The Political Economy of Organ Transplantation with Hagai Boas

Today’s guest is the Israeli sociologist, Hagai Boas, a four-time organ transplant recipient and the author of The Political Economy of Organ Transplantation, published by Routledge. Hagai is the second transplant recipient on the podcast (Sally Satel, an earlier guest, has received two kidney transplants), but I’ve never met anyone before who has been transplanted *four* times, or who has purchased an organ on the black market, as Hagai did with his third transplant. Boas is the director of the Science, Technology, and Society unit at Van Leer Jerusalem Institute. He is also a senior lecturer in the Department of Politics and Government at Ben-Gurion University. 

Transcript

[00:00] Hagai Boas: It was very difficult then and it is still now. And I knew that I'm doing something which is wrong. I'm still thinking that it is wrong. There is no way that I want to rationalize that in any way. It was awful, it was abusive in a way. It was difficult, and I had no choice but to do it. And I'm not covering or laundering it in any way. I bought an organ. This is the invisible scar, let's say, that’s been accompanying me since then.

[00:38] Kim Krawiec: Hey. Hey, everybody. Welcome to the Taboo Trades podcast, a show about stuff we aren't supposed to sell, but do anyway. I'm your host, Kim Kravick.

[00:54] Kim Krawiec: Today's guest is the Israeli sociologist Hagai Boaz, a four time organ transplant recipient and the author of The Political Economy of Organ Transplantation. Hagai is the second transplant recipient on the podcast. Sally Satell, an earlier guest, has received two kidney transplants, but I've never met anyone before who has been transplanted four times or who has purchased an organ on the black market as Hagai did with his third transplant. Boaz is the director of the Science, Technology, and Society unit at Van Lear Jerusalem Institute. He is also a senior lecturer in the Department of Politics and Government at Bengurion University.

[01:38] Hagai Boas: Hi, Kim.

[01:40] Kim Krawiec: Morning. Or I guess, evening for you. You are actually the second transplant recipient who's been on here. Sally Satell was on and she had had two transplants. And I have also had two donors on martha Gershon and Josh Morrison. But you are the only person not only who's been on the podcast, but who I've ever talked to who has had four transplants. So can you talk a little bit about that?

[02:05] Hagai Boas: Yes. Thank you first for having me in.

[02:08] Kim Krawiec: Your thank you for being here.

[02:10] Hagai Boas: I'm very honored. Yes. Actually reaching my birthday in exactly four months from now. And all my life I lived in the shadow of some kidney disease or its complication. And I was born in Jerusalem, Israel, at the eve of Yom Kippur war in 1973. And a few days after my birth, my mother noticed that something is not right with me my color, my my overall status. And she rushed with me to the hospital and they discovered that I'm suffering from a renal failure. And we are talking about the early 70s with in Israel with hardly no knowledge on organ transplants, which was worldwide at kind of not a routine medicine, but rather experimental medicine at that stage and with a few dialysis machine. And I was a ten day baby, actually. I spent three months in the hospital during my infancy. And my mother recalls that my father was sent to war and she had my older brother, a two year old, and we are talking about the period, it's hard to imagine, but with no cell phone or any other devices like that. And she rushed to the hospital each morning to see if I made it through the night.

[04:04] Kim Krawiec: Your mom's a hero, by the way. As I was reading that part of the book, I was so impressed. I mean, your father is too, but as you I think maybe you even mentioned in the book as sort of the war was going on, there's a lot of women left behind, left to sort of do all of this work on their own. And she sounds amazing.

