You own your body. So should you be able to sell parts of it? This week, we explore the concept of “repugnant transactions” with the man who coined the term, Nobel Prize- winning economist Al Roth. He says repugnant transactions can range from selling organs to poorly-planned gift exchanges — and what’s repugnant in one place and time is often not repugnant in another.
The transcript below may be for an earlier version of this episode. Our transcripts are provided by various partners and may contain errors or deviate slightly from the audio.SHANKAR VEDANTAM, HOST: This is HIDDEN BRAIN. I'm Shankar Vedantam. Let's say someone wanted to buy one of your eyes, would you go for it?UNIDENTIFIED PERSON #1: I wouldn't sell my eyes.UNIDENTIFIED PERSON #2: No (laughter) because sight is precious.VEDANTAM: OK, but would you say yes for a million dollars?UNIDENTIFIED PERSON #3: No.UNIDENTIFIED PERSON #4: No.UNIDENTIFIED PERSON #5: No. Because I had a lot of vision problems growing up, and I already had, like, resolved that. I went through LASIK so I'm, like, good now.VEDANTAM: What about $10 million?UNIDENTIFIED PERSON #6: Well (laughter) I don't think so.UNIDENTIFIED PERSON #5: Yeah, I'm going to still say - I'm going to pass, yeah.UNIDENTIFIED PERSON #3: If you said $10 million, hell yeah. I'm building a house in Honduras. I'm helping the fam. I'm going to just, like, have an eye patch on like slick rick and we good.(SOUNDBITE OF MUSIC)VEDANTAM: Maybe you're listening to this and thinking, hey, if someone prefers $10 million over two eyes, well, that's their business. Or maybe you think commodifying human eyes in this way is just wrong. Our hypothetical marketplace for eyes is one example of what economists sometimes refer to as repugnant transactions. They make us uneasy. They force us to define the boundaries of what is acceptable to buy and sell. They put morality into conflict with economics.(SOUNDBITE OF MONTAGE)TOMEK: And he said I'm going to pay you 100 euro if you're going to tattoo something more on your forehead.NINA TOTENBERG, BYLINE: In a family court in Hackensack, N.J...MARY BETH WHITEHEAD: She's my child...TOTENBERG: ...One surrogate mother has refused to give up the baby.WHITEHEAD: ...And I know what she wants and what she needs.ALVIN ROTH: It's not clear as a society that we want everything that we disapprove of to be against the law.VEDANTAM: Studying what makes us uneasy can reveal interesting things about human behavior and the evolution of our social norms. The psychology of repugnant transactions - this week on HIDDEN BRAIN.(SOUNDBITE OF MUSIC)VEDANTAM: It's illegal in the state of California to buy or sell horse meat.ROTH: So when you come to California, we have many fine restaurants, but none of them will serve you horse meat.VEDANTAM: My guest today spends a lot of time thinking about things like horse meat. Al Roth is an economist at Stanford University. He won the 2012 Nobel Prize in economics, and he's coined the term repugnant transactions.ROTH: We have no laws in California against drinking spit or eating worms...VEDANTAM: (Laughter).ROTH: ...Probably because no one wants to do that. The reason we have a law against eating horse meat in California is because some people like to eat horse meat, and other people don't think that they should be allowed to.(SOUNDBITE OF MUSIC)ROTH: So when I talk about a repugnant transaction, the short version I give is that it's a transaction that some people would like to engage in and other people don't think they should be allowed to, even if it's hard to see how those other people are harmed.(SOUNDBITE OF MUSIC)VEDANTAM: Al and others find that one key way to turn a perfectly acceptable donation or exchange into a repugnant transaction is by introducing the element of money.ROTH: It's against the law almost everywhere in the world to pay a kidney donor, a living kidney donor, for a kidney for transplantation. It's a lovely thing if someone loves you enough to donate a kidney to save your life. That's possible because healthy people have two kidneys and can remain healthy with one. But it's illegal to buy a kidney with - everywhere in the world with the single exception of the Islamic Republic of Iran where there is a monetary market for kidneys.VEDANTAM: So let's just look at that in a little bit more detail. We'll come to Iran in just a second. But there's something interesting here, which is that if I donate my kidney to my friend, I'm a hero, but if I try and sell my kidney to my friend, I'm something of a jerk.ROTH: Well, you're a felon in the United States. That's right. So it's an unusual state of the world in the sense that it's universally acknowledged that you own your kidneys, but you're not allowed to sell the kidney nor am I allowed to buy one.VEDANTAM: What is it, do you think, about the introduction of money that changes this transaction from being a heroic transaction to one that is really seen as repugnant?ROTH: I think it has something to do with people's idea about what kinds of things should go on in close family circles and what kinds of things should go on in relatively impersonal markets. So over the long