Freakonomics Radio - 209. Make Me a Match
Episode Date: June 18, 2015Sure, markets generally work well. But for some transactions -- like school admissions and organ transplants -- money alone can't solve the problem. That's when you need a market-design wizard like Al... Roth.
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Okay, I'm Al Roth, and I'm a professor of economics at Stanford.
For many years, Roth had taught economics at Harvard, but he and his wife, who's a human
factors engineer, had relocated.
We had just moved into our new apartment.
We had moved to Stanford in September of 2012.
Shortly thereafter, on October 15th, something memorable happened.
And my wife woke up around 3 in the morning and said,
the phone's ringing.
And I woke up and it wasn't ringing anymore.
We only had one phone at that point and it was in her office, which was downstairs.
So I said to her, it's not ringing.
And I went back to sleep.
And she went down and got the phone and it started ringing again. It turns out it's a her office, which was downstairs. So I said to her, it's not ringing, and I went back to sleep. And she went down and got the phone, and it started ringing again. It
turns out it's a good thing they call you back. They don't go down their list. And it was the
Nobel Committee. Roth, half asleep, was informed that he, along with Lloyd Shapley, had won the
Bank of Sweden Prize in Economic Sciences in memory of Alfred Nobel,
also known as the Nobel Prize in Economics.
Did you think you had a chance?
You know, it's hard to answer that humbly.
So I knew that I was on the big list of people who, if I won a Nobel Prize,
it wouldn't cause the Nobel Committee to be embarrassed.
The newspapers the next day would not say craziness in Stockholm. But there are many,
many people in that category. So indeed, we were asleep. We were not waiting for a call.
And it's an interesting call because one of the things they're concerned about,
they have a lot of experience with this, is convincing you that it's not a prank.
So the person who first spoke to me said, you know, congratulations, you've won the
Nobel Prize.
And then he said, and I'm here with six of my colleagues and two of them know you and
they're going to talk to you now.
To persuade you that this is for real.
Right.
Either that or a very elaborate prank.
Exactly.
But they call you up and they say, so in half an hour
this is going to happen.
Get ready.
And I took a shower and got dressed, which
was a good thing because there wasn't an opportunity to do
that again all day. And what was the rest
of the day like then? Well, so at
five minutes to, someone
calls you back. And again,
there's still, I guess, concern that you shouldn't
appear confused on
the phone. So what she said is she said, point your browser to the Nobel site and you will see
your name being announced. And then we will come on the line and have a press conference by
telephone. So by the time that happened, I was ready. And then the Stanford press office,
fortunately, descended on our house at 4 a.m. and started fielding calls from journalists.
You know, they'd say, Professor Roth is ready now.
Are you ready?
And I'd get the phone and I'd get five questions from someone and I would speak to many, many people.
And apparently, I mostly answered them very, very seriously.
But I told a joke or two that I hadn't intended to tell.
But people would say to me, oh, I heard you on NPR.
You said something a little odd.
But and then there was a press conference.
And then at 11, I had a class.
So people seemed a little surprised.
But, you know, that's how we ended the press conference.
This was a surprise.
And it was a Monday.
And I teach on Mondays.
Word had traveled to your students by then, I assume.
It had.
There was champagne in the classroom.
Yeah, yeah.
So what kind of work did Al Roth do to land a Nobel Prize in economics?
Well, it's not the kind of work that typically wins a Nobel.
He has helped people who need a kidney transplant find a donor.
He's helped new doctors find their first jobs.
He's helped high school students in New York City find the right high school,
even though Roth himself, who grew up in New York City, dropped out of high school.
I was a, you know, poor, ungrateful student and didn't appreciate what my teachers were trying to do for me.
You should tell all your listeners they should complete high school. From WNYC, this is Freakonomics Radio,
the podcast that explores the hidden side of everything.
Here's your host, Stephen Dupner. I recently visited Palo Alto, California, home to Stanford University and a few other things, to talk with Al Roth.
He was, as you have heard, a high school dropout. Don't worry. He did go on to college, many, many years of college. Not finishing high school is not the only odd thing about Al Roth as a
Nobel laureate. Consider this. Even though he won the prize in economics, and even though he's a
professor of economics, he is not technically an economist. I mean, my degrees are in engineering.
And I wrote a paper once, a manifesto of market design called The Economist as Engineer. So I think of myself as
something like an engineer. I'd like to be an engineer. A manifesto of market design, Roth
calls it. The Nobel Committee's citation noted his theory of stable allocations and the practice
of market design. So what is market design and why can it win you a Nobel Prize?
Market design is an ancient human activity.
