Tuesday, August 22, 2017

Global Kidney Exchange: a reply to some skeptics, forthcoming in the AJT

Our recent paper in the American Journal of Transplantation about the first Global Kidney Exchange chain was accompanied by a skeptical editorial, and has now also drawn some letters to the editor.  Our reply is forthcoming, and is now online here:

Global Kidney Exchange: Financially Incompatible Pairs Are Not Transplantable Compatible Pairs
Authors
M. A. Rees, S. Paloyo, A. E. Roth, K. D. Krawiec, O. Ekwenna, C. L. Marsh, A. J. Wenig, T. B. Dunn.   Accepted manuscript online: 31 July 2017

Here is the full text pdf file.

Here are the first sentences and the main paragraph.

"Honest debate makes ideas better; we appreciate our colleagues’ engagement. We agree with Wiseman and Gill that Global Kidney Exchange (GKE) must be conducted in an ethical manner that is sensitive to the possibilities of commodification and exploitation and, that it is important to be both careful with and transparent about how patient-donor pairs are selected from developing countries.1,2 We further agree that GKE should continue to be run in a way that enhances rather than competes with local medical services. However, Wiseman and Gill approached GKE from their American and Canadian perspective of near universal access to healthcare for end stage renal disease. They view GKE through a lens of commodification and exploitation...
...
"Let us be clear: without GKE the Filipino husband was never going to receive his spouse’s kidney. Without GKE, the husband was going to die, the wife was going to lose her spouse, and their son was going to be fatherless. That is exactly how the story was going to end without GKE. The goal of GKE is to change this fate for emotionally-related pairs referred by our medical collaborators in their home country when financial barriers prevent transplantation. Our selection process aims to provide a transplant for every GKE-eligible pair that creates enough savings to pay for a GKE transplant.  It is not scalable to propose that GKE could take place without consideration of the savings produced by transplanting patients in the United States. There are not unlimited philanthropic resources available to overcome the needs of patients facing financial barriers to transplantation. By creating and utilizing a portion of the savings produced by reducing the cost of dialysis in the United States through accelerated access to renal transplantation, GKE becomes scalable. However, the net savings produced by GKE must exceed the overall cost in order for US-based healthcare payers to participate. Thus, if we want to achieve GKE’s first goal: to help impoverished patients by overcoming financial barriers to transplantation, GKE must take account of the savings produced. We have now performed four GKE transplants—all funded by philanthropy. We simply evaluated every patient who presented for evaluation and moved forward with every instance where the projected savings from accelerated transplantation of American incompatible pairs in the Alliance for Paired Donation (APD) pool exceeded the cost of the GKE by an amount greater than the anticipated cost. To scale this concept, we are working to produce an ethical and legal process, built on sound business principles, so that it can scale to help as many rich and poor patients as possible. In this first case, an easy-to-match unsensitized blood type A GKE candidate with a blood type O donor easily produced more transplants/savings in the APD pool than without their participation.  No alternative existed for this Filipino pair and millions more like them.3 GKE did not exploit this Filipino couple—it provided the mechanism for the wife to literally save her husband’s life. They could not afford dialysis. Two months prior to travelling to the US and after their identification and evaluation for participation in GKE, their Filipino physician called to say that if the APD did not pay for the husband’s continued dialysis in the Philippines, that he was going to die as no additional funds were available to pay for dialysis. At a societal level, did American patients with access to dialysis really disproportionally benefit from the APD’s “exploitation” of this patient by paying for two months of dialysis in the Philippines? When the husband lived instead of dying, was the Filipino donor’s kidney really undervalued? We ask Wiseman and Gill to seriously consider whether the Filipino wife feels she disproportionately benefited American patients rather than her own family. For three years on Father’s Day the couple’s child has written our team to thank us for saving his daddy’s life. Two and a half years after this first GKE transplant, both the Filipino donor and recipient have normal renal function, countering the editorial’s accusation that “limited post-transplant care provided to the Filipino recipient were probably inequitable.” While the gratifying success of the first case does not guarantee the same outcome for all future patients, it does demonstrate how GKE—even if inequitable—is able to add years of life to patients who would have died without it."
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There's a lot more that can be said, and I have an inkling that I'm going to have the opportunity to say a lot more, as there are going to be more critiques and objections.  Issues of repugnance deserve to be taken seriously.  The many positive responses (like this and this from Mexico) that GKE has received gives me cautious hope that we'll be able to move forward in a way that addresses the chief concerns and  commands broad support.  There are lots of families in which someone has kidney failure whose life could be saved by giving them access to a transplant through kidney exchange.
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Here are all my posts on Global Kidney Exchange

Monday, August 21, 2017

Organ donation in Israel

The Israeli Ministry of Health has a number of interesting web pages concerning organ transplantation.

