Superiority Burger

Outside Shot

 

What kind of name for a restaurant is Superiority Burger? To some, it’s a simple claim to be a superior burger. And it is a superior burger: delicious like White Castle but gourmet and without meat. The ice cream’s pretty dope too.

Ice Cream

But you might suspect another intention: to make a burger so good that it bestows superiority on its consumer— a magical hipster burger that translates dollars and attention to elevation above the plebes. You order at a takeout counter. There’s six things on the menu. There’s no space, an insane line, you’re in the know.

Bruce Headley

The chef is Brook Headley, once drummer for punk bands Born Against and the Wrangler Brutes, then the head pastry chef at Mario Batali’s four-star flagship Del Posto. He left that job to make the perfect veggie burger, $6 each– the Shake Shack of tomorrow brought to you in the East Village today.

Burgers

But what makes Superiority Burger and its kin Loco’l and Dirt Candy interesting (along with their ancestors Blue Hill, Shake Shack and Chipotle) is that the hipster superiority being offered has grown from aesthetic to moral. Food that’s vegetarian or ethically raises, service by people given an ethical wage and health insurance, the tastiness of your meal is inseparable from the care and responsibility with which it was prepared. No longer just for cosmopolitans with all taste, no heart, and  New York Values, ethical consumerism lets you perform your moral identity by choosing a place to eat.

Screen Shot 2016-04-03 at 2.34.36 PM

At this point, you’re probably like ugh, and “look at this fucking hipster,” because pretension feels gross even if (here) it’s in the service of something worthwhile. Hipsterism combines the idolatry of cultural consumerism with the prejudice of class difference.

Hipster tshirt merchandise

And if you want to pass on in populist disgust at the etiolation and ennui of New York’s creative class, I can’t blame you. But… maaaaybe animal suffering is the moral struggle that is our age’s version of slavery. And maaybe… empowering workers in the service industry is crucial to the 21st century labor movement. And maybe there’s something deep and primal about the act of putting something pure and unpolluted into our body. And maybe we live in a consumerist market society for better or worse and we might as well harness our more ridiculous urges in the direction of social justice. If we have the chance, I mean. If it’s not too much. And if that’s all true, maybe ethical consumerism with trendy hipster places in the village could be the start of something bigger.

Lines

So ya, Superiority Burger. Eat there. It’s good.

Stop Gawking at Terrorism

The Best Thing You Can Do for the Victims in Brussels is Pretend They Didn’t Exist

So the first thing I need to say here is that the violence in Brussels is an unspeakable tragedy, and my chest shudders to picture the expanding waves of grief and fear emanating out from the killings and woundings that happened today. It’s easy to focus on the thirty lives lost, more than an entire grade-school class, but dozens more are in the hospital—their families terrified that they’re on the brink of death. The horror of the crime that was committed is literally beyond any individual comprehension or accounting.

So it’s only natural to cast our sympathies and attention to the act of terror whose results we mourn. Because their end is so awful, we picture it so vividly. We empathize and imagine our own life cut short. One moment running late to work; the next an explosion of blood and fear.

The image is so garish we can’t look away. So media supply us with an unlimited stream, self-perpetuating that attention to a raging froth. That rage is channeled to violence, the violence benefits the hawks, the hawks provoke the killers, a storm cycle of more violence ensues.

This is called terrorism.

We might say the right response is to simply eschew a violent response, ignore the provocation. Would that it were so simple. Our national emotions are not under our rational control (nor would we want them entirely to be). Rather we need to tackle the problem one level up, by making a mindful effort to redirect our attention away from terror and towards types of grief that are not so self-perpetuating and self-destructive.

I know that sounds like a cold and overly clinical approach to our reaction to terror. I know there is no way that tomorrow we’ll stop having the urge to pay attention – that it’s unrealistic to expect that terrorism will ever be denied outsized attention by our society.

But I do think it’s worth the effort to acknowledge, when we can’t look away from the attacks, that our attention is at least a vice—that we would prefer to be able to look elsewhere even if right now we’re not able. I think we should do that individually, that we should expect commentators to include it as part of their remarks, and eventually news reports themselves need to emphasize that our attention is the literal object of these murderers desire.

