Showing posts with label Britain. Show all posts
Showing posts with label Britain. Show all posts

Friday, March 1, 2024

Medical aid in dying--the ongoing debate in Britain

 The Guardian has this opinion piece, connected to the current debate in England about medically assisted dying, and the slippery slope:

I’m glad the debate on assisted dying is forging ahead. But few understand why it frightens so many  by Frances Ryan

"On Thursday, MPs published the findings of a 14-month inquiry into assisted dying. The inquiry – which attracted more than 68,000 responses from the public – made no conclusive statement but instead collected evidence as a “significant and useful resource” for future debates.

That debate is no longer abstract. Legislation is making its way through the parliaments of Scotland, Jersey and the Isle of Man that, if passed, would enable competent adults who are terminally ill to be provided at their request with assistance to end their life.

...

"And yet it also feels a disservice to pretend that any of this is simple or that giving autonomy to some would not potentially harm others. It is deeply telling that among the many voices calling for a new assisted dying law, I have heard no human rights groups, celebrity or politician mention concerns – as advocated by many disability activists – that a law change could lead to disabled people being coerced into euthanasia, or feeling they had no other option.

We only need look to the countries that have legalised assisted dying in recent years to see these fears realised. One study reported the euthanasia of a number of Dutch people who were said simply to have felt unable to live with having a learning disability or autism. Many included being lonely as a key cause of unbearable suffering.

...

"This is not to say that the UK shouldn’t go down the path of legalising assisted dying, but we must at least do so with eyes wide open. The right to die does not exist in a vacuum: it fundamentally alters the doctor-patient relationship, and risks making members of society who are already vulnerable that little bit more insecure. Perhaps that is a price worth paying to end some terminally ill people’s suffering. Perhaps it is too much to ask. There are no black and white boxes to tick labelled “right” and “wrong” – just the messy, painful grey of being human.

In the coming months, politicians will correctly dedicate hours to discussing the right to a good death. Imagine, though, if they were to give equal attention to the right to a good life: from building social housing, exploring a basic income, investing in mental and physical health services, to – as the inquiry recommends – funding universal coverage of palliative care and more specialists in end-of-life pain."

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Earlier:

Friday, January 12, 2024

Friday, January 12, 2024

Medical aid in dying, and slippery slopes--the debate in Britain

 The Oxford blog Practical Ethics considers medical aid in dying (MAID), and the slippery slope arguments that accompany current debates on the subject in Britain.

Medical assistance in dying: what are we talking about? By Alberto Giubilini, Oxford Uehiro Centre for Practical Ethics

"Medical assistance in dying  – or “MAiD”,  to use the somehow infelicitous acronym – is likely to be a central topic in bioethics this year. That might not be true of bioethics as an academic field, where MAiD has been widely discussed over the past 40 years. But it is likely true of bioethics as a wider societal and political area of discussion. There are two reasons to think this.  First, the topic has attracted a lot of attention the last year, especially with “slippery slope” concerns around Canada’s policies. Second, MAiD has recently been in the news in the UK, where national elections will take place in 2024.  It is not hard to imagine it will feature in the heated political polarization that always accompanies election campaigns

...

"Canada is often taken as the best example in support of ‘slippery slope’ arguments against legalizing MAiD. According to these arguments, even assuming MAiD was acceptable in some form, legalization would open the door to clearly wrong or problematic practices down the line. For instance, legalizing physician-assisted suicide in cases of “unbearable suffering” for someone whose death is reasonably foreseeable in the short term might lead to relaxing our attitudes towards MAiD for those suffering only from mental illness. In the bioethics literature, slippery slope arguments against MAiD have often been put forward and traditionally been dismissed as fallacious, overly cautious, or easily addressable (for an overview and a critical appraisal, see Fumagalli 2020).  However, contrary to the prevailing view, they are not necessarily fallacious in nature (Walton 1992). To many people, Canada is a case in point, calling for a more nuanced take.

"Canada started off by decriminalizing medical assistance in dying in 2016. In 2019, the Superior Court of Quebec found the “reasonable foreseeability of natural death” unconstitutional as an eligibility criterion for MAiD. The criterion was removed in 2021, making MAiD available for patients without terminal illness. From March 2024, patients suffering solely from mental illness will also be able to legally access MAiD. According to Government data, nearly 45,000 people died through MAiD in Canada from 2016 to 2022. Between 2020 and 2022, the number of requests for MAiD increased on average by 28% per year. At the same time, the number of patients found ineligible consistently declined from 8% in 2019 to 3.4% in 2022.

...

"One question is about whether suicide is morally permissible. As mentioned, many religious  and non religious views consider suicide in most cases morally impermissible. However, the moral impermissibility of suicide is not a decisive reason against legalizing MAiD. More important is whether suicide is a right and, if so, what type of right it is. That is a different type of question, because arguably we often have the right to do morally wrong things (Waldron 1982). I might have a right to kill myself even if suicide is morally wrong.

...

"I have not provided any answer to any of these questions here. I just want to point out that some of the differences in ethical and religious views about suicide or about the right to end one’s own life are less relevant to a debate on MAiD than one might initially assume.

"At the same time, many concerns around slippery slopes are more relevant than one might initially assume. As a matter of fact and of logic, MAiD legislations tend to expand by extending their eligibility criteria. When debating MAiD legislations, we need to ask if we are prepared for that."

Wednesday, December 27, 2023

Medical aid in dying considered in Britain, and evolving in Canada

The Guardian has the story about England and Wales, and the NYT has a story on Canada.

Here's the Guardian:

Senior Conservative and Labour figures said they would back changes to legislation on the issue in England and Wales.  by Michael Savage

"Two former health secretaries on Saturday night became the latest senior figures to join the growing demands for a new attempt to legalise assisted dying, as a prominent Tory said he is willing to champion the legislation in parliament.

"With both former Conservative minister Stephen Dorrell and Labour’s Alan Milburn stating they back changing the law in England and Wales, the Observer understands that a Labour government would make time and expert advice available for an assisted dying bill should MPs back it in a free House of Commons vote.

"The news comes as campaigners hope to hold a new vote on the issue early in the next parliament, almost 10 years after the last attempt to alter the law. Kit Malthouse, a former cabinet minister, said he was “absolutely” prepared to front a new private member’s bill on the matter.
...
"Doing nothing is not a passive choice. Leaving the law as it is will consign many thousands of people who may want a different end to a horrible death.”
...
"Milburn, who served as health secretary under Tony Blair, said: “When people today expect to have control over so many aspects of their lives, it feels paradoxical that we are denied the same about how we want to die. It’s perhaps the most important decision any of us can make. To deny that choice feels increasingly anachronistic. The time has come for a free vote in parliament on the issue.”
...
"However, other senior figures such as Michael Gove have expressed doubts about any change.

"Critics of an assisted dying law have also warned about the difficulties in defining who is eligible, the danger of people being pressured into a decision and subsequent attempts to widen the law.

"Alistair Thompson, a spokesperson for Care Not Killing, a group that opposes assisted dying, pointed to polling that suggested public support for assisted dying