KidneysforSale:WhoDisapproves,andWhy?2.RapaportFT.Thecaseforalivingemo - PDF document

KidneysforSale:WhoDisapproves,andWhy?2.RapaportFT.Thecaseforalivingemotionallyrelatedinternationalkidneydonorexchangeregistry.TransplantProc1986;XVIII:5–9.3.CharlieW.NorwoodLivingOrganDonationAct,PublicLaw110–144,121Stat.1813–1814,21/12/2007.4.RothAE,SonmezT,UnverMU.Kidneyexchange.QuartJEcon2004;119:457–488.5.RothAE,SonmezT,UnverMU,DelmonicoFL,SaidmanSL.Utiliz-inglistexchangeandundirectedgoodSamaritandonationthrough‘chain’pairedkidneydonationsAmJTransplant2006;6:2694–6.ReesMA,KopkeJE,PelletierRPetal.Anon-simultaneousex-tendedaltruisticdonorchain.NEnglJMed2009;360:1096–1101.7.RodrigueJR,CristK,RobertsJP,FreemanRB,MerionRM,ReedAI.Stimulusfororgandonation:AsurveyoftheAmericanSocietyofTransplantSurgeonsMembership.AmJTransplant2009;9:8.WhaplesR.ThepolicyviewsofAmericanEconomicAssociationMembers:Theresultsofanewsurvey.EconJWatch2009;6:9.KranenburgL,WeimarW.Incentivesforlivingkidneydonation:Whatdoesthepublicthink?Transplantation2008;86:500–10.BoulwareLE,TrollMU,WangNY,PoweNR.Publicattitudesto-wardsincentivesfororgandonation:Anationalstudyofdifferentracial/ethnicandincomegroups.AmJTransplant2006;6:2772–11.GuttmannA,GuttmannRD.Attitudesofhealthcareprofessionalsandthepublictowardsthesaleofkidneysfortransplantation.JMedEthics1993;19:148–153.12.KitturDS,HoganMM,ThukralVK,McGrawLJ,AlexanderJW.Incentivesfororgandonation?Lancet1991;338:1441–1443.13.Americansaredividedonofferingnancialincentivestoor-gandonors.WallStJMay17,2007http://online.wsj.com/14.Wait-listedtodeath,improvingincentivesforor-gandonations.WallStJDecember17,2008,A20,http://online.wsj.com/article/SB122948107890913051.html.15.MatasAJ,HippenB,SatelS.Indefenseofaregulatedsystemofcompensationforlivingdonation.CurrOpinOrganTransplant2008;13:379–385.16.DanovitchGM,DelmonicoFL.Theprohibitionofkidneysalesandorganmarketsshouldremain.CurrOpinOrganTransplant2008;13:386–394.17.Delmonico,FrancisL.Thedevelopmentofthedeclarationofis-tanbulonorgantrafckingandtransplanttourism.NephrolDialTransplant2008;23:3381–3382.18.RobinYoung.The‘Yuck!’factor.NationalPublicRadioMarch25,2008,minute13:3019.LephardtNE,BredeenCH.Themarketattitudeinventory:Thedevelopmentandtestingofreliabilityandvalidity.JEconEconEducRes2005;6:63–72.20.CouperMP.Websurveys:Areviewofissuesandapproaches.PublicOpinQ2000;64:464–494.21.SchonlauM,FrickerR,ElliottM.Conductingresearchsurveysviae-mailandtheweb.RAND,SantaMonica,CA,2002:20–24.22.YeagerDS,KrasnickJA,ChangLCetal.Comparingtheaccu-racyofRDDtelephonesurveysandinternetsurveysconductedwithprobabilityandnon-probabilitysamples.[workingpaperup-datedAugust1,2009citedNovember21,2009]availableat:http://www.knowledgenetworks.com/insights/docs/Mode-04_2.pdf.23.GrovesRM.Nonresponseratesandnonresponsebiasinhouse-holdsurveys.PublicOpinQ2006;70:646–675.24.ChangLC,KrasnickJA.NationalsurveysviaRDDtelephonein-terviewingvs.theinternet:Comparingsamplerepresentative-nessandresponsequality.