[04:23] Hagai Boas: Both of them certainly are. And I actually managed to survive and to to grow as a kid with a problem, a small kid with a problem. But by the age of 13, with the body demands more energy for growth and maturation, we encountered a problem. My kidneys were not sufficient to sustain the growing demands of the body. And we are talking now on we are stopped at 1986 and there is a need for something new transplant in Israel. And I was I am one of the first kids who underwent a kidney transplant. The technology in Israel at that time was new. Although kidney transplants in Israel were performed already in the 60s, it came to a halt, I think, all over the world during the 70s with problems, with problems and the history of organ transplantation. There is one, what can be termed as the immunosuppressive revolution in the beginning of the 80s where drugs were manufactured that helped overcome the rejection barrier. And this revolution actually reversalized transplant medicine turned it from a routine medicine, from experimental medicine to routine medicine. My first transplant was at the age of 1386. My father was the donor. When I spoke with my parents and asked them to tell me the story about that transplantation, they told me that they were both tested and they were both found as a good match. But my father said it is his turn now to give life where my mother gave me life birth, it was his turn. So my first transplant was from him. He was at the age of 42, I was at the age of 13 and it lasted for 13 years and actually helped me.

[06:56] Kim Krawiec: You were 13, your father was, I think you said, 42 and that was your first transplant. And at the time you probably expected that that would not be your last transplant or had you I mean, you were only 13, so maybe nobody discussed that with you.

[07:10] Hagai Boas: No one discussed that with me. I don't know if anyone discussed that with my parents as well. Yeah, I was under the impression that it was difficult. It's hard and I'm on specific diet even afterwards and on the specific regime of immonosuppressants agents and medicines and checkups. But I didn't imagine that something could go wrong. And it was a total shock at the age of 20, 613 years afterwards that suddenly, out of the sudden, I had to undergo another transplant. I was then after in Israel, you have a master thesis and I was planning actually on doing a PhD in the US. And I did the GRE and all that examination and actually was accepted to very prestigious university. And we planned my girlfriend then to now my wife, we planned to travel to the US. To see if that at all fits us living in the US. For some years and have been an academic way of life. But then I came to a regular checkup and my creatinine level this is the measurement of kidney function just rockets and the doctor says you are not going anywhere. And I was in shock. And actually it was very quickly that it turned out that there is I'm facing again the crossing of the crossroad of weather dialysis which now became much more developed in Israel or transplantation at that time. My mother immediately decided that now it's her turn to donate and she donated to me. The operation went out in Israel but very soon something went wrong. I was infected with the virus. The period, let's say the three months after the transplantation is a very sensitive period. You are receiving heavy treatments for immunosuppressant agents and there is the risk of infections. And unfortunately I was infected by a virus that although I was able to overcome the infections, it did damage the kidney and from the beginning something did not went as well. And although it lasted, the kidney survived for five years after. After five years I found myself again at the same crossword. At the same crossword. But at this time I could not look up to any help from my parents but rather to look right and left to my peers, my family, my wife, my brothers, my friends and for the first time the question that actually is the subtitle of my book where do kidney come from? Where do organs come from? Where do my next kidney come from? How can one ask a person to donate him a kidney in a case where you have a family member, is it possible at all? Imagine the situation, the impossibility of that situation to ask not for a loan, not for not of anything physical, not of a favor that you can return, but ask someone to undergo an operation for you. It is something that I think from my own experience that you need to receive. You need to perhaps to signal and not ask specifically. It's horrible. And also from the other side, think of someone of your brother or your sister that asks you for a kidney. Can you say no? Can you say no? Think of the impossibility of the situation. There is a huge difference in the position within family. Now, afterwards I learned it from my own studies but there is a huge differences between parents willing to donate to their children and sibling and also parents who refuse. And I can understand that refusal to accept kidneys from their children.

[12:32] Kim Krawiec: I actually also know a number of parents who made that same decision they just weren't willing to accept from their children.

[12:40] Hagai Boas: I won't say universal because that's problematic and we know that culture makes differences but at that time I was at the age of 31, we just got married and we had no children and the dilemma was terrible. The dilemma was whether I would go on dialysis for five to seven years and then in Israel this is the line, this is the average time at that time at the end of it was 2004. So on dialysis I'm surrendering the chance of having children. Actually I thought that it would be impossible for me to achieve any academic career while on that is at that stage where I'm just a PhD student at the most. I didn't even wanted to write at that time my dissertation on organ transplantation. I had other plans actually. I wanted to do something on the sociology of archaeology in Israel, a fascinating topic still is all my friends just were accepted to US universities and flew and stayed there and I stayed with the dilemma, what to do.

