Kidney Failure

Oh no, my deadlines have come and gone. Work on the kidney transplant paper has been minimal. I did make progress on my larger project, however, so I won't claim that all has been unproductive. It does mean that I am well behind on the kidney paper, though. I'd like to have a very rough draft in  a few days.

One goal I did reach was to finish reading The Kidney Sellers, by Sigrid Fry-Revere, on the Iranian system(s) of compensated donations. I learned a heap from this fine book. My next reading goal is to take on Sex Cells: The Medical Market for Eggs and Sperm, by Rene Almeling, but I will need a few weeks for this one, I think.

The Next Challenge

From Vice to Kidneys. The Five Drafts commitment device, which more-or-less has succeeded for two vice papers, is now being repositioned for a paper offering a behavioral economics take on compensated live kidney donations. One complication/improvement is that this paper involves a mystery co-author, who will be revealed at a later date!

We seem to be having fewer and fewer drafts.....hmmm. Anyway, I am calling for three drafts for this paper, at least for the version that is scheduled to be presented at a conference. Here's the schedule:

Draft One: Saturday, August 2, 2014
Draft Two: Wednesday, August 20, 2014
Draft Three: Wednesday, September 3, 2014.

The main confounding factor is the looming deadline for my larger project. Oh, but I do want to make a kidney reading commitment. I hope, within one week, to complete reading the very interesting book, The Kidney Sellers, by Sigrid Fry-Revere, concerning the Iranian system(s) of compensated donations; it's been a treat so far.

Here's the current abstract:

Healthy adults are allowed, and even encouraged, to donate a kidney to patients in dire need of a functional kidney. The encouragement can take various forms, but under US law (and under the laws of most other jurisdictions), a kidney donor cannot receive any “valuable consideration.” The standard contention that informed, rational, voluntary exchange between adults is mutually (and, absent negative externalities) socially beneficial does not carry the day with respect to current public policy towards compensated kidney donations.

Arguments in support of the ban, then, tend to focus on the extent to which a compensated kidney transfer is informed and voluntary and rational, and on the possibility of negative externalities. Those externalities might be of an abstract nature, such as a view that organ sales are repugnant (Roth, 2007). The wide support that uncompensated kidney donation receives, however, suggests that considerations of coercion, poor information, departures from rationality, and negative externalities are perceived as being more potent in the realm of organ transactions when valuable consideration is added into the mix.

Departures from rationality in individual decision making are the central focus of behavioral economics, and hence behavioral economics has direct applicability to the debate on compensated organ donations. In Beard and Leitzel (2013), we briefly discussed some behavioral influences – risk misperceptions, loss aversion, the endowment effect, and present bias – on the decision to donate a kidney. The goal here is to broaden and deepen that analysis, and to go beyond donors to look at behavioral influences on four other sets of actors: patients and potential patients, family members of patients, organ procurement agents, and physicians and other medical personnel. How does the addition of valuable compensation to organ donors influence the rationality of the decisionmaking of all actors involved in transplants? How can a compensated system be designed to address the concerns that are heightened with respect to kidney sales as opposed to uncompensated donations?

Update on the Four Drafts Paper

Back in early April we posted Draft 3.5a of the handbook chapter on vice regulation. Just wanted to indicate what happened from that point. First, a version nearly identical to Draft 3.5a was sent to the editor of the volume at about the same time that the draft was posted here. A mildly updated version was sent a few weeks later, and that is where things now stand. The editor's initial reaction was rather favorable, so if all goes well, the revisions for the published version will be minimal -- I'll let the devoted Five Drafts reader know about any new developments. But now, I need to set some draft deadlines for another paper....

Draft 3.5(a), Composite

Draft 3.5(a) of Regulating Vice

1.Vice

2. Why Regulate Vice?

3. Surveying the Range of Controls
          First half
          Second half

4. One Guiding Principle for Vice Regulation

5. Robustly Regulating Casino Gambling

6. Changing Times

7. Vice 3.0

References

Draft 3.5(a), References

References

Becker, Gary and Kevin Murphy, “A Theory of Rational Addiction.” Journal of Political Economy 96: 675-700, 1988.

Bentham, Jeremy, An Introduction to the Principles of Morals and Legislation. New York: Hafner Press, 1948 [1823].

Bogart, W. A., Permit But Discourage: Regulating Excessive Consumption. New York: Oxford University Press, 2011.