We are giving the terrorists exactly what they want. We owe the victims an attempt to break the cycle and frustrate the their murderers’ intention.

And yet, part of me worries that this approach might be callous. Even if we would be better off looking away, would we really want to be a people who turn our heads from suffering just for calculated reasons?

But, sadly we ignore suffering every day. Today, sixteen thousand children under five died. Picture the parents. Twelve hundred deaths from malaria. In America alone, as many as 30 from the kidney shortage. All of these deserve our attention. The sufferings are just as agonizing as the deaths in Brussels, but these ones are amenable to our focus on a solution.

Perhaps a little intersectionality is what is called for, something that expresses solidarity between the types of grief around us, that demands our moral attention for the problems that could use it, not the ones whose horror stem from it.

Maybe what we owe to the victims of the Brussels killings is the privacy to mourn the ones whose killers used as fuel for their public, hateful act.

It’s the Extinction, Stupid (DRAFT) 1.0

Here’s another (very rough) draft I’m working on. Sorry it’s depressing — was in a bad mood last week when I wrote it and now that Trump is set to be President of America’s Next Top Reich, this seemed appropriate. Comments and criticisms very welcome– blunt ones especially.

 

It’s the Extinction, Stupid–

Fear and Loathing in 2016 America

tl;dr – People like The Walking Dead because our species is about to blow itself into smithereens. We need to get our shit together and start treating this like an emergency.

Table of Contents

  1. Funny Coincidences Are Funny and Maybe Mean There’s a Higher Being
    1. Americans Love The Walking Dead Because It Me (It Us? It U.S.?)
  2. The World Is Going to End
    1. The Math: It’s Unlikely You’re One of the First Humans—There Probably Won’t Be That Many More of Us
    2. Nuclear Weapons Will Continue to Be a Thing
    3. Existential Russian Roulette Ends Poorly: We Will Keep Developing Technologies that Will Have Some Risk of Destroying Us Until We Kill Ourselves
  3. Our Political System Is Fucked and Cannot Solve the Problem
    1. We Can’t Even Get Global Warming Right
    2. Look at This Fucking Election
    3. Political Parties Have Dumb Incentives
    4. We’re Doing a Terrible Job Regulating Technology and Consumer Data
  4. (Detour: Major Technological Revolutions Are Awful for Early Generations—Sucked to Be a Chimney-Sweep)
  5. But Why Is Our Public Sphere So Terrible?
    1. We Live in a Totalitarian Consumerist Market Society (Bummer…)
      1. Companies Can Control You (Like a Lot)
      2. Corporate Managers Are Tied to the Profit-Maximizing Shareholder Value Machine (Or “The Singularity” as I Like to Call It)
    2. Our Public Sphere Has Deflated
      1. Where Are All the Academics and Journalists? Shivering Quietly in the Corner
      2. Public Institutions Are Permeable to Dominant Private Interests
    3. The Internet Is for Apocalypse
      1. Artificial Intelligence Is Just One Example of Terrible, Unsafe Digital Infrastructure
      2. What If Human Identity Became Impossible to Prove Online? Scary, Right?
    4. Much Like the GOP Nominees Who Didn’t Realize Trump Had Practically Already Won, We Should Treat This as an Emergency, Because It Is

–        –        –

Funny Coincidences: If you’re drawn to being a spiritual person, you’ll often find yourself wondering about the artful coincidences that sometimes feel like your fate. For example, that I live in a country whose abbreviated name reads literally as “Us” is amusing to me. Or one time, right after a serious breakup, I tore a muscle in my chest—tangible evidence of my broken heart. Little things like that.

This amusing parlor game can take on a paranoid cast if you’re a younger member of the American ruling class staring out at the bleak national banquet that feels like our future. Why was I born at the inflection point of a declining empire?

That the most obvious looming catastrophe of our making is the earth literally heating up and summoning up a global flood may seem an especially appropriate metaphor. (Never mind that it is not nearly the worst danger we face.)

Indeed, I think one of the most perfect of these fitting ironies is that it looks like the world is going to end, and the name for my generation is “millennial.”