[14:21] Kim Krawiec: Can I ask you a couple of questions before we continue on with this third transplant? Did you become harder to match with a donor after your successive transplants? In other words, did you develop more antibodies that made it more difficult for you to find donors after your first transplants?

[14:43] Hagai Boas: No.

[14:44] Kim Krawiec: Interesting.

[14:45] Hagai Boas: Okay, yeah, that's very interesting because I know that many other recipients do develop yeah, right, and become more synthesized for more transplantations. But I actually had a very opposite reaction and perhaps because of I cannot put my finger on specific reason, but medically I could find a match. So it became more of an ethical, moral and social dilemma in the sense that what's next? But still, even with my, let's say, increased potential to find a match, still the waiting time was long and impossible for me as a 31 years old young person.

[15:48] Kim Krawiec: That was going to be my next question because in Israel at that time there was a particular shortage as I understand it, from your book. Is that right? And if so, can you talk about that a little bit about the state of the shortage then and its causes?

[16:01] Hagai Boas: Yeah, well, Israel still is in a state of a shortage, but not as much right? It has improved, but not as much as it was during the early and the first decade of our century.

[16:18] Kim Krawiec: Okay.

[16:23] Hagai Boas: Still there is a shortage still transplant waiting list are long and there is a gap between the advanced and the advanced medicine that we have the medical infrastructure for transplant. We have four or five transplant centers in Israel. We have insurance coverage that covers every aspect, operative and post operative treatments. We had a very good infrastructure for transplants, one of the most advanced in the world, but we don't have enough donors. That's the tragedy, that's the irony perhaps and the reasons are many there is many of the listeners that perhaps know bit on organ transplantation know that there is a tendency to put the finger on one reason religious opposition to brain death, so on and so forth. And that is all correct. There is a debate in Israel still going on about brain death, although a compromise was achieved and even legalized in what is called now Respiratory Brain Death Act of 2008. But still the the brain death issue is contested. But it's not just that. The reasons for organ shortage are many fold and they are from a blessed decrease in motor vehicle accidents to the detection of brain death, to the status of the organs. And there is no point of entering this very complicated and convoluted issue of what is the potential number of organs that can be procured. And I think that today in Israel and in other places in the world as well, even if we could utilize all the brand dead and even marginal donations as they are called, non heartbeating donors and such, we could not fulfill the demand and eliminate the shortage. There will always be a gap.

[19:15] Kim Krawiec: This is really important and I just want to emphasize what you just said and the reason for that is I think a lot of people don't understand that. And in the US, where you may or may not have followed it, the procurement organizations are under heat for their failures and of course we should improve that. Having said that, it is important to recognize that even if we had 100% rates of procurement that there would still be a shortfall. And so I just want to emphasize that.

[19:47] Hagai Boas: So patients on the waiting list are actually caught in unbelievable situation. There is this technology handed to them in Israel, free for free and there is a free and open post operative treatment that can just wait for them and wonderful treatment in the sense of nephrologists that follow them. And it's all for free or for very small sum of money. But there is simply no organ. The organ shortage is the only obstacle that prevents them from having healthy life and this is quite an absurd or impossibility. And yeah, we just said that there is actually the shortage is insurmountable even if we could utilize all the cases of brain death but there is for kidney patients the alternative of living donation and living donations are on the rise. I think not. I think this is actually the main conclusion or the main finding in my book, that you can notice a systematic increase in living donation because organ shortage, although it varies between time and country, is a dead end for many patients and alternative channels of organ supply are actually the answers. Mainly for kidney patients, who, by the way, composed most of the transplantations everywhere. So here comes the political economy of organ transplantation. It begins with a shortage problem and although shortage is something which features any economy. There is no economy without shortage. But in regular economies, shortage is something which flips to the other side. It reverses and is temporarily and dependent on supply and demand. In the realm of organ for transplantations, the shortage is chronic and exacerbating and as I said, insurmountable. This is the starting point, let's say the zero degree of the transplantation reality. And this for me is not just a research question, as you can all guess. This was also my life question, the questions that I needed to answer in order to understand how do I survive, actually. So the political economy, like any political economy, is an outcome of a shortage. And then it is actually the gamut of three bases of organ supply. Usually when we speak about political economy, we speak about the interplay between the state and the market. Feminist critics added also the household or the family as another basis or another factor that has to be taken into account when we speak about political economy. So the political economy has three bases the family or the household economy, the market and the state. And these are specifically the different, let's say, resources of organ supply. You can either obtain or receive a deceased donation from someone you don't know through the formal mechanisms of the state or the organ procurement organization, funded and supervised by state regulations and formal guidelines. So this is the one base. The second base is your family, which I described earlier, how to ask, how to obtain the very intricate relationship between that always characterized familial history and the sociology of family. There is everything in the family from love and care to power, relation and coercion. And there is the black market. There is the black market of organ trafficking, of the underground networks that were very, very common at the turn of the century, specifically at the time where I needed my third transplant.