Cook, Philip J., and Michael J. Moore, “The Economics of Alcohol Abuse and Alcohol-Control Policies.” Health Affairs 21(2): 120-133, 2002.

Carpenter, Christopher, and Carlos Dobkin, “The Minimum Legal Drinking Age and Public Health.” Journal of Economic Perspectives 25(2): 133-156, 2011.

Crime in the United States 2012, Federal Bureau of Investigation; available at http://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2012/crime-in-the-u.s.-2012/persons-arrested/persons-arrested.

Cunningham, Scott, and Todd D. Kendall, “Prostitution 3.0: A Comment.” Iowa Law Review Bulletin 98: 131-141, 2013.

Cunningham, Scott, and Todd D. Kendall, “Prostitution 2.0: The Changing Face of Sex Work.” Journal of Urban Economics 69(3): 273-287, May 2011.

Federal Bureau of Prisons, Inmate Statistics, Offenses; available at http://www.bop.gov/about/statistics/statistics_inmate_offenses.jsp.

Fong, Timothy W., Michael D. Campos, Mary-Lynn Brecht, et al., “Problem and Pathological Gambling in a Sample of Casino Patrons.” Journal of Gambling Studies 27(1): 35-47, March 2011.

Gruber, Jonathan, “The Economics of Tobacco Regulation.” Health Affairs 21(2): 146-162, 2002.

Gruber, Jonathan, and Botond Köszegi, “Is Addiction ‘Rational’? Theory and Evidence.” Quarterly Journal of Economics 116(4): 1261-1303, November 2001.

Holford, T. R., R. Meza, K. E. Warner, et al., “Tobacco Control and the Reduction in Smoking-Related Premature Deaths in the United States, 1964-2012.” Journal of the American Medical Association 311(2): 164-171, 2014.

Kilmer, Beau, and Keith Humphreys, “Losing Your ‘License to Drink’: The Radical South Dakota Approach to Heavy Drinkers Who Threaten Public Safety.” The Brown Journal of World Affairs 20(1): 267-279, Fall/Winter 2013.

Leitzel, Jim, “Toward Drug Control: Exclusion and Buyer Licensing.” Criminal Law and Philosophy 7(1): 99-119, 2013.

Leitzel, Jim, “On Self-exclusion.” Milken Institute Review, 76-81, First Quarter, 2008. Leitzel, Jim, Regulating Vice. New York: Cambridge University Press, 2008.

Leitzel, Jim, “Secret Deviants.” Carceral Notebooks 2: 121-125, 2006.

MacAndrew, Craig, and Robert B. Edgerton, Drunken Comportment: A Social Explanation. London: Thomas Nelson and Sons, 1969.

MacCoun, Robert J., and Peter Reuter, Drug War Heresies: Learning from Other Vices, Times, and Places. Cambridge: Cambridge University Press, 2001.

Mill, John Stuart, On Liberty, edited by Elizabeth Rapaport. Indianapolis: Hackett Publishing Company, 1978 [1859].

Mill, John Stuart, Principles of Political Economy with some of their Applications to Social Philosophy. William J. Ashley, ed., 1909 [1848]. Library of Economics and Liberty; available at http://www.econlib.org/library/Mill/mlP.html.

Ng, M., M. K. Freeman, T. D. Fleming, et al., “Smoking Prevalence and Cigarette Consumption in 187 Countries, 1980-2012.” Journal of the American Medical Association 311(2): 183-192, 2014.

Nelson, Sarah E., Debi A. LaPlante, Allyson J. Peller, et al., “Real Limits in the Virtual World: Self-Limiting Behavior of Internet Gamblers.” Journal of Gambling Studies 24(4): 463-477, December 2008.


Nutt, David, Drugs Without the Hot Air. Cambridge: UIT Cambridge LTD, 2012.

Peppet, Scott R., “Prostitution 3.0?” Iowa Law Review 98, 2013.

Room, Robin, “Individualised control of drinkers: back to the future?” Contemporary Drug Problems 39(2):311-343, 2012.

Smith, Adam, An Inquiry into the Nature and Causes of the Wealth of Nations, Edwin Cannan, editor. Chicago: University of Chicago Press, 1976 [1776; Cannan edition, 1904].

