good evening everybody we're going to have an english session here thanks to the audience for joining us in today's conversation thanks to tito boyeri and the organizers for for this opportunity uh and thanks to our our speakers my name is mario machis i'm an associate professor of economics at johns hopkins uh university it's my great pleasure to be uh moderating this uh panel today i'm going to introduce our our speakers and i'm going to introduce our our topic our speakers are professors uh nicola lachetta moreno and alvin roth unfortunately professor cincia caporale was supposed to be with us she couldn't join us due to some unforeseen events and we wish her well so nicola is associate professor of economics and management at the university of toronto in canada his research interests include the economics of innovation experimental economics and the role of psychology and ethics in influencing decision making related to today's topic nicola and myself and other co-authors have done quite a bit of work uh trying to understand the role of incentives in the context of blood donation we're also studying attitudes and preferences of people towards morally contentious transactions well we all know enya marino professor mourinho is currently a professor of surgery at sydney kimball medical college thomas the thomas jefferson university in philadelphia where he's also a strategic advisor to the president and the ceo of that university professor marino is a transplant surgeon in 1992-1993 he was a member of the team that that performed the first transplant a liver transplant from a baboon to a human being the first such transplant in the history of medicine in 2001 he performed the first organ transplant in italy on an hiv-positive person he is very interested and very passionate about civil rights including end-of-life issues and ethical questions about transplants and in particular organ organ trafficking and professor alvin roth you might have seen him at his talk yesterday and at his book presentation today his book has just been uh translated into italian it's called matchmaking la chance economica di dare access he's professor of economics at stanford university and he received in 2012 the nobel prize in uh in economics of course professor rod has a number of contributions in in economics and game theory experimental economics market design most relevant for today's conversation he studies morally repugnant transactions and he has helped create the kidney exchange program in the u.s and in other countries which is a system that has that to increase substantially the number of kidney transplants being performed uh so the topic of today's conversation is markets for body parts so some of you many of you perhaps are wondering why even think about introducing prices and economic transactions in the context of blood plasma and and organs only cold calculating economists could possibly think of consider even consider you know introducing prices in such context so why what is the reason so the reason is that blood and plasma transfusions and organ transplants are often necessary to save lives and economists are interested in them because these resources are resources are often scarce um so we're not just and of course you know studying you know how to allocate scarce resources is central to economics and we're not just talking about blood transfusions needed in case of accidents or traumas there are many diseases many types of cancer cancers leukemia anemia that require patients to receive periodic transfusions of blood or plasma or to to receive drugs derived from from plasma and often an organ transplant is the only option for survival for many patients for example in italy about 9 000 patients are on the waiting list for an organ of these almost 7 000 have kidney disease and so they're waiting for a kidney in 2016 um fewer than 2 000 kidney transplants were performed in italy we have a shortage of kidneys in in italy and that is also the case in many other countries almost 500 patients dropped out of the waiting list in 2016 without receiving a transplant either because they died or because they became too sick to receive the uh transplant in the united states of course the numbers are even bigger 100 000 people are currently waiting for a kidney and several thousands of people die every year so the demand for kidneys exceeds supply there's a shortage of organs for transplant this has large human costs and also financial costs the alternative to a kidney transplant dialysis is expensive and also unpleasant leading to reduce quality of life and also reduce life expectancy for pa patients compared to receiving a a transplant each transplant saves the american healthcare system about 200 000 dollars and this doesn't even include you know the uh you know improved life expectancy and quality of life including those quantities would lead to about one million dollars in in gains from each additional transplant so when economists observe a shortage in in a market they typically suspect that something's wrong with the price the price is too low otherwise supply would be higher in the case of organs the price is set to zero because it is illegal uh to pay money uh to kidney donors or other other organ donors in all countries around the world with only one exception iran and later today we will have an opportunity to briefly talk about the iranian system so patients who are waiting for a kidney or other organs they must rely on altruistic donors altruism is of course wonderful the problem is that altruism doesn't appear to be enough so providing monetary payments to donors or other forms of compensation can contribute to increasing supply saving lives and saving costs to the healthcare sector so why not allowing the price mechanism to to do the job we rely after all we rely on markets a lot in our in our society to allocate many types of resources however the fact that payments are essentially universally prohibited indicates that the opposition to such payments is strong so what are the sources of this opposition what are the concerns associated with payments for organs and other controversial transactions should we use can we use economic incentives in this context these are some of the questions that we will explore with our uh speakers today so the goal is not to provide the final final answers to these questions the goal is more modestly but importantly we believe to provide elements for discussion and elements that will enrich our thinking about these these issues so i would like to uh begin with professor marino um you have you know you've been a transplant surgeon for most of your professional life um and um so your perspective is we're very interested in in your perspective you've also been of course you know able to influence or attempt to influence policy in this in this domain so we're very interested in your perspective on on these issues so professor mourinho uh will um before he begins uh to talk he would like to show a video to the to the audience so i'd like to ask our every year thousands of organs are bought and sold on a flourishing black market with a single organ selling for up to two hundred thousand dollars some might consider that a small