You know, when you look at the distribution of stone tools around the Middle East and
Europe, you find that long before the invention of agriculture, stone tools were moving thousands
of miles from where they were quarried and made. And that's a sign that there were markets, stone tools were moving thousands of miles from where they were quarried
and made. And that's a sign that there were markets for stone tools. There were ways to
meet and trade things. And we don't really know much about those markets, but the stone tools,
which are very durable, are evidence that markets are older than agriculture. But the stone age
men who traded those stone tools and weapons had to make markets somehow.
They had to make them safe.
They had to feel confident that they could bring the things they would trade for these stone tools
and not be robbed by guys with stone axes who would take their stuff.
And that's been a big part of market design for a long time is making markets safe.
Today we think about fraud and identity theft and securing your credit card.
But there was a time when kings thought about securing the roads against highwaymen so you wouldn't be waylaid on your way to and from the market.
So if I were the king of England and I wanted to have markets in England, I had to make sure that the roads were safe to get to the markets.
Al Roth has now written a book, a really wonderful book, I should say.
It's called Who Gets What and Why?
The New Economics of Matchmaking and Market Design.
If market design is, as Roth says, an ancient human activity,
why does someone like him need to get involved?
After all, we're told that markets generally organize themselves, right?
There are sellers and buyers, supply meeting demand,
with price being the glue that holds it all together.
In this regard, the invention of money was a big breakthrough.
Barter is very hard because you need a double coincidence of wants.
You need to find someone who has what you want and who wants what you have.
Right. You happen to have salt. I happen to have wool.
And we each want what the other wants or we find a third party.
Right. Well, so finding the third party starts getting you involved in other things.
And, of course, money is a great market design invention for helping you find third parties
because you can sell what you have for money and then go look for what you want.
But there are some transactions, entire realms of transactions, really, where money cannot do what it does in a typical market, where for whatever reason,
supply is not allowed to naturally meet demand with price as the arbiter. And that is where
someone like Al Roth comes in handy, the economist as engineer, because these atypical markets have
to be set up differently. They have to be helped along.
This is sometimes called a matching market.
Matching markets are markets where money, prices don't do all the work.
And some of the markets I've studied, we don't let prices do any of the work.
And I like to think of matching markets as markets where you can't just choose what you want.
Even if you can afford it, you also have to be chosen. So job markets are like that. Getting into college is like that.
Those things cost money, but money doesn't decide who gets into Stanford. Stanford doesn't
raise the tuition until supply equals demand and just enough freshmen want to come to fill the
seats. Stanford is expensive, but it's cheap enough that
a lot of people would like to come to Stanford. And so Stanford has this whole other set of
market institutions, applications and admissions, and you can't just come to Stanford,
you have to be admitted. Or think about this problem, which Al Roth has worked on directly.
What is the best way for hospitals to hire newly minted doctors
and for those doctors to find the most appropriate hospital for them to work in?
The current system is called the National Resident Matching Program.
So I got involved in helping it during a crisis in the 1990s.
But you have to go back to the 1900s to understand how doctors get jobs.
And the 1900s is around the time when the medical degrees as we know them, the MD degree, became the dominant medical degree.
And about 1900, that's when internships began.
So instead of graduating from medical school and immediately beginning to practice medicine, as we say.
A word that's always bothered me.
Yes.
You should be good at it by now.
The first job, the standard first job for medical graduates became what was called an internship
and is today called a residency. And that's a job where you work in a hospital and take care
of patients under the supervision of a more experienced attending physician. And it's a giant part of the
professional education of doctors. So it's very important to doctors where they get their
internship and residency. And it's very important to hospitals because the interns and residents
are a very important part of the labor force of a hospital.
As Roth tells it, there was an arms race between hospitals for the best future
doctors. They began grabbing medical students earlier and earlier, sometimes two years before
graduation. And when you try hiring people two years in advance, it's hard to tell who the good
doctors will be. It's also hard for the doctors to tell what kind of jobs they want. So the medical
schools intervened. In 1952, they created the National Resident Matching Program.
They developed a marketplace that has a form that has survived till today, although my colleagues and I have helped modify it since then.
And what that form was, you go on interviews and you find out the salary and the working conditions of the various jobs that you might be offered.
And then instead of working the phones and maybe getting an offer that says you have to take it yes or no right now on the phone, what you do is you consider in advance which jobs you would like
and you submit a rank order preference. This would be my first choice of the jobs I've interviewed at.
Here's my second choice. Here's my third. And the jobs do the same thing. The hospital residency
programs do the same thing. And hospital residency programs do the same thing.
And then a match is made in a centralized clearinghouse.
By the 1990s, this system was showing strain.
Some people thought the hospitals had too much leverage over the residents.