I haven’t seen anyone really bite the bullet and predict our generation will extinguish itself, but in my opinion, this unspoken sense of existential dread pervades American life. Why do you think we’re so obsessed with zombies and the apocalypse after all? Because we’re expecting one. Why do we hate any and all public institutions—because we know they’ve failed us and we’re careening toward catastrophe.

This essay is saying that we need to wake the fuck up and publicly acknowledge what’s going on. Unless something major changes, our species won’t make it out of the 21st century alive.

–        –        –

Odds Are: Here’s a mathematical conjecture that initially struck me as silly but that I never could quite disprove. It implies the world will likely end soon. The idea is fairly simple: imagine all the human lives to ever exist as names in the telephone book, but spread out chronologically beginning to end. Your life, the one you’re living now, is as one picked randomly from this book, so it’s probably fairly close to the middle. So far, so good.

On the one hand, you might think there’s no surprise that you’re living in the 21st century because the most humans alive at one time do indeed live today. But that raises a scary question: if humanity were destined to grow and thrive for millennia to come—if there were trillions of us yet to be born, what would be the odds of your having drawn a 21st century life and not a later one? Pretty low.

But if our candle is soon to be wicked out, your being here to see the end is no surprise at all: the odds work out quite reasonably. If you’re in the middle of the book, you’re only one or two generations and maybe 15B or so people from the end. (Spoiler alert…)

This logic is far from incontrovertible (someone has to be alive today, no matter how many trillions of people end up being born). It would be merely an amusing parlor trick if only the other augurs of doom were not so insistent.

Nukes: Start with nuclear weapons—thousands of which are in the hands of despotic dictator whose guiding principle is machismo and whose constituency is dying off rapidly. That’s before you get to Pakistan, China, India, Israel —how many nuclear states will undergo massive upheaval this century? (Trump Trump Trump Trump Trump Trump).

While we’re talking odds, how likely was our surviving the 20th century? 70%? Even if each year our chance of avoiding nuclear catastrophe is 99.5%, that gives our species a half-life of a century just from the nuclear threat alone.

Russian Roulette: The key thing to realize is that nuclear weapons are simply the first of an indefinite number of existential threats. Humanity will continue developing technologies with some probability of our extinction. Take bioengineered pandemics, artificial intelligence, climate change, cyberwar, autonomous weapons, nano-machines. (Please). Each one is a different sized bullet in the game of Russian roulette our species is playing. The specific odds each time you pull the trigger aren’t important: if you keep playing, you’re destined to lose.

–        –        –

Bad Politics: So the question then becomes whether we can build an infrastructure to develop technology safely in time to stop the fatal trigger pull. And in this context both global warming and the current American election each provide a particularly bleak reply.

Global warming because the problem is so obvious yet the solution so far beyond reach. (It’s become increasingly clear that geoengineering will be needed. That brings its own risks.)

Today’s political climate in America is awful both on its own terms as a failure in responsible governance and on a deeper level as to what it means for our declining public sphere.

The incentives American political actors face no longer bear much relation to the welfare of Americans. I don’t want to belabor here the horrifying, Trump-ean specifics of the 2016 election. The point to emphasize is that we live in a time where technological change is accelerating and the ability of the political system and public sphere to manage that change is declining. We’re like a car strapped to a rocket engine—the acceleration feels exhilarating until you lose control, crash and explode.

Our Wimpy Government: Look at the fight between the DOJ and Apple—ignore whether their respective positions are reasonable. Instead notice that the issue of mass consumer data collection, both by the government and by private companies, is absolutely transformative to our society and also nearly entirely removed from public reason or the capacity for reform. The battle lines are set between the unrelenting private interests of tech capital who wants to own this massive windfall and the security state motivated brutishly by dumb fear. The capacity of public interests to compete feels like it’s at a low ebb.

(Btw the government’s handling of bitcoin is similarly Keystone Kops).

In some ways, this dominance by capital is has precedent in American life—look at the robber baron era of the late 19th century. The wealth generated fed into a future Progressive era and the rise of the modern state—a development that may imply a reassuring type of cyclicality and renewal. This to me is the greatest grounds for hope.