[25:14] Kim Krawiec: Yeah, so let's finish talking about your third transplant and then we'll talk about the fourth. So if we go to your three political economies that sort of form the framework of the book and they also form the framework of your life in some ways, right? Because they represent all four of your transplants. So the family, as you discussed, those were your first and second transplants. Now we're up to your third. It's a time of great shortage. Your mother and father have already donated to you, and you turn to another source of organs, which is the market. Can you talk a little bit about that? Let me just say that I really love your discussion of this in the book. I mean, I love all of the book, as you know. But I especially like this particular discussion. I like the way you weave your first hand account together with sort of data and other research on this. And I love the sort of empathy and I don't know, humanity for lack of a better word with which you discuss the entire situation, your donor, the way you clearly hear about him and what happened to him and his family and all of that. So can you just discuss that a little bit?

[26:28] Hagai Boas: Yeah, although it's very difficult to me.

[26:30] Kim Krawiec: Of course it is. I'm not surprised.

[26:33] Hagai Boas: It's been about 20 years since then and it was very difficult then and it is still now. It was difficult because I had a sociological training my and I couldn't say that I didn't know or didn't understand what coercion is or what our power relations about. And I knew that I'm doing something which is wrong. I'm still thinking that it is wrong. There is no way that I want to rationalize that in any way. It was awful, it was abusive in a way, it was difficult and I had no choice but to do it. So how do you live in such a contradictory dilemma, in such a moral complex? We like to think of ourselves as something which is very morally coherent. We have our values, we have our attitude, and we try to act according to our values and attitudes and we tell ourselves a moral narrative about ourselves. What happens when you face such a clash between your values and your life? Actually, you have to do something that you know is wrong. And I had very difficult time deciding and I'm not covering or laundering it in any way. I bought an organ. This is the invisible scar, let's say, that accompanying me since then. It was terrible. There is nothing that I can do to change that. It is a fact. And along the way, during those days, this week in Istanbul where we did the transplantation, istanbul was a hub of organ trafficking, mainly for Israeli patients. No, no longer, I think, but during that time, it was a hub of that criminal activity. It were criminals that were running the operations over there and it were unfortunately poor people or people that were pushed into selling their organs without any, let's say without any supervision or even someone who knew about that. I went to Istanbul together with another patient. It was operated by two pairs, organ vendor and the recipient and another pair like that.

[29:48] Kim Krawiec: Can I just ask you, how did you find out about this? When I hear about people trying to access black markets or whatever it is, the first question that I always come up with is how do you even know where to go? How were you introduced to this network?

[30:06] Hagai Boas: Okay? And we are speaking about days without internet or.net or even cell phones. It's hard to believe, but there were times like that as well. But the reality of shortage actually created a bond between organ recipients that transferred information about what to do when you need a transplant. It was actually with a silent cooperation of the doctors. They also knew about that. They knew they were not involved there, at least the majority of them. But when you sit at the doctor, the nephrology department waiting for your conversation with the doctors and you sit together with a bunch of other organ recipients, dialysis patients and it's in Israel, everyone speaks with everyone. It's like a very big, small family. Everyone asks anyone about his or her status and we just exchange information. And there were also ads in the newspaper at that time. It was not criminal, it was banned, it was not allowed, but it was not criminalized yet. So you could find also some even small ads in the newspaper or even on your way to the hospital, people posted small paper ads saying I want to sell my kidney, please call me at this and that.

