joshcmorrison

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Kidney donation is a reasonable choice for effective altruists and more should consider it

The claim about donor survival is more based off of Segev, 2010, which does use controls matched on health (http://jama.jamanetwork.com/article.aspx?articleid=185508&resultclick=1). (There was an editing error in the footnote above, sorry about that).

Good point about the age-matching, which I'll update our website to reflect. Agree that the Mjoen piece definitely has value (which is why we included it), but there are other reasonable criticisms (like the controls all being drawn from the same region and from an earlier time period) raised as well.

Kidney donation is a reasonable choice for effective altruists and more should consider it

The U.S. is third in the world for deceased donation per million persons. The difference between us and the #1 (Spain, which has a suite of good deceased donation policies, one of which is a version of presumed consent) can be explained by our generally not accepting deceased donors over 70 and Spain doing so. http://onlinelibrary.wiley.com/doi/10.1002/lt.23684/full

Also, the kidney shortfall is 20K/yr. Total deceased donor kidneys are about 12K per year. Opinions differ as to what percent of those eligible to be deceased donors donate, but the official government estimate is 75% (I think a range of 50-75% is probably credible), so even if all eligible deceased donors donated, there would still be an enormous shortfall in kidney transplants each year.

If you were try to adapt the EA message to be more successful in the Spanish context, how do you think you'd do so?

Kidney donation is a reasonable choice for effective altruists and more should consider it

To follow up on Alexander's point a bit, I think applying the charitable benefits standard to non-charity decisions leads to some really weird results. For example, say someone who identifies as an EA chooses to give 10% of her income each year to a GW charity, and she’s choosing employment between being a schoolteacher for $50K a year or a job that’s not especially prosocial that pays $55K a year; say she has no innate preference between them, prefers to make more money all things being equal, and that being a schoolteacher would be worthmore than the $500 donation.

According to the logic Alexander points to about kidney donation, when deciding whether to forgo the $5000 to choose a socially beneficial job, the right calculus is -- 1. does giving up that money do as much good as donating to a GW charity (i.e. saving a life) and 2. if no, EAs shouldn't do it. That leads to the really weird result, though, of committing EA ideology to rejecting socially positive choices even if they involve fairly small sacrifices (here $5,000).

Let me give one final thought experiment on this point, which can be a variant of the child-drowning-in-the-puddle -- let's say instead of a child drowning, it's an older woman, and you're wearing expensive clothing that'll be ruined. If the EA standard is -- don't do altruistic acts that aren't of similar value to GW charitable donations -- that principle could very well commit you to not saving the older woman, which, again, seems bizarre.

To be clear, that's not to say that should mean donating a kidney -- far from it. Instead considering kidney donation is a way of broadening the options available to EAs beyond giving money.

Kidney donation is a reasonable choice for effective altruists and more should consider it

In terms of opt-out, I only know the data in the U.S. but basically while it might be a good idea, it's unlikely to yield significant increases: it seems like such an attractive decision architecture/nudge type intervention, but when you dig in, it's a much closer call (which is why Sunstein and Thaler don't recommend it, for example).

The current American system is more of a hybrid than clear opt-in. Right now, about 75% of those who could become deceased donors ultimately consent to do so (about 40-50% are registered as organ donors and of the remainder, the family consents about 40-50% of the time). Thus even if an opt-out system worked as intended, the marginal upside isn't so high (and the downside to it failing or being counterproductive would be quite severe). Spain, the country with the highest deceased donation rates in the world, ostensibly has an opt-out system, but the families are very empowered to say no to donation, and the actual difference between Spain and the U.S. is that in Spain a lot of their deceased donors are over 70 and here very few are.

There'd also be some risks of going to an opt-out system. So imagine what happens when someone is actually eligible to become a deceased donor -- they're brain dead, so their death is often sudden and unexpected to their family. Let's say the donor didn't choose to opt out. What do you tell the family who's in the room with a brain-dead patient whose heart is still beating -- "she's dead. Now you have to leave the room so we can harvest her organs"? If they have no control over what happens to their loved ones body, you can imagine a lot of people becoming pretty upset, even people who might have been persuaded to say yes to donation. The deceased organ donation relies on the public's support and good graces, so if you have repeated instances of grieving families publicly decrying the opt-out system, that creates a significant risk that the change will be counterproductive.

