[Preamble: I wrote this post about the non-market for organs three years ago. The friend mentioned here went on to have her bilateral lung transplant at the end of the following year. Last week, devastatingly, the clock ran out on her extra time. In the two years of her second life, she devoted much of her precious time to the fight for organ donation awareness. She co-founded an NGO called Love Life, Gift Life. And took every opportunity to tell people to go green and recycle. You can read her story in her own words here. And on side-note – while I have edited this piece for readability and refreshed some of the links, I have not updated the time references. The context was specific, and it should remain that way.]

One of the important people in my life is preparing to go onto the transplant list. The process is bizarre: in particular, all the psychological assessments. You’re apparently expected to maintain an upbeat attitude all the time. Which seems like a really tall order for someone facing imminent eternity with a side of slim hope that someone else’s encounter with eternity might delay their own.

But apart from that, there are the politics. For reasons that I’m about to get to, the decisions about transplant list placement are made by committee. And when it comes to allocation by committee: the personalities can be difficult, and the decision-making process overshadowed by the unspoken threat that causing a personal offence might lose you a vote.

And when she and I discussed her fight to make it onto the transplant list, the question we kept coming back to was: “Why?”

“Why is this the way that the transplant list is diced?”

At which point, it was suggested that I write this post.

There Is No Market Mechanism For Organs

Economists love to talk about market mechanisms – and really, what they’re talking about is price.

Price is our standard market mechanism: if the price is right, the buyer will buy and the seller will sell and everyone will get what they want. And much of our current economic thought (and law) is focused on the idea of letting the price be as unbiased as possible: antitrust laws and free trade agreements and so on.

But what do you do in a situation where the price mechanism does not work? Or where we believe that the price mechanism would encourage unethical behaviour?

When it comes to organs, allowing a free market exchange where buyers can bid on someone’s organs is only a small step away from being robbed of both your cellphone and your cornea. And human organ farms where enslaved mothers are forced to rear babies for liver harvest.

Of course, a version of this reality already happens today – although I’m not talking about the infamous wake-up-in-an-ice-bath urban myth. Until 2006, China was quite the transplant-tourist destination, regularly harvesting organs from the thousands of prisoners that it executes every year. Although that practice has since stopped (they say).

Then there is Iran, which is the only country in the world that legally permits that sale of kidneys (although not other organs). And perhaps unsurprisingly, that market is not especially well-functioning.


In 2012, Al Roth won the Nobel Prize for his work on market-matching – and specifically, how it relates to the process of allocating kidneys.

Kidneys are unique in the world of organ transplants – you can live with just one, but you generally have two. So frequently, a family member will offer one of theirs to the patient that needs it.

Unfortunately, many donors are not biologically compatible with their sick family members. Given that there was no market exchange where the donor could go and offer a swap with someone who is biologically compatible, there seemed to be a lot of wasted good intention.

What Roth did was design algorithms for the creation of matched pairs. The idea was to identify scenarios where donor A was a match for patient B, and donor B was a match for patient A. And you can extend that to include more pairs of donors and patients – donor A gives to patient B, donor B gives to patient C, donor C gives to patient A.

And the whole chain is only constrained by the number of operations that can take place concurrently (if the operations don’t all happen at once, then donor B can just renege on his/her commitment to patient A once patient B gets donor A’s kidney).

Is it perfect? Well no. But it’s certainly better than what came before it.

When It’s All Or Nothing

As I write this though, there is no clever algorithmic allocation for the other kinds of organs. There are no matched pairs for hearts or lungs – we’re not ethically up for that kind of sacrifice.

So instead, there are waiting lists where committees decide who should, and who should not, be entitled to a donor organ if it comes along. The decisions are based on subjective assessments of psychological well-being and commitment to the process. There are also less subjective assessments based on age and blood types and degree of illness (you can’t waste an organ on the shortly-departing – you need to give an organ to the relatively-healthy who have the best chance of living to use the organ in question).

And the strictness of those criteria is directly related to the number of organs available. So in countries where rates of organ donation are extremely low, the access bar is set high. This is not helped by the fact that an organ donor’s wishes have to be fulfilled almost immediately after death, right at the time when their family members are reeling in shock. Which means that organs are in very short supply.

This, in turn, means that a transplant patient has to campaign for her place on the list.

In some ways, perhaps it can be positive: a fight for a place means a distraction from the depressive possibility of an end game. On the other hand, how counter-productive is that stress?

Mostly, that’s a moot point. Life’s lemons must just be squeezed and the juice cut with sugar. Or: it is what it is, for now.

But it would be nice if the 3D printing people could just move themselves along a little faster. That way, there could be real free markets. And less psychological game-play.

Until then, the world needs more organ donors to make this as fair as possible.

And family members who know what to do if the moment ever comes.

[PS: please go support Love Life, Gift Life. As was written on the back of her memorial program, Siobhan’s last gift to us was making all donations to LLGL tax-deductible. Girl was a rockstar pragmatist #letliterallynothinggotowaste]

Rolling Alpha posts opinions on finance, economics, and sometimes things that are only loosely related. Follow me on Twitter @RollingAlpha, and on Facebook at www.facebook.com/rollingalpha. Also, check out the RA podcast on iTunes: The Story of Money.