Also, by now, there were a lot more female medical students,
some of whom had a significant other who was also a medical student. and such a couple typically wanted to get a
residency in the same hospital, or at least in the same region, but the matching program couldn't
handle that kind of request. So those candidates might opt out. In 1995, Al Roth was asked to help
write an algorithm that could fix these problems. The algorithm worked well, and it now matches more than 20,000 applicants each year.
It sounds as though this works pretty well, according to most people involved.
Yes?
Most people involved in this scenario are pretty happy with how it works, correct?
Well, labor markets are stressful for everyone.
So I think you're overstating how happy people are with the labor market.
But I think it works very well.
I mean, in the medical residency matching particularly,
or at least as an improvement over what was before it?
It's a vast improvement.
Okay. Here's my question really for you is this, is broader labor markets. If we consider the
medical residency matching program relatively successful to what preceded it, at least,
why is it not used more widely in the labor markets?
Well, the medical market is an easier one to coordinate than many markets because just about everyone becomes available at the same time when they graduate from medical school.
And they all start their jobs, therefore, about the same time in July.
So it's a market that can easily move people all at the same time. Whereas many markets, think about the market for journalists, they might be hired at different
moments and jobs might become available and need to be filled and not be able to wait for you to
consider many jobs. Yeah, but you and your colleagues are pretty brilliant and you have
mathematical backgrounds. I would think you could deal with rolling admissions. Is that right? I
mean, for all the talk about how modern labor markets have so many
mismatches in them, so many people doing jobs that they don't really want to be doing, so many
corporations with all these theoretically qualified people out there not being able to find the people
to fill them without going through a lot of, going to a lot of trouble. I mean, hiring practices
become more and more complicated, it seems, as one way to address the matching problem.
But it seems as though your complicated mathematical foundation might provide, ironically, a simpler way to address that problem.
So I'm not sure that's true.
Again, one of the special things about residency positions is, although they're very different at different places, they're sort of similar to each other. If you're thinking about should you be a journalist or an airplane pilot or a chef, you're dealing with very different jobs
with very different employers. And one of the things that we do in the medical match is we make
all the jobs available at the same time that allows you to consider them, to have preferences
over them. That's hard to do if you're thinking about being a chef or an auto mechanic. Sure. I'm curious to know what's a market
or scenario that you've looked at before that you thought, boy, I would love to help fix that one,
but either haven't had a shot or maybe tried and failed? Well, the markets for new lawyers might fall into that category. And certainly the fanciest job that top graduates of elite law schools get is a lot like a medical residency. It's a clerkship with an appellate judge. but the doctor market was around 1940, where jobs are being contracted
far before law school graduation.
And probably a dozen times in the last 30 years,
the lawyers have tried to fix this
with things like setting dates
before which you shouldn't hire and things like that.
But it turns out it's hard to make rules
that judges have to follow. Judges are a law unto themselves and they break the rules.
They cheat. If you know someone who's in law school now who wants a clerkship, they're probably
going to get an offer sometime in their second year, you know, so the middle of their second
year, a year and a half before they are ready to graduate. And what would it take for you to have the
authority to get in there and redo that market? Well, the question is, is there a desire for
judges to coordinate in a way that would control the market? And so far, there hasn't been.
So you can win all the Nobel Prizes you want and there's a limit to your power nonetheless.
There is. As complicated as it may seem to match future lawyers or doctors
with their employers, consider an even more complicated match. A person who will die unless
they can get a kidney transplant. You can't buy a kidney. You can't pay for somebody's college education to get a kidney.
You can't buy them a car.
It's illegal in the United States to obtain a kidney through any kind of valuable consideration.
That is Ruthann Leishman.
I'm the program manager for the Kidney Pair Donation Program at the United Network for Organ Sharing. The United Network for Organ Sharing, or UNOS, maintains the registry of all the people
in the U.S. who need an organ transplant. According to the National Kidney Foundation,
out of the roughly 123,000 people awaiting an organ transplant, more than 100,000 of
them, roughly 80%, need a kidney.
We don't have enough supply of kidneys available. And so the list is ever-growing,
but the number of kidneys available for transplant is pretty stagnant.
It's estimated that 12 people die each day in the U.S. while waiting for a life-saving kidney
transplant. And that's because, as Leishman says, the demand for kidneys keeps rising,
but the supply hasn't risen to meet it. Why is that?
Consider where most donated organs come from.
They primarily come from cadavers, from people who have died,
but who have died under just the right circumstances,
from a brain trauma, for instance,
to allow their still-functioning organs to be harvested for transplant.
Only about 1% of the population who die are actually able to donate their organs.
So if you need a heart transplant, let's say, you are waiting for a cadaver organ,
but a kidney is different from a heart. Why is that? Because humans are born with two kidneys,
and yet we really need only one, which means that in a country like the U.S. with a few hundred
million people, there are potentially a few hundred million spare kidneys out there.