price to pay if it's about saving your own life but it's a complicated life and death business with legal moral and ethical issues involved they are the subject of a documentary called tales from the organ trade which tackles the problem from all points of view i sat down with the film's director okay i effectively have to decide at this point whether you know if i can't find a donor in this country fairly soon i have to decide whether i'm willing to take on my soul the ethical burden of purchasing a kidney from somebody or choose to die diseases like diabetes are increasing across the western world and the desperate need for kidneys leaves many patients struggling with difficult decisions as depicted in the documentary to live with the painful and time-consuming process of dialysis you can't stay on this machine forever it doesn't do what a kidney does this is it unless somebody offers me a kidney or unless a cadaver becomes available this is what keeps me in alive province in the philippines organ cells are common amongst the male population a documentary found many of them have no follow-up health care but for others with undetected kidney disease and other illnesses donating can be a death sentence based on the ultrasound findings the left kidney has a mild renal disease and this is a sign of a deteriorating left kidney there is really a problem he will be a candidate for dialysis and he himself will be looking for yes well good afternoon everybody and thank you to professor matches for his kind introduction as he stated i've been for most of my life a transplant surgeon and therefore you know i really believe that transplantation is a terrific achievement in healthcare and through transplantation we can not survive but get back to a normal quality of life there are people that you know do incredible things in their life after being saved through an organ transplant a transplantation is actually in medicine relatively new because as yesterday professor rod showed to us the first successful kidney transplantation happened only one year before i was born happened in 1954 so compared to you know other things in medicine is a completely new branch and has been incredibly successful in a very in very few years was not like that at the beginning at the beginning most of the people were dying after a transplant but nowadays the success rate the organ survival for example for a kidney at one year is close to 98 99 so you know going from zero percent to 99 in a matter of a few decades is something that is not very common in in medicine and in surgery on the other hand uh it has been victim of his own success as a professor matches did say before as we speak here comfortably sitting in this nice room there are 100 000 people are waiting for an organ transplant in the united states of america and about the same number of people in our continent in europe nine thousand only in italy and only you know by the end of 2017 only 15 percent more or less of these people we get an organ and the other people will continue to wait and many of them will die awaiting a foreign organ actually i can tell you that as a transplant surgeon the single question that any patient ask you after you see him the first time every time you see him the first question is when i will have my organ when will i get a kidney when i will get a liver and you know therefore um because of that and because we live in a society where we are used to buy and sell whatever we need in our life a market that is obviously an illegal market developed in the last few decades in many countries in the planet and basically you know people go in other countries and try to get a key name most of the time is a kidney donor because obviously we have two kidneys and and i believe so i start you know the our discussion with a strong statement that you know exploiting the life of somebody else that is poor because does not have enough money to you know to give food to their children or enough money to have a decent life and buy his or her kidney for 800 900 dollars and you know all the organizations surrounding this event will make thousand two hundred thousand dollars i think that is really not a moral action i think that is a crime because obviously i don't think that we ever heard about somebody that has an income of 500 000 per year that is selling a kidney to somebody while we hear about people that are desperate and are selling their kidneys and there are things that are even worse than these because uh you know for many years in a can in a country in a specific country china the the many the most of the organs are used for transplantation uh were harvested from people that were killed because they were executed prisoners prisoners that had the death sentence and they were killed with a bullet in the back of their head and they moved faster to an operating a mobile operating room the organ harvested and is not fiction this happened thousands and thousands and thousands of times and if you check on google you can see that people could actually schedule when to get a heart transplant because the people in china who'd match you with the perfect donor that there was a prisoner and they you know decide on which day they execute that prisoner to get the heart or deliver and they sell to this foreign patient that organ and the operation for saving seventy or eighty thousand uh eighty thousand dollars i think you know thought that this is a issue that uh i i spoke about a stream but what i would like to discuss today and hopefully you know even if professor matches say that we cannot get to a conclusion or something but i think it would be nice to understand what we think about maybe not giving money which as i said i consider a crime to uh you know to to buy an organ from a human being but maybe to remove some of the disincentive in donating an organ and my question to the other panelists here is what do we think about a situation where for example not an individual but the state you know pays for the funeral of somebody and you know in in exchange uh the family donates the organs that anyhow are going to be buried with a cadaver to the society so not to an individual not a single person but to the sickest on the transplant waiting uh leases this wrong or this is something that we could possibly consider and you know and the other thing is the thing that uh made one of the things obviously amongst many things that made alvin wrote famous in the transplant community is you know starting a chain and i will try to explain with my words um within our planet you know for example if i uh i'm a very good friend of alvin and he needs a kidney and i because of emotional relationship i decide to give my kidney but i cannot give my kidney because i have a different blood type so he cannot get my kidney somebody somebody in some other part of the planet is in the same situation with a different blood type isn't that good to try to fund a system that that person may be from a country where he cannot have any access to any treatment so he will die and we are not talking about fantasy because as we speak some something in between of two to seven million people every year die because they have no access to dialysis no access