Dynamist Blog

The National Kidney Foundation's Bad Math and Guilty Conscience

USA Today has endorsed (very) limited financial incentives for organ donation. The editorial concludes, "More than 6,000 patients die each year while on waiting lists. Demanding patience, when the price of delay is death, is no answer. It's time to try new ideas."

The National Kidney Foundation, represented by its chairman, Charles B. Fruit, takes the "just let them die" view. Fruit's article includes this misleading little math exercise:

Payment stands as an affront to those families that have already donated organs of loved ones out of charity. There is evidence to suggest it might prove similarly offensive to future donors. In 2005, the National Survey of Organ Donation found that 10.8% of those polled would be less likely to grant consent for the organs of a deceased family member to be used for transplant if they were offered payment; 68% said they would be neither more nor less likely to grant consent. Thus, there is little data to show that financial incentives would increase donation rates.

So, to round the figures a bit, 70 percent would be unaffected, and 11 percent would be less likely to grant consent. What happened to the other 19 percent? They were, ahem, conveniently left out--because they would be more likely to grant consent. That's what's called a net increase.

The argument that paying organ donors is "an affront" to unpaid donors is disgusting. Are unpaid donors giving organs to save lives or just to make themselves feel morally superior? Even in the latter case, they shouldn't care if other people get paid. They can still hold their noses in the air. Underlying this argument, which the NKF loves, seems to be a nagging sense of guilt: The current system takes something valuable without offering anything in return. It is, in other words, highly exploitative. If that exploitation suddenly goes away, the people who've been exploited in the past will realize they've been used and be mad. Personally, I don't think that's terribly likely, because most of today's donors are, in fact, motivated by sympathy for recipients. But the fact that defenders of the system keep making the argument suggests they know they're doing something a little shady.

Where Am I?

I'm in Florence, home of great art, great food, and poor Internet service. They're still in the Internet cafe stage, with little wi-fi to be found.


Here is Steve in front of a re-creation of Galileo's inclined plane in the science museum. There are bells along the top, spaced at proportional intervals. As the ball rolls down the incline, it rings the bells, making it possible to time the descent.

We were going to take a photo of me in front of Galileo's actual telescopes, but it turns out you aren't supposed to take pictures, and we were busted--very politetly and apologetically--as I was posing.

The anti-photo policies of museums don't necessarily make sense, except as some kind of revenue enhancer. Prohibiting flash is one thing. And I don't blame the Louvre for blocking photos in the often-crowded Italian painting gallery. But prohibiting all photos in an uncrowded museum filled with works in the public domain is unnecessary--unless you think it will generate sales in the museum store. But the very cool, and virtually empty, science museum, which hardly even has a bookstore, would get more visitors if it let them pose for photos.

Learning from Habitat

In chapter 5 of The Future and Its Enemies (excerpted here), I talk about the insights into governance gained from the early online game Habitat:

Back in 1985, when personal computers were strange and wondrous inventions just filtering into American homes, Chip Morningstar and his colleagues created an online world in which Commodore 64 owners could meet, play, and communicate with each other. The computers were simple, the modems slow, but the world--called Habitat--quickly became complex. Habitat provided its users with an animated landscape, props, activities, and cartoon personas called avatars. Users could send each other e-mail or converse through text in word balloons. Working from this underlying structure, Habitat's virtual citizens developed a wide variety of social activities and institutions. They invented games and dance routines, went on treasure hunts and quests, published a newspaper, threw parties, got "married" and divorced, founded religions and businesses, wrote and sold poems and stories, and debated weighty issues.

Watching Habitat develop made Morningstar think seriously about how rules shape societies, and what the limits of rule making are. "It was a small but more or less complete world, with hundreds and later thousands of inhabitants," he recalls. "And I, along with my coworkers, was God." In theory, the programmers made the rules, knew them thoroughly, and could change them at a stroke. But their godlike powers weren't as limitless as they seemed. Says Morningstar: "Again and again we found that activities that we had planned based on often unconscious assumptions about user behavior had completely unexpected outcomes....We could provide opportunities for things to happen, but we could not predict or dictate the outcome."