(Facebook Is Digital Manchester: It’s worth saying that the changing of technological epochs (from hunter-gatherers to agricultural society; from agriculture to the Industrial Revolution; now from industry to the Digital Revolution) tend to be quite bad for their early generations. Farmers lived shorter and shittier lives than hunter-gatherers; same for the denizens of industrial London and Manchester compared to those who remained in the countryside. If we’re lucky, our digital descendants will look back at our Facebook in 2016 the way we perceive benighted Dickens characters and chimney sweeps.)

But there are a couple crucial distinctions: (1) in no other epochal change did we possess the capacity to destroy ourselves; (2) at no other point did we have the density of centralized control that’s possible (indeed normal) now. The totalitarian state is a 20th century invention.

–        –        –

Don Draper as 1960s Marx: I do think we have to come to grips with consumerism as a type of totalitarian ideology. Not to say it is as bad as communism or fascism. Protecting voluntary choice is a powerful safeguard albeit an imperfect one that deteriorates over time.

We see this now with the tech boom: the companies that mediate your social life, attention, information, and buying decisions know an incredible amount about you and can test interventions on massive numbers of customers until they find the ones that most reliably trigger a response.

This will only become more dramatic over time. For example, n every time you contact another human being is now a part of some corporate database (online obviously; in person via GPS).

And to close the loop—not only are your choices dominated by the interests of capital, but the ideology of shareholder value also locks corporate management into exclusively using their power to maximize profit. It’s no better sign of what some would call late capitalism that the most profitable profession is the one with literally no other purpose than to make money. The centralization of control in the financial sector further shrinks any behavior that doesn’t maximize profit.

This is not to say capitalism is evil (it continues to lift enormous numbers of people out of poverty), but that our system has become terrifyingly single-minded and denuded of other goals. Civic society in the form of group membership has collapsed (see Bowling Alone; also e.g. religious affiliation). “People have lost the narrative of their lives.” The space for public spirit has shrunk. Private interests are indeed private, closed off, hard-to-regulate, hard even to see.

Along with declining social participation, failing community, and diminishment of alternate sources of meaning, our capacity for public reason has also declined. You can spot this most clearly in the decline of journalism in the 21st century. Despite a growing population and economy, half as many journalists are working today as did twenty years ago. Academia is similarly diminished. Thus, the media infrastructure through which our public discourse is conducted has become broken down and inadequate to the task of understanding and managing massive technological change.

Moreover, because public institutions (the government but also nonprofits) are permeable to the interests of capital, a sclerotic, closed-off, dominant private economy helps lead to a dysfunctional public one. (Informational polarization via social media doesn’t help).

–        –        –

This all compounds the problem of existential risk. We have no reason to belief the shared infrastructure of the internet (or of our food supply, or our electricity, etc.) is being developed in a safe, sustainable, healthy way. The financial collapse was one example of this, and even then nothing systemic seems to have been fixed.

But our shoddy technological infrastructure is the most frightening. Take data breaches—which are extraordinarily common. Take identity theft—skilled hackers can easily ruin your life. Take the casual disregard for the law of model companies like Uber, AirBnB, and Zenefits. Realize that no federal agency even exists to handle these issues nor is there any pressure to create one.

There’s been a lot of discussion about artificial intelligence as an existential risk—that an artificial agent might become so powerful that it’s misaligned goals could literally spell human doom. To me this is just a particular subspecies of the broader concern of digital infrastructure safety: that our interdependent internet monoculture could break down (or be broken) in an unpredictable set of ways.

To pick one example at random, how do you prove you’re you online? Imagine a technology that can ape you well enough (knows enough data about you for example, can copy your voice) that proving you’re you becomes impossible or very difficult. What would a day look like when no one’s log-ins were secure? Think of all the bank accounts plundered, all the public infrastructure to go haywire. The mind boggles at the mayhem.

–        –        –

The End: Ultimately, we’re on history’s greatest engineering spree in the shadow of potential extinction. We have no reason to think we can safely regulate what we’re doing. We deserve to be fucking terrified.