When someone has kidney failure, typically both their kidneys fail.
So they're left with zero healthy kidneys, whereas the typical healthy person has a perfectly good spare.
So while it might seem that there is a massive demand for donated kidneys, remember there are more than 100,000 people on the list.
The fact is that the potential supply is really massive.
Here's Al Roth again.
If you're healthy enough, you can remain healthy with just one.
And that means if someone you love is dying of kidney disease, you could give him a kidney and save his life.
If you happen to be a match.
If you happen to be a match.
And that's where kidney exchange comes in.
Ah, kidney exchange.
Because remember, unlike some markets where price is allowed to let demand meet supply,
organ donation is a market that doesn't allow money.
As a society, we've decided it isn't right to reimburse people in any way for donating
an organ.
Although I should say
some economists have argued that we should rethink that. But for now, at least, kidney donation is
reliant on altruism, which, judging by the backlog of kidney patients waiting for an organ,
isn't working so well. And that's why Al Roth got involved.
People often ask me how I got involved in kidney transplantation, and I think
the romantic thing that they're hoping I'll say is that I knew someone who was ill or that I was
ill, but that isn't the case at all. I entered through the mathematics. Coming up on Freakonomics
Radio, how Al Roth and his comrades used mathematics to save lives. We have about 600
kidney pair donation transplants a year
right now in the United States.
In 2000, we had two.
And Al Roth's greatest hope
for his new book, Who Gets What and Why.
My hope is that
this book will help you to see markets
in new ways. So may I take you
to dinner to celebrate the completion of this book?
From WNYC, this is Freakonomics Radio.
Here's your host, Stephen Dubner.
Al Roth, high school dropout, Nobel laureate, author of the book Who Gets What and Why, began working on organ donation more than 40 years ago, as it turned out.
So in 1974, in volume one, number one of the Journal of Mathematical Economics, Herb Scarfe and Lloyd Shapley, with whom I eventually shared a Nobel Prize, wrote an article about how to trade indivisible goods
when you couldn't use money.
And this was a theoretical argument.
It was entirely, yes.
Entirely theoretical.
And sort of whimsically, they said,
let's call the object houses,
and let's suppose everyone has a house,
and people have preferences over houses,
and they can trade houses, but they can't use money. All you
can do is barter. You can say, I'll trade my house for yours, or you could do it among three people.
You know, I'll give you my house and you give someone your house and he gives me his house.
That's all you can do. How would trade work? So they wrote a paper about that.
And I had just gotten my PhD in 1974 when this article came out. And I read the article
and I thought, what an interesting problem to think about how to trade without money. So I wrote
some articles about that too with Andy Postlewaite and-
Still theoretical or did you-
Entirely theoretical. We were talking about how to trade houses. And of course,
no one trades houses without money. I can tell you, I've just bought a house in California and money played a role. But it's, you know, the way
economists learn about things, the way mathematical economists learn about things is a little bit
the way children learn about things. You find toys to play with. And then by playing with the toys,
you gain experiences that might help you with other things. So this is a toy, this toy model that allows you to think about the question of how to trade goods when you can't use money and when you can't divide the good.
You can't say you have a big house and I have a little house, so just give me half of your house for my house.
You know, you say houses are indivisible.
We have to trade.
In 1982, Roth took a teaching job at the University of Pittsburgh, which happened to have an excellent medical center with a prominent organ transplant program.
Roth began thinking about kidneys from the perspective of supply and demand. Again, there's a seemingly huge demand for donated kidneys,
but in fact, a much, much larger supply of potential kidneys for donation,
since healthy people have two but only need one.
So let's say that your spouse or sibling or parent needs a kidney transplant.
You could voluntarily undergo surgery to give up one of yours, if that is,
you happen to be a biological match. If you aren't a match, then you're healthy enough to
give someone a kidney, but you can't give the person you love a kidney. So there they are
with an indivisible object that we had been calling houses, but now call it a kidney.
And here are these incompatible patient-donor pairs, and they have an indivisible object,
and it's against the law to buy and sell kidneys for transplantation.
So all of a sudden, this toy model that we'd been playing with that didn't make a lot of
sense for houses, because we use money for houses, made sense for kidneys.
Was there a light bulb moment for you where you saw that the kidney was the, you know,
concrete version of what had been discussed in this model or no?
Again, I'd like to say that there was, but there wasn't.
Were you looking for something to plug into that model?
I was looking for a teaching tool. I was teaching the model, and my students would say,
this is an interesting model, but isn't it a little silly? Here in Pittsburgh, we use money
for housing, professor.
And I'd say, yes, yes, but this is a toy model.
