Understanding Repugnance: Implications for Public Policy

• Author: Nicola Lacetera,Julio J. Elias,Mario Macis
• Published date: 01 December 2017
• DOI: http://doi.org/10.1002/wmh3.246
• Date: 01 December 2017

Understanding Repugnance: Implications for Public

Policy

Julio J. Elias , Nicola Lacetera, and Mario Macis

Understanding the inf‌luence of moral repugnance on social decisions is challenging, particularly

because in several cases not all of the relevant policy options can be observed. In a series of recent

studies, we designed survey experiments to identify individual preferences in morally controversial

transactions, with focus on the provision of payments to kidney donors in the United States (Elias,

Lacetera, & Macis, 2015a, 2015b, 2016a). We found that providing information on how a price

mechanism can help alleviate the organ shortage signif‌icantly reduces opposition toward payments

for organs. Moreover, we quantif‌ied the trade-off that people make between the repugnance and the

eff‌iciency of alternative kidney procurement systems. In Elias, Lacetera, Macis, and Salardi (2017),

f‌inally, we analyzed how the regulation of controversial activities is related to economic

development. This paper summarizes these f‌indings and analyzes their main implications for public

policy and market design.

KEY WORDS: repugnance, market for organs, economics and moral

Introduction

In most modern societies, several transactions are prohibited or restricted. In

addition to reasons related to health, safety, or negative externalities, the

motivation for banning certain trades resides mainly in ethical concerns—in other

words, societies perceive these transactions as “repugnant.” Roth (2007) intro-

duced in the economics literature the concept of “repugnance” for a transaction

as the aversion toward other individuals engaging in it, even if the parties

directly involved benef‌it from that trade (i.e., “There are some things no one

should be allowed to do”). Repugnance considerations have important conse-

quences on the types of markets and transactions that we observe and, as such,

they impose a challenge for policy and market design. This paper discusses recent

experimental evidence on repugnance and its main implications, with specif‌ic

reference to the procurement and allocation of kidneys for transplantation.

The United States as well as several other countries allow some forms of

“trades” in the kidney market, specif‌ically in the form of “kidney exchanges,”

World Medical & Health Policy, Vol. 9, No. 4, 2017

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doi: 10.1002/wmh3.246

#2017 Policy Studies Organization

whereby pairs of living would-be donors and recipients who prove incompatible

look for another pair or pairs of donors and recipients who would be compatible

for transplants, cutting their wait time. However, monetary compensation to

people who give their organs are prohibited everywhere (with the exception of

the Islamic Republic of Iran), because this is considered morally unacceptable.

The current policy debate on using markets to boost donations relies mainly on

ethical arguments. One set of objections is based on concerns of exploitation of the

poor and coercion of choice. In a recent debate in the New York Times, ethicist

Katrina Bramstedt argues that allowing kidney sales would create “an economic

class war.” Another set of objections concerns the concept of human dignity that

payments would hamper (Gillespie, 2017); scholars have appealed to “inalienable

values” and “fundamental truths” in opposing payments, (Delmonico et al., 2002),

arguing that they would be “degrading the human condition” (Sandel, 2012). The

def‌initive words often used suggest that keeping these transactions out of the

marketplace is considered a “protected value”—that is, a value that people are

unwilling to trade off no matter what the costs of doing so may be. In fact,

arguments against payments for organs often acknowledge the potential benef‌its of

allowing such trades; yet the moral basis of the opposition is considered strong

enough to forego those benef‌its (Delmonico et al., 2002; Sandel, 2012).

Understanding and quantifying the inf‌luence of repugnance on social

decisions is challenging. For example, in the context of kidney donations we

cannot observe a paid-donor regime because payments are illegal. In a series of

recent papers (Elias et al., 2015a, 2015b, 2016a), we used survey experiments

conducted in on-line platforms with U.S. residents to study preferences for

repugnance in morally controversial transactions, with focus on the provision of

payments to kidney donors.

In a f‌irst study (Elias et al., 2015a), we found that providing information on

how a price mechanism can help alleviate the organ shortage signif‌icantly

reduced repugnance toward payments for organs. To further understand the

effect of information, in another study (Elias et al., 2015b) we found no effect of

general information about “market eff‌iciency” on the support for paying organ

donors. This indicates that the results of Elias et al. (2015a) were not due to the

participants’ belief that markets can solve every social problem; rather, morally

controversial economic incentives may be accepted only when they are seen as a

solution to a specif‌ic problem.

In a more recent study (Elias et al., 2016a), we found that although systems

that allow for payments to donors raise higher moral concerns than a system with

no payments, a majority of individuals would be willing to accept a more

repugnant system provided that it produced a suff‌iciently large additional

number of transplants.

From a normative standpoint, there is disagreement about what criteria

should shape public policy and regulations and whether the preferences of the

public should inf‌luence the design of those policies. For example, Gillespie (2017)

claims that ethics and legality should be the main guide for policy design. In

contrast, Brennan and Jaworski (2015) advance a consequentialist view to favor

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