course of human history, we've gone from doing everything with people we know to doing many things with people we don't know or might be quite distant. There's also a slippery slope concern that if people could sell their kidneys, maybe we would feel less of a social obligation to take care of poor people because, after all, they have a kidney. They could sell it.And there's a moral repugnance that comes into play that people often talk about that people should always be ends in themselves and never means. And for me to buy your kidney might be to commodify you, to objectify you. Now, of course, what makes it particularly unusual is you can give me your kidney. So you own your kidney. You own it securely enough that you could give it to me if you wished, but you can't sell it to me.VEDANTAM: So there's obviously a moral argument to be made against monetizing the sale of kidneys, but there is also a moral argument in some ways in favor of doing it, as you and others have pointed out. Thousands of people die each year waiting for a kidney donor, and at the same time, there are millions of people walking around with a spare kidney that they don't need. And economists might say there is an obvious solution here.ROTH: Yes. Yes. Kidney disease is one of the top 10 causes of death among human beings worldwide. So it's a big deal. And here in the United States this morning, there are about 100,000 people on the waiting list for a deceased donor kidney. And we only expect to get about 13,000 deceased donor kidneys for transplantation each year. So the wait is long, and it's dangerous. And as you say, thousands of people die each year while waiting, and waiting is no fun. Dialysis keeps you alive, but it might - having to undergo dialysis might prevent you from being able to work, for instance, or leading a normal life.VEDANTAM: So one question is what would happen in the thought experiment where you actually are able to buy and sell kidneys? And as you mentioned a little while ago, there is a country where this is legally possible. Tell me what happens in Iran and whether they have the same organ shortages that we have in the United States.ROTH: Well, we're going to learn a lot more about that in the near future because my colleague here at Stanford, Mohammad Akbarpour, and some of his colleagues are studying that. And so we'll get very reliable information soon. But the story is that it's not that there's no waiting time. It still takes time to arrange a kidney. But it's substantially shorter than in countries that primarily depend on the deceased donation and on altruistic donation of kidneys by living donors.So it seems to be working well in some respects but not so well in other respects. Apparently, when you interview organ donor sellers in Iran, often they wish to remain anonymous. So it's a legal transaction, but it's not one that they are happy to have advertised to their friends and colleagues that they've done. So that suggests that it's operating in something of a shadow. When we talk about repugnant transactions in general, you see other repugnant transactions that becoming legal doesn't make them unrepugnant.(SOUNDBITE OF MUSIC)ROTH: Without meaning to draw any parallels at all between kidney donation and Iran, prostitution is legal in Germany, but I don't get the sense that sex workers in Germany write home to their families about how their workday is going, even though it's legal.(SOUNDBITE OF MUSIC)VEDANTAM: In 2018, a group of men celebrating a bachelor party in Spain approached a homeless man named Tomek and offered him cash in exchange for tattooing the groom's name on his forehead. Here is Tomek in a video published by the German website Ruptly.(SOUNDBITE OF VIDEO)TOMEK: And he said I'm going to to pay you 100 euro if you're going to tattoo something more on your forehead. A hundred euro for me is quite - quite a lot. So I say, yeah, OK, why not?ROTH: So, you know, this certainly sounds exploitative. On the other hand, it's not clear that every vile transaction should be illegal. It doesn't make us think better of the man who's getting married. You know, perhaps the young woman who is about to marry him should...VEDANTAM: (Laughter).ROTH: ...Update her preferences.VEDANTAM: (Laughter).(SOUNDBITE OF MUSIC)VEDANTAM: So I - as an economist, I'm trying to - I'd love you to try and explain for me what the difference is between these two different kinds of transactions. On the one hand, if I tell you, Al Roth, I'm going to pay you $100 million to get a tattoo on your forehead, that seems truly wrong and obnoxious. On the other hand, if I tell you, you know, I'm Stanford University and I'm going to hire you, Al Roth, to teach my economics class and I'm going to pay you X amount of dollars to do that, that feels perfectly aboveboard. They're both, in some ways, transactions. You're providing some kind of a service or you're doing something for me that involves yourself. In both cases, you're getting paid. Why does one seem so problematic?ROTH: So I'm not quite sure. It's hard to draw lines between the things that are just - should be just on one side of a line and just on the other.