And we are (even if we don’t acknowledge the reason consciously). When you see people furious at Mark Zuckerberg for giving 99% of his money to charity, that’s why. When you see an insane panic at a disease that kills zero Americans, that’s why. When approval rates for public institutions are at a record low amid a growing economy, that’s why. When tens of millions vote for Donald Trump (or elect Trump President) that will be why. In our bones, Americans can feel that things are very, very wrong and that no one even has an idea for how to fix it.

I don’t think we’re literally doomed, but I don’t have much interest now in sketching out my theories for how to fix it.

Instead, I want to sound the alarm that we are driving off a cliff and we need to wake the fuck up and realize we’re in the midst of an emergency and that drastic measures are needed.

I Wanted the Government to Buy Kidneys: Why I Changed My Mind (2.0)

Here’s a new draft brought to you by the blizzard currently striking NYC. Same caveats as the previous one. Thanks to everyone who’s provided comments so far.

Please let me know any ideas for how to make it better. In particular, it got even lengthier, so if you have ideas for how to shorten it, I’m in great need.

Four years ago, when I became a kidney donor, I passionately believed that the government should pay people for their kidneys, save a great deal of money, and rescue tens of thousands from a grueling death. So in 2013, I left my job at a corporate law firm (and my home in Boston), moved to Toledo, and joined the transplant field in order to enact this change.

A year after that, I co-authored a letter in favor of incentives signed by hundreds. By that June, I’d received a grant from a major foundation to plan a nonprofit to bring incentives to the transplant field. But then I changed my mind.

I didn’t change it all at once or entirely. I still think donors should be treated better than they are. A lot better. But what’s different is where I used to think kidneys could be an item to be purchased by a government monopoly, now I think it’s a bad idea to treat organs as just another commodity up for exchange. Instead, for kidney donation to be respected, our society needs to treat it like an act of public service and to honor donors accordingly.

Here’s how I got there.

Why I Liked Incentives

The kidney transplant shortage might be the most underrated public health problem in America. The current waiting list is a hundred thousand names long. Each year, twenty thousand more people go on the list than receive a transplant. That number represents 50% more than all the homicides committed in the nation last year. Year after year, this shortage crisis represents a truly massive number of lives lost.

<infographic comparing mortality of car accidents, gun related homicides and suicides, kidney failure, war deaths>

Kidney donation is a safe, laparoscopic procedure. Most donors are out of the hospital after a couple nights and off prescription painkillers after a week. Donors lead normal, healthy lives.

As with any surgery, there are risks: about 1% of donors will develop kidney failure over their lifetime, compared to 0.1% if they hadn’t donated. By contrast, the lifetime risk in the general population is 3.2% (kidney donors are healthier to start with). Like any surgery, donation can have complications, but the chance of dying is just 3 in 10,000.

<risk infographic>

And there is uncertainty; the real risks may be higher than our estimate. People have been donating kidneys for sixty years, but ascertaining exact health effects decades down the line for an unrepresentative population is an epidemiological struggle– one that with necessarily imperfect results.

But what is clear is that kidney donors remain as healthy or healthier than the general population after they donate.

Moreover, kidney donation saves the government a great deal of money: Medicare guarantees coverage for patients with kidney failure regardless of age, and over their first five years, transplants cost $60K less per year than dialysis. Since a living donor kidney lasts for fourteen years on average, saving $300K per transplant is conservative.

That means the government could easily afford to pay $50K or $100K for donors to undergo a surgery that is safe and saves another person’s life. If you persuaded one in two thousand Americans to take that deal, you’d end the shortage tomorrow. No more waitlist: a hundred thousand lives saved; a hundred thousand families rescued from tragedy.

Back when I donated, it seemed like a no-brainer.

And while it’s reasonable to worry that most kidney sellers would be poor, the shortage is itself extremely discriminatory. Minorities make up 38% of the American population but 63% of its waiting list. African Americans get kidney failure more often, are less likely to be listed for transplant when eligible, wait longer for an organ once listed, and are less likely to find a living donor. An incentive system could correct vast inequities in access to life-saving care.

