Cascades of Debt

This article in the New York times is fascinating.  It’s about kidney transplants.  We all have a spare kidney.  But because donating a kidney isn’t like loaning somebody your car for weekend, so the transaction is a bit more complex.  A simple case a child needs a kidney and a parent donates.  That transaction doesn’t surprise people.  From the article…

Until recently, hospitals regularly turned away Good Samaritan donors on the working assumption that they were unstable. … But when Rick Ruzzamenti showed up at Riverside Community Hospital asking to give a kidney to anyone in need, he still underwent rounds of psychological screening as well as medical tests.

The doctors and social workers did not know what to make of Mr. Ruzzamenti at first. He had a flat affect and an arid wit, and did not open up right away. As the hospital’s transplant coordinator, Shannon White, pressed him about his motivations and expectations, he explained that his decision seemed rather obvious.

“People think it’s so odd that I’m donating a kidney,” Mr. Ruzzamenti told her. “I think it’s so odd that they think it’s so odd.”

The hospital wanted to make sure that he was not expecting glory, or even gratitude. Mr. Ruzzamenti stressed that no one should mistake him for a saint.

He had, after all, been a heavy drinker in his youth and had caroused his way through the Navy. He could be an unsmiling presence at work, where he helped manage a family electrical contracting business. He admitted that he did not visit his parents or grandmother enough.

Despite his occasional surliness, Mr. Ruzzamenti said he felt driven to help others when possible. And as he considered the relative risks and benefits of organ donation, particularly to relieve a whole chain of suffering, it just made so much sense. “It causes a shift in the world,” he said.

Perhaps, he said, there was some influence from a Tibetan meditation he had practiced when he was first drawn to Buddhism six years ago. It is known as Tonglen. “You think of the pain someone’s in, and imagine you take it from them and give them back good,” he said.

Mr. Ruzzamenti said he was in a position to donate only because the economy had dried up so much of his work. He was essentially unemployed and could take time off to recuperate. The 30 kidney recipients, he observed dryly, could “all thank the  recession.”

When Mr. Ruzzamenti told his wife… she made it abundantly clear, … she would leave him …

There is much to chew on there.  But let’s not get distracted.  The economy that the parent/child donation is embedded in is as disjoint from the commercial economy as it could be.  Which is why observers of that transaction are so unlikely to ask how the residual debt from the transaction will be cleared.  While, the transaction that Rick engages in is apparently full of mystery.  I think that illuminates how tainted our understanding of social science has been by the reign of one narrow-minded subfield of the social sciences, e.g. economics.

The ease with which we can comprehend the parent/child example v.s. the Rick/<X> transaction leads to a problem – it’s a problem of teasing out motivations.  Apparently the hospital devoted substantial resources to that puzzle when Rick showed up; but in the parent/child case I assume they don’t even pause on the way to the operating table.


Motivations aren’t particularly fungible.  You can steal my enthusiasm for mushroom hunting.  I can’t sell it to you.  Though apparently I can sell you on it’s benefits.  Ascription is an anathema to any enthusiasm.

That is a problem when it comes to kidney transplants, and the article is about a work around.

Let’s say the Sally needs a kidney and Bob her parent isn’t a match.  Maybe we can find another child and parent; Alice and Larry and Larry can give his kidney to Sally while Bob gives his to Sally.  That’s all well and good but the probabilities stink.  The chance of a good match between any given child and any random parent is very low.  But we can generalize.

First off it’s not just parents and children were the motivational mystery seems to evaporate.  It doesn’t seem odd than if Sally needs a kidney anybody who’s related to Sally in almost anyway might offer to help – friends, family, church, office, etc. etc.  – goodness even most tenuous of Facebook friends.  But sadly that doesn’t solve the problem; many in need still can’t find a match – even people with huge social networks.

This is the clever bit.  It is possible to create long cascading chains of donors.  N people in need who have friends F willing to donate to help them can be cascaded together so that each person obtains a kidney from one of the friends of somebody else in the chain.  The motivational puzzle: “Why the hell would F donate a kidney to a stranger?” is converted into the non-puzzle “Of course a friend would step up to donate.”

The transaction described in the article has 60 people in it.  30 donors and 30 recipients.  Transaction cascades of any kind require complex coordination.  The reasons some people fetishize the market is how this coordination appears to happen invisibly.  In this case we met another hero in our story.  The former logistics executive Mr. Hil who calling turned out to be coordinating these transaction cascades.

“The chain began with an algorithm and an altruist. Over the months it fractured time and again, suspending the fates of those down the line until Mr. Hil could repair the breach.

I find the details fascinating.  The chains start with a Samaritan and end with a patient who lacks a friend willing to donate.  They are fragile; a donor drops out, a patient dies or lacks health insurance.    The pool of pairs he has to play with is still small – 250 pairs according to the article.

While my favorite part of this article is the bit about how bewildering the establishment finds the Samaritan.  I like it when economic calculus is bewildered; and so too I liked this bit of anti-free market regulation:  “Airplanes carrying donor organs are granted special status, allowing them to move to the front of takeoff lines and ahead of air traffic.”


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