(SOUNDBITE OF MUSIC)ROTH: One of the reasons I think this should be of interest to economists is that the philosophical discussion and the discussion in the ethics literature often seems to be a little confused. One of the things that they talk about is coercion. And one of the ways they define coercion - this is having to do with adding money to transactions that might not otherwise involve money, like surrogacy or, like, donating eggs for fertility or donating plasma or blood.One of the things they say is something is coercive, money is coercive, if you do it for the money and in the absence of money, you wouldn't do it. But my guess is you make many more radio broadcasts than you would if you weren't paid for it. And as you say, I teach more economics classes than I would if I weren't paid for it. But I don't feel coerced, and I'm betting you don't feel coerced. We feel paid. We feel appreciated for the work that we do. So at least to an economist, it's not obviously coercive to say to someone I'll pay you to do something that you otherwise wouldn't do.So the question is is there some deeper meaning maybe that the ethicists and philosophers are missing that might nevertheless support their intuition that some things are coercive? And we had a - there is a professor at University of Toronto who got his Ph.D. here at Stanford a few years ago named Sandro Ambuehl who's been doing laboratory experiments in which, among other things, he tries to see whether he can harm you by paying you too much. And sure enough, the more you pay people, the more often they take a money-losing gamble. So at least his experiment gives us some indication that if we want to talk about informed consent, we have to take incentives very seriously. It might be harder to get fully informed consent when the transaction seems more tempting to engage in.VEDANTAM: And so the interesting thing from an economist's point of view is that you would say if someone pays you more for the same product, then you should take it because your welfare is improving. But at an intuitive level, I think it is clear that if I paid you $100 million for one of your eyes, it does feel like I'm trying to coerce you into making a bad decision.ROTH: It does. Of course, for $100 million, it might be less of a bad decision, right? So I'd have to form an opinion of how much the $100 million would, you know, change my life and how much having only one eye would reduce my quality of life and that might be a difficult decision to make. And of course, could I give you the one of my eyes that doesn't work as well as the other, for instance, you know? So we'd both have to be well-informed. You know, one of the other concerns about buying kidneys from people is, you know, supposing I have one eye that doesn't work very well, you might get that one, and you'd be more likely to get that one than if I was only giving an eye to someone who I really loved and wanted to see very well and who I would know that my eye might not work so well for them.But the issue of can you pay for blood plasma, for example, there was a time when it was hard to test for various diseases. And so in the United States and elsewhere, we have a long tradition that whole blood is donated altruistically. You don't get paid for whole blood in the United States. But you can get paid for plasma. And as a result, the United States exports lots of plasma products that are important medicines - interferon and albumin and clotting factor.Now, in Canada, as we speak, recently laws have been passed against paying plasma donors, and Canada imports millions of dollars of plasma products each year from the United States. So there's a sense in which, in Canada, they're taking the point of view that it would be wrong to pay Canadians to donate plasma. But it's quite all right to buy plasma products from pharmaceutical companies that get plasma from Americans.(SOUNDBITE OF MUSIC)VEDANTAM: Ideas of what is repugnant vary not just from country to country but from era to era. When we come back, we discuss the role that technology plays in pushing the boundaries of what we consider repugnant.(SOUNDBITE OF MUSIC)VEDANTAM: This is HIDDEN BRAIN. I'm Shankar Vedantam. In 1986, a woman named Mary Beth Whitehead gave birth to a girl who eventually came to be known in headlines around the world as Baby M.(SOUNDBITE OF ARCHIVED RECORDING)UNIDENTIFIED REPORTER #1: The trial of the matter of Baby M began today in Hackensack, N.J. Baby M is a 9-month-old girl born to a surrogate mother.VEDANTAM: Al Roth picks up the story.ROTH: There was a New York couple that was unable to bear a baby for some reason. And they contracted with a surrogate mom to bear the baby for them. And they did what today is called traditional surrogacy - that is, the man's sperm and the surrogate mom's egg were used. The baby was brought to term by the surrogate mom and transferred to the New York couple that had contracted for this surrogacy. But the surrogate mom later regretted this, and there was a custody battle. And it was a complicated custody battle because the surrogate mom was the genetic mom.