You should study it.
But there we were at Pittsburgh, and we had all these transplants going on.
And I said, well, so supposing it's kidneys.
So we talked about kidney exchange without my ever thinking it would become a practical thing.
I was not seeking to design kidney exchange. But in 1998, I moved to Boston to teach at Harvard.
And in 2000, the first kidney exchange in the United States was done in New England.
That's an exchange between incompatible patient-donor pairs, as Al Roth calls them,
two couples, let's say, with the healthy member of each couple agreeing to
give a kidney to the needy member of the other couple. The first kidney-paired exchange ever
took place in South Korea in 1991. The first U.S. exchange that Roth mentioned
happened at Rhode Island Hospital in Providence.
And it was covered in the press. It was an unusual thing. And there I was. I had notes
about kidney exchange.
So with a former student of mine from Pittsburgh who was visiting at Harvard, Utku Unver, I said to him, look at this.
There's kidney exchange.
Let's give a class.
It's teaching a market design class.
Let's give a class on how we would do kidney exchange.
Meaning this one had happened without your help.
Yes.
And you looked at this and thought, hey, if this is happening on a small scale, we can
maybe...
We can help organize it.
We have played all these years with toy models.
We know how to organize, on a large scale, trade among people dealing with indivisible
goods when you can't use money.
We know a lot about this.
Several other economists began thinking about the problem.
And eventually we wrote a paper
about how to organize kidney exchange
if you weren't too worried
about logistical problems.
So we hadn't yet talked to doctors.
We hadn't yet talked to surgeons.
Although...
Like where the kidney needs to be
and what...
Right, and just...
What kind the preparation is for surgery and so on.
And how hard it is to do big exchanges compared to little exchanges.
So we sent the paper to all the surgeons we could think of and only one answered.
It was Frank Delmonico.
That's a good one to have answered then.
Absolutely.
He was the director of the New England Organ Bank, and he came to lunch,
and he and I have been colleagues on kidney exchange and other things for more than a
decade now. But we helped him build the New England Program for Kidney Exchange.
One person that Delmonico hired at the New England Program for Kidney Exchange, or NEPKI,
was Ruthann Leishman,
who helped set up their kidney-paired donation program.
Remember, the Rhode Island transplant had already happened in 2000.
But that was just done manually, looking at the blood types of the donors and the candidates.
And then in 2004, we started working with Alan using his optimization program.
The idea behind using Al Roth's algorithm was to make it so transplant centers could simply enter
the medical and demographic data on potential organ donors and recipients, type in a few keystrokes,
and then voila, it would produce a match.
It would really be impossible to do this by hand because of the number of antibodies that we're
talking about and the number of people that we're talking about. We really need a computer to look at it, not just to
do any kind of matching, but really to optimize the matching. Matching a potential kidney donor
is harder than it sounds. Not only does any given person have one of four major blood types, but
we also each have our own stew of antibodies and antigens. We're born with a certain amount of inherited antigens, but when our bodies encounter foreign
antigens, we develop antibodies that battle them.
This can happen during a blood transfusion, for instance.
That was the case with a Minnesota woman named Julie Park.
What really happened was I broke my leg about, I don't know, five, eight years ago.
And unbeknownst to me, they gave me a blood transfusion during it.
And that just changed a bunch of antigens and antibodies
enough so that Ray no longer was going to be a match for me.
Ray is Julie's husband, Ray Book.
They've been married for 24 years.
Julie and I went to high school together, didn't know each other,
had one date when we were freshmen at the University of Minnesota.
I told her I'd get back to her, and at our 20-year class reunion, I got back to her.
Julie and Ray have one daughter, three grandchildren.
Julie has been a type 1 diabetic
since she was eight years old. And it basically, you know, has caused all my medical issues over
the years. Julie got her first kidney transplant when she was 35. It came from a deceased donor.
And it lasted me quite a while. And that was great, like 26-plus years.
And then that one, for whatever reason, was failing.
So all of a sudden I needed another one.
Ray's blood type is O, which means he's a universal donor.
We were kind of going down that road thinking he'd be able to donate to me someday.
But after that blood transfusion,
Julie was told by her doctors
that Ray was no longer a match.
In Julie's body,
Ray's kidney would have failed.
Ruthanne Leishman is familiar
with Julie's case.
She had a lot of antibodies.
94% was her antibody level,
which means basically
she only matches with about 6% of the population.
So if Julie went the route that got her her first donated kidney,
it likely would have taken a long time to get another one.
Given her particulars, one doctor told her, she could wait five years or more.
Years which, as Leishman describes, are hard on anyone with kidney failure.
And then they're waiting on dialysis.