The Problem with Incentives

When I moved to Toledo, Ohio to join the Alliance for Paired Donation, I didn’t know anyone that lived in the Midwest. I had a lot of free time.

Much of that was spent gorging on Netflix and text messaging with my ex-girlfriend, but some was spent on kidneys and some smaller portion of that was spent trying to understand why people disagreed with me about incentives. Since I’m a philosophy geek, that meant reading authors like Elizabeth Anderson, Margaret Radin, Lewis Hyde, and Michael Sandel to better understand commodification and the philosophy of market exchange. That led me to reconsider my views.
To vastly simplify, commodification is when you take something that’s sacred and sell it like it’s scrap. But sacred how? A bible is sacred, but selling bibles does nothing to tarnish them.

Things are commodified when selling them reduces them from a rich, multi-dimensional source of value down to just their worth as a dollar figure. Picture prostitution. Whether or not it should be legal, whether or not it can be empowering for workers who perform it, there is some change in meaning of a sex act when it includes a transaction for money. If this were the only the type of sex we had access to, we would justifiably feel diminished.

The commodifying effect of organ selling isn’t purely hypothetical. While organ trafficking is a scourge throughout the developing world, Iran is the only country where it’s legal to buy and sell an organ. Not coincidentally, it’s reported to be the only nation without a shortage.

But in many parts of the country, kidney donation is a source of shame and signal of desperation. Rather than feeling honored to have saved a life, donors may hide their good deed for fear of being treated as a lesser person who sold off a part of themselves.

That does not mean the decision can’t be a rational one—the going rate is more than the average annual income. But a decision can leave us worse off in some dimensions that cannot simply be converted to money or aggregate welfare

Somewhat embarrassingly, the example that best illuminated this for me was my time as a corporate lawyer. Like many such, I was all at once unreasonably well-paid, extraordinarily lucky to have the job, and absolutely miserable. Though it may have been completely rational to sell years of my life for money, in some real way it left me diminished.

So how to weigh this risk of commodification against the benefits? I’m honestly not sure, but I do know the lives saved by incentives don’t just erase the problem. A society that looks down on kidney donors as desperate and unclean – as mere human vending machines – would be unspeakable no matter how much healthier it was than our own.

Moreover, diminishing the value of donation could also have bad consequences. Living donors currently give 5,500 kidneys a year; deceased donors 11,500 more: will people still be so generous if the status of organ donation were to decline?

And then there’s the risk. What would the price of organs even be? How much would it cost to buy up enough organs, even the ones that were now given for free? Would donors lie about their health history to be able to donate? How would we avoid trying to save on cost by neglecting safety standards? Market incentives would represent a drastic change with consequences that aren’t totally knowable.

The national regime of organ donation took hard effort to build and relies on only the public’s good will to survive. Jeopardizing that system through drastic change could sacrifice people who definitely receive transplants today for the mere potential of lives saved tomorrow. We should avoid that risk if at all possible.

Transplant Support

When my co-founder Thomas Kelly and I started the planning of Waitlist Zero in 2014, we conducted a listening tour of the transplant field. We saw great respect for this 2006 paper arguing for lifetime health insurance for kidney donors. The leading professional societies published a paper in favor of incentives, but were fearful of brooking controversy: to many in the field, cash incentives would never be acceptable.

On the other hand, free health insurance for donors just make sense. Donors risk their lives in ways that are limited but real and not perfectly known. They do it to help others, and their gift helps not just the recipient but the broader community as a whole. Public servants like teachers, firefighters, police officers, and soldiers all receive special benefits that are not reducible to cash (e.g. health insurance, early retirement, free education). Why can’t we think of donors the same way?

A GI Bill for kidney donation wouldn’t be stingy, but it would avoid the worst problems of incentives. Transplant support would treat kidney donors like public servants. Far from commodifying donors, transplant support would honor them. Instead of crowding out generosity, support would nourish it. It builds from the current system and sets an example that we would want the rest of the world to follow.

In practice, respecting donors as public servants could mean things like:

I admit that the idea isn’t perfect and the details need to be worked out. But the kidney shortage is a crisis, and these measures have broad support today. We need to move beyond the old debate about incentives and forge a new path.