Here is the one on the compensation of living donors for related expenses:

Compensating Live Organ Donors

The compensation is given to donors when the donation and transplant surgery is performed in Israel.

For this purpose, the following refunds are given: 
  • Refund due to loss of earnings - A sum equivalent to the benefit paid by the National Insurance Institute to a person serving in reserve duty for a period of less than 40 days: minimum NIS 7,841, maximum NIS 57,563 
  • Refund of travel expenses - In a standard and set sum of NIS 2,676, with no need to produce receipts.
  • Psychological treatment - Refund for 5 treatments to the value of up to NIS 428 per treatment, subject to the presentation of receipts proving that the treatment was performed, and subject to the treatments being conducted within a period of up to 48 months after the donation.
  • Recovery leave - Refund for vacation in a hotel for a period of 7 consecutive days at a value of up to NIS 535 per day. Subject to the presentation of receipts and subject to the vacation being taken within a period of up to 90 days after the donation is made.
Insurance refunds
  • Private medical insurance or supplementary insurance of healthcare organizations - Refund to the value of up to NIS 59 per month for a period of 60 months, subject to presentation of the policy and receipts proving purchase of the insurance. It is advisable to purchase this insurance before the operation or in the first three months after the operation.
  • Loss of working capacity insurance - Refund to the value of up to NIS 203 per month for a period of 60 months, subject to presentation of the policy and receipts proving purchase of the insurance.
  • Life insurance - Refund to the value of up to NIS 128 per month for a period of 60 months, subject to presentation of the policy and receipts proving purchase of the insurance.
All of the insurance payments above will be made from the end of the first year of the donation and for 60 months (5 years). Before the end of the first year from the day of donation, the donor will receive a reminder to send the insurance forms, according to the breakdown appearing in the directions and forms for submitter of an application for expenses file.
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Here is the page on kidney exchange:
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And here's a page on deceased organ donation from the point of view of Jewish religious law:

Sunday, August 20, 2017

2017 Subjective Probability, Utility and Decision Making (SPUDM 26) at the Technion

I'm on my way to SPUDM26 (The 26th Subjective Probability, Utility, and Decision Making Conference) August 20th-24th 2017, hosted by the Industrial Engineering and Management Faculty of the Technion in Haifa, Israel.

Here's the program.

My talk will be called Repugnant transactions and Forbidden Markets.

I’m planning to talk a bit about repugnant transactions generally, and why I think they are important, and perhaps also about black markets. But I’ll use kidneys as my main example, and some of the repugnance issues we’re encountering as we try to move forward with Global Kidney Exchange, in which we’ll include patient-donor pairs from poor countries in American kidney exchange…

Saturday, August 19, 2017

Interview in London's Jewish Chronicle

Wait for this, they have a column called Jewniversity Corner:

Al Roth: Matching the market from dates to organs
In his latest Jewniversity Corner column, David Edmonds examines the theories of economist Al Roth

Notable quote (even though they put the apostrophe in the wrong place): "Born in New York City in 1951, Roth was raised in New York City, in the borough of Queens (which explains why, he told The JC, he speaks the Queen’s English). "

Friday, August 18, 2017

The ASSA / AEA meetings, preliminary program

This year's ASSA preliminary program is now online:  https://www.aeaweb.org/conference/2018/preliminary 
The AEA sessions were organized by President Elect Olivier Blanchard (and his program committee).  David Laibson will give the Ely lecture.

Here are two sessions that caught my eye from just the first page (of 11).

Thursday, Jan. 4, 2018   5:30 PM - 7:00 PM
 Marriott Philadelphia Downtown, Grand Ballroom Salon H
 Econometric Society Presidential Address

Drew Fudenberg, Massachusetts Institute of Technology 


Inner Workings of Organ Markets and Organ Allocation


Paper Session
  • Chair: Eric BudishUniversity of Chicago

The Inner Workings of Kidney Exchange Markets

Nikhil Agarwal
,
Massachusetts Institute of Technology
Itai Ashlagi
,
Stanford University
Eduardo Azevedo
,
University of Pennsylvania
Clayton Featherstone
,
University of Pennsylvania
Omer Karaduman
,
Massachusetts Institute of Technology

Abstract

The market for kidney exchange was created to address the shortage of kidneys for donations. The market allows patients with a willing but incompatible live donor to swap donors, so that they can perform transplants, and has grown to about 800 transplants per year. This paper uses detailed administrative data to describe the functioning of this market. The most striking finding is that the market is fragmented into dozens of small platforms instead of working in a single large platform, with most transactions happening in platforms that operate within a single transplant center. This may lead to substantial inefficiency if there are increasing returns to scale to matching patients in a large, thick market.