[workingpaperupdatedFebruary24,2009citedNovember21,2009]availableat:http://www.knowledgenetworks.com/ganp/docs/RDD-vs-Web.pdf.25.BerrensRP,BoharaAK,Jenkins-SmithH,SilvaC,WeimerDLTheadventofinternetsurveysforpoliticalresearch:Acomparisonoftelephoneandinternetsamples.PolitAnal2003;11:1–22.AmericanJournalofTransplantation2010;10:1221–1227 LeiderandRothWendthatamajorityofourrespondentsapproveofeachofthefourkidneymarketswedescribe,whileasubstan-tialminoritydisapprovesofatleastonepotentialmarket.Asimilarmajorityfavorsthelegalityofhavingthegovern-mentand/orinsurancecompaniesgiveastandardpaymenttodonors;apluralityalsowouldlikeanindividualmarkettobelegal,butnearlyasmanywantsuchmarketstobeille-gal.WhilerecentsurveysoftheASTS(7)andthepublic(10)ndmuchgreaterdisapprovalofcashpaymentstodonors,ourresultsareinmanywayscongruentwiththeirs.InRodrigueetal.(7)nearly65%oftransplantsurgeonsfa-voranincometaxcreditfordonors,whileinBoulwareetal.(10)between28%and41%approvepaymentsortaxcreditstolivingdonorsfromeithergovernmentortheiremployer.OurmethodologyofdescribingscenarioswithahypotheticalpatientisclosesttoGuttmannandGuttmann(11);theyalsondamajorityofthepublic(between69%and74%)infavorofallowingapatienttopayalivingdonor.Theyfoundmuchlowerapprovalamongphysiciansandtransplantspecialists(between21%and43%approval).The2007Harrispoll(13)alsofoundsimilarresultstoours,with49%infavoroflivingdonorsreceivingnancialWecautionthatsurveysresponsescanbeinuencedbyquestionwording,hencewetriedtoavoidemotivecontexts.Themostreliableinformationcomesfromwithin-surveycomparisonsofresponsestothedifferentlowcon-textquestionsweask,ratherthanbetween-surveycom-parisons,orattemptstoassessabsoluteratesofparticularviewswithinthepopulation.Thuswhilealargeminorityofourrespondentsdisapproveofmarketsforkidneys,itismoreinformativetonotethatthisismuchlessthantherateofdisapprovalofprostitution,comparabletotherateofdisapprovalofhiringasurrogatemother,andmorethantherateofdisapprovalforbuyingblood.Wemainlyexploretherelationshipbetweendisapprovalofkidneymarketsandotherattitudes.Weconsiderthreehypotheses.First,thisdisapprovalispartofageneraldis-approvalofthesaleandcommoditizationofbodyparts.Second,itreectsadisapprovaloftheencroachmentofmarketsontraditionallynonmarkettransactions.Third,dis-approvalofkidneysalesreectsdistrustofmarketsgener-ally.Becausewearecomparinganswerstosimilarlycon-structedquestions,theresultingcorrelationsshouldreectpatternsofattitudesinthepopulation.Howeveroursurveycannotidentifycausation.Theresponsessupportthersttwohypotheses,asinde-pendentpredictorsofdisapprovalofkidneysales,butfailtosupportthethird.Disapprovalofsalesofblood,surro-gatewombsanddeceaseddonorsforanatomystudyisapredictorofdisapprovalofmarketsforkidneys.Theseef-fectsarestrong—increasingthelikelihoodofdisapprovingofakidneymarketbymorethan20percentagepoints.Asecondpredictorofdisapprovalofkidneymarketsisdis-approvaloforderingtakeoutfoodinsteadofcookingatwhereagainthisattitudeincreasesthelikelihoodofdisapprovingofakidneymarketbymorethan20percent-agepoints.Moreover,disapprovaloforderingtakeoutfoodpredictsdisapprovalofkidneymarketsinadifferentsubsetofpeoplethandisapprovalofmarketsinvolvingotherbodyFinally,distasteforkidneymarketsdoesarisefromdistasteformarketsgenerally.Onthecontrary,peoplewhodisapproveofkidneymarketstendtoapproveofmar-ketsgenerally.