If there were chinks in the rules, the players found them. A few enterprising souls spent hours shuffling between a "Vendroid" machine selling dolls for 75 tokens and a pawn machine in another region buying them for 100 tokens. When the arbitrageurs had enough profit to buy crystal balls for 18,000 tokens, they repeated the same procedure with a pawn machine paying 30,000 tokens, until the Habitat money supply had quintupled overnight. When questioned about the source of their newfound wealth, they replied, "We got it fair and square!"

"Unintended consequences really have to do with naive people believing that there are no holes [in the rules]. It's very easy to seduce yourself into thinking that you've got everything under control," says Morningstar. "And the reality is, it's almost never true." Clever people will always come up with ideas no central rule maker has conceived.

Over and over again, Habitat's designers ran into the limits of their own knowledge. The range of tastes and knowledge its many users brought to Habitat quickly overwhelmed the ability of designers to foresee how users would react. A treasure hunt that took weeks to build lasted less than a day, after a single Habitat resident quickly discovered a critical clue; the winner had a great time, but most of the other players barely got started. The system's operators soon realized the value of letting users create their own games. "It's not that they could necessarily do things that were as good as some of the things that we had the facilities to do," says Morningstar. "But the things which they did were much more directly in tune with what people immediately wanted--because they were much more directly in contact with themselves."

I was pleased to discover that Chip Morningstar and Randy Farmer now have a blog extending their insights to the present day. It's full of good stuff.

And, in the "I am so old" department, my "7-year-old niece" mentioned in the chapter's lead is now a 16-year-old rising senior at the South Carolina Governor's School for the Arts & Humanities, specializing in visual arts. She'll doing some college shopping while visiting us later this summer.

Build a Bag Workshop

Here's a fun site for those too old for teddy bears. Startup Freddy & Ma is an experiment in mass customization and web-based marketing, including blog that tracks the company's progress and also comments on fashion. At the website, customers design their own handbags online, combining a huge selection of fabrics (many specially designed for the company) and trims.

I met Anthony Pigliacampo, who founded the company with his sister, when he came to a talk I gave at IDEO. A few months ago, he kindly lent me a couple of prototype bags to test. They're pretty and well-made--but the company's real appeal is the design-your-own angle. It's good for entertainment, even if you don't buy anything. But if you do, use the code DYNAMIST and get 20% off.

Smart and Pretty

The NYT's Claudia Deutsch reports on how GE saved its appliance division with...the substance of style.

"We used to care only that people weren't alienated by the look of our appliances," said Paul Klein, general manager of brand and advertising for GE Consumer & Industrial. "But we've realized that affluent people think of their kitchen as décor, even if a caterer is doing the cooking."

Financial results are great, Deutsch reports--quite a contrast to the days when GE wanted to sell the division, only to find that no one wanted to buy it.

One result is that G.E.'s appliance sales were up 16 percent in the first quarter of 2006, and analysts expect them to keep growing. The unit's return on total capital was 60 percent last year, compared with 16.4 percent for the company as a whole. And the appliance business generated $700 million in cash.

As I often point out in speeches, usually by playing the "Interrogation" commercial, GE has realized the importance of aesthetics in one division after another--a striking, bottom-up strategy from a hard-nosed engineering- and finance-oriented company. That's why I used GE Plastics as the lead example in chapter one of The Substance of Style.

As the ad says, you can have beauty and brains.

Overnight Remodeling

In Sunday's Dallas Morning News, Cheryl Hall profiles a local construction company with an interesting business niche:

Every midnight, construction crews of his Fort Worth-based RightWay Facility Services move into a dozen or so restaurants around the country like commandoes. These eight- to 10-man teams lay carpet, put down tile, install kitchen equipment, replace sewer lines, knock out and rebuild walls.

Eight hours later, they fold drop cloths, gather tools and clean up so that the eateries can serve food in a few hours without missing a beat.

"What we do isn't glamorous, but it is amazing," says the 51-year-old owner of RightWay, which lists many of America's leading chains as clients. "We get no timeouts or do-overs."

His company routinely updates restrooms at Olive Gardens and Red Lobsters for Darden Restaurants Inc. and has overhauled nearly 100 TGI Friday's for Carlson Restaurants Worldwide Inc.