Spinoza, Benedict de, The Chief Works of Benedict de Spinoza, translated from the Latin, with an Introduction by R.H.M. Elwes, vol. 1 Introduction, Tractatus-Theologico-Politicus, Tractatus Politicus. Revised edition (London: George Bell and Sons, 1891 [1670]). Available from The Online Library of Liberty, at http://oll.libertyfund.org/index.php?option=com_staticxt&staticfile=show.php%3Ftitle=1710&Itemid=27#toc_list

Stutz, Howard, “Singapore casinos produce $6 billion in gaming revenue in 2013; market still trails Las Vegas Strip.” Las Vegas Review-Journal, February 21, 2014.

Thaler, Richard H., and Cass R. Sunstein, Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven & London: Yale University Press, 2008.

Thompson, William N., “Handling Corporate Social Responsibility: A Third Way.” Gaming Law Review and Economics 14(5): 355-361, 2010.

Tomkins, S., L. Saburova, N. Kiryanov, et al., “Prevalence and socio-economic distribution of hazardous patterns of alcohol drinking: study of alcohol consumption in men aged 25–54 years in Izhevsk, Russia.” Addiction 102(4): 544-553, 2007.

Weitzer, Ronald, Legalizing Prostitution: From Illicit Vice to Lawful Business. New York University Press, 2012.

WHO Framework Convention on Tobacco Control. World Health Organization, updated 2005; available at www.who.int/fctc/text_download/en/.

Williams, R. J., R. A. Volberg, and R. M. G. Stevens, The Population Prevalence of Problem Gambling: Methodological Influences, Standardized Rates, Jurisdictional Differences, and Worldwide Trends. Report prepared for the Ontario Problem Gambling Research Centre and the Ontario Ministry of Health and Long Term Care, May 8, 2012 available at http://hdl.handle.net/10133/3068.

Zimmerman, M., I. Chelminski, and D. Young, “Prevalence and diagnostic correlates of DSM-IV pathological gambling in psychiatric outpatients.” Journal of Gambling Studies 22: 255-262, 2006.

Zinberg, Norman E., Drug, Set, and Setting: The Basis for Controlled Intoxicant Use. New Haven: Yale University Press, 1984.

Draft 3.5(a), Section 7

7. Vice 3.0

It is a commonplace to note that the internet has changed everything, and this trope would apply to vice regulation, too. Then again, vice has changed the internet: pornography, gambling, prostitution, and prescription pharmaceuticals have been major elements of web commerce almost since the internet’s inception, and have helped to push forward internet technology, including web video quality, anonymity protections, and age verification. But the direction of influence that moves from the internet to vice is, if anything, more profound, and holds the potential to drive future policy regimes.

In the case of pornography and gambling, the internet has allowed “consumption” to take place in the privacy and comfort of one’s home, instead of in a public theatre or casino, say. This privatization of consumption represents a vast expansion in the availability of these vices. Often the existing regulatory structure pre-supposes or enforces a certain level of availability and a specific mode of consumption. Regulations aimed at bricks-and-mortar casinos or strip clubs might not extend to internet gambling or webcam porn, leaving these types of online vice initially unregulated. Simultaneously, the external costs associated with vice consumption can be reduced via private consumption; public nuisance problems or streetwalking in the area of a triple-x theatre do not have obvious parallels with internet porn.

At-home participation also goes a long way to eliminate some of the non-monetary “costs” of consuming vice, such as the potential for embarrassment when seen walking into an adult book store or cinema, or when transacting with the clerks in such establishments. Prescription pharmaceuticals such as Viagra might be purchasable over the internet without an initial in-person consultation with a physician. Payments for internet vice might be shielded from the view of family members, too, through the use of PayPal or Bitcoins. Greater availability and lower costs suggest the possibility of considerable increases in consumption and perhaps compulsive behavior. Surely internet pornography and gambling have led to addictive conduct among many people who were not at much risk of a non-virtual porn or betting addiction; video games and the internet in general have sparked their own digital addictions (though perhaps these have served as a substitute for alcohol consumption or other vices that are less salubrious).

The internet has revolutionized what might be termed the supply sides of pornography and prostitution. Aspiring porn actors now need not travel to southern California; rather, they can produce – and distribute globally – pornography from their own homes. Escorts can advertise on the web, easing the task of making a connection with clients, and also use the internet to verify potential clients’ identities, reputations, and credit cards. Internet-based sex work is by no means a perfectly safe endeavor, but it involves much lower risks than streetwalking, and is perhaps safer still in areas where prostitution itself is legal (Weitzer 2012). Where prostitution is illegal, web publicity not only allows connections to be made, it allows law enforcers to track sellers, too. Nonetheless, the overall impact of the web seems to be, so far, on the side of diminishing the arrest risks for prostitutes (Cunningham and Kendall, 2011).

