One of the important people in my life is preparing to go onto the transplant list. The process seems bizarre; in particular, the psychological assessments. You’re apparently expected to maintain an upbeat attitude – which seems like a tall order for someone that faces 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 are made by committee, where the personalities can be difficult and the lead-up overshadowed by the unspoken threat that causing a personal offence might lose you a vote. And like all committees where there is some power (in this case, the power to play God), I suspect that it acts like a magnet for the pathologically insecure. Which is not to say that there aren’t committee members who are well-intentioned and fair – but it’s still a political position.

And when we discussed it, the question 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, rather, where we believe that the price mechanism would perpetuate unethical behaviour)?

When it comes to organs, many feel that developing a free market exchange where buyers can bid on someone’s organs is but a small step away from being robbed of both your cellphone and your cornea. And human organ farms where mothers rear babies for their livers.

Of course, some of that 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).

But then, ironically, you have Iran, which is the only country in the world that legally permits that sale of kidneys (although not other organs). And that market seems to be well-functioning. That said, the market is for locals-only. If caught, foreigners would presumably find their organs reclaimed in a rather public setting…


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, you generally have two, so frequently, a family member will offer his/hers. Unfortunately, many donors are not biologically compatible with the person that needs the kidney. Given that there is no market exchange where the donor can 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. Which is extendable 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 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

At this point in time, there is no clever algorithmic allocation of the other organs that can function as a market mechanism. There are no matched pairs for hearts – we’re not ethically into that kind of sacrifice.

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

Which means that the transplant patient has to more or less campaign for her place on the list. In some ways, perhaps it’s positive – a fight for a place means a distraction from the depressive constant of the end game. On the other hand, how productive is all that stress?

Mostly, that’s a moot point. The lemons must just be squeezed and the juice cut with sugar. But it would be nice if the 3D printing people could just move themselves along a little faster.

That way, there could be free markets and less psychological game-play.