(SOUNDBITE OF ARCHIVED RECORDING)WHITEHEAD: She's my child. And I know what she wants and what she needs. And I'm only - the only one that can know that because of carrying her the nine months, caring for her for the first four months. I know her needs.UNIDENTIFIED REPORTER #2: From Hackensack, N.J., today - a decision in the Baby M trial. The judge in the case has upheld the legality of the surrogate mother agreement and has given undisputed custody of the baby girl to her father, William Stern.ROTH: So New York outlawed surrogacy in the wake of that custody battle.(SOUNDBITE OF ARCHIVED RECORDING)UNIDENTIFIED REPORTER #3: Opponents of surrogate parenting say a New Jersey Supreme Court decision in the Baby M case marks the end of surrogate contracts. The state court ruled...ROTH: But in California, where I live, surrogacy has been legal for a long time. And the form of surrogacy that's legal is gestational surrogacy - so an embryo is implanted into the surrogate's womb, so the surrogate is not genetically related to the baby. And there are reliable legal contracts and ways of going about this in California so that if you have a surrogate baby in California, your name can be on the California birth certificate as the parent.VEDANTAM: Millions of people around the world suffer from extraordinarily painful fertility issues. Their desire to be parents sometimes comes into conflict with society's attitudes about the appropriate way to have a child. The entire supply chain of having a baby, as Al Roth sometimes puts it, can now be outsourced through a combination of sperm and egg donation and surrogacy. Some people might find that problematic, but Al points out that any individual part of that supply chain is less controversial than the sum of its parts.ROTH: Especially now that we allow same-sex marriage so that there are lesbian households that don't have sperm and there are gay male households that don't have a womb between them. So being able to buy sperm when you don't have viable sperm between you and being able to buy eggs when you don't have eggs between you and being able to rent a womb when you don't have a womb between you - a working womb - all seem to me to be somewhat less problematic than buying the whole supply chain.VEDANTAM: If you think buying the whole supply chain of having a baby is repugnant, consider the changes that have unfolded when it comes to each part of that supply chain. In vitro fertilization, for example, was once seen as controversial. Technology and time have changed that.ROTH: Over time, technology gives us different options than we had in the past, and we see some of the new options as repugnant. And then over time, as we get used to them, we see them as less repugnant. So in vitro fertilization was just developed in the 1970s. It won a Nobel Prize. It was regarded with some repugnance when it was developed, that you could implant an embryo - so have a baby - that didn't result from sex. And, of course, it also made possible gestational surrogacy. So all of a sudden, a woman could bear a child who wasn't genetically related. I think in vitro fertilization - which as I said, won a Nobel Prize - I think it's successfully gotten over the repugnance hump. Not everyone approves of it, but it's widely approved of. It's a standard part of medical care for fertility. So technology made some new things possible, some of them more regarded as repugnant for some time and then we got used to them; some might still be regarded as repugnant.VEDANTAM: So what's interesting is that when we think about repugnant transactions, I think many of us are using an intuitive system to say, I think this feels wrong. What you might be hinting at, in some ways, is that that intuition might actually comprise of different - it might be comprised of different things. In other words, part of it might be a moral problem. Part of it might be a safety problem. Part of it might be a money problem. And what our minds are doing in some ways are integrating all of those to create the intuition of the whole thing is wrong, but as technology progresses and as things become safer, part of that falls away.ROTH: I think you're absolutely right that repugnance is a big net into which I'm allowing things to be classified together. My colleague, Debra Satz, who's a philosopher here at Stanford, thinks that I'm casting it too widely for just the reason you say, that repugnance is a lot of different things. Things are repugnant for different reasons.VEDANTAM: One advantage of casting that wide net is that it lets Al think about situations that on the surface appear innocuous. You can have repugnant transactions even when no one is harmed, no organs are exchanged and neither sex nor babies are involved.ROTH: If you invite me to dinner at your house, I can do a lot of things. I can bring a nice bottle of wine. I can say to you afterward, you know, you really must come to dinner at our house. One thing I can't do after the dinner is take out my wallet and say, you know, you're such a good cook. That would have cost me $75 at a nice restaurant. Can I just put that down by my plate here to thank you for the dinner? And your