(Bothdisapprovingofkidneymarketsandapprovingofmarketsgenerallyarepositivelycorre-latedwithidentifyingassociallyconservativeand/orRepublican.)Theshortageoftransplantkidneyshasspurredextensivedebateaboutmonetarymarkets.Ourresultssuggestboththatthegeneralpublicmaybeopentosomeformofmon-etarycompensationtokidneydonors,andthattheoppo-sitiontosuchmarketsreectsnotonlyspecicconcernsaboutpolicydetailsbutthatasubstantialminorityndkid-neymarketsrepugnant,thatistheydisapproveofotherstakingpartinthem.Wendmajorityapprovalofeachkidneymarket,thoughamajoritysupportslegalityonlyformarketswiththegovern-mentorinsurancecompaniesaspurchaser.Thissuggeststhatmonetarycompensationtodonorsbyinstitutionalin-termediariescouldreceivepublicsupport.Bothgeneraldisapprovalofbody-relatedmarketsanddisapprovalofmar-ketencroachmentontraditionallynonmarketspherescon-tributetodisapprovalofkidneymarkets;howeverwendnoevidencethatgenerallynegativeattitudestowardmar-ketsdrivethisrepugnance.SocialconservatismandbeingareligiouslyactiveChristianalsopredictofkidneymarketdisapproval,thoughlargelyasproxiesforgeneraldisap-provalforbody-relatedmarkets.Furthermore,disapprovalforkidneymarketsseemsdrivenbyconcernsaboutrepug-nanttransactionsatleastasmuchassensitivitytospecicpolicydetails.Unlessproposalsengagethesefundamen-talconcerns,perhapsbyaddressingthelong-termwelfareofkidneyproviders,theywillfailtoaddresstheobjectionsofasubstantialminority.AcknowledgmentWeacknowledge,withoutimplicating,helpfulconversationsandencour-agementfromdoctorswithviewsonallsidesofthisdebate,includingparticularlyFrankDelmonico,GabeDanovitch,DougHanto,ArthurMatasandSallySatel,andsupportfromtheNationalScienceFoundation.References1.RothAE.Repugnanceasaconstraintonmarkets.JEconPerspect2007;21:37–58.AmericanJournalofTransplantation2010;10:1221–1227 KidneysforSale:WhoDisapproves,andWhy?disapprovalofthespecicscenarioiscorrelatedwithdis-approvingofkidneymarkets.Disapprovaltowardscenariosrepresentingbothhypothe-sesissignicantlycorrelatedwithdisapprovaltowardkid-neymarkets.Threetransactionsrelatingtobodypartsaresignicantwhenlookingattotaldisapproval,withtwoofthem(surrogacyanddeceaseddonors)alsobeingmarginallysignicantfordisapprovingofatleastonemar-ket.Theeffectsarelarge.Therstspecicationindicatesthat,foranyofthethreebodyscenarios,ifwecomparedrespondentswhostronglyapprovedofthebodyscenariowithrespondentswhostronglydisapprovedwewouldex-pectthelattergrouptohavealargertotaldisapprovalto-wardkidneymarketsbetween3.12and3.79points(anincreaseofbetween0.52and0.66standarddeviationsinthetotalkidneydisapprovalmeasure).Similarly,thesecondspecicationindicatesthatifwecomparedrespondentswhostronglyapprovedofthesurrogacyscenarioorde-ceaseddonorscenariotothosewhostronglydisapprovedthelattergroupwouldbe22percentagepointsmorelikelytodisapproveofatleastoneofthekidneymarkets.Disapprovaltowardoneofthescenariosrelatingtotra-ditionallynonmarkettransactionsisalsosignicantlycor-related:respondentswhodisapproveofthebusyparentswhoconsistentlyeatoutorordertakeoutratherthancook-ingfortheirchildrenaresignicantlymoredisapprovingofkidneymarkets.Theeffectsizeisagainlarge:respon-dentswhostronglydisapproveofthetakeoutscenarioareestimatedtodisapproveofkidneymarketsby2.85morepointsthanrespondentswhostronglyapproveofthetake-outscenario(anincreaseof0.50standarddeviationsinthetotalkidneydisapprovalmeasure).Thosewhostronglydis-approveofthetakeoutscenarioare