Taiwan has the world's highest rate of end-stage kidney disease—and one of its worst transplant bottlenecks. More than 8,800 patients are on the waiting list. Fewer than 430 transplants are completed each year. To Nobel Prize-winning economistAlvin Roth, that gap is not inevitable. It is a design flaw.
"Taiwan's law requires that organ donors must be relatives, but sometimes patients receive kidneys from non-family members, and that makes transplantation very difficult in Taiwan," Roth told The Storm Media in an exclusive interview. "It would be better if the law could be relaxed."
Roth, a Stanford economics professor who shared the 2012 Nobel Prize with Lloyd Shapley for their work on matching theory and market design, was in Taiwan for the first time under the Taiwan Bridge Program—a joint initiative of Academia Sinica, National Taiwan University, National Tsing Hua University, and the International Peace Foundation. He delivered a lecture titled "Markets, Market Design and Medicine" at National Tsing Hua University on April 20.
The Law That Blocks the Match
Under Taiwan's Human Organ Transplant Act, living donors must be blood relatives within five degrees of kinship or a legal spouse. Paired kidney exchange between two unrelated families is technically permitted—but has produced zero cases in practice, according to the National Organ Procurement and Transplantation Center.
Roth's diagnosis is direct: a law designed around family ties prevents the kind of cross-family matching that drives successful transplant programs everywhere else.
A Career Redirected by One Phone Call
Roth holds a doctorate in operations research from Stanford and spent his early career in game theory—studying how market rules shape behavior. The pivot came in 1995, while he was a professor at the University of Pittsburgh.
"A phone call changed my career," he recalled. The caller asked him to help redesign the National Resident Matching Program, which pairs medical graduates with hospital residency positions. "Before that call, I would study a market, describe its problems, and then say: this is a hard problem. Suddenly I realized that if I agreed to help redesign this market, these hard problems immediately became my problems. I had to learn how to solve them. That was the moment I became a market designer—it was an adventurous journey."
He went on to redesign school admissions systems in New York City and Boston. Then, starting in 2000, he turned to organ transplantation. The algorithms he developed powered the launch of the New England Program for Kidney Exchange in 2004—enabling kidney-for-kidney swaps between incompatible donor-recipient pairs.
Progress That Cannot Keep Up With Demand
The exchange program has saved thousands of lives. It has not solved the problem.
The number of Americans waiting for a kidney has tripled since 2000, from roughly 40,000 to approximately 100,000 today. "No one should be satisfied with the current state of kidney transplantation and kidney disease treatment," Roth said. "We have to do more, because the number of patients waiting for a transplant keeps growing."
Two trends compound each other. Declining traffic fatalities—a public health success—have reduced the supply of deceased-donor organs. Meanwhile, improved dialysis technology allows patients to survive longer on the waiting list, steadily expanding it. "The problem is quite complicated," he said.
What the U.S. Can Learn from Taiwan—and Vice Versa
Roth offered an unexpected compliment: Taiwan's practice of providing funeral subsidies to the families of deceased donors is something the United States prohibits and should reconsider. "The U.S. probably should do this. It would help encourage more people to donate kidneys."
He identified several structural deterrents to living donation in the U.S.—donors who must absorb their own medical costs, those unable to take time off work, those without childcare or elder care during recovery. "We have to do better at making the donation process easier," he said.
On financial compensation more broadly, he said the field is converging on a baseline: donation should at minimum be financially neutral, meaning donors should not be left out of pocket. "Perhaps donors should be compensated for the pain, suffering, and contribution they make," he added.
Scale Is Everything—and That Means Crossing Borders
A kidney exchange system only works if the matching pool is large enough to generate compatible pairs. Even in the United States—population 330 million—living-donor exchanges account for only about 30 percent of all kidney transplants. Smaller countries face a more acute version of the same constraint.
"The kidney exchange system needs a larger market to work," Roth said. "Countries or markets with small populations will struggle to find matched donors. Borders shouldn't be a barrier—neighboring countries should be invited to join a shared system."
He cited a 2021 collaboration he helped broker between Israel and the United Arab Emirates as proof of concept. Both countries have populations of around 10 million and had independently struggled to generate enough matches domestically. Under a framework Roth helped establish, hospitals on both sides cooperated across a long-standing geopolitical divide—and three pairs of families completed cross-border kidney exchanges.
"It started from the hospitals," he explained. "Patients waiting for kidneys couldn't find matches, so the market had to expand. The hospital cooperation benefited patients in both countries."
The Cross-Strait Possibility
The Israel-UAE precedent has direct implications for Taiwan. By the same logic, Roth argued, Taiwan and China could form a joint kidney exchange mechanism—pairing Taiwan's smaller population with China's vastly larger one to generate a far more viable matching pool.
"If hospitals in Taiwan and China could cooperate on kidney exchange, it would save more lives," he said.
He acknowledged the distance between vision and reality. Neither side currently operates a functioning domestic exchange system. Any cross-strait framework would require clearing formidable legal, political, and institutional barriers. His near-term priority is domestic: Taiwan must first reform its donation laws before any larger cooperation becomes possible.
Four Nobel Prizes from One Mentor
Now 75, Roth credits much of his intellectual formation to his doctoral adviser, Stanford Professor Emeritus Robert Wilson, now 89. Roth said he still regularly encounters Wilson on campus in good health.
Wilson has an extraordinary distinction: three of his doctoral students have won the Nobel Prize in Economics. Roth received it in 2012, Bengt Holmström in 2016, and Paul Milgrom in 2020—the last of whom shared the prize with Wilson himself. Four Nobel laureates from a single mentor-student lineage is, by any measure, without precedent.
On a personal level, Roth named his wife as the greatest influence on his life. "She is a rigorous scientist—she studies human factors engineering—and I have learned a great deal from her," he said. The couple will celebrate their 50th wedding anniversary next year. "We built our lives together."
The Digital Economy as Market Design
Market design, Roth argued, operates in every corner of modern life. Its most powerful expression is the digital economy. Platforms like Uber, Airbnb, Amazon, and Google are not simply businesses—they are engineered markets whose rules are embedded in code that must anticipate every possible interaction in advance.
"In a physical store, a customer can walk in and ask an assistant where to find something," he said. "In an online store, everything must be pre-designed through computer code so that the shopping process is completely clear." The digital economy constitutes a large and growing share of both the U.S. and Taiwanese economies, making market design central to understanding how those economies function.
AI: Optimistic in the Long Run, Alarmed Right Now
On artificial intelligence, Roth is a long-term optimist with a short-term warning. His frame of reference is Pittsburgh in the early 1980s, when he arrived just as the city's steel mills were shutting down.
"If you were 50 years old and your steel mill closed, you would never find as good a job again," he said. "But if you were a high school student at the time, you would find other work—and do well. That's what I mean by the difference between short-term and long-term effects." Measured over a century, he noted, human life expectancy has risen, and people today are on average healthier and more prosperous—partly because of technological change.
His specific alarm is narrower and more immediate. The falling cost of applying for jobs and graduate programs has vastly outpaced any reduction in the cost of evaluating candidates. AI will widen that gap further. Stanford's economics doctoral program receives more than 800 applications annually and admits roughly 20 students. The university prohibits AI in the evaluation process, relying on personal recommendation letters from scholars the admissions committee knows. But that safeguard is giving way.
"More and more of those human reference letters are being written by AI," Roth said. "This is genuinely a challenging moment."
