
- [45:43]
Alvin Roth
Yeah. So part of a conclusion I try to draw in the book is that not only do markets need social support to work well, but so do bans on markets. And the ban on drugs doesn't have enough social support to work well. That is, we have a lot of drugs, even though it's against the law. So we're losing the war on drugs. But it also turns out it's not so easy to have the war on drugs accept our surrender. Right. In places like Portland, where they've tried decriminalizing use, they find themselves with sort of open air drug use that's also very distressing. It makes cities difficult to live in, and that's a real cost to the citizens of Portland. So they've walked that back. So I think drugs are the market that I have the most. I have the least ability to make helpful suggestions about what we should do, except that we should continue to experiment. Right. So in many places we allow clean needle exchange. So at least we're not getting as much HIV together with drugs that we used to do. That seems to work. It helps a little bit. We have to find other things to do. It may be that incarceration will still be among the treatment options that we want for drug addicts, but we'll certainly have to combine it with other kinds of more medical kind of treatment to help people deal with addiction. And we don't know the answer yet, but that calls for more experimentation, more search for solutions, rather than less.
- [47:14]
Host (possibly Jasia Monk)
What does success actually look like in this case, right. I mean, there's laws against jaywalking which I think are largely silly, but presumably their success looks like something like fewer people die, fewer pedestrians die in car
- [47:29]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
accidents, or something like that.
- [47:30]
Host (possibly Jasia Monk)
That's the actual ultimate goal. Right. You wouldn't say that the goal of the prohibition on jaywalking is nobody ever jaywalking, but that definition is obviously a failed law. Perhaps somehow the prohibition on jaywalking actually leads to fewer pedestrian deaths, in which case it's a sensible law. I suspect that it doesn't.
- [47:49]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
I haven't seen any empirical studies on it.
- [47:51]
Host (possibly Jasia Monk)
And if it doesn't, then I think we should abolish it. But that's sort of a way to
- [47:54]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
think about it, right?
- [47:55]
Host (possibly Jasia Monk)
When you think about the success of a prohibition on theft, part of that is to allow a thriving economy with
- [48:06]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
economic exchange and to spare the costs
- [48:10]
Host (possibly Jasia Monk)
of extremely elaborate safety procedures, et cetera.
- [48:15]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
Part of it is to reduce the numbers of thefts because it's upsetting when somebody's stolen from you. But we can think that the law against theft in the United States is broadly successful for, even for obviously every day. There's plenty of things stolen in the United States, so we don't need perfect compliance for it to be successful. I mean, when we think about the prohibition on heroin, the prohibition on meth, what is the criterion of success and how are the laws doing relative to that criterion of success?
- [48:44]
Alvin Roth
Okay, that's a great question. And jaywalking isn't a bad example because I believe that in New York City it's jaywalking has been taken off the criminal list, it's been decriminalized, and if
- [48:56]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
there's one God given right of New Yorkers, it's to cross the damn street.
- [48:59]
Alvin Roth
That's right.
- [49:00]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
But what's the point of a grid system where nearly everything is a one way, if not that you can safely cross nearly every street?
- [49:06]
Alvin Roth
So one reason I think that jaywalking was decriminalized was it gave too much discretion on enforcement and was enforced inequitably against people who were not high socioeconomic status people. So part of having laws is do we support the way they're enforced? But to come back to drugs, I think part of the reason it's hard to move forward is we have deep disagreement about what our goals are. There are people who think that it's simply wrong to allow sales of drugs like heroin or fentanyl because fentanyl for private use. I mean, I've had fentanyl when I have Surgeries all the time. It's an essential drug for quick acting anesthetic.
- [49:59]
Host (possibly Jasia Monk)
I was astonished by the way, when I had a wisdom tooth out, which turned out to be relatively minor pain. Perhaps I was lucky, but my dentist prescribed me an opioid without telling me it was one. I mean, I googled it. When she said, and here's the prescription, I said, isn't this an opioid? He's like, yeah. I'm like, do I need this? It's like, I guess you don't need to get it. You could just try some Advil. And so I never went to pick up the opioid because I was a little scared.