to transplant so maybe a country that has more money can you know help the patient that has an insurance or has the national health system that is supporting the transplant and at the same time you know performing the transplant with the other patient that is coming from a country where he has no access to any kind of treatment and i believe that there is a this is really a win-win situation because you know somebody that will not have access to treatment will actually have access to treatment and you know our country where we have a national health system we pay about 100 000 100 000 euro per year for a dialysis treatment if that patient get a kidney next year we will cost to the society only 15 000 dollars but there is even more than that because the patient you know think about somebody that is going to dialysis three times a week and then we will have very very little strength to do to do much in his life instead is going to be back a productive member of the society and you know so this is the the state the health care system will save money the person will get to it back to a normal life and somebody else in another country will has a will have a chance to a good life that obviously before he did not have because there is no treatment no money for dialysis no money and no equipment for transplantation so i guess you know i just wanted to make this short introduction i think then we will get to other questions by you know seeing what we consider uh moral what we consider immoral what we think we could do is such a difficult issue like you know consider organ as a you know thing that we can use to save a life but at the same time you we should not probably consider them as you know something that we can buy or sell because otherwise we are going to exploit uh you know the life of people that are poor thank you thank you thank you professor mourinho so professor roth of course you're welcome to address the question that professor mourinho posed but i would like you to tell the audience something specific you've been a pioneer in many areas in economics in one one in particular you've been the first to point out to economists that we need to take moral repugnance seriously if we want to understand why many societies do not allow the price mechanism to operate in certain contexts so the case of human organs for transplantation is very interesting both because of its human and social implications but also because societies are banning the sale of a good whose supply we actually wish to support and encourage um you know giving an organ to somebody who would otherwise die so um what is moral repugnance and how is it that it influences what types of transactions society is allowed to take place well my uh my first paper on repugnant transactions was called repugnance as a constraint on markets and i'm a market designer i tried to make things work better i you know to improve welfare but of course sometimes economists can have ideas of improving welfare and and other people will say to them you know professor maybe that's not such a good idea and so certainly the buying and selling of kidneys is illegal just about everywhere in the world and whatever your opinion is on whether kidneys should be bought and sold and whether donors should be compensated when you see something that's against the law everywhere in the world you have to be a little impressed by that and think that whether you think those are good laws or bad laws they might be hard to change because when something is against the law everywhere there's probably powerful forces in motion and so we started kidney exchange as a way of increasing the supply of kidneys without engaging in monetary payments but let me try to put the question of repugnant transactions in a little bit of a broader context for hundreds of years in the middle ages it was considered repugnant to charge interest on loans in europe now today with some exceptions in islamic jurisprudence we're mostly pretty comfortable with the idea that that we can charge interest on loans and it would be hard to imagine our global capitalist economy if we didn't have a market for capital so so sometimes old repugnances fade but also i i spoke earlier today about my book sometimes things that were not so repugnant in the past become repugnant in the united states we used to have markets for slaves we don't anymore so aside from kidneys and organs for transplant you might want to think about the different repugnances in different parts of the world for for other transactions for instance one that has been well some related transactions that have been uh cause of current controversy here in italy are same-sex marriage and surrogacy which fit together a little bit because uh same-sex couples particularly male couples don't have a womb between them and so if they want to have children they have to find some some other arrangement and in california where i live surrogacy is perfectly legal you can pay surrogates you can sign a contract that will engage a surrogate and will have your name on the california birth certificate as the parent here in italy that's not the case at all incidentally in the united states we also have same-sex marriage in all states now only for the last two years it was a long difficult process a political and legal and legislative process in italy surrogacy is not legal but recently here in trento a court allowed uh a couple a male couple to adopt the child who they had had through surrogacy in canada whereas not long before court elsewhere in italy seized a child from a couple that came back from russia with with a surrogate baby and put it up for adoption and the european court of human rights you know ratified that decision so surrogacy in a way is also selling of body parts right it's renting a womb and in california which is a very civilized part of the world we have very different rules about that than you do here in italy so so partly we can learn from the experience of places that do different things to find out what are the consequences whether terrible things happen or good things let me also just partly remarking to ignacio's story about black markets black markets are run by criminals and by and large you have to be a pretty desperate person to to engage in a market run by criminals because they are criminals they might not do what they have promised for you they might you and they will be outside the law we can have a good discussion of whether and if so how donors might be compensated or disincentives might be removed as as ignacio began to to explore uh without having to think that they would look like illegal black markets you know again i live in well in the united states from the late 1920s to the early 1930s we had a constitutional amendment against the sale of alcohol it's called prohibition and it gave rise to organized crime and illegal bootleg whiskey but today since the early 1930s it's again been legal to sell alcohol in the united states and today you can go into a wine store and buy wonderful italian wines in the united states which is a good thing by itself and it also limits some of the bad things that happened when only criminals could sell alcohol so i think that as we speak about whether