And then three days a week, they go into a dialysis unit to have their blood cleared of the toxins that the kidney usually removes.
Or they're at home at night doing home peritoneal dialysis.
And so that's a nightly ritual for people. And it makes it difficult to work. It makes people tired. It makes people sicker. So when they do get a transplant, they may not be in a kidney exchange program. And her chances were greatly increased because her husband, Ray, was offering to donate one of his kidneys to someone, anyone, since he wasn't a match with Julie.
This is what's known as being a paired donor, meaning that Ray was offering his kidney under the condition that his wife would receive a kidney donated by someone who was a match with her.
I wanted to help my wife in any way that I could, so I went out and got tested.
All the information went into the computer.
We just put it out there into the network, and thank God there's a network like that.
And the algorithm obviously worked.
And it worked fast.
You know, I went on dialysis November 1st.
They called me around Christmastime and, you know, told me,
well, it looks like we've got something, you know, on the schedule here,
but, you know, you've got to heal this wound you've got on your foot.
So I spent the month of January in bed.
So anyway, that was January, And then we had the transplant February
5th. So, you know, it certainly wasn't five years or more. The kidney exchange landscape has changed.
There have been consolidations. Nepke, for instance, has been dissolved under a push to
create a national program. And the numbers have grown. Last year, for instance, there were just
over 17,000 kidney transplants in the U.S. About one-third of those came from living donors, not
all kidney-paired donation. But still, that's a lot. As Al Roth points out, in one respect,
it's even more than it sounds. So what that means is in the United States, we now have more
living donors than we have deceased donors because deceased donors give two kidneys and living donors only give one.
So there are more living donors than deceased donors, but more deceased donor transplants than living donor transplants.
But the growth possibilities would be in living donor transplantation because everyone has two kidneys. The growth possibilities are substantial, not only because the matching algorithm is successful, but perhaps because it's so successful, it has allowed for another kind of kidney donor to enter the program.
Ray Book, you'll remember, was a paired donor.
But there's also room for what's called a non-directed donor.
Ruthann Leishman again.
Somebody who comes into the
computer program without a recipient. They don't know anybody who needs a kidney transplant. They
just want to donate to somebody and help somebody. Well, they come into the program and they match
with a recipient whose donor matches with another recipient, whose donor matches with another
recipient. And this can go on and on.
And so instead of that non-directed donor helping just one person receive a transplant,
they can help two, three, five, 10, 30, 60 people receive a transplant as we go down the line in
the chain. It was one of these incredibly generous people, a non-directed donor, who wound up giving
Julie Park a new kidney. This chain started with a woman named Jodi.
Hello.
My name is Jodi Shakley-Wright.
Jodi Shakley-Wright is 42 years old.
At the time, she was living in Charlotte, North Carolina.
In May 2012, I was working as a telephonic health coach for a company in Dallas, Texas,
and I worked from home in Charlotte.
I had a client who needed to lose 20 pounds so that he
could donate a kidney to his sister. And I knew nothing about organ donation at the time. And at
first, I wanted to do some internet research to determine how his lifestyle might change after the
surgery, as well as what he could expect to do pre-op in order to prepare for the procedure. In my research, I came across
something called kidney paired donation. I wasn't really familiar with that at first, but I had also
seen around the same time an episode of Grey's Anatomy. It's actually season five, episode five,
if you're interested in checking that out, but it's about paired donation. And at first, when I
had seen it on Grey's Anatomy, I wasn't really sure if it was a
Hollywood thing or if it really existed.
So I did some more research.
And sure enough, it was a real thing.
And I wasn't looking to donate, but kind of sat back and thought, you know, I'm at a place
in my life where I think that I'm healthy enough.
I work out of my house.
I'm financially stable. And this is something that I could do.
She began working with the transplant center at Piedmont Hospital in Atlanta. She went through a long series of physical and psychological tests.
They wanted to know if I had considered all of the factors why I should not donate. First and foremost, I was asked to make a few minor lifestyle
changes, or at least I felt that they were minor, but things like they didn't want me to do any
death-defying stunts like ride motorcycles or jump out of airplanes. I had already jumped out of an
airplane, so that was okay. But with one kidney, you kind of have to take a little bit more care.
So basically, you know, they wanted to make sure that I was sure about donating one of my kidneys
because I really only have, you know, one to donate.
I need the other one to survive.
And, you know, they really want you to think about things like,
are you going to be okay with the decisions that your recipient makes?
Meaning that once you give this kidney up, it's not mine to direct how it's used anymore.
And I was really okay with that.
That's the recipient's call.
I'm giving a gift.
After passing her tests, Shakley-Wright's information was entered into the computer program used by the kidney-paired donor system, and the algorithm went to work on her data.
It quickly found a match.