- [50:27]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
If I had been in terrible pain,
- [50:29]
Host (possibly Jasia Monk)
I would have gone and done it. But the ease with which this was a couple of years ago. Even now opioids are given out in those circumstances is astonishing.
- [50:37]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
Sorry.
- [50:37]
Alvin Roth
Side note, think about alcohol, or probably let's also talk about tobacco at some point, but let's think about alcohol. Ending prohibition. We ended prohibition because it turned the United States into a nation of lawbreakers. Whenever you had a drink, you were aiding and abetting the crime of whoever sold you that drink. And it didn't have a big effect on alcohol consumption, but it did have a big effect on creating organized crime. But ending prohibition didn't solve the problem of alcohol. There's still people who are alcoholic and there are organizations like Alcoholics Anonymous that try to help them with this addiction. And there's still people who drive when they're drunk and they kill other people. So alcohol didn't. The problem of alcohol and the problems that caused people to support Prohibition didn't go away. It's just Prohibition didn't solve those problems. So I think when we talk about drugs, that's essentially where we are. The problem of addictive, lethal, addict, you know, drugs is very big. And it's not completely clear from the libertarian point of view that people are choosing to take these addictive drugs. You might be choosing to take it initially and then you find you're enslaved by it. So there's also a question maybe we should discuss between what I call repugnance, but also what's called paternalism, right? Sometimes we are trying to protect people from mistakes they could make that will harm them. And we have a lot of laws that do that, like prescription drug laws. Right. Before you got that prescription for opioids, it would have been more difficult for you to get opioids, but your dentist thought you might need them. And on his advice, you were legally allowed to buy them. But we require that you get a prescription for a vast array of prescription drugs because we think you need expert advice before you can safely consume them. So where we're going forward on drug use might be in the direction of treating addicts more like patients than like criminals. But it's not so simple, because addiction is complicated. It's enslaving. Tobacco is a good drug to think about nicotine, because it causes a lot more deaths than opioids do or even than alcohol does. Alcohol, also legal alcohol, causes more deaths than opioids do. Some of them are delayed. Cirrhosis of the liver is not quite as dramatic as someone falling down on the sidewalk. But of course, we have legal tobacco. Americans smoke much less than they used to. There were big ad campaigns you referred to not wanting, you know, heroin to be advertised by big heroin, but big tobacco did a lot of ads. You're probably old enough to remember the Virginia slim's ads that said, you've come a long way, baby, and tried to convince more women to smoke. And they were, I think, largely successful at the time, at least among those liberated women who didn't mind being referred to as baby. But tobacco is legal, but heavily regulated. More and more regulated, yeah.
- [53:58]
Host (possibly Jasia Monk)
And so that's interesting, right, that we tend to think in terms of fully open markets or fully prohibited markets, but there's many graduations in between. One of the strange ironies I find is that in many contexts now, smoking a cigarette is very poorly viewed. It's at the very least, the break of a taboo and often against the rules. And at least in New York City, smoking a joint has come to be much more morally acceptable. I mean, you probably see more people smoking joints in the streets of Brooklyn than smoking cigarettes at this point, which is kind of astonishing. You don't have very much open advertising
- [54:38]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
of cigarettes because of all kinds of rules and regulations. But in my neighborhood, there's three or four different shops very aggressively advertising marijuana. So I'd love to hear your view on marijuana, because I think it's an important case. Marijuana is both the drug where the war on drugs clearly went too far and was most damaging because it is a less immediately dangerous and deadly drug than many, many other drugs, Because a
- [55:06]
Host (possibly Jasia Monk)
lot of people did go to prison for selling marijuana, sometimes for consuming marijuana, for that was actually quite rare. And so the case for overturning prohibition on marijuana was very strong. At the same time, we are seeing precisely some of these damaging mechanisms. Marijuana is much, much, much stronger now than it was even 20 years ago. So the nature of a drug has actually changed. There are some pretty suggestive results that it both is very bad for its users and might be bad for people around them. So one recent study suggests that if you significant use of marijuana in the months before pregnancy, even as a guy, the likelihood that your offspring has autism or some other serious challenge is significantly augmented. And precisely this kind of mechanism, by which now there's much more organized economic concerns, spreading this product, marketing it, perfecting
- [56:16]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
it, making it more powerful, improving it,
- [56:19]
Host (possibly Jasia Monk)
but in ways that actually make it more addictive and more dangerous, is in full swing. You say that this is kind of an experiment we're in the middle of, and the results aren't quite clear yet. But how do you feel about how
- [56:31]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
marijuana legalization has gone?