Chick-fil-A, Bennigan's, Chili's, Denny's, On the Border, Outback Steakhouse, Kentucky Fried Chicken, Jack in the Box, Applebee's and Tony Roma's also depend on RightWay to keep their buildings up to corporate snuff.

"Restaurants expect miracles. If you have to close down to get a job done, they want you to close down and reopen like that," Mr. Robertson says, snapping his fingers.

Hall pulls out some good details about the business, from wages (significantly higher than run-of-the-mill construction jobs) to specialized problem-solving (how do you lay down new kitchen tile without closing the place for two days while it dries?). RightWay represents the kind of specialization and innovation that rarely get press coverage--there's no news peg--yet contribute enormously to the cumulative process of economic growth.

Kidney Conference

The video of our AEI conference is now available. Click the link in the upper right-hand corner. For a PDF of my PowerPoint, go here.

On a related issue, the AARP Bulletin has published this excellent article on living donors. (The one flaw is that the mention of Lifesharers at the end doesn't make clear that the organization is made up of people who've agreed to be deceased donors.)

UPDATE: And here's some good news. In a show of good sense, the American Medical Association's annual meeting has adopted a new policy that "Public solicitation of organs from living donors that increase the quantity of available organs and do not unreasonably disadvantage others on the organ waiting list are ethically acceptable."

Cash--and a Little Respect--for Kidneys

I have an op-ed in today's LAT on--surprise!--kidney donations. It's called "Cash for Kidneys," and it does argue that payments would be a good idea. But before we get a market, we have to change the widespread attitude toward live donation: that kidney donors are quite likely crazy or criminal and, hence, should be deterred. Here's an excerpt:

Unfortunately, our laws and culture discourage healthy people from donating organs, as I learned this spring when I gave a kidney to a friend.

My parents were appalled. My doctor told me, "You know you can change your mind." Many people couldn't understand why I didn't at least wait until my friend had been on dialysis for a while.

This pervasive attitude not only pressures donors to back out, it shapes policies that deter them. Some transplant centers require intrusive, demeaning psychological probes that scare people off. Some bioethicists suspect that donors suffer from a mental disorder, as opposed to being motivated by benevolence or religious conviction.

The scrutiny is particularly nasty when healthy people want to give their organs to strangers — not truly unknown people, mind you, but patients they have gotten to know through Internet sites or press coverage.

Many transplant centers flatly refuse "directed donations" to specific strangers. Some argue that it's "unfair" for patients to jump the queue with personal initiative and an appealing story; others insist that such donors aren't to be trusted (they must be either criminal or crazy). Posters at livingdonorsonline.org warn givers to never even mention the Internet, lest their good intentions be thwarted.

Sandra Grijalva, a San Francisco woman with polycystic kidney disease, asked Kaiser officials if she could find a donor online — after having one of her friends disqualified because of high blood pressure. "They said absolutely not," she says. The donor, Kaiser maintained, might someday try to extort money. (So might your cousin, but at least you'd be alive.)

Instead of dire possibilities, consider a cold reality: Without tens of thousands of new living donors, most of the people on that very long waiting list are going to suffer and die on dialysis. The transplant community's top priority should be increasing the supply of willing donors.

I also take aim at the National Kidney Foundation's shocking attitude toward discussing incentives.

But even talking about incentives is taboo to some self-styled patient advocates. On Monday, the American Enterprise Institute will hold a conference in Washington on incentive-based transplant reforms. (It's organized by my kidney recipient, a physician and health-policy scholar at the institute.) When the National Kidney Foundation heard about the conference, its chief executive, John Davis, complained to the institute's president, "We don't see how an AEI forum would contribute substantively to debate on this issue."

Davis' group adamantly opposes donor compensation, lobbying against even experimental programs and small tax credits. It's as though the National Parkinson Foundation opposed stem cell research, or thought researchers should work for free.

The AEI conference, which is open to the public, will be aired live on C-Span2, beginning at 10:00 a.m. Eastern on Monday. I will moderate the first panel and speak on the second. After the conference, AEI will probably also post video.

Perfect Timing? Or Not?

While I'm plugging my new part-time employer, I should mention that the new Atlantic has a cover story on Zarqawi. The online version bears the title "The Short, Violent Life of Abu Musab al-Zarqawi" and the note "Edited for the Web, June 8, 2006."

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