Brother, can you spare a tissue?

Driving home from work yesterday, I caught a minute or two of an NPR piece on tissue donation. In case you're not completely familiar with the practice, it's much like organ donation, except that instead of whole organs like kidneys, hearts, corneas or lungs, donations are smaller bits and bobs, like heart valves, earlobes or, more commonly, skin.

Here's Part 1 of the series, and I apologize, but I have no idea what segment I caught yesterday. What struck me was the interviewee's remarks on his own participation as a donor. The gentleman being interviewed, a former tissue harvesting technician, had removed himself from the donor list. He acknowledged that deserving patients (I think the example was a father of four waiting for a heart valve or a four-year old burn victim or some other heartstrings-tugging thing) might run the risk of privation, but that he did not feel comfortable donating skin if it meant that it could end up as part of a penile enhancement procedure.

Alas, I was too busy to sit in my driveway and listen to the balance of the interview, so I had to mull the moral intuition with little context. I was first struck by the gross paternalism: in much the same way people feel compelled to attach strings to transfer payments (please see Munger, 2012 and inquire via email or in the comments about my response piece for more on the role of paternalism in transfers),  it appears that people feel more than comfortable setting boundaries on the disposal of their generosity. In the case of anonymous medical donations, the profession does not allow for usage restrictions (and even if it did, donations from multiple sources are more or less fungible*) so the only guaranteed way to ensure your tissues don't end up as material for the vanity of others is to exit the (quasi-**) market altogether.

I have an inkling that the exact same moral intuition behind taxpayers pressing for SNAP benefit limitations sits behind this gentleman's decision to scrub his name from the donor rolls: "it's my [money, skin, other donation], so I have a right to determine how it's used." Now, I won't comment on the moral legitimacy of this argument, as it's awfully subjective, but I will say that it bears in common with the staple examples of non-euvoluntary exchange bans in that it makes people already in a bad situation worse off: it restricts the supply of transplantable tissues for all patients (including those burn victims) just as surely as the police impounding a post-hurricane, yahoo-driven ice truck deprives the citizens of Raleigh of the ability to keep their food from spoiling. It takes an already bad situation and makes it worse.

Presumably, the exploitation here is patient-on-patient. The penis embiggeners exploit the heroes running into the apartment complex to save a baby by buying up skin from under them. Even the most cynical, hard-nosed economist would agree that this hardly seems just. I should know, I asked him. He works at the DoE and we play poker every third Friday in Annandale. His name is Paul. But Paul also agrees that this response hardly makes the situation better. It's sweatshops and slums and minimum wage all over again: disapproval over an outcome distribution is met with a ban or a restriction, and the supposed beneficiaries end up forced to take a worse alternative. This is an improvement?

Now, after Hurricane Fran, the locals cheered when the cops provided their BATNA-worsening brand of justice. I wonder if patients suffering chronic heart failure express the same sense of victory against abuses of the system. More interestingly from where I sit, this suggests that paternalism is ubiquitous and chimeric. It appears to be more important to enforce social norms than it is to run the risk that deserving people don't get help. To a pragmatist or a utilitarian, this is unconscionable. To a deonotologist, this puts rule conformity ahead of care, which is quite striking in an liberal, Western society.

Economists do a lot of head-scratching when it comes to increasing the supply of transplantables, from theory to empirics to design. When pondering incremental changes to the status quo, it might be worth keeping in mind folks' propensity for casual paternalism. The counterfactual isn't that you open up the market to liberalized sales and hey-presto, we're all farting through silk sheets. Paternalism lurks. Forget that at your own peril.



*here, fungibility is limited by type and cross-match--rare allele frequencies may have no matches in the donor pool for years if not decades. This is one reason why it's so important for minorities to join marrow donor lists.

**Al Roth is the economist best known for kidney matching arrangements, which is an improvement over the existing ban on direct sales. I sadly don't know enough about tissue donation to say whether or not similar arrangements are in the works for tissue donation, though the ban on marrow (and hematopoietic stem-cell) donation has been lifted, which is pretty awesome if you're a leukemia patient.