- [56:33]
Host (possibly Jasia Monk)
What are the positive elements of these changes, and where are you also concerned about what's happening?
- [56:41]
Alvin Roth
So marijuana is becoming more like tobacco. It's legal. As you say, companies may be perfecting its addictive qualities, as tobacco companies did. Apparently quite consciously. They understood the addictive qualities of nicotine, but the laws against consuming marijuana were not effective. So if the point of those laws was to make marijuana unavailable, they failed. And they had these consequences that people were going to jail and were dealing with criminals and were becoming criminals in ways that led to widespread lawbreaking. I've seen surveys recently that say that the number of Americans who use marijuana every day now exceeds the number of Americans who take a drink of an alcoholic beverage every day, have a beer or a glass of wine. So. Well, I mean, it's what you're observing in New York, and, you know, it's easy to smell when you're near a cannabis user. So.
- [57:41]
Host (possibly Jasia Monk)
And for now, I think that's just about more bars in Brooklyn than cannabis dispensaries. But, you know, the ratio is shortening.
- [57:48]
Alvin Roth
Yeah. And, you know, so we'll see. You know, cannabis is now much more potent. Incidentally, the growers. There was an organization called the California Growers association, and California has many organizations with similar names, but normally they have a vegetable in their name. The California Artichoke Growers Association. Well, the California Growers association was ambivalent about legalizing marijuana because if you knew people in the illegal marijuana age who grew marijuana to sell, they could talk to you about how many plants they had, how many hundreds or thousands of plants. But farmers talk about yield per acre. So the artisanal growers who are hiding their crops in national forests to not be raided by the Drug Enforcement Agency, they've been largely put out of business, I think. But it's not a crime to smoke or consume edibles or other things, so we haven't reached equilibrium yet. We don't know how it's going to compare to alcohol and tobacco or sugar or other things we consume, so it remains to be seen. But we shouldn't regret that marijuana is now available because it was also available when it was a crime. So the question is how to manage it. And often leaving the management of these difficult questions in the hands of criminals is not the best way to manage.
- [59:33]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
Thank you so much for listening to
- [59:34]
Host (possibly Jasia Monk)
this episode of a Good Fight. In the rest of this conversation, we talk about surrogacy and whether it is a crucial tool that allows us to fight depopulation and empower people to fulfill their dreams of starting a family. Whether it is a form of exploitation of the women who are offering those services, often because they are in significant financial need. We also talk about sex work. Why is sex work allowed in Germany, even though Germany prohibits many of these other morally controversial transactions we've been talking about? Why is it prohibited in the United
- [60:08]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
States in four years?
- [60:09]
Host (possibly Jasia Monk)
Why is it allows many of those other prohibited transactions? And should we be worried about the number of people offering the service on OnlyFans to listen to that part of the conversation? To support the podcast to get two full episodes of the podcast without annoying ads into your inbox every single week, please go to writing.yashamunk.com Listen.
- [60:33]
Co-host or Philosopher (possibly a moral philosopher or political theorist)
I'll be very grateful.
- [60:34]
Host (possibly Jasia Monk)
Writing.jmonk.com Listen.