23percentagepointsmorelikelytodisapproveofatleastonekidneymarketcomparedtothosewhostronglyapproveofthetakeoutscenario.Notethatdisapprovalforthecorrespondingsce-nariowithanonmarketsolution(havingafamilymembercook)doesnotsignicantlypredictdisapprovalforkidneymarkets(andinfacthasacoefcientnearzero).Thissug-geststhattheconnectionbetweendisapprovalforeatingout/orderingtakeoutanddisapprovalforkidneymarketsiscomingfromtheuseofthemarketratherthanotherfeaturesofthescenario(suchasbothparentsworking).Thecoefcientsonthereligionandpoliticsvariablesarenolongersignicantwhenincludedalongsidedisapprovaltowardthesescenarios.Thissuggeststhatthesegeneralideologiesareimportantinpredictingattitudestowardkid-neymarketsasproxiesforthemoreparticularattitudesto-wardbody-relatedortraditionallynonmarkettransactions.ComparinggeneralobjectionstopolicyconcernsWenowwanttocomparetheimportanceofgeneralcon-cernsaboutrepugnanttransactionstoconcernsaboutspe-cicpolicydetailsininuencingattitudestowardkidneymarkets.Weidentifyrespondentsas‘sensitivetorepug-nance’iftheydisapproveofatleastoneofthefoursignif-icantscenarios(takeoutfood,blooddonations,surrogacy,medicaldeceaseddonors).Atotalof68%ofrespondentswhodisapproveofkidneymarketsaresensitivetorepug-nance(signicantlymorethanthe51%whodonotdis-approveofkidneymarkets;Fisher’sexacttestpWeidentifyrespondentsas‘sensitivetopolicydetails’iftheyconsistentlyrateboththeindividualmarketshigherorlowerthanthecorrespondinggovernmentmarkets,oriftheyrateboththelivingdonormarketshigherorlowerthanthecorrespondingdeceaseddonormarkets.Notethatarespondentcanbepolicysensitivewhetherornottheydisapproveofanykidneymarket.Atotalof60%ofrespon-dentswhodisapproveofkidneymarketsaresensitivetopolicydetails(signicantlymorethanthe26%whodonotdisapproveofkidneymarkets;p0.01).Therefore,amongthosewhodisapproveofkidneymarketsatleastasmanyrespondentsareconcernedwithrepugnanttrans-actions(68%)asareconcernedwithpolicydetails(60%).Moreover,amongkidneymarketdisapproverscaringaboutrepugnanceandcaringaboutpolicydetailsarenegativelycorrelated(0.21,pArefood-andbody-relateddisapprovaldistinct?Wenowdemonstratethatbody-relatedtransactionsandfamilyfoodpreparationrepresenttwodistinctpredictorsofkidneydisapproval.First,whilethecorrelationbetweenthetakeoutfoodscenarioandeachofthebodyscenariosissignicant,theyareallsmall(between0.05and0.15).Second,amongrespondentswhoaresensitivetorepug-nance,manydisapproveofonlythetakeoutfoodscenariooronlyoneofthebodyscenarios.Specically,ofthere-spondentswhodisapproveofkidneymarkets,21%disap-proveofboththetakeoutfoodscenarioandatleastoneofthebodyscenarios,17%disapproveofonlythetakeoutfoodscenario,30%disapproveofonlyoneormoreofthebodyscenarios,and32%disapproveofneither.Moreover,respondentswhodisapproveofthemarketin-fringingonfamilyfoodpreparationhavedifferentreligiousandpoliticalcharacteristicsthanrespondentswhodisap-proveofbody-relatedtransactions.ReligiouslyactiveChris-tiansarenotsignicantlymorelikelytodisapproveofor-deringtakeout(-testp0.42),butarestronglymoredisapprovingofpayingforblood,surrogatemothersanddeceaseddonorsformedicalpurposes(p0.01,p0.02respectively).Inaddition,socialconservativesdonothavestrongerviewsontakeoutfood(p0.39),whiletheydosignicantlydisapproveofallthreebodyrelatedmarkets(p0.02,p0.01,p0.01).Similarly,beinganeconomicconservativehasnorelationshipwithattitudestowardtakeoutfood(p0.93),whileitpredictsdisap-provalofthebodyrelatedmarkets(p0.01forallthree).Thus,whilemanyrespondentsdisapproveofboththetake-outfoodscenarioandbody-relatedmarketscenarios,thequestionsmeasuretwodistinctattitudes.AmericanJournalofTransplantation2010;10:1221–1227 