Julie Park in Minnesota.
Less than two months later, it was surgery day. My surgery was in Atlanta, first thing in the morning. And once they removed my
kidney, it's put in a styrofoam container and it's put on a commercial flight and was flown to
Minneapolis. Her kidney is actually put on a plane and flown to Minnesota,
where it is transplanted into Julie.
I think I went in about 4 in the afternoon, something like that.
Julie's husband, the same day, is having his kidney recovered at a hospital in Minnesota.
It was a very emotional time.
I told my kidney,
go and do a good job and take care of somebody. And I shed some tears. So Ray's kidney, at the same time that my kidney was flying from Atlanta to Minneapolis, his was flying from Minneapolis
to Atlanta for the second recipient in the chain to receive her kidney. So Ray Book donated his kidney as a paired donor so that his wife, Julie Park, could
get a kidney from a stranger, the non-directed donor, Jody Shakley-Wright.
And who got Ray's kidney?
We did find out it was a woman that got my kidney.
And she was in the next room next to the woman who was donating to Julie.
Now, my recovery room in Atlanta was next door to Ray's recipient's recovery room.
And I had the respect enough not to barge in there and introduce myself, although I have to be honest, I really wanted to.
All I know about her is that she's
doing well.
That recipient had also come into the kidney exchange with someone willing to
give her a kidney, but she wasn't a match.
So this person in Georgia who received Ray's kidney, her daughter the same day, went to the operating room and donated her kidney.
And that kidney stayed right there in the same hospital and went to somebody on the deceased donor wait list who didn't have a living donor available to them.
So, this one act of kindness by Jodi Shakely Wright.
Who donated out of the goodness of her heart.
She didn't even have anyone she was donating for.
This one act had a multiplier effect.
So what Jodi did by entering the program without a recipient attached to her,
she was able to unlock matches that otherwise wouldn't have been possible.
It also wouldn't have been possible without the algorithm created by Al Roth and his colleagues.
It's saving a lot of lives. We have about 600 kidney pair donation transplants
a year right now in the United States. In 2000, we had two.
We would have stayed doing two or four or six a year without the algorithm.
The entire process is incredible. I don't have that much knowledge
about algorithms. It's been a little while since high school and college, so I'd have to revisit
some of my math skills. But I do know that it's amazingly complex. And just to match blood types
and antibodies, and especially knowing that at this time, there are almost 124,000 people in need of an organ.
So how somebody begins to sift through all that is beyond me.
But thankfully, it's not beyond everyone.
Al Roth again.
This is about exchange.
You know, the thing we can call it kidney exchanges.
There's real exchange going on.
So when I started talking to surgeons,
they didn't automatically think of economists as fellow members of the helping profession.
But when I talk about it nowadays, you know, I say exchange, you know, that's what economists
study. Of course, this is a subject for economists. But initially, many people found it odd that
economists were getting involved in organizing surgeries.
You write in the book or maybe hint in the book that all this work that you and others have done
to try to solve this problem will hopefully be obviated one day not too long from now when
there's either medical treatment or perhaps artificial organs. Yeah, I mean.
Oh, I hope so. I think that your grandchildren and maybe mine will just be appalled.
They'll say to you, you know, Grandpa, so tell me again.
You used to cut the organ out of a dead person and sew it into a sick person, and that was modern medicine?
And we'll have to say to them, yeah, yeah, we were proud and lucky to be able to do that.
It saved lots and lots of lives.
And even more antediluvian perhaps would be the notion that you'd have had to create this complicated way to get a living donor to match with a donor, yes?
Right.
So my hope is that stem cell technologies will allow you to grow a new kidney the way you grew the ones you have originally.
But we're far from that now.
And while that may eventually happen, everyone who has end-stage renal disease today will be dead by that time. So our responsibility is to try to take care of the people who are sick today, even though there will be better ways to take care of them in the future.
What's it feel like to have played a role in helping redesign? I don't know if you call this a market. It is a market, yes? I call it a market. I mean, it's not a market where money plays a role, but it's exchange, and you want to get efficient exchange.
You want to get as many and as good quality transplants as you can.
So, absolutely, it's a market.
So, there are a bunch of people out there who are alive who would not have been alive had not you and others working with you done what you've done.
What's that feel like?
Well, many others.
It feels good, but economics in general does good things for people. So,
I think that it may be an illusion to say, here we are, saving lives is not great, and it is great,
but imagine all the other good things that markets do.
You know, the economy has been immensely productive.
We all live much, much longer than people like us lived even 100 years ago.
And this has to do with the rapidly increasing prosperity that the world experiences because of the way markets work. So the big job of economists,
of market designers, is to help that process along. It's been going along for many, many centuries without the help of economists, but it goes by trial and error. And maybe we can reduce some
of the errors and make some of the trials go more quickly and more fruitfully.