Along with a degree of anonymity, the web offers the ability to selectively undo that anonymity. Those with an interest in legal, consensual behaviors – behaviors that people might not want to openly disclose to the world – can make good use of the internet, then. People who would like to explore sado-masochistic sexual practices, for instance, can make connections over the internet in a relatively safe manner (Leitzel 2008b). They can learn about S&M, purchase books and equipment, and reveal their own experiences and fantasies. The internet has proved to be a huge boon to poker, as players can easily be brought together via the web nexus, and novice players needn’t fear face-to-face embarrassment from poor play, while honing their skills at low or even zero stakes.

Vice researchers, policymakers, and the public at large also can be educated via the internet. To the extent that it is unfamiliarity that stokes fear and suspicions of immorality, the internet holds the potential to broaden minds and liberalize the attitudes and laws that currently are arrayed against seemingly immoral vices. As always, however, the vice-related internet is doubled-edged, and depictions of odd or alarming behavior by vice participants can go viral on the web – this happened in the US in the case of the drug mephedrone (“bath salts”), which was banned in 2011 – and induce those moral panics that often drive repressive legislation. (Moral panics are not an exclusively digital phenomenon, of course; regulatory action against mephedrone in the UK was stimulated by various mistaken newspaper reports of horrific outcomes for some young people suspected of using the drug (Nutt, 2012).) The intended “selective disclosure” of sexting or social media photos of drinking or drug taking has proven to be insufficiently selective at times, with indiscretions becoming widely publicized and available to almost anyone, including future employers.

Beyond offering much greater availability to vice, the internet eases the access to treatment resources: people can be just as shy about seeking treatment as they are about publicly indulging in vice, so options to contact treatment providers over the internet can be helpful. Web-based casinos can be required to provide links to treatment providers, as well as highlight opportunities to self-exclude or self-limit.

The internet can go beyond reducing information and transaction costs and enhancing privacy; rather, it can facilitate a wholesale transformation in the nature of commercial vice, something akin to how the internet and digitization revolutionized “games”. Prostitutes and their clients, for instance, could be thoroughly vetted for disease, trustworthiness, financial solvency, and safety, even while protecting their anonymity, through internet intermediaries that collect and verify information on STD tests, credit histories, and criminal backgrounds, for instance, and allow both the buyer and seller access to that information before their encounter. (This scenario is developed more fully in Peppet (2013).) The harms associated with prostitution thereby might be greatly diminished. Personalized drugs might be designed and purchased via the web, or fabricated at home from web-acquired directions on 3D printers.

In terms of the robustness approach to vice regulation, the internet, on balance, and for the time being, seems to be helpful. Vice consumption choices are better informed, with the dangers of vices and the effects, many of them unintended and negative, connected with regulations made clearer. Those repressive regulatory regimes that are furthest from meeting the robustness principle, especially drug prohibition, are eased somewhat, and have their harms reduced, by the de facto web-based liberalization (Pepett, 2013; Cunningham and Kendall, 2013). This liberalization might make it still more evident that vice cannot be abolished – at least at any tolerable cost – and illustrate Spinoza’s wisdom, that “It is best to grant what cannot be abolished, even though it be in itself harmful.”

Draft 3.5(a), Section Six

6. Changing Times

The absence of significant harms-to-others from vice lends an instability to vice policy. If burdens or punishments cannot be calibrated against the harm of an act to society, fads and moral panics tend to fill the vacuum. At any rate, vice regulation demonstrates tremendous variation over time and place, with specific vices sometimes banned, and at other times made widely available and all-but-lauded. Some of the recent trends will be outlined here.

(1) Tobacco  The regulatory approach to tobacco, and particularly towards cigarettes, has become much stricter in recent decades. The tightening of restrictions on tobacco is a global phenomenon. The World Health Organization’s Framework Convention on Tobacco Control came into force in 2005, and has been joined by more than 175 nations. The Convention commits countries to an array of measures, including taxes and advertising controls, aimed at reducing tobacco consumption. In the US (which signed but never ratified the WHO Convention), higher taxes and diminished availability of vending machine outlets for cigarettes are two notable changes of the past twenty years, but perhaps most telling is the severe reduction in legal places to smoke in public. A trend that started with bans on smoking in airplanes and hospitals, has, in the US as in much of the world, spread to most workplaces, restaurants, and even pubs. In the US, the percentage of adults who smoke has fallen from over 40% in the mid-1960s to about 18 percent in recent years – a smoking rate that is near the global average (Holford, Meza, Warner, et al., 2014; Ng, Freeman, Fleming, et al., 2014). We have come a long way (baby), from the World War I and World War II eras, when cigarettes were included in the rations provided to soldiers and prisoners of war.