[32:14] Kim Krawiec: These sellers were Israeli.

[32:16] Hagai Boas: Was the reality there then in Israel?

[32:19] Kim Krawiec: And these sellers were Israeli. Is that correct?

[32:21] Hagai Boas: Sellers were Israeli.

[32:23] Kim Krawiec: And your seller was Israeli.

[32:25] Hagai Boas: Also Israeli.

[32:26] Kim Krawiec: Even though you guys went to Istanbul.

[32:27] Hagai Boas: Another absurd, without disclosing any material, any information about him, he and his brother both sold their kidneys in order to pay their deceased father debts to the state of Israel. The irony celebrates here. The amazing thing was that the line when you go underground is reversed. Whereas in dialysis there is a line for and waiting time for receiving a disease donation, which are scarce when you are going underground. The line is of sellers waiting to sell their organs and their kidneys actually to patients. So it was incredible, the political economy of that and the reverse between the market and the state and the denied connection actually between the two entities, the medical establishment, underground market. So we went to Eastern Bull and we did the operation and I met, although I was warned not to meet or not to speak even with my vendor, I thought that there is a person there. Where do my organ come from? Is also an ethical imperative. There is a person who did something for you to live. And I met my kidney seller and also the other one, the person who sold his kidney to the other patient who came with me was a gambler, even a cliche of organ trafficking. One person who gambled and lost money to, let's say, not so pleasant organizations and had to come up with a huge sum quickly and decided to sell his kidney. Terrible story, terrible. And these cases need to be stopped. Of course. My kidney seller, as I told you, was actually in debts and had to repay the debts to the state. So he and his brother sold their kidneys. And when I approached him and told him and asked him actually about his decision, he told me something that actually astonished me and reshuffled all my thoughts about altruism utilitarianism trafficking. He said me in very simple words, he said yeah, I sold my kidney, I did it for the money. But I also had the chance to save someone. And it is important to me that I also had the chance to save a person in doing so. Yeah, I did it for the money. But it's not exclusionary in any way, that it's not simple black and white. There are many shades in between. And he said, yeah, I chose to sell the kidney because I thought, yeah, I do it for the money. But this is also something that helps someone else, another person. And I must admit that although the simplicity of this argument, I never thought about it that way. I didn't want to say brainwashed, but so indoctrinated or taught in critical school that there is no real choice and there is exploitation and coercion and all that which is true. But nevertheless, the agency of that person that he could also help another person in the process struck me actually as something that I came home with that thought in my head.

[37:13] Kim Krawiec: Why do you think we struggle in the context of something like organ donation? It's not unique to organ donation. The title of this podcast is Taboo Trades. And so the theme sort of permeates all of the trades that we talk about here. But we don't typically have a hard time thinking that doctors get paid and also want to help people, or that I love my job and my research, but I would not do it if I didn't get paid and like my students, but I also wouldn't show up for class for free. Why do you think that we have such a hard time rationalizing the coexistence of those two motives in the context of organ donation and not in other parts of life?

[37:55] Hagai Boas: Well, can I say that's $1 million question?

[37:58] Kim Krawiec: Yes, I want you to answer it and then I'm going to put it in my next article.

[38:03] Hagai Boas: Yeah, I think there is no clear answer to that. I have a Marxist explanation on that, which is kind of satire of Marxist explanation, which is let's bend all the commodification of bodily transfers in order to overlook the huge commodification of work and mental and the whole bunch. So there is a small fraction of bodily transfer in the capitalist market. So let's use it as a valve, as a safety valve to drain all the energy about commodification to that direction. But I think that there is also an historical answer in the history of ideas, let's say, and I think one of the major or the key person, let's say, in the decommodification of body transfer is Richard Titmus, the British sociologist. And he was also a welfare advocate and he thought that he wrote about blood donation. And his famous book The Gift Relationship actually argues that by transferring the blood collection into a voluntary system or into altruistic mode would serve the purpose of fostering solidarity in society, would for him. It was also reassuring that there will be no fraud in blood because people will do it not for money, but rather for altruistic reasons. It would also be a buffer against other forms of commodification. There are many critics later oh, they've.