The last chapter in your book is called Free Markets and Market Design.
Do you happen to have a copy with you?
I don't, but I remember it.
I'm glad you do.
I do have a copy.
I'd like you to read then, if I may, pass you the book,
the first two paragraphs there.
Thinking about the design of markets
gives us a new way of looking at them,
noticing them, and understanding them.
My hope is that this book will help you
to see markets in new ways.
So may I take you to dinner to celebrate
the completion of this book?
Okay, that's great. So Al,
are you interested in continuing this conversation
over a bit of dinner then?
That sounds like a great idea.
Al, do you have any ideas for where we can go grab a bite then?
Well, we could go to California Avenue. There's a thick market for restaurants there.
We didn't really get into that. What do you mean by a thick market?
Lots of restaurants and lots of people who like to eat at them.
And thickness is good in a market because why?
Well, if we didn't have a reservation, which I know that you did make.
Did I?
Did I?
Someone in your office made a reservation.
But if we didn't have a reservation, the advantage of a thick market is we could just walk down California Avenue and open doors and say,
do you have room for two guys at this hour?
And we'd eventually get to one.
Okay, let's go.
We went to a nice place in Palo Alto on California Avenue
called Spalti, Northern Italian.
Al, are you interested in something to drink?
Yeah.
So we're going to split a half bottle of that sort of margarita?
We could order food as well.
I'll have the salmon.
Chicken marsala.
Thank you very much.
Salmon?
Salmon here.
Thank you.
Some peppers?
I'd love some pepper, please.
Thank you. Thank you.
You wrote about something that was so fascinating to me. It was just a tiny little aside.
I just wanted to ask you, not about it per se,
but about what it's like to do the kind of work you do
and the things that you learn about these fields where you're coming from outside.
So when you were writing about organ transplantation, you wrote that if, let's say, a husband and wife,
if a spouse needs a kidney and the other one is willing to donate,
and they might be physiologically blood type tissue type they
might be compatible but that if they've had children there might be a higher chance of
rejection because proteins intermingle or something during uh so it turns out which
sounded made up to me but i believed you because you're you know a nobel laureate so
so one of the things that could stop you from taking my kidney
is that you might have antibodies, preformed antibodies, against some of my proteins.
So if you have antibodies against my proteins,
then your immune system is waiting, ready to attack my proteins
if they should show up in my kidney, for instance.
But mostly you shouldn't have antibodies against human proteins that you don't have.
You have to be exposed to those proteins
to develop antibodies.
So the chance that,
so if I didn't know my blood type,
the chance that you could take my kidney
is somewhat over 50%.
But the chance that my wife can take my kidney
is only about 30%.
And the reason is we're parents
and in the course of childbirth, not pregnancy,
but childbirth, my wife's immune system might have been exposed to some of the proteins
that our boys inherit from me. And if so, her immune system might have developed antibodies
that would now be prepared to attack my kidney if it should appear. So for parents, husbands donating to
wives is harder than other donations. And I assume that's just one of many strange,
interesting, fascinating things you learn in your work about realms that you knew, right?
Nothing coming in. Market design is an outward facing part of economics, which means we're
always learning new things. Economics is about almost everything that people do, which means the nice thing for
being an economist is it means we can learn things from almost anyone.
And of course, you have to learn a lot about kidney surgery to be able to help surgeons
organize surgeries.
You have to learn a lot about medical practice and education in order to help organize labor markets for doctors.
You have to learn a lot about New York City schools to be able to help high schools do their admissions process.
And that learning is a chain of its own, like the kidney donor chain that Al Roth and others helped create, and which is saving lives.
And as Al Roth and people like him continue to learn,
they pass that knowledge along to people like you and me,
making all of us a bit wiser, a bit more curious,
a bit better off every day.
Cheers.
Cheers. Hey, podcast listeners. On next week's episode, you ever notice how all the servers in your favorite sushi restaurant are Asian, even if they're not Japanese?
Or that all the servers in your favorite Mexican restaurant are from the Dominican Republic?
When it comes to ethnic food, I'm not sure why, but we've decided that it tastes better when it's served by people of that ethnicity.
Does this hiring practice make business sense?
Is it fair? Is it legal?
The statute is pretty clear,
and if you're taking ethnicity into account
without some of these other possible defenses being present,
you are technically subject
to an employment discrimination lawsuit.
Racial profiling in the front of the house. That's next time on Freakonomics Radio. Thank you. If you want more Freakonomics Radio, you can subscribe to our podcast on iTunes or go to Freakonomics.com, where you'll find lots of radio, a blog, the books, and more.