and how uh incentives even monetary incentives might be used for for body parts we should keep in mind that if we wanted to go in this direction we would have to design ethical safe markets that would allow us to increase the supply of kidneys of blood of blood plasma and and they we would want to prevent them from being black markets and in fact there are two ways to try to prevent illegal transactions one is to increase the police enforcement and the penalties and the the the war on drugs for example and another is to allow legal markets to compete with the illegal markets so in the united states we are presently seeing some shift state by state in whether it is illegal to buy and sell marijuana in many states it's now in the united states it's now legal to to consume marijuana for medical purposes and in a growing number of states in colorado and washington and oregon it's it becomes legal to consume marijuana for recreational purposes now marijuana is like is regulated like alcohol in these places it has good and bad consequences to to have legal marijuana but we were never able to eliminate the illegal market for marijuana just as we are not able to eliminate the illegal market for heroin which i think everyone agrees is never good for anyone but in the united states the war against drugs has filled our prisons this is not a good thing either so laws against and regulated markets for both come with trade-offs and it's the job of economists to think about trade-offs thank you i i just want to add one detail to what brilliantly alvin roth said and that you know our society any society italy united states any country you know in europe we actually pretend that we do not see what is happening and why i'm making such a strong statement because think about the physician in our national health service or a physician in united states doesn't make any difference that we have you know a public health service or insurance-based health service you have a patient that up to a month ago came to you as a physician and you were following him through dialysis and then all of a sudden goes to the general practitioner and doesn't need you know help to go to dialysis but need a prescription for immunosuppression because all of a sudden has a new organ and does not have a medical record from a hospital where he got the organ so you know these things happen every day in front of our eyes and we just pretend that we don't see them thank you like to now turn to professor lachaitera so among the objections put forward by opponents of economic incentives or payments to organ donors two objections have been particularly influential in the policy debate and for actual policy making the first is that introducing payments for an activity that people already perform even in the absence of payments out of altruism um so out of a desire to help others that introducing incentives in these contexts might reduce people's intrinsic motivation to do so and so intrinsic motivation is the satisfaction that people derive simply from you know performing a certain a certain action from helping others in this in this case and so through this mechanism the object the objection is that introducing incentives might actually reduce donations rather than increase donations the second objection is that the promise of a payment might attract the wrong kind of donor for example in the context of blood donation the concern is that monetary payments might induce individuals who are more likely to have infectious diseases for example to give blood and and therefore the the incentives could jeopardize the safety of the blood supply now these are of course hypothesis that in principle can be empirically tested uh so what is the empirical evidence on this and how real is the concern that incentives reduce intrinsic motivation and that jeopardize the safety of blood supply and other so yeah we started to look at this problem uh especially with the focus on the donation of blood and blood components with with mario and other cauters and we realized that the debate has been going on for a long time since the early since the early 70s and uh but there wasn't really satisfactory empirical evidence there in good data telling us do rewarding donors in some way does it wouldn't know in some way actually increase or decrease a supply of blood or maybe doesn't have any any impact any but whatsoever and so it's just a cost that we might want to avoid so we set out to perform a number of studies collecting data from different countries uh both retrospective data and also data from randomized trials that we run in argentina in the us mostly in italy as well and even from this very different context and with partially different methodologies actually we got very sort of consistent uh results that the different incentives the different rewards uh uh that the donor received actually helped in increasing supply uh increasing the amount of blood that was available without any consequences on what we can call the quality of blood infections or the percentage of people who are ineligible to donate because of their health history and so on and so forth and uh so in a sense uh we didn't mean to uh sort of settle the debate science always uh evolved but we you know we we thought we'd at least channel the debate in the right uh in the right place you know asking the question do incentives work if they work well let's implement some of these incentives things didn't go so easy in some way because we got quite a bit of pushback from various agencies like the who the world health organization and others and what they were criticizing us for was was actually quite interesting so they weren't criticizing the results or the quality of the methods they were using they were essentially saying we believe your results we believe what you found that providing some incentives will actually increases supply we just we just don't like it we don't like the idea of it and so in a sense they were telling us we kind of prefer a system where we have less blood available for uh transfusion but we don't give any compensation to um uh to donors uh and so that's what that's why we sort of got interested in the idea that maybe it's not just about providing evidence but it's to a large extent about understanding the social support or the level of moral repugnance uh toward certain markets certain transactions when they include some form of uh compensation and that's how we got to know uh al's work on uh repugnant transactions and we wanted again to apply empirical methodology to understand are actually uh people are people really sort of concerned about the moral issues around paying for blood and for organs as well and what are the concerns uh that people have so some of the studies we recently uh we recently run asked exactly this question what we found is actually people have some ethical concerns so by serving a few thousand individuals in the u.s it turns out that if you ask them what do you think essentially about a system that includes payments they do consider it more coercive than a system without payment so they have a sense that maybe people are making the choice to donate when there is money uh on the table uh not really freely they're not