[40:25] Kim Krawiec: Been on this podcast.

[40:26] Hagai Boas: Yeah, there are many later critics on Kitmas. But after all, after all these critics have been voiced, you cannot deny the fact that he actually revolutionized the field in the sense that he entered and inserted, actually, the concept that bodily giving should not be in return of money. You should not put money tag on by the exchange. And this cut very quickly. Why did it cut very quickly in the most capitalistic age? He wrote his book on 1970. Still, you had an anticapitalist system or so called anticapitalist system in the USSR then. But nevertheless, his idea really caught in the liberal capitalist world, which makes you wonder that there is something inherent what exactly there is no also we need to think there's something inherent in the liberal idea that prevents us from thinking about putting prices into some sort of market, what is called moralized markets. And so how it came about and is it should we or can we bridge this very strict taboo on these markets? This is a very good question that I don't have a good answer for that. I'm sorry. I won't.

[42:25] Kim Krawiec: Nobody does it's. Okay. So those are your first three transplants. Let's talk about your fourth one, which represents yet another political economy, which is the state.

[42:38] Hagai Boas: Yeah.

[42:39] Kim Krawiec: And this was in your most recent transplant was 2020, is that correct?

[42:44] Hagai Boas: Yes, June 2020, which means that the third transplant kept me for more than 16 years. So in terms of transplant medicine, it's very success. I always said that when they told me that if the transplant would sustain for 6710 years, you should be lucky, and I said and I remember myself saying, but I'm 20 something. Well, that's not an answer for me. So it was on June 2020, that before that my kidney failed for different reasons, but I went into dialysis. This is also a story because I did dialysis during the COVID pandemic and we are risk population. The organ recipient was very scary, very risky to do that. And my situation actually led to the decision that I need to undergo a combined transplant of both a liver and kidney. And such a transplant can be only done by getting organs from a desist donation.

[44:08] Kim Krawiec: Do the liver and kidney just enlighten me on the medicine behind this? Is it necessary or desirable for both the liver and the kidney to come from the same donor or no, it is. Okay.

[44:21] Hagai Boas: Yes. Because you are matching with someone specific and you have to be matching the so you have to be matched for both organs from the same person.

[44:36] Kim Krawiec: So for you for this time, it was going to be deceased donation or nothing. Okay, got it?

[44:42] Hagai Boas: Yeah. I had to go to dialysis and to wait on the waiting. List for livers. Actually, when you are combined in Israel, when you are of a need for a combination of liver and kidney, you are transferred from blood kidney list to the liver list, which is differently organized, but let's not go into that. So actually the story here is rather a classic. One of how do organs come to transplantation? Someone died and his family decided to donate the kidneys, his kidneys and his liver and his heart and pancreas and lungs. And their generous acts led to the saving of life of five people, one in East Jerusalem, another one received a heart and I'm not sure about the other ones, but I received the liver and the liver and the kidney and it was so heartbreaking to know that you are living thanks to the death of someone else. This is an experience that he was.

[46:10] Kim Krawiec: A young person, right?

[46:12] Hagai Boas: He was a young person, an 18 year old. In the book I inserted the letter that I wrote to the family very much. They don't know the person, of course, that will receive the organs and you don't know the family that donated the organ. And nevertheless, you know that your day of transplantation is a day after the burial or even the day of the burial of the deceased one. It's very difficult to understand or even to get it. And then you can write a letter and send it to the Israeli Transplant Center and they give the letter to the family. And if the family wants, they give a telephone number to the transplant center and the center handles that to you and you can connect with directly with the family. So for a year it was, for them very hard to speak with me and I spoke only with the uncle of the boy who died. But after a year things were changed for the mother and we spoke and we are still in touch during holidays and special days and yes, so that's the story of the fourth transplantation that actually marks the third way of the third base of organ transplantation. So I think I covered it all for me. I can stop.

