Living kidney donation operations involve significant savings for the health system, on the order of $100,000
Does this account for the costs of the transplant operation and followup costs such as anti-rejection drugs?
While I agree that a donation to the health system is positive, I would expect it to have an effect mostly by decreasing how much we pay into it instead of health outcomes. I would be surprised if the benefit here was even 1:1000 compared to AMF.
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.
This applies on both sides of the question, though. There are also economic benefits of fewer people getting malaria. I don't know the relative magnitudes of these.
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.
Ok; I'm going to update the post with a 3x multiplier due to chains.
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
Because I estimated DALYs just from an overall $/life-saved and an estimate at life expectancy then we the question here is whether I'm right to treat one life saved via a malarial net as four times more valuable than ten additional years via a kidney donation. We don't have to bring DALYs into it.
(I do think DALYs are a pretty much the right thing to look at. As far as I can tell, I care about happiness and avoiding suffering, where two years of at joy-minus-suffering level X matter twice as much as one year at level X. For saving a newborn vs an adult there's the further issue that emotional attachments to the deceased of people who survive are probably much larger in the adult's case, causing a lot more pain at their death. But neither the AMF's nor kidney donation's benefit comes much from an effect on newborns, so that doesn't apply here.)
I don't the expected value of a $1600 donation to AMF is actually anywhere near one life saved.
That's unfortunate. I would really like it if GiveWell could give me $/life-saved that corrected for these issues and was as accurate enough to take literally.
How far off do you think this number is? 2x? 100x?
altruistic donors have been able to take medical leave of some kind from their job
Isn't medical leave generally unpaid, especially for elective surgeries? If you miss two weeks of work and take home $50K/year then that's about $2K in missed pay.
As rational altruists, we can achieve great outcomes for others at relatively little harm to ourselves. In order to maximize the return to others for the sacrifices we're willing to accept, we should sort potential actions by their expected return and work our way down the list until we've used up our willingness to sacrifice.
This is how I think we should think about it, yes. Well phrased.
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.
Yes. I would do this.
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.
Let's say I, as you seem to be suggesting, compartamentalize my giving. I might have compartments for donation of body parts, career choice, doing without, volunteer time, and abstaining from certain foods. Within each compartment I would optimize, giving to the best charity I could find, avoiding high-carbon footprint foods, but I would get worse results for less happiness on my part than if I optimize overall. Perhaps volunteer time doesn't matter much but monetary donations are huge. Or it makes me really unhappy to give up eating beef and I would be happier to work a somewhat less fulfilling but more lucrative career. Without being able to trade off between categories I make choices that benefit everyone less than if I could.
Envisioning people as having a fixed amount of suffering they're willing to undergo does not strike me as a very accurate psychological model
It doesn't? As long as you account for things like "giving up meat is hard at first but gets easier" it seems about right to me.
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
I'm careful not to put the limit in a place where it would make life too unpleasant, but yes, I try to do this. It seems to work well for me, while also working well in terms of how much good I can do.
(For example, in 2009 Julia and I lived on about $22,000 and gave about $45,000. This still meant we could eat ice cream and go dancing, but it was a level at which we would have had to start giving up some things we really enjoyed if we were to increase our giving more.)
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.
This seems to be a case of fuzzies and utilons. Every charitable act gives some amount of personl benefit (fuzzies) and benfit to others (utilons). For the most part actions that give a lot of fuzzies (volunteering at a day care) don't give a lot of utilons, and the reverse. Kidney donation is unusual here in that people often find it highly personally fulfilling while it is also at least in the same ballpark as the most effective known charities. For me, however, I have lots of sources of fuzzies in my life and so I basically ignore personal benefit when choosing between giving opportunities. This is a case where I expect the answer to vary a lot between people.
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.
No argument here.