doing it completely willingly uh they they have concern about the fairness of these transactions and also concerned about the fact that the human body shouldn't have a price so there is a degradation of in a sense of um of the human body or human dignity however it turns out that payment per se uh the presence of a payment is not what really concerns people and here i come to what uh inator was saying a minute ago about proposal various proposals so if the payment comes from a third party say the government the public sector not from the recipient so it's not the system of individual transactions that people are actually much more comfortable with the idea of providing payments because they consider that this is a fairer system as opposed to a system of individual transactions where essentially those who have more means are richer have more possibilities to find uh to find the kidney maybe at the expense of a poorer of a poorer person so people sort of their concerns are allayed by the fact that the third party provide equal opportunities to uh to everybody and they are willing to consider this system with payments as long as at least hypothetically we couldn't test this because you know pain is illegal uh but at least hypothetically people are willing to consider are willing to support a system that includes payment if that increased increased supply so what we derived from this is that yes moral issues are an essential part of the picture of understanding how we can increase supply but these values these moral values that people consider are not entirely sacred they're not values that people are not willing to compromise against anything in front of a significant increase in the supply for example of kidneys people are willing to consider the idea of uh of the payment i also wanted to connect to another thing that nazis said that i found extremely uh sort of inspiring and interesting he was saying you know one question you are asked by a patient is when will i get my kidney right was it one or two years ago i don't even remember now we had the symposium at johns hopkins university al and mario were there and dr arthur matas uh was there he's a transplant surgeon and so he said yes that's one question he said exactly the same thing that that's the first question you are you are asked and there is one thing you don't want to tell people and it is we don't have any kidney for you sorry and he was initially in his career very opposed to the idea of any form of compensation but he came to the point of saying i am tired of telling people we don't have a kidney for you i can't do it anymore it's it's really too much we need to do something and it seems very much in line with what the larger uh sample about 3 000 people in our in our survey we're saying essentially in front of some significant increase in supply well let's let's think about it at least so that's where we are uh at least my knowledge with the evidence about about these issues to date thank you nico so i so i i would like i mean this is already sort of conversation taking the shape the shape that i was hoping meaning that i was hoping that this could generate some conversation and debate between our speakers and so i'd like to invite them to ask each other uh you know questions uh how would you like to start okay well we we discussed some of our questions before so so i thought i have a question for ignazio um some incidentally sometimes people's ideas about what's a bad idea or a good idea when it comes to things like selling body parts sometimes people have very strong opinions they think that not only are some things bad ideas they're the kind of bad ideas that only bad people have and recently ignazio was at a meeting of the uh pontifical academy of sciences the vatican's academy of sciences that that was a very interesting meeting it spoke about organ transplantation and included a delegation from china which as ignacio mentioned is a tough country for transplants and they issued a statement which said that three things were crimes against humanity now that's language that that is nuremberg language crimes against humanity we normally think of as war crimes world war ii they said three things are crimes against humanity one is killing prisoners for their organs another is compensating living donors voluntary donors and a third is compensating the families of deceased donors and my question to ignacio is of these three things it seems to me that one is different from the others well i agree with the conclusion of professor roth but let me explain a little bit about the meeting that he described to you this meeting was arranged as he said by the pontifical academy of science which is a you know is an academy that has been there for a number of years is the academy that brought to trial like galileo galley so you know and so and um you know thanks god nowadays you know they they they do not have the same kind of procedures otherwise most of us will will not end in a nice in a nice way but jokes aside you know there was a more than a discussion actually there was there were arguments about uh this meeting and you know arranging this meeting and inviting people at this meeting we were about 60 people mostly transplant surgeons or transplant physicians and the critical question was is it right or is it wrong to invite the people that are performing transplantation in china using organs coming from executed prisoners and i have to be honest with you i was uh you know not very much in favor of inviting them and maybe i was wrong i don't know i think everybody needs to develop his own judgment on that because you know the the idea was exclude them from a public debate and a public community where to discuss you know what is right what is wrong or include them and you know maybe establish new rules and you know in a way push them to obey to this kind of rules that we think are right and not to their to their system so the first day actually was really i was as i was telling al before was really tough because you know nobody was addressing this issue directly and at a certain point you know i say look you know the question and i had just in front of me huang yeefu is the most important uh transplant surgeon in china and he probably transplanted thousands of organs that came for prisoners that were killed and i said you know the the bottom line at the end of the day is this is it right or wrong that somebody that you know is in italy or united states or france and as we have seen on that video before is living because of dialysis or maybe has a cirrhotic liver or you know a failing heart and it is right or wrong uh you know for the for this person that has you know the amount of money that is needed uh to go and on google to connect with people in china send his medical records and you know get back a notice that he needs to travel uh you know on august 15 because the following week they will have a heart donor with a perfect match and it will cost 70 000 to him i mean if they can schedule a perfect match for the week of august 15 that means that they will kill somebody the week of august 15. and so you know the discussion developed and at the beginning was not uh that nice because the people