- A majority of American workers would not be able to cover a $500 emergency expense according to a 2023 survey.

Of those, 19% said they would ask a friend or family member for the money, and 18% said they would put it on a credit card.

- But what if those options aren't available to you?

Maybe you don't have anything of value left to sell or pawn, but have you considered what might be of value inside your body?

- Hold on.

Time out.

We are getting into some serious late stage capitalist nightmare territory here.

- Legalizing the sale of human organs may sound like dystopian sci-fi, but the debate has been raging for decades, and in fact, there are good faith arguments on both sides.

- However you may feel about the issue, it goes to show that economics and ethics are irrevocably intertwined.

(upbeat music) - [Julia] Most humans are born with two functioning kidneys, but you only need one to live a healthy, normal life.

The removal procedure is safe and minimally invasive, and donors can expect to be back at work in just a few weeks.

It's almost like we were supposed to share them.

- And yet there are around 90,000 Americans on the kidney transplant waiting list.

Thousands of them will die every year, mainly because there are not nearly enough donors to fill the need.

Even though the number of annual donors has increased in recent years, it's far outpaced by new patients on the waiting list.

- There is an argument that market forces could solve this problem.

Currently, it's illegal in the US and most of the world for anyone to receive monetary compensation for a human organ.

But if the prohibition were lifted, some say, the financial incentive could swell the donor ranks and potentially save tens of thousands of lives.

- In the early 1980s, as human organ transplants were becoming safer and more effective, a Virginia doctor announced his plan to begin buying organs from willing donors and reselling them for a profit.

The reaction from lawmakers, the medical community, and the public at large was swift and highly negative.

By the following year, Congress had passed the National Organ Transplant Act, which made it illegal to compensate donors for human organs, blood or bone marrow.

- Part of the reason behind the ban is about health and safety.

For instance, there is evidence that offering payment for blood donations can incentivize people to lie about diseases and infections in their screening questionnaires, which can be deadly to transfusion recipients.

Plasma, on the other hand, is so thoroughly processed that there is very little risk of contamination, so it's legal to offer money for it.

- Currently, organ transplants are arranged by a nonprofit organization called the United Network for Organ Sharing.

They manage the national waiting list and match donors to prospective recipients using criteria like medical status, distance, and time waited.

No one gets special treatment or can buy their way higher on the list.

- Of course, rich people can always find ways around the rules, especially when their lives are on the line.

Transplant tourism is a crude term for the practice of traveling to other countries where the buying of human organs may not be technically legal, but not as strictly enforced.

It's estimated that around 10% of organ transplants worldwide are illegal, roughly 12,000 every year.

- Critics of organ trade bans say that this is exactly the kind of exploitative system the laws were intended to avoid.

Wealthy recipients can pay brokers up to $80,000 for a transplant, but many donors, usually poor people from countries like India, Pakistan, and the Philippines, will see less than $2,000 of that.

And studies show that most of that money ends up in the hands of debt collectors, and donors' financial situations are often not improved by the sale.

- Instead of allowing a black market to flourish, advocates of a legalized organ trade point to the only country where it's allowed, Iran.

In 1988, the government of Iran created a legal but highly regulated organ trade.

Donors can be compensated at a set price of $4,600 per organ, but only by a governmental organization, which then allocates the organs to recipients based on similar criteria to the American system.

As in India and Pakistan, the majority of donors are impoverished and use the money to pay off debts.

But transplant Dr. Nasser Simforoosh counters that instead of doing something illegal to cover their debts like stealing or smuggling, "They are saving a life first.

This is not exploitation."

- Proponents of the Iranian system claim that they have successfully eliminated their kidney waiting list, but others suggest that may be because a lot of people with kidney disease are simply not being properly diagnosed.

This may explain why Iran still has a kidney black market in which desperate sellers pose as family members to push wealthy buyers higher on the list.

- But there's an even more philosophical reason underlying the organ trade ban, human dignity.

Since the end of slavery, no human or part of a human has been considered a legally tradable commodity.

Even the remains of deceased individuals are only considered quasi-property of their families, meaning they only have the power to determine how the remains should be buried, but cannot rent, sell, or otherwise transfer ownership.

- [Philip] The line can be a bit blurry.

For instance, one court ruled that a man was allowed to bequeath his frozen sperm to his widow, but another court ruled that frozen embryos could not similarly be treated as property.

- While lawmakers and ethicists argue abstractions, leave it to behavioral economists to focus on getting results.

Richard Thaler, whose groundbreaking work we've discussed in a previous video, pioneered the idea of nudges, small systemic changes that gently guide people towards positive behavior without depriving them of the freedom to choose.

- For instance, people are far less likely to enroll in 401ks offered by their employers if they have to take the time to opt in.

But if you make enrollment automatic with the option to opt out, the number of employees who participate goes up dramatically and the benefits are lifelong.

- This same strategy has been applied to organ donations with some success.

Assuming that everyone will automatically be an organ donor upon death, but still giving them the freedom to opt out if they wish seems to increase donor rates while respecting individual autonomy.

- Such nudges can backfire, however.

While most European countries had success with opt-out organ donation plans, in the Netherlands, it was a disaster.

Even though they had the freedom to opt out, many Dutch saw automatic enrollment as an attack on civil liberties and organ donor rates actually dropped.

Based on some Americans' reaction to mask and vaccine requirements during Covid, there is an understandable fear that the same thing would happen here.

- Still, the opt-out system of organ donation seems more likely than legalization of kidney sales.

There simply isn't enough evidence to justify such a fundamental breach in our cultural understanding of human dignity.

- And Americans have a right to be skeptical about the magic of the market.

The US healthcare industry hasn't given us a lot of reason to trust they'll behave ethically and equitably when profits are on the line.

- It's understandable to ask if these are really the same people you want opening you up and selling what's inside.