At the framework level
The basic framework you envision seems to have a certain fixed level of charitable resources (potential "sacrifice"), to be stewarded and spent in a utility-optimizing way over time. Once spent, these resources are gone. In this framework, asking "is the amount I would have to donate to the best charity to accomplish the same benefits as donating a kidney less than the price for which I would sell my kidney?" is a coherent and useful question, because you plan to offset your charitable contributions by that amount ...
People are dying because their kidneys have failed, and you probably have an extra one: should you donate it? A dialysis machine can do most of the work of a kidney, but it's not as good. A donated kidney gives someone an average of 10 additional years. [1] (Some of them reject it right away, others live for years before having problems.) This is pretty good: if you volunteer to be a kidney donor and are selected as a match, you give someone an average of another 10 years of life. [2]
A kidney donation is a surgery, however, and does have some risk for you. It's hard to calculate the risk because people who are selected for kidney donation are a weird group: they're heavily screened (so they tend to be healthier) but they're likely to be related to the person they're donating to (so they tend to be at risk for kidney problems themself). An ideal study on the dangers of kidney donation would compare donors with people who were going to donate and then didn't for some nearly-random reason. I can't find such a study, but I've heard people give odds of around 1:3000 for dying due to donating. You also spend several days in the hospital, miss some weeks of work, and take several months to fully recover. [3] This sounds like a lot, but giving someone 10 years of life is a lot too.
The question isn't so much "does this do good," however, but "does this maximize the good I can do for the amount of sacrifice I'm willing to accept?" GiveWell estimates that each $1600 given to the AMF for antimalarial net distribution prevents the death of someone with an average life expectancy of maybe 40 years [4]. So another way to give a stranger 10 more years of life is to give $400 to the AMF. Kidney donation is in the same ballpark as this, in terms of the ratio of benefit (to others) to cost (to you) [5], but even ignoring the risk of death [6] I would pay that $400 just to avoid the hospital and recovery time.
Update 2012-06-22: BDan and Alexander Berger have convinced me I was wrong to write off chains. At least right now there are more possible chains than kidneys to start them, and they can be quite long. My updated estimate is that this gets you a 3x multiplier on the value of a donated kidney, bringing the $400 charity equivalent to $1200. Which is still less than the $10-$100K at which I think I would sell a kidney, but substantially higher.
(I also posted this on my blog)
[1] Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. (1999), table 3. This is from a longitudinal study on 23,275 people who got kidney transplants from cadavers and had never had one before. In our case we're interested in live donation, but I would guess it's about the same.
[2] It's possible that you could do better than this if your donation to a stranger set off a chain of donations. The idea is that there are lots of people who would give their kidney to a friend of family member if they could, but are for whatever reason incompatible. You can make donor-donee-donor-donee chains where it just takes one altruistic person to set the whole thing off. (Cycles are also possible, but they don't need someone to get them started.) The question is, though, how likely are these chains to happen anyway? And how long a chain can you reasonably expect? My understanding is that these are quite rare, with most altruistic kidney donors not starting one. I'm going to ignore chains.
[3] Someone who gave their kidney wrote in a Guardian article: "I was in hospital for four days--the worst part of the whole ordeal was removing the catheter. In just two weeks I was back at work (the full recovery is supposed to be three months)."
[4] I would love to find a GiveWell estimate of what life expectancy for the people who don't die of malaria because of a net, but I can't find one. So this "40 years" is a guess after looking at life expectancies for different ages in the countries where the AMF works.
[5] There are huge costs to both dialysis and kidney transplant, so as a health intervention distributing antimalarial nets [makes much more sense]. From the perspective of a prospective donor, however, I don't think this matters.
[6] You might think that if you're someone who gives a substantial fraction of their earnings to effective charity, a 1:3000 risk of death would be pretty bad because you'd be able to help other people much less. But 3000 is really big: if you're giving $20K/year and have an expected additional 30 years of working life, a 1:3000 chance of not being able to do that has an undiscounted expected value of only $200 less donated. [7]
[7] $20K * 30 years * 1:3000 = $200