LeiderandRothpositivetoneutralandfromneutraltonegative).Thiscouldbeduetoabiastowardthestatusquo,orconsiderationfortheattitudesofotherswhoaremoredisapproving.Toconsiderwhatotherresponsescorrelatewithdisap-provalofkidneymarkets,weusetwodependentvariablestocaptureoverallkidneydisapproval.First,wesumthedis-approvalratingstoconstructanaggregatemeasureofdis-approvalofkidneymarkets.(Weweightresponsesequally,becauseweightsgeneratedbyfactoranalysisoneachofthefourdisapprovalmeasuresdifferedbylessthan0.024.)Thisaggregatemeasurehadmean13.1andstandarddevi-ation5.7.Wealsoconstructadummyvariablethatequalsoneiftherespondentdisapprovedofatleastoneofthefourmarkets.Atotalof38%ofrespondentsdisapprovedofatleastonemarket.DemographicsandpersonalexperienceRespondentsemployedinhealthcarehavesomewhathighertotaldisapprovalofkidneymarkets,althoughthedifferenceisinsignicant(-testp0.45),howevertheyaresignicantlymorelikelytodisapproveofatleastonemarket(adifferenceof8percentagepoints,p0.05).Or-gandonorsarenotmoredisapprovingbyeithermeasure0.67,p0.22,respectively).However,reswhoknowatransplantrecipientarelessdisapprovingover-all(p0.04)andare22percentagepointslesslikelytodisapproveofanysuchmarket(p0.04).Womenaresomewhatmoredisapprovingofkidneymarketsoverall0.04),althoughtheirlikelihoodofdisapprovingofatleastonemarketisnotsignicantlydifferent(pTheredonotappeartobeconsistentpatternsforrace,nordoesdisapprovaldecreasebyincomeoranylevelofReligionandpoliticsReligiouslyactiveChristiansaresignicantlymoredisap-provingofkidneymarkets(p0.01),andare14per-centagepointsmorelikelytodisapproveofatleastonemarket(p0.01).Atotalof92%ofreligiouslyactivere-spondentsidentiedasChristian.Notenoughrespondentsidentiedasreligiouslyactivenon-Christianstodeterminetheirattitudes.Tomeasurepoliticalattitudes,weelicitpartyidenticationandidenticationassocially/economicallylib-eral/conservative.Whilewedonotndasignicanteffectofpartyafliation,bothsocialandeconomicconservativesaresignicantlymoredisapprovingofkidneymarkets(totaldisapproval:p0.01andp0.07,respectively),withso-cialconservativesbeing16percentagepointsmorelikelytodisapproveofatleastonemarket(p0.01)andeco-nomicconservatives12percentagepointsmorelikelytodisapprove(pAttitudestowardcapitalismIfrespondentsdislikekidneymarketsbecausetheythinkmarketsgenerallyareexploitative,thenweshouldexpectpeoplewhoagreewithnegativestatementsaboutmarketsand/ordisagreewithpositivestatementstodisapproveofTable3:Traditionallynonmarketandbody-relatedtransactions (1)(2)TotalDisapproveofVariablesdisapprovalatleastone Food:familycooks0.0680(0.186)0.0530(0.0461)Food:ordertakeout0.473(0.180)0.0993Kids:familycaresfor0.269(0.218)0.0115(0.0568)Kids:daycare0.0248(0.212)0.0265(0.0527)Eldercare0.0187(0.173)0.00609(0.0455)Sex:promiscuous0.144(0.170)0.0624(0.0446)Sex:prostitute0.198(0.167)0.0584(0.0472)Payforblood0.629(0.198)0.0352(0.0445)Payforsurrogacy0.616(0.172)0.0810Payfordeceaseddonors(Medical)(0.206)0.0836Payfordeceaseddonors(Misc)0.120(0.214)0.0527(0.0491)PoliticalandreligiousYesYesDemographicandexperiencecontrolsYesYesConstant4.836Observations415415R-squared0.280 