from china you know declared themselves offended because they said that you know these people this is their law and you know is the republic of china they have that sentence as it exists in united states of america and the difference that in the united states of america they kill people with that centers but they don't save people with their organs and they they say also that they were spontaneously donated because the prisoner would sign you know a donation act but before getting killed but i don't think he agreed on getting killed you know he just signed the donation act before but i don't consider that the free donation donation act and so to answer to the to the important question of all why three different things like that were put together because they you know insisted in having everything put together in order to accept uh to call what they were doing a crime against against the humanity and you know maybe it just doesn't mean much but we all got the participant to that meeting last week we all got an email from some physicians in singapore and this group of physicians wrote to us that for the first time ever in the last three months they didn't get any as i was saying before you know if you get an organ in in and you do not have medical records no matter what you need to go to your physician to get immunosuppression because you need the anti-rejection drugs and this physician in singapore said that for the first time ever they didn't have anybody coming back from china with a new organ asking for anti-rejection drugs so maybe they stopped but so far they did not accept any random inspection uh to their hospital so you know is is difficult to say if they really uh stopped to use the organs of uh killed the prisoners because they did not accept for people from other countries to go and see what they are doing in their hospital i do really think that is really bad and that we need you know to fight these things because i maybe considering extreme but i think is i do think is a crime uh you know and is something that should not be performed uh if you uh are on dialysis um obviously is right for you to hope to have a organ and to get back to a normal life but i don't think that just because you have the money to do so you can you know just say okay who cares if somebody get killed and i get the org and you know i go back to a normal life and next year instead of buying a new bmw i just buy a new heart i think that is wrong so i i had a question for uh for all so yesterday in your lecture um you told us a lot about kidney exchanges and kidney chains and how they have helped enhancing the supply supply of kidneys mostly in the us but now also in other countries including italy and uh and you as well as tito boeren introducing your lecture really stressed how you know this is uh you know a great application of economic theory and market design in trying to increase efficiency so in this case in increasing the supply of kidney in a way that is uh socially and ethically acceptable and so i mean this is an incredibly important progress uh both in economics and in health care but in a sense this solution is is very specific right specific to the fact that we have two kidneys we can give one away while being alive and live live well in general with with the other it has to do with the fact that there are compatibility issues uh and so on so it's a very targeted uh solution so my question is can we think of the use of the tools of market design to improve the efficiency of other of these you know ethically uh controversial markets you were mentioning surrogacy uh earlier on think about in bitter fertilization but also medically assisted uh dying which is an issue that also initially has been discussed uh lately so can we think of market design solution to improve the efficiency of these markets while at the same time uh limiting as much as possible the moral concerns and increasing the social support for for this for this uh that's a good question and i i think that the tools of market design might be very useful for thinking about how to construct legal ethically acceptable markets uh and and part of the questions that you have to ask is what is it that we find so repugnant about the black markets that we see incidentally there are some markets that we successfully ban there are not black markets for instance if you wanted to murder someone probably you couldn't hire someone to do it for you there may be people who can do this but often they rely on employees there's not a spot market because we pretty successfully have through the legal process made sure that there's not a a thick market for for murderers but we're not nearly as successful at eliminating the market for heroin for example or cocaine and so sometime when we when we uh make laws against markets we are already doing market design we are designing the black market that will take the place of the legal markets and we might prefer to have legal markets that that mitigated some of the the harms that black markets can cause so for example one reason why why many people find markets for kidneys repugnant is we wouldn't like the idea that only rich people could have kidney transplants and only poor people would would sell their kidneys uh but as ignacio mentioned when he talked about uh perhaps paying the funeral expenses for deceased donors it doesn't have to be rich people buying kidneys this way it could be the the state you know one one buyer uh helping deceased donation to happen and then and then distributing the organs the way we do now but just having more organs uh so that's a case of a market design that that ignacio proposed in his comments that i think would address some of the concerns we have that it would give rich people unfair advantages in the matter of organs these questions the the question of will a market successfully overcome repugnance and become a socially supported market is a tough one to know the answer to when i was young the united states was engaged in the vietnam war and we had a conscription army the way we recruited soldiers was by by saying to them uncle sam wants you and and you had to be a soldier but when the war ended we had a big public political debate about whether we should move whether we should abolish conscription and move to what we call a volunteer army which is to say we would start to pay soldiers it would be a job and one of the concerns that was expressed was that maybe this would be a repugnant transaction maybe american soldiers would become to come to be seen as as mercenaries now we could have a long discussion about whether a conscription army or a volunteer army is a good thing or not but certainly in the united states soldiers have not come to be seen as mercenaries when we line up for getting on a an airplane we we line up behind serving soldiers and when someone runs for the senate if he was a serving soldier he's proud to to speak about it i served my country when i was young whereas other legal markets don't don't have that uh necessarily in many parts of europe in germany for example prostitution is legal but no one runs for german political office for mayor of bonn uh by saying you should vote for me because when i was young i was a