reaction, of course, sensibly enough, would be we're not a restaurant. Why does he think he can pay us for this dinner? And it's because being invited to dinner at your house is an invitation to be your friend. And when I pay at a restaurant. I completely obliterate my debt, right? I go to the restaurant. They present me with a bill. I pay it. I don't have to invite them to my house. I don't have to bring them a bottle of wine. I don't have to be nice to them in the future. I don't have to ever come back.But when you invite me to your house, there's at least the idea that maybe we'll become friends and you'll come to dinner at my house and we'll go to coffee together sometime when we're both at loose ends. And by offering to pay you, which wasn't what you had in mind at all, I guess I'm making it look like I think I can extinguish my debt as if you're a restaurant. So even economists understand that sometimes adding money to a transaction is inappropriate.VEDANTAM: I'm wondering if one problem with paying for your dinner at a friend's house is that it makes what actually might be a transaction visible in ways that it might not be otherwise. So in other words, if I invite you over to my house and you have a nice dinner at my house, there is some expectation that you will reciprocate at some point - and maybe not with a dinner, maybe something else - but we are essentially trading favors back and forth. You know, we're doing nice things for one another, and that's what friends do. But at some level, you could argue that this is a transaction. It's not a transaction in money. It's a transaction in activities. And in some ways, by bringing money into the picture, what we have done is make a transaction that is implicit into a transaction that's explicit. And what's repugnant is that we don't like those transactions being made explicit.ROTH: That's, I think, part of what's repugnant. But also there's this idea that transactions in kind might be more intimate than transactions in money. And this might have to do with this ancient idea that before we invented money, many of our transactions were repeated interactions. And as you say, we traded favors. So I think no one objects if, when you invite me to dinner, I bring an unusually expensive bottle of wine, right? That could be flamboyant, but it's not offensive because we could drink the wine with dinner. So money suggests something - a more arm's length transaction I think.I like New Yorker cartoons, and there's one I sometimes think of when I - when we have this kind of discussion about a man coming in the door at dinner holding in his hand a bill. You can't see the denomination of the bill, and he says we were going to bring wine but didn't get around to it. This is what we would have spent.VEDANTAM: (Laughter) A lot of economists have studied what they might call the idiocy of gift exchanges. And this might be especially true around, you know, Christmastime. You know, you get me a sweater that I hate, and I get you a toaster that you don't need. And some economists have gone so far as to propose that really what we should be doing is trading gift cards and cash because we'd actually end up not buying each other things that we don't need. But, of course, that runs into the problem of repugnant transactions, which is if I actually gave my partner or my friends cash for every birthday party or anniversary, you know, I'm not going to be seen as a very good friend.ROTH: Right. So I think that wedding registries are a very interesting development addressed to that problem. So here's a couple getting married, and perhaps if they're young and first married and all of those things, they are starting a new household. So there was this idea that they need all sorts of pots and pans and linens and all of that. But if their friends just give them what they feel like giving them, they may end up with lots of big red pots and not enough linen whereas if their friends were to give them money, they could use it to buy what they wanted and needed, but giving them money seems cold. So you see wedding registries.They can go to a big retailer and choose the linen they want and the pots they want and the silverware they want. And you can sign up to buy them the linen or the pots or a bunch of steak knives or something like that. So that's very close to giving them money because once someone has bought them steak knives, you can't buy them steak knives on the registry anymore. It'll say that's already been bought.VEDANTAM: So there's obviously a cleverness here, which is wedding registries are a way to essentially design out the repugnance in what actually might be a repugnant transaction. You have done a lot of thinking out about how to apply in some ways a similar kind of insight to the world of kidney donations. And it doesn't involve buying and selling kidneys but something else that's actually much more clever. What have you done?ROTH: Well - so recall that we talked about how in kind exchanges might be acceptable when exchanges for money are not. And part of the great shortage of kidneys for transplantation has to do with the fact that you can't