Column1isOLS,Column2isProbit.Robuststandarderrorsinparentheses.kidneymarketsmore.However,wendeithernorelation-shiportheoppositerelationship.Respondentswhoagreethatmarketsleadtounequaloutcomes(anantimarketatti-tude)arelessdisapprovingofkidneymarketswithmarginalsignicance(p0.08),asarerespondentswhoagreethatmarketsneedtobestronglycontrolled(p0.07).Inaddi-tion,neitheragreeingwithspecicpromarketstatements,norhavinganoverallfavorableimpressionofmarkets,aresignicantlyrelatedtoattitudestowardkidneymarkets.Hencethereisnopatternthatantimarketattitudespredictdisapprovalofkidneymarkets.FamilyandbodytransactionscenariosWenowexaminewhetherdisapprovalofkidneymarketsisrelatedtomoregeneralrepugnance,eithertowardcom-moditizationofotherbodypartsortowardotherformsofmarketencroachmentontraditionallynonmarketmecha-nisms.Table2PanelBshowsapprovalanddisapprovalofeachofthescenariosrelatingtofamilyandbodytransac-tions.Onlyprostitutionelicitsmajoritydisapproval.Disap-provalofkidneymarketsislessthandisapprovaloffre-quentlyorderingtakeoutfood,isgreaterthandisapprovalforpayingblooddonorsandcomparabletothedisapprovalofpayingsurrogatemothersandpurchasingdeceaseddonorsformedicalpurposes.Toassesswhetherdisapprovaltowardkidneymarketsisre-latedtoeitherdisapprovalofmarkettransactionsforbodiesand/orothertypicallynonmarketinteractions,weregresskidneydisapprovalondisapprovaltowardtheothersce-narios(Table3).SignicantpositivecoefcientsindicateAmericanJournalofTransplantation2010;10:1221–1227 KidneysforSale:WhoDisapproves,andWhy?Table1:Summaryofdemographicvariablesofrespondents U.S.Oursamplepopulation Meanage44.6044.30%Female54.68%52.4%%White79.5%68.2%%Black7.5%11.6%%Asian5.3%4.6%%Hispanic6.1%13.8%%Married56.21%54.1%Meannumberofchildren1.581.9Medianhouseholdincome$50–$59K$50K%Householdincome22.41%25.69%%Gradeschoolorhighschooleducationonly23.71%48.42%%Collegeeducated39.96%33.0%%Christian69.46%76.0%%Attendingreligiousservices36.52%N/A%Republican27.60%39%%Democrat29.64%32% U.S.populationdatadrawnfrom2008currentpopulationsurvey(CPS),2008Americanreligiousidenticationsurvey(ARIS)and2008electionexitpolls.U.S.populationdataforindividualsagewherepossible.Internetsurveysareanemergingmethodologycomparedtotelephonesurveys.Researchdescribingtheirrelativeperformanceisstilldeveloping.Initialstudiessuggestin-ternetsurveysdonotintroduceadditionalbiasescomparedtorandomdigitphonesurveys.Internetsurveysoftenyieldresponseratesoflessthan10%(20),andaslowas2%(21,22).Whilenonresponsebiasisalwaysaconcern,re-searchsuggeststhatlowresponseratesdonotnecessarilyindicatenonresponsebias(22,23).Notably,ChangandKrasnick(24)andBerrensetal.