sex worker uh so so the market has remained repugnant even though legal so i think the the issues to address the issues that market design would have to help us address are both how to organize markets especially in cases where we cannot prevent black markets and how to organize them so that not only would they increase supply but that they would be socially acceptable on this matter let me just add that the the questions about market design are sometimes complicated by the fact that we reached different solutions in different jurisdictions so so professor lachetta spoke about the market for blood and in the united states where i live we we get whole blood only from volunteer donors but we get plasma blood without the red blood cells and and those things we get those from paid donors in canada our neighbor to the north they think that it's a terrible idea to pay people for plasma and so they get all of their whole blood and all of their plasma from volunteer donors but this doesn't give them enough plasma so they buy hundreds of millions of dollars of plasma products each year from the united states where there's an abundant supply of plasma and plasma is not just the plasma itself it's medical products like interferon and and such which are valuable and save people's lives and the united states is a big exporter of plasma products so uh so our canadian friends are able to adopt uh what they regard as a very highly ethical position of not paying for plasma which they don't need to do because they can buy it from the united states thanks i i have a follow-up question and following up on some of what you just said and also to so some of what the um nico said earlier there seems to be a strong opposition uh towards you know individual transactions in you know individuals privately purchasing uh kidneys but in our work with nico we found that there is a lot less opposition to a system that separates organ procurement from organ allocation so with a with the government agency doing the procurement and so compensating the donors and then an agency again allocating organs according to some priority rules perhaps similar to the rules currently adopted to to allocate organs from uh from cadavers so unfortunately i mean unfortunately we only have one example of a legal system of uh uh our payments to kidney donors which is the example of iran we were talking earlier professor mourinho has just been in iran so i was wondering could you share your and the other penalties of course if you want to add something share your take on what can we learn what from the iranian system of payments to kidney donors well what uh professor matches is uh saying is that iran is the only country in our planet where you can actually legally buy a kidney from a live donor if you have been on the waiting list for a number of months and no kidney became available for for a kidney transplant you can you're encouraged by the government to ask to some family member or friend to donate a kidney to you and if you don't find anybody compatible uh within your family or your friends you can ask to other people and the government put a cup which is 900 and you can buy for this amount of money a kidney for you know somebody that is you know somebody that you don't know that is ready to sell the kidney his kidney to to you and we had a transplant meeting because iran is becoming very successful with organ transplantation because the religious leader uh issued a fatwa uh saying that is a good thing to donate organs after you die so because of that the number of donations that were almost zero because in their culture the body needs to be intact after the death because of these statement by their religious leaders the donation after that went from zero uh to 20 donor per million which is about the same that we have in in italy and this happened in a matter of few years so right now uh you know the number of transactions between people individuals that are buying and selling organs are decreasing because the number of organs from cadaveric donors is actually increasing significantly but when we addressed you know we had a transplant meeting there when we addressed this topic they um you know they become a little bit upset because uh they consider that like you know comments uh by people that do not understand that they fully their society and you know they had they made the point that because of that uh because of this rule that they have you know the waiting list for a kidney in iran is almost zero and one other detail that should be added the different from for example from china you cannot buy a kidney unless you are from iran you know you cannot i cannot go to iran and buy a kidney get a kidney transplant only citizen of iran can do that and the entire system is regulated that does not happen with brokers or with the black market it happens in the open and is regulated by the by the state nevertheless you know i consider that really not good because you know again you know in iran there is a big disparity between a very rich people and very poor people and you don't really see very rich people selling a kidney for 900 dollars so you see very poor people selling a kidney for 900 and again i think that that is even if has been regulated by this government is is wrong i have to be honest with you and if you go on the british medical journal of 2001 i wrote a paper that was much more radical i i did write that we exactly as the law says in united states of america you cannot exchange anything of value for an organ and i was really convinced about that nowadays i think that maybe if we have a system where not the individual but the state you know gives something to so to the family of this of a deceased person and you know maybe paying the as i was saying before the funeral expenses and the kidney or the orga or the other organs do not go to a specific person but go to the first person in need of that organ to the general transplant list of the country so there is not an individual transaction maybe we should at least open the discussion and see what the people think about about that and you know and by the end of the day i think that this is a matter at least these are i maybe ten days ten years from now i will change my opinion even on the on this but you know i i do think that by the end of the day is not up to the physicians to decide what is right and what is wrong but is a matter that should be decide but the society at large is the society that needs to set the rules and decide what is good and what is wrong not the physician okay so we have until 7 45 so we do have a few minutes for questions from the audience i would like to ask that you keep them short so we can maximize the number of questions in the time that we that we have i just want to ask you what about the artificial organs for transplanting and i know it's another sub topic but it seems to me that could be the the only solution and uh and the second thing is to uh to reply to what professor mourinho said is up to society to this to debate it's true it's a very tough debate and very difficult but uh personally i think that the act of donating should go back to um to a sort of um to a more awareness of people of about what is going