A Regulated Market for Kidneys

Mohammad Akbarpour
,
Stanford University

Abstract

The persistent shortage of kidneys for transplantation is a global problem for end-stage renal disease (ESRD) patients. Many countries have tried to address this issue by increasing deceased donation, by introducing kidney exchange programs, and by optimizing the allocation algorithms. Despite such efforts, the problem of shortage is growing in most countries, with more than 100,000 people waiting for a kidney transplant only in the U.S. Iran is the only country in the world that has introduced a different program of living unrelated renal donation, which includes two kinds of monetary compensation of donors: a "gift for altruism" from the government to donors, as well as an additional compensation from the patients themselves. We will discuss the impacts of this program on waiting times, organ shortage, and its equilibrium effects on other kinds of live donation.

Strategic Behavior in the Kidney Waitlist

Nikhil Agarwal
,
Massachusetts Institute of Technology
Itai Ashlagi
,
Stanford University
Paulo J. Somaini
,
Stanford University

Abstract

A transplant can improve a patient's life while saving several hundred thousands of dollars of healthcare expenditures. Organs from deceased donors, like many other common pool resources (e.g. public housing, child-care slots, publicly funded long-term care), are rationed via a waitlist. The efficiency and equity properties of design choices such as penalties for refusing offers or object-type specific lists are not well understood and depend on agent preferences. This paper establishes an empirical framework for analyzing the trade-offs involved in waitlist design and applies it to study the allocation of deceased donor kidneys. We model the decision to accept an offer from a waiting list as an optimal stopping problem and use it to estimate the value of accepting various kidneys. Our estimated values for various kidneys is highly correlated with predicted patient outcomes as measured by life-years from transplantation (LYFT). While some types of donors are preferable for all patients (e.g. young donors), there is substantial heterogeneity in willingness to wait for good donors and also substantial match-specific heterogeneity in values (due to biological similarity). We find that the high willingness to wait for good donors without considering the effects of these decisions on others results in agents being too selective relative to socially optimal. This suggests that mild penalties for refusal (e.g. loss in priority) may improve efficiency. Similarly, the heterogeneity in willingness to wait for young, healthy donors suggests that separate queues by donor quality may increase efficiency by inducing sorting without significantly hurting assignments based on match-specific payoffs.

Discussant(s)
Utku Unver, Boston College
Glen Weyl, Microsoft Research
Benjamin R. Handel, University of California-Berkeley


A still-skeptical view of transplantation in China

My recent post on transplantation in China reported on optimistic assessments of the move away from using executed prisoners as a source of organs. Not everyone is optimistic: here's a recent editorial from the BMJ:

Engaging with China on organ transplantation
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j665  (Published 07 February 2017)
by Wendy A Rogers, Matthew P Robertson, and Jacob Lavee

It starts with a story from the bad old days, and then turns to the current environment, saying in part:

"Since January 2015, China has vowed to halt the use of organs from executed prisoners. After a pilot in 2010-14, a procurement programme using donated organs from people who meet circulatory death criteria was rolled out nationally. There are now national transplantation registries and organ procurement organisations. Yet there is no new law or regulation in China banning the use of organs from executed prisoners. Nor have existing regulations permitting the use of prisoners’ organs been rescinded. Prisoners remain a legal source of organs if they are deemed to have consented before execution, thus permitting ongoing retrieval of organs from prisoners executed with or without due process.1

"The transplant registries are not open to public scrutiny or independent verification. Inexplicably high volumes of transplantation continue to take place in China,8 and wealthy foreigners can still obtain liver and heart transplants, booked in advance.11 The Transplantation Society’s former president Francis Delmonico acknowledged under oath at a recent US Congressional hearing that he cannot verify claims about reform in China. The main evidence for reform has simply been the public assertions of Huang Jiefu and other government officials."

Thursday, August 17, 2017

Harm reduction: decriminalizing drugs to reduce overdoses?

From the Toronto Star:
Should Toronto push to decriminalize all drugs? The city’s medical health officer ready to consider it
The city is convening a committee of health and drug policy experts to explore “a different approach that puts the health of the community first,” Dr. Eileen De Villa said.