(2) Marijuana  Marijuana has been globally prohibited (and covered by the UN conventions on drugs that promote worldwide prohibition) for many decades now, but the once near-consensus that a ban (usually extended to possession as well as purchase, sale, manufacture, and transport) is desirable has shown significant cracks. (The three UN drug treaties can be accessed at http://www.unodc.org/unodc/en/treaties/index.html?ref=menuside.) Initial forays have included the legalization of marijuana for medical purposes, a change that has occurred in 20 US states and the District of Columbia. (Marijuana, medical or otherwise, remains prohibited at the federal level in the United States.) Uruguay has legalized marijuana for recreational use, too, as have two US states, Colorado and Washington. Many countries and US states have adopted decriminalization or depenalization reforms that generally preclude any sort of serious punishment for marijuana users, though sellers might still be arrested and receive significant jail time.

(3) War on Drugs  Marijuana is one of the more benign of the currently illegal drugs, and also the most popular. These factors, perhaps combined with pot’s obvious ability to offer relief to some patients in medical distress, help to explain why marijuana is the drug for which global prohibition is proving least sustainable. Nonetheless, the entire edifice of a prohibitory stance towards recreational drugs also has begun to crumble, probably due to the horrific consequences of the war on drugs. Portugal, the Czech Republic, the Netherlands, Mexico, Argentina, Uruguay, and some other countries have adopted fairly broad depenalization plans for personal use, and addiction is treated in many countries as a health problem, not a criminal justice concern. Still, much of the world, including Malaysia, Singapore, China, Vietnam, Indonesia, and Iran, among other nations, enforces draconian penalties against those deemed to be in the illicit drug trade – and possession of rather small amounts of drugs is viewed as per se evidence as involvement in the trade.

(4) Gambling  The last half century has witnessed a significant global liberalization of gambling regulations. Since 1960, the number of US states hosting legal casinos (including Native American casinos) has gone from one to more than 30, and the number of states offering lotteries has climbed from zero to more than 40. Asia recently has become a world casino powerhouse: gambling revenues in Macau are much higher than in any other casino locale, while Singapore’s two casinos have combined revenues from gambling that are about the same as that generated by the dozens of casinos in Las Vegas (Stutz, 2014).

One hopeful lesson from the expansion of global gambling opportunities is that this expansion has not been accompanied by a significant long-term increase in the proportion of the population facing serious gambling problems; nonetheless, in the shorter-term, there is evidence that problem gambling tends to rise with gambling availability (Williams, Volberg, and Stevens, 2012). One possible explanation of the differing short and long-term impacts is that with time, the novelty of easily accessible gambling dissipates, while some problem gamblers are able to adapt to abstinence or a more recreational style of play. [Adam Smith (1776, p. 518) noted such a pattern with respect to an increased availability of alcohol: “When a French regiment comes from some of the northern provinces of France, where wine is somewhat dear, to be quartered in the southern, where it is very cheap, the soldiers, I have frequently heard it observed, are at first debauched by the cheapness and novelty of good wine; but after a few months residence, the greater part of them become as sober as the rest of the inhabitants.”]

(5) Prostitution  While tobacco has become more tightly regulated in recent decades, the trend for marijuana and other drugs, and in gambling, has been towards liberalization. Prostitution is harder to characterize on a leniency scale, as the world has been splitting between opposite approaches, one that accepts some forms of legal, regulated prostitution, and another that shifts the focus on the traditional ban from prostitutes to their customers. In much of the world, prostitution is illegal, though in some places where it is criminalized – including Thailand – it is tolerated, while in other locales it is severely punished. In Britain and Canada, prostitution per se is legal, though related activities, such a streetwalking or keeping a brothel, are illegal. Brothel prostitution is legal in many countries, including Germany and Switzerland, as well as in some Australian states. New Zealand has perhaps the most liberal rules governing prostitution: consensual agreements between adults for paid sex are legal, as are related activities, including streetwalking. The alternative approach of one-sided enforcement, where sellers are not breaking the law but buyers are, was instituted in Sweden in 1999, subsequently adopted in Iceland and Norway, and continues to be influential in prostitution policy debates.