Just to be clear, I think that in jkaufman’s argument, the $400 is not the opportunity cost of undergoing surgery, but rather an estimate of the amount of money AMF would require to achieve comparable benefit as donating a kidney.
I agree that if you had to forego income during surgery or incur other costs, then it would be reasonable to add those onto the other side of the ledger as you propose. As I mentioned above, though, I think that’s typically not the case; medical leave policies are often quite generous in these cases, and public funds are available for incurred costs.
A couple disclosures right off the bat: I donated a kidney to a stranger last year and I work for GiveWell (but this post represents my views, not GiveWell’s).
I think this is a really interesting and informative analysis (you might also be interested in David Barry’s post along the same lines). However, I think these both miss a few important points:
Living kidney donation operations involve significant savings for the health system, on the order of $100,000 (coming from averting the need for dialysis, which is extremely costly) (Matas and Schnitzler 2003). Giving $100K to medicare or a private insurer is obviously not the best conceivable use of money, but it’s hardly a 100% waste. Similarly, most people on dialysis are not able to work, but most who receive transplants are able to do so; the economic benefits from recipients returning to work are not included in the $100K figure.
I don’t think it’s the right decision to assume away chains. For most altruistic donors in the U.S., chains are possible, and if you opt against a chain, you can choose a recipient who is demographically likely to achieve greater than average benefit from a donated kidney (someone young and healthy) through a website like matchingdonors.com. I’ve talked to some fairly senior transplant surgeons and people who helped write the algorithms for matching kidney exchanges, and they don’t think chains have been saturated in, e.g., the National Kidney Registry, so adding another altruistic donor is expected to increase the number of kidneys passed along. That said, the right multiplier to use is unclear; the average chain length has been declining over time, giving some credence to the worry that more donors are just shortening the length of the average chain. My personal guess is that the chain multiplier is something like 2x; that’s meant to be conservative, if haphazard, but it certainly could turn out to be too aggressive. That is significantly less than the average chain length: I’ve never heard of a chain that included fewer than 3 kidneys; mine had 8.
I think DALYs are the wrong ethical framework and that adult lives matter more than the DALY framework makes them seem. Undiscounted DALYs assume that saving a newborn is twice as good as saving someone midway through their life, whereas I believe something roughly like the converse (see this discussion at the GiveWell blog ).
I don’t think the AMF cost-effectiveness figures and the kidney-donation figures are comparable in the way that you’re reporting. Holden’s posts about Bayesian charity evaluation give some reasons for my view here, but the basic story is that I don’t think the expected value of a $1600 donation to AMF is actually anywhere near one life saved. The reason for this has nothing to do with how AMF works and is more a feature of its place in the total distribution of charity cost-effectiveness. I think there are a variety of practices in cost-effectiveness estimation that push in favor of a difficult-to-estimate positive bias (e.g. using evidence from RCTs, which are generally conducted in the most promising circumstances), that the most extreme cost-effectiveness estimates are more likely to be biased, and that the benefit of a marginal contribution is almost always less than the benefit of an average contribution. All of these conspire to make me think that the estimate that GiveWell provides for the “cost-per-life saved” for AMF is not the correct number for estimating the expected value of a contribution to AMF. (I do think it is extremely useful for deciding between charities. I just don’t think these numbers mean what they appear to mean. I haven’t discussed this thoroughly with other GiveWell staff and don’t know whether they agree; GiveWell hasn’t published a clear view about how these cost-effectiveness estimates should be used.)
As a practical matter, most people I’ve heard of who have been altruistic donors have been able to take medical leave of some kind from their job (many states have a law requiring this), which does’t entail using up vacation. This doesn’t answer the point about being willing to pay $400 to avoid the suffering, but it does answer the “just work and donate the money” objection.
Separately from the fact that I don’t think $400 gets as much benefit as you seem to, I don’t think the idea that you would be willing to pay $400 to avoid a nephrectomy is a good reason not to donate a kidney, at least without the additional stipulation that you’re not willing to donate $400 more. Imagine a case where an individual believes that donating a kidney is worthwhile for benefits to others, but that they would happily pay $400 to not undergo the surgery (this may be your case, I think it would be mine, too). He pays the $400, and then face the question again. He still has both kidneys, can still benefit someone else by the same amount as before, but he has $400 less, so then he decides again whether to donate a kidney or donate $400. (...induction...) Eventually, he either donates a kidney or decides that enough has been asked of him. Another, perhaps more straightforward, way to put this is to say that the fact that there’s some amount of money that achieves equivalent benefit to donating a kidney only tells you not to donate a kidney if you’re sure you’re not willing to give more money; the implication could just as easily be that you need to give a lot more money. I’m actually not sure what the amount of money (i.e. the $400) has to do with it in your framework, since for any given amount of money the repeated question means that you eventually reach your limit in willingness to pay to avoid surgery.
The model I have of what you’re trying to say here is something along these lines:
In this framework, if you thought the return to donating a kidney was high enough that it fell above your marginal charitable contribution on your ranked list, it would offset that contribution below the limit for sacrifice you’re willing to endure. Because of the very general framing of “sacrifice,” donating a kidney—if it were “worth doing”—would imply that you thereby reduce your charitable obligations.
I find this an unlikely conclusion, and I don’t share your very general conception of “sacrifice.” I have a policy on how much money I give to charity, and I decided to donate a kidney, but both decisions depended on the specific circumstances of what would be asked of me. Envisioning people as having a fixed amount of suffering they’re willing to undergo does not strike me as a very accurate psychological model, and living on the margin of the maximum suffering you’re willing to endure to benefit others doesn’t strike me as a good life choice (or at least self-conception).
A final consideration is that I think we relate differently to our bodies than we do our cash. I think that donating a kidney is fundamentally different from donating money in terms of impact on a donor, and that may or may not be something that matters to you. Relatedly, donating a kidney may also have different implications for a professional giving advocate than simply giving more money does. I suspect that it opens up publicity avenues that wouldn’t otherwise be available, and changes the tenor of conversations with people who might be more typically emotional in their giving.