[48:05] Kim Krawiec: One of the things that I as I as you know, I like a lot about the book. One of the things that struck me from the very outset, not surprising, I guess, from a sociologist, was your statement that if you don't mind, I'm just going to read this from the preface of the book. You say every piece written about transplants is about couples me and my donor, me and the family that donated its son's organs, me and the guy who sold me his organs, me and my family. For transplant recipients, the matter of dependence on others can't be denied. That was really powerful to me of thinking about thinking about donation and transplantation as just sort of inevitably a connected system. We don't have to take the title approach to recognize that it does tie you to others and make you dependent on others in a very particular way.

[49:03] Hagai Boas: Yes, I think that it converges with my sociological reasoning in sociology, we know that we are not islands. We are always in connection, always embedded in some sort of interdependence with others. Even if we don't see them, the clothes that we wear, the computer that we use, they are all the product of work of a social history in organ transplantation. These interdependence is materializing in your faith, and you know that ethically, morally, you cannot tell yourself an individualistic story. I a few minutes ago, I spoke about one bridge on our individualistic story. When we are telling ourselves a coherent moral story about ourselves, we often think of ourselves as the heroes of this narrative. I did that and I did that, and I graduated and I married and I fell in love and I hated and I loved and I, and I, and I everything is very egocentric in our narrative, in our age of heroism. I think that for organ recipients, at least for me, let's say, let's be on more modest. For me, I never bought this story of individualism, of that it is all about you. Yeah, it's about me, but it's about me and others and the dependence and the ethics and the morals that connects between ourselves. And if we speak about dependence or interdependence so what are the ethics of this dependency? How should we understand that the relation between so it's not something new that I'm not taking anyone by surprise because we know that we have to think about relation with others, with our spouses, with our children, with our colleagues at work and so on and so forth, but with the people who saved your life. That is something that actually accompanies me since childhood.

[51:31] Kim Krawiec: Yeah. So having gone through your four transplants, having written this book, having now spent a good chunk of your career researching this, where are you now in terms of thinking about the organ shortage? How to alleviate it? Or maybe you don't think about it, but I mean, where did this journey lead you, sort of today?

[51:56] Hagai Boas: Well, yeah, I must say that I'm pessimistic.

[52:00] Kim Krawiec: I am as well. Yeah.

[52:01] Hagai Boas: In the sense that I think that 70 years of transplant medicine proved that there are very heavy taboos and cultural problems in obtaining organs from other people. We can call it altruism, placing the organ transfer very high in our moral order. But still, altruism is not the rule of our society. You cannot base a social policy on our altruism. And I'm not sure that organ markets is also the solution. From my own experience, people are not inclined to sell their organs even if the state would grant them, I don't know, $100,000. And I'm not sure that the state can afford such an amount.

[52:55] Kim Krawiec: Let me go back to this then. When we were talking about the black market you said that the political economy was flipped and that there was a line of people trying to sell their organs. So my intuition then would be that in a legalized organ market you would continue to see that. And I mean, I don't want to hold the Iranian system up as a model in a lot of ways, right? It has a lot of problems, but one thing they don't have is a shortage. I guess I would press you on the notion that there wouldn't be enough people to sell their organs or that it wouldn't, as a matter of economic policy, save us money rather than continuing to have people on dialysis, which we're paying for. And then they're not fully productive members of society often, right, as you know. Now, that doesn't answer the ethics question, but it does to me answer the economics question.