"Toronto’s new Medical Officer of Health is calling for a public discussion on the merits of decriminalizing all drugs in the wake of the ongoing overdose epidemic.

“It’s clear that our current approach to drugs in this city and this country doesn’t seem to be having the desired impact,” Dr. Eileen De Villa told reporters Friday at a briefing on how the city is responding to drug users overdosing and, in some cases, dying.
...
"On Friday, following Thursday’s emergency meeting of city partners, De Villa reviewed with reporters the city’s overdose prevention strategies which include asking police to carry the fentanyl antidote and speeding up the opening of three safe injection sites.

De Villa said among the 10 key strategies in Toronto’s Overdose Action plan is a call for a public health approach to drug policy that puts the health of the community first, “rather than looking at this as an issue of criminal behavior and or an area for law enforcement.”

The city is convening a committee of health and drug policy experts to explore “a different approach that puts the health of the community first,” she said.

While acknowledging the city doesn’t have the power to change the Criminal Code, “Toronto has always been a leader … in policy and I don’t see why we wouldn’t continue to be a leader on this front,” said De Villa, who stepped into her high-profile position four months ago."
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Not everyone is interested in this kind of harm reduction. Here's a Washington Post story about a different point of view expressed by an Ohio sheriff (I think this is a point of view that also comes up in opposition to e.g. making clean needles available to drug addicts):

Why this Ohio sheriff refuses to let his deputies carry Narcan to reverse overdoses

"No one has come up with a solution to the opioid epidemic that has decimated Rust Belt states, but for people who overdose, Naloxone is about as effective an antidote as there is. The results of the opioid antagonist, which is sprayed up a person's nose and reverses the effect of opioid overdoses, have been likened to resurrecting someone from the dead.

"Paramedics and firefighters routinely carry the easy-to-administer medication in their vehicles. For police officers in the nation's hardest hit areas, like southwest Ohio, the Food and Drug Administration-approved nasal spray, known by the brand name Narcan, can be as common as handcuffs. Even some librarians have learned to use the drug to revive people who overdose in their stacks.

"But Richard K. Jones, the sheriff of Butler County, Ohio, raised eyebrows recently when he said that his deputies will never carry the medication.
...
"Jones said Narcan is the wrong approach for a war on opioids that “we're not winning,” and said he favored stronger prevention efforts to prevent people from first using the drug."

Wednesday, August 16, 2017

Surrogacy in France (and IVF for unmarried folks)

Surrogacy has long been illegal in France, but the fact that it is legal elsewhere in the world (such as California) has put pressure on French authorities to recognize French parents and children who have come through surrogacy.

Here's a post from frequent surrogacy-watcher Ellen Trachman at Above the Law on recent progress:
French Gay Dads Win A Surrogacy Victory

"Many European countries have either completely banned surrogacy, or at least severely limited its legality. France is among those European countries that have outlawed surrogacy within its borders. But despite the ban, high demand by French citizens — including gay couples who want a biologically-linked child — has led to many French citizens conceiving children abroad via surrogacy, and in some cases, turning to desperate measures.
...
"Last week, the Court of Cassation — which is apparently what they call France’s highest court of appeals — ruled on a surrogacy dispute. (Here’s the French manuscript for my fluent followers.) In the case, four couples with children born via surrogacy outside of France asked the court to require the government to recognize their (and especially the non-biological parent’s) parental rights to their child.
At Least It’s Not Three Years Ago. Fortunately, the couples at least had one parent with recognized rights to the child. Three years ago, France was refusing to recognize any French parental rights or French citizenship for a child born elsewhere via surrogacy. The European Court of Human Rights chastised the French government, finding that such a stance was a violation of human rights — specifically for the parentless, and possibly country-less, child. That 2014 ECHR ruling allowed a genetically-linked father to a surrogate-born child to be recognized as the legal parent, and the child be given French citizenship.
...
"[Last week]...the court agreed to a middle route, and ruled that the non-bio partner could adopt the surrogate-born child. 
...  [and on to IVF]
"While campaigning, President Emmanuel Macron took the position that single women and same-sex female couples should be eligible to use assisted reproductive technology services to conceive. Currently, the country allows those services to be available only for heterosexual couples. ...
... Macron hedged his position by saying that he would wait for the National Consultative Ethics Committee to issue a recommendation on the matter before acting. ... last week, after considering the issue for over three years, the Committee finally issued its opinion. It concluded that, indeed, singles and same-sex couples should be permitted to use assisted reproductive technology services. "