compensate kidney donors. But what we do is something called kidney exchange. It turns out a healthy person has two kidneys and can remain healthy with one. And so if you love someone who's dying from kidney failure, you might be able to save their life by giving them one of your kidneys.But sometimes it happens that you're healthy enough to give someone a kidney, but you can't give it to the person you love because it turns out kidneys have to be very well matched to the recipient. So it used to be that if you wanted to give a kidney to someone and were healthy enough to do it but you couldn't give it to the person you love, you would just be sent home and the person you loved would continue the long, dangerous wait for a deceased donor organ, which could take years and is full of hazards.(SOUNDBITE OF MUSIC)ROTH: But now what we can do is we can say, you know, you are healthy enough to give a kidney, but you can't give it to the person you love. And maybe I'm healthy enough to give a kidney, but I can't give it to the person I love. But I could give a kidney to your patient, then you could give a kidney to my patient. And through that exchange of kidneys without any money changing hands, we would legally and ethically have found a way to create two more transplants than would have happened otherwise. Through simple exchanges like that and through more complex exchanges that involve chains of kidney donation, kidney exchange has become a standard form of transplantation in the United States now.VEDANTAM: And I understand that some of these are extraordinarily complex. They could involve much more than two individuals. They can involve 10, 20 or even 30 people in a very complex exchange.ROTH: Right. So the complex exchanges begin with non-directed donors. Sometimes someone wants to donate a kidney, and they don't have a particular patient in mind. And those non-directed donors can start long chains of donations where they give a kidney to a patient who, with his prospective donor, are waiting for an exchange and the donor of that kidney patient passes it forward and gives to another patient, and the donor from that patient passes it forward. Some of those chains have been very long and have - you know, when you look at a set of photographs afterwards, they can have 60 or 70 people in them, so...VEDANTAM: Wow.ROTH: Thirty or 35 transplants and an equal number of nephrectomies. The average chain in the United States has 10 people in the picture - five donations and five transplants. So it's become a very effective way of amplifying the gift.(SOUNDBITE OF MUSIC)VEDANTAM: What's interesting, of course, is that this is mindful of both the psychology and the economics of repugnant transactions. It's not saying let's do away with them entirely and have a market for kidneys because that runs into other problems. And it's not sort of saying let's actually just ignore the problem altogether. It's saying let's actually keep these concerns front and center and essentially design around them to get what we want without sort of sacrificing our moral qualms about buying and selling organs.ROTH: I think that's exactly right. So it satisfies, I think, those who have moral qualms about buying and selling, and it also is a - even if you don't have moral qualms about buying and selling, when you see something that's against the law almost everywhere in the world, you might correctly figure out that it wouldn't be an easy thing to change. And if you want to help people who have kidney disease today, you have to find a way of doing it that doesn't arouse repugnance even if you don't feel it yourself.(SOUNDBITE OF MUSIC)VEDANTAM: Alvin Roth is an economist at Stanford University. He won the 2012 Nobel Prize in economics. You can read more about his ideas at marketdesigner.blogspot.com. Al, thank you for joining me today on HIDDEN BRAIN.ROTH: Oh, thank you for having me.(SOUNDBITE OF MUSIC)VEDANTAM: This week's show was produced by Parth Shah. It was edited by Tara Boyle. Our team includes Jenny Schmidt, Rhaina Cohen, Thomas Lu and Laura Kwerel. Our unsung hero this week as Marco Martire. For the past few years, Marco has managed Sound Bites, the cafeteria at NPR. He's always upbeat. He remembers people's names. This was Marco's last week at NPR. When I talked to him recently, he said he's going to be launching a cafeteria at a new location because he's done so well here. I reminded him that this was the danger of demonstrating competence. Thank you, Marco.(SOUNDBITE OF MUSIC)VEDANTAM: One last thing before we wrap today. We're just getting started on an episode about workplace culture. Have you ever witnessed something troubling or inappropriate at work and struggled with whether to remain silent or speak up about it? If you're willing to talk about what happened, please record a voice memo on your phone and email it to us at firstname.lastname@example.org. Be sure to include a phone number where we can reach you. That email address again is email@example.com. Please use the subject line workplace.(SOUNDBITE OF MUSIC)VEDANTAM: I'm Shankar Vedantam, and this is NPR. Transcript provided by NPR, Copyright NPR.