(25)eachranthesamesurveywithbothtelephoneandinternetsamples.WhileChangandKrasnickndtheinternetsam-plehadsomewhatgreaterdemographicdeviationsfromtheU.S.population,itwasmoreaccurateonanumberofdimensionsincludinggreaterpredictivevalidity,greaterre-liabilityandlesssocialdesirabilitybias.Berrensetal.ndthatwithdemographiccontrolstheopinionsmeasuredarenotsignicantlydifferentbetweenmethodologies.ThuswhileoursampleissomewhatmoreeducatedthantheU.S.population(seeTable1),andhasbasiccomputerskills,thesecomparativestudiessuggestourapprovalmeasuresmaybelargelyrepresentative.Nonresponsebiasisalsomitigatedinoursurveybecausethesolicitationemaildidnotincludethetopic,hencewewouldnotexpectrespon-derstohavedifferentattitudestowardkidneymarketsthanDataanalysisTable1summarizesthedemographiccharacteristicsofoursample,whichhasbroadenoughcoveragetoidentifytheimpactofthesevariables.AttitudestowardkidneymarketsWebeginbyexaminingrespondents’overallsupportto-wardkidneymarkets.Table2,PanelAreportstheper-centofrespondentswhoapproveanddisapproveofeachmarket(i.e.thefractionwhochoseanyofthethree‘ap-prove’/’disapprove’answers—theomittedcategoryis‘nei-therapprovenordisapprove’).Amajorityapprovedofeachpotentialmarket;onlybetween16and27%disapproved.Respondentsweremorefavorabletomarketsinvolvinggovernmentoranotherinstitutionalpurchaser,ratherthanindividualpatientsbuyingkidneysdirectly.Thisdifferencewassignicantforbothlivinganddeceaseddonors(usingatwo-tailed-test,p0.01forbothcomparisons).Whileattitudestowardlegalityshowasimilarlargedifferencebetweenpositiveandnegativeratingsforpaymentsfromthegovernment(orinsurancecompanies),individualmar-ketshaveamuchsmallerdifference(only42–44%choose‘legal’comparedto31–35%choosing‘illegal’).Respon-dents’policypreferenceswereslightlymorenegativethantheirapprovalsentiments(shiftingsomerespondentsfromTable2:Disapprovalrates PanelA:Kidneymarkets DonorPurchaserApprove(%)Disapprove(%)Legal(%)Illegal(%)Modalrank DeceasedIndividual50.6726.5842.2633.843DeceasedGovernment62.7215.8757.5516.831LivingIndividual54.4922.7544.1731.174LivingGovernment60.9917.4056.2119.692 PanelB:Familyandbodytransactions ScenarioApprove(%)Disapprove(%)ScenarioApprove(%)Disapprove(%) Sistercookfood46.8523.90Sex:prostitute8.4171.51Orderfood43.0231.17Payforblood68.0711.85Kidswithgrandma79.546.12Surrogacy65.7716.44Kidsindaycare66.1616.25Buybodyformedical54.8824.47Eldercare65.2016.25Buybodyformisc.42.8332.12Sex:promiscuous31.3635.18 AmericanJournalofTransplantation2010;10:1221–1227 IntroductionThedemandfortransplantablekidneysexceedsthesupply.Ifkidneyswereapurchasedcommodity,thegapbetween LeiderandRothMarketsforkidneysWedescribedfourpotentialkidneymarkets,varyingbothdonortype(livingvs.deceased)andpurchasertype(indi-vidualvs.government).Respondentsratedeachmarketona7-pointscale(1‘approveagreatdeal’approvenordisapprove’‘disapproveagreatdeal’).Forexample,thescenariodescribingtheindividualmarketfordeceaseddonationsis:Alanhasaseriouskidneydisease,andneedstohaveakidneytransplant.Hedoesnothaveanyfriendsorfamilywhowouldbecompatibledonors.ScenarioA:Supposeitwaslegalforpaythefamilyofadeceaseddonortoimmediatelyreceiveadonatedkidney.Wouldyouapproveordis-approveofAlanpayingforakidneyfromadeceasedThecorrespondingscenariodescribingaregulatedinstitu-tionalmarketinvolvingthegovernmentand/orinsurancecompaniesis:ScenarioB:Supposethatthegovernmentand/orhealthinsurancecompanieswereallowedtopayastandardpaymenttothefamilyofa.Wouldyouapproveordisapproveofsuchaprogramtopayforkidneysfromdeceaseddonors?Thetwoscenariosforlivingdonorsarewrittensimilarly.Wealsoaskedwhichmarketsrespondentswouldwanttobelegalized(1‘stronglybelieveitshouldbelegal’‘noopinion’‘stronglybelieveitshouldbelegal’).Lastlyweaskedrespondentstorankthefourmarketsinorderofacceptability.MarketsforotherbodypartsIfdisapprovalofkidneymarketsarisesfromgeneralaver-siontocommoditizingbodies,individualswhodisapproveofkidneymarketswilldisapproveofmarketsforotherbodyparts.Tomeasuretheseattitudeswepresentedscenariosforpayingblooddonors,payingasurrogatemotherandpurchasingdeceaseddonors.Forexample,thescenariodescribingpayingblooddonorsis:Background:OrangeDiamondisacharitythatorga-nizesblooddonations.Sincetheyoftendon’thaveenoughdonors,theypay$50eachtimeapersondonatesblood.DoyouapproveordisapproveofpayingthesedonorsMarketssubstitutingfornonmarkettransactionsIfdisapprovalreectsthebeliefthatorgansshouldbegivenbyfriendsorfamily,peoplewhodisapproveofkidneymar-ketsmayalsodisapproveofotherpurchasesofservicesotherwisegivenforfreebylovedones(suchasfoodprepa-rationandchildcare).Wepresentedpairedmarketandnon-marketscenarios.Thequestionsforcookingandtakeoutfoodare:Background:JohnandMarybothworkfulltimejobs,andhavesuccessfulcareers.Theyhavetwoschool-agedchildren.Theyareaprosperousmiddleclassfamily.Theirjobskeepthemquitebusy,andJohnandMaryareoftentootiredtocookafamilymeal.ScenarioA:Supposethat3to4nightsaweekJohnandMaryhaveMary’ssisterCorriecomeovertomakedinner.DoyouapproveordisapproveofJohnandMaryhavingCorriecookdinnerinsteadofmakingdinnerthemselves?ScenarioB:Supposethat3to4nightsaweekJohnandMaryordertakeoutorgoouttorestaurantswiththeirchildren.DoyouapproveordisapproveofJohnandMarybuyingdinnerfromarestaurantinsteadofmakingdinnerthemselves?Bycontrastingthetwoscenarioswecanidentifydisap-provaltowardthemarket-basedsolution,ratherthandis-approvaltowardotheraspectsofthescenario(e.g.bothparentsworking).Wealsomeasureddisapprovalforpros-titution,andpromiscuity.MarketsgenerallyPeoplewhodisapproveofkidneymarketsmaysimplyre-gardmarketsasgenerallyexploitative.Toassessthisweemployquestionsdrawnfromasurveyofattitudestowardcapitalismandfreemarkets(19).Wemeasureagreementwithstatementsthatmarketscause‘anunfairdistributionofincome’,‘rewardspeoplefairly’,‘leadtoanefcientuseofresources’,‘requirealotofgovernmentcontrol’,andareoverall‘fairandethical’.Thusindividualswhodisapproveofkidneymarketsmayagreewiththenegativestatementsand/ordisagreewiththepositiveones.InternetsurveyWeusedtheZoomerangonlinesurveypanelofMarket-Tools,Inc(SanFrancisco,CA).MarketToolsrecruits2.5millionpotentialparticipantsthroughtheirwebsite,aswellastargetedrecruitmentsothatthepanelisnationallyrepre-sentative.Respondentsearnpoints(worthapproximately$1)redeemableforprizesforeachcompletedsurvey.ThesurveywasconductedinMay2008.Atotalof8755potentialrespondents15yearsorolderwereinvitedbyemailtotakethesurvey,with575(5.97%)accessingthesurveywebsite.Atotalof523respondentscompletedthesurvey,withacompletionrateof90.96%.AmericanJournalofTransplantation2010;10:1221–1227 AmericanJournalofTransplantation2010;10:1221–1227WileyPeriodicalsInc.2010TheAuthorsJournalcompilation2010TheAmericanSocietyofTransplantationandtheAmericanSocietyofTransplantSurgeons doi:10.1111/j.1600-6143.2010.03019.xKidneysforSale:WhoDisapproves,andWhy?S.LeiderandA.E.RothUniversityofMichiganRossSchoolofBusiness,Ann