Kidney donation is a reasonable choice for effective altruists and more should consider it

(re: political credibility) -- Ehhh, let's say you become a doctor because you think healthcare is important. You want to help people and by being a doctor, you hope to have the status to advocate politically for expanding access to healthcare. I don't see how your authority is impugned because of your desire for advocacy. I think what you're going for is the loss of authority if you have an ulterior motive that cuts against the stated motive -- e.g. if you join a church for political gain but don't believe in god. As a kidney donor, though, your desire to give and desire to change policy are aligned.

Kidney donation is a reasonable choice for effective altruists and more should consider it

Austen, I see your point but think you have the wrong model of how social movements work. Basically any successful social movement I can think of (e.g. civil rights, women's rights, gay rights) has had extremists who were important to the movement and has included acts of extremism that were historically important to the movement's self-identity. More to the point, it's impossible to know ahead of time what acts will end up considered extremist, so it's silly to criticize an action that aligns with the movement's values as being against the movement because of potential PR consequences, particularly when the act is non-violent and widely considered admirable. (Another way of saying all this is that effective movements are internally diverse and should be wary of self-policing).

Kidney donation is a reasonable choice for effective altruists and more should consider it

Politically, it probably wouldn't be feasible to allow organ sales, but there are a lot of intermediate policy alternatives likely sufficient to end the shortage by supporting donors better (just to start, you could pay lost wages and travel, but you could also provide health insurance, tax credits, or an annuity to donors). If you think that's a good idea (we think it would save about 160K QALYs annually), donating your kidney gives you unique moral authority and power in advocating that policy.

Also you might be interested in signing this open letter if you support benefit for donors --http://www.ustransplantopenletter.org/home.html

Kidney donation is a reasonable choice for effective altruists and more should consider it

Got it! Thanks for explaining that, and I do think we wrote it in a confusing way (sorry!). There are two separate facts --1. the half-life for all living donor grafts is 14.2 years (figure 6.7 here http://srtr.transplant.hrsa.gov/annual_reports/2012/pdf/01_kidney_13.pdf). 2. Expected lifespan for those who receive any kidney transplant between the years of 60 and 64 in particular is 14.0 years. (See p. 266 here -- http://www.usrds.org/2013/pdf/v2_ch5_13.pdf).

Expected lifespan can vary from graft survival half-life both because half-lives are different from averages and (moreso) because most patients end up surviving graft failure and going back on dialysis or getting another transplant (thus extending life further).

We used the 60-64 age as the baseline for the calculation because (1) it's fairly typical of when patients develop ESRD; (2) the life-spans from both dialysis and transplant treatments fit the average transplant candidate; and (3) the transplant survival figure included both living and deceased, so it skewed conservative compared to a figure that only included living, which gave us a margin of error to avoid bias towards overoptimism.

Kidney donation is a reasonable choice for effective altruists and more should consider it

Bernadette, maybe I'm misunderstanding your point, but the 14 year estimate is for patients 60-64 who receive a transplant (this might be a bit unclear as we wrote it though). Patients 60-64 on dialysis can expect 5.1 years of life, so that gives a 8.9 differential, which when you discount years by disability comes to 8.29 or about 8, which is our (admittedly imprecise) estimate. We don't think it's skewed in an optimistic direction though. To be clear, the 14-year overall estimate is 8 per transplant * 1.75 per marginal transplants created by starting a chain.

Patients 45-49 with a transplant have an average life expectancy of 22.8 years (8.3 if they're on dialysis). But we're not assuming they're the median recipient.

I haven't seen half-life outcomes broken out by living related vs. unrelated donors, but 5-year graft survival is similar. See p. 14 of the 2012 OPTN Report -- (http://srtr.transplant.hrsa.gov/annual_reports/2012/pdf/01_kidney_13.pdf). This makes sense because deceased donor organs are not worse primarily because of mismatching but because (besides the fact that they're dead) the quality of donor pre-death is worse (they don't go through rigorous screening; little health data is available; something caused them to die, etc.).

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