If you told me there was a button I could push tomorrow that would install incentives and end the shortage, I’d still have a hard time saying no. The lives saved would weigh too heavily for me to honestly prefer the status quo. But that’s not the best system we can create. It would leave donors worse off and risk failing entirely.

Transplant support would end the shortage by treating donors with respect. It is the best way I could come up with to simultaneously save tens of thousands of lives and improve our society’s sense of dignity and self-respect. It is what I am working to achieve today.

 

I Wanted the Government to Buy Kidneys: Then I Changed My Mind (DRAFT)

Here’s a draft of a piece I’m working on. Would love any suggestions for improvement or other thoughts. The more critical the better!

Also note that it’s just a draft, so I may make dumb points or say things in stupid ways. Wait till it’s final to hold it against me.

I Wanted the Government to Buy Kidneys: Then I Changed My Mind

Four years ago, when I donated my kidney, I was a passionate believer that the government could pay people for their kidneys, save a great deal of money and rescue tens of thousands from a grueling death. So in 2013, I left my job at a corporate law firm (and my home in Boston), moved to Toledo, and joined the transplant field so that I could enact this change.

A year after that, I co-authored a letter in favor of incentives signed by hundreds. By that June, I’d received a grant from a major foundation to plan a nonprofit to bring incentives to the transplant field. But then I changed my mind.

I didn’t change it all at once or entirely. I still think donors should be treated better than they are. A lot better. But what’s different is where I used to think kidneys could be an item to be purchased by the government, now I think it’s a bad idea to treat them as just another commodity up for exchange. Instead, for kidney donation to be respected, our society needs to treat it like an act of public service and honor donors accordingly.

Here’s how I got there.

Why I Liked Incentives

The kidney transplant shortage might be the most underrated public health problem in America. The current waiting list is a hundred thousand names long. Each year, twenty thousand more people go on the list than receive a transplant. That number represents 50% more than all the homicides committed in the nation last year. Each living donor transplant saves a decade or more of life. Year after year, this shortage crisis represents a truly massive number of lives lost.

Kidney donation is a safe, laparoscopic procedure. Most donors are out of the hospital after a couple nights and off prescription painkillers after a week. Donors lead normal, healthy lives. As with any surgery, there are risks: about 1% of donors will develop kidney failure over their lifetime, which is 0.9% higher than if they hadn’t donated. By comparison, the lifetime risk in the general population is 3.2% (kidney donors need to be healthier to start with). Like any surgery, donation can have complications, but the chance of dying is just 3 in 10,000. And there is uncertainty—people have been donating kidneys for sixty years, but ascertaining exact health effects decades down the line for an unrepresentative population is an epidemiological struggle– one that is necessarily imperfect.

But what is clear is that kidney donors remain as healthy or healthier than the general population after they donate.

Moreover, kidney donation saves the government a great deal of money: Medicare guarantees coverage for patients with kidney failure regardless of age, and averaged over the first five years, transplants costs $60K per year less than dialysis. Since live donor kidneys last for fourteen years on average, a cost savings of $300K is conservative.

That means the government could easily afford to pay $50K or $100K to donors to undergo a surgery that is safe and saves another person’s life. If you persuaded one in two thousand Americans to take that deal, you’d end the shortage tomorrow. No more waitlist: a hundred thousand lives saved; a hundred thousand families rescued from tragedy. Seemed like a no-brainer.

And while we may reasonably worry that the people incentivized to donate would be disproportionately poor, the shortage itself primarily affects people of color and the impoverished. The primary causes of kidney failure are obesity, diabetes, and hypertension, which each share a racial bias. Minorities make up 38% of the American population but 63% of the kidney waiting list. Access to living donation is also racially skewed. Only 29% of living kidney donation comes from minorities, and a white person in the top income quintile is three times more likely to donate than an African American in the bottom quintile, despite African Americans needing kidneys at three times the rate of whites.

Whatever negative racial pattern incentives might have for donors would be dwarfed by the extraordinary health improvement it would achieve for vulnerable communities.