[53:54] Hagai Boas: Yeah, but I don't think that they can be divorced ethical and economic. And the Iranian model, as much as we know about them, that model yes, you're right, they are saying that there is no shortage. Let's take that as something that we can understand. But still the account of the people that participate in this market tell a story of shame. As I recall, they are stigmatized. It's not something that you are taking pride of selling in Oregon. And I must tell you that the Oregon vendors, when you encounter someone, ran them on the street and he said, well, I would do that and I would sell my kidney in order to buy all that arguments. People think that people that you can change your life with selling an organ or something like that, but the poor people do it for very small amounts of money. The recipients need to say pay a lot and most of the money goes to the brokers. In reality, people sell their kidneys in a dark alley for much less an amount sum of money than imagined in the abstract idea of organ markets. Now, I think that there will be, as we know from the Iranian model, there will be a strong stigmatized and also a strong opposition to state regulated markets of Oregon. People just wouldn't accept without any elaborate arguments, that they would say this will not be happening here in the US or in Israel or anywhere else. We will not allow people to sell their kidneys to the state. We will not tolerate such a transaction. There is something that there is something offensive in the collective understanding of the possibility of poverty that organ markets are portrayed as something so dystopic that people will not tolerate that. And unlike surrogacy that in Israel is under contract and for money or the selling of organ recipients or people on the waiting list, although they are growing in numbers, are not a pressure group in the sense of their agency, of their political agency. That is also a factor that needed to take into account. But I think that there is no sum of money that would compensate a person on the stigmatization. And another story about the organ vendor that I met and he told me and showed me when we met, that soon after the transplant took place, he tattooed the scar and told me that any other vendor that he knew, any other kidney vendor that he knew, also made a tattoo, a very big tattoo. It was very large scars at the time and did not kept the whole story of his kidney cell secret. A few years later I tried to reach him and I learned that he divorced his wife. And I suddenly realized that he did not want any connection with me and he kept the idea of him selling a kidney a secret and he did not went into checkups, did not tell that he has only one kidney. So do you think that the shame will be away when the state pays for the organ? I'm not sure.

[58:54] Kim Krawiec: No, I am not sure either. But here's what I would say, and then we can move on to another topic. To me, an analogy for this and the stigma. And stigmatization is sex work. Legalizing sex work, I think, doesn't get rid of the stigma of it, but making it illegal sure doesn't help reduce that stigma, you know what I'm saying? And so I personally do not consider the fact that society has decided to stigmatize what certainly in the case of organ donation is a positive activity when it's done for money as being a good argument against permitting it. Now, there may be other good arguments which we haven't addressed here, but to me, I never find stigmatization to be a good argument for prohibiting an activity. It's not going to reduce the stigma and it introduces a lot of other harms, some of which you've talked about. Then you've got criminals basically running the trade, you've got people getting paid too little, often in unsafe conditions, lack of information. I mean, the list could go on. So I don't consider that to be even though it's undoubtedly correct, that the stigma that you've identified and that has been identified in black markets and in the Iranian legalized market, I think it's true, but it's something to work on, not something that should cause us to say this is an argument against legalization.

[01:00:18] Hagai Boas: Well, I think that the effort should be put somewhere else. We earlier discussed the shortage of something insurmountable. But still, I think that we should not surrender the hope of convincing enough people to donate. And even if not eliminating the shortage, curtiling it or shorten it a bit, in the sense that the waiting time will not be measured in seven years, but perhaps in a year or two or something like that. This is perhaps a solution. Another solution is to more seriously address the option of living donation. And from my own study, I discovered that living donation entails a host of ethical problems that are not addressed seriously enough by transplant establishment. And they should be encouraging this channel for kidney donation. So I think that the market is still very problematic. You're completely right in your observation that a regulated market is better than an unregulated criminalized market. Of course it is. But still, I think that it should be the last resort. And I'm ending the book. My conclusion part, or the epilogue actually is about the future. What happens when shortage ends? There is in the future, the technology promises different solutions to the human organ donation. It could be from animal, what is called xanotransplantations, or from printed organs. But then I detail actually another host of ethical and social problems that will accompany this new brave world. If you want, it will end shortage but will create another problem that I think should can be resolved, but we also need to be aware of that.

[01:02:42] Kim Krawiec: Okay, great. This was fun.

[01:02:43] Hagai Boas: Okay, thank you very much. Thank you.

[01:02:45] Kim Krawiec: Okay, talk to you later. Bye.