on when you when you have a new organs so people just buy and sell things that as in a supermarket that is the the problem i think and i wonder whether you said a third-party state is managing these uh interaction between donators and offers i wonder whether i know it seems very eutopical but if the person who received an organs commits himself or herself to dedicate his new life her life to society i mean it's something that we should start considering it's a new life is you can do considering the high numbers of donators our world will change well um the the the the issue of the artificial organ is actually a very is becoming the last i do not have here the slides but i gave a presentation about that in taiwan a couple of weeks ago and you know it's really fascinating because uh technology nowadays is such that we can use not a liver but a heart and a kidney or a lung from a pig and then you can inject in his vessel some you know chemicals the chemicals destroy all the cells that have the immune system target and then you can inject the new cells that are coming maybe from me or from you so our self you know self cells and you can repopulate the organ and actually they had a heart like that and kidney like that you know transplanted from a pig originally to a primate and actually they function so you know is a and and that maybe al knows that because uh is more in the field of economics than in the field of surgery i have read that you know a big company for you know raising peaks for food in united states may cut a deal with a drug company because when this you know new technology became available they think that maybe they can produce peaks uh for this purpose so maybe that is not too far and we could have artificial organs that obviously these will uh will will be completely different will be a completely different game but is not available as as as of yet about the other thing that you have said i think you know um maybe one thing that could work well and in and they've been discussion in the uh transplant community and even outside of the transplant community about these is how to you know push people to be aware as you were saying about how good could be organ donation and particularly you know after you are dead i mean and you know i think that one system that obviously is not an exchange of anything so maybe i don't know i i asked the help of the other three panelists to judge this statement of mine maybe it's not illegal even with the law that we have at the present time in united states and many other countries if you give priority you know like priority boarding on an airline you give priority boarding for you know a kidney transplant to somebody that has a donor card you know if i have a donor i wrote i you know i subscribed a donor card so and i am and you know so i i i cut a deal with my country or wherever i will die that at the time of my death all my organs will be used then why shouldn't the society give me some advantage to somebody else that is not a donor so if i will need a heart or i will need a kidney i should go sorry nicola ahead of nicola on the on the transplant waiting list because nicole has not did not sign a donor card and i think that will make people think you know there is something that i cannot buy that is envelop you know the value is so high that i there's no price but if i will be generous enough and that is not that generous that i will donate my organs when i don't need the orgasm any longer because i'm dead i will go on priority boarding i think that will work let me just remark that since 2012 israel has had such a priority law uh for deceased donation and there too market design is an issue it may make perfect sense for ignazio to go ahead of nico because nico didn't sign up in this hypothetical but but not against nico's children who are who are not able to sign up so when you start giving people priority you have to think you have to design the system to make sure that that the priorities work the way you want them to that you shouldn't move for example children who are not registered donors to the back of the list yeah um thank you very much for an interesting discussion and i'd like to bring it back to the issue that you mentioned several times today from organ selling to organ renting and um this to market seems to be conceptually different and speaking in economic terms living apart the whole ethical discussion apart because it deserves a separate panel itself these two markets are trying to solve different problems while in kidney exchange market there is the supply falls short on demand because there is a long waiting list and few people willing to donate those organs and therefore introducing an incentive to um can help to find an equilibrium between supply and demand on the market while their surrogate maternity they're re there are a lot of uh orphaned children and there are a few people willing to adopt them and still there is so by introducing this surrogate maternity or one branding will increase the supply in the market where supply is already very high so how do you think a market design can help here and what are other differences between those markets thank you i'm not sure i understood your question what kind of markets do you have in mind gestational services so well so so surrogacy you know is it a market where where there's already a great supply obviously many people can have their own children but the demand for surrogacy comes from people who cannot have their own children uh so uh so sometimes it turns out people can have a great desire to have children in sweden where surrogacy is illegal wound transplantation has been initiated they pioneered the transplant of womb so so apparently the desire to have your own children can be very strong there are of course black markets for surrogacy there are many places where circus is illegal like italy uh but there's there's fertility tourism just as there's transplant tourism so um and there are there are more dimensions to this than i can think about but but there are some markets that are simply hard to prevent and one of the questions we face as a society is what should we do with markets that we may be uncomfortable about but that we cannot prevent unfortunately time is over but this gentleman asks for the floor you just promised to say three uh things my name is father celestino i always take a floor at the festival i'd like to thank give three thanks uh for this meeting i'd like to thank the festival uh to bring about new ideas then i would like to thank the speakers who in indeed offer universal ideas opening us up to the uh to europe under the whole world and then a third thank to the former mayor of rome nazio marino who was brave enough to uh in a way uh burn his career as a politician to chase for the mafia so please uh take this opportunity uh to put yourself at a test uh because we want peace in the world a final a conclusion uh our nobel prize told us that uh the money used by weapons should be used for health purposes i don't know whether you copied pope francis or pope francis copied you thank you i also would like to thank the speakers thank you to the audience i hope you have enjoyed today's conversation thank you you