The Problem with Incentives

When I joined the transplant field, I wanted to understand the best case against incentives (so I could beat it). Since I’m a philosophy geek, that meant reading authors like Elizabeth Anderson, Margaret Radin, Lewis Hyde, and Michael Sandel to better understand commodification and the philosophy of market exchange.

To vastly simplify, commodification is when you take something that’s sacred and sell it like it’s scrap. Prostitution takes something intimate and reduces it to something more empty. Selling organs could turn our very bodies into a mere repository for parts (“Kidney Depot”). Even though the seller can rationally consent, she might not be able to avoid being in some way worse off.

Mortifyingly, the example that best illuminated this for me was my time as a corporate lawyer. Like many such, I was all at once unreasonably well-paid, extraordinarily lucky to have the job, and absolutely miserable. Though it may have been completely rational to sell years of my life for money, in some real way it left me diminished.

So how to weigh this risk of commodification against the benefits? I’m honestly not sure, but I do know the lives saved by incentives don’t just erase the problem. A society that looks down on kidney donors as desperate and unclean – as mere human vending machines – would be unspeakable no matter how much healthier it was than our own.

Moreover, diminishing the value of donation could also have bad consequences. Living donors currently give 5,500 kidneys a year; deceased donors 11,500 more: will people still be so generous if the status of organ donation were to decline?

And then there’s the risk. Market incentives would be a drastic change to a national regime of organ donation whose creation was hard-fought and which relies on only the public’s good will to survive. Jeopardizing that system through drastic change could sacrifice people who definitely receive transplants today for the mere potential of lives saved tomorrow. We should avoid that risk if at all possible.

Transplant Support

Transplant support was my way of trying to get the benefits of incentives while avoiding their pitfalls. Transplant support treats kidney donation as a public service: making donation an act of community support rather than individual heroism.

In practice, respecting donors as public servants means offering them lifetime health insurance to alleviate and offset the risks of donation; it means providing annual research stipends to donors to encourage participation in follow-up study and care; and it means removing disincentives to donation by paying donor expenses like lost wages and making the experience of donating as convenient and easy as possible.

This GI Bill for kidney donation isn’t stingy, but it also avoids the problems inherent to incentives. Far from commodifying donors, transplant support honors them. Instead of crowding out generosity, support nourishes it. It builds from the current system and sets an example that we would want the rest of the world to follow.

I admit that the idea isn’t perfect and the details need to be worked out. If you told me there was a button I could push that would immediately install incentives and end the shortage, I’d still have a hard time saying no. The lives saved would weigh too heavily for me to honestly prefer the status quo.

But that’s not the best system we can create. Transplant support can end the shortage by treating donors with respect—by transforming a system that demands a patient beg for her life to one where transplant is supported by the community.

 

crimes

I’m Not Here to Tell You About Jesus

Do you think that God exists? If you had to choose, would you describe yourself as a believer, an atheist, or an agnostic? Now, the first thing I should flag about this question is that for most people it yields a firm answer. For thousands of years, erudite scholars have made argument after  argument on all sides of this question, but I bet that, whichever one of these options you choose, your choice is an unreserved one: you don’t tend to qualify it with “well, I could be totally wrong: there’s a lot on each side.”

Now maybe I’m looking at this the wrong way, and actually agnosticism is just the box to check for “there’s a lot on both sides.” But I think agnostic means a bit more than that: it’s a term that describes a range of people running from atheists-in-sheep’s-clothing to those who think it is truly an unknowable question and either side could be equally right. In my personal experience I tend to find more of the former than the latter, but your mileage may vary.

More importantly, though, is that the agnostic is not someone who is half a religious believer and half an atheist, she doesn’t just sit astride the midpoint of that spectrum. There is an entire type of religious experience the believer has access to that the agnostic forsakes. She doesn’t worship in temple on Monday, Wednesday and Friday and then stay home in disbelief the rest of the time*[1]: the act of worship is totally cut off by her self-designation. This is not because she has doubt – the religious believer also has doubt (indeed it’s the very crucible of faith). The agnostic’s doubt is different because it leads her to rationally designate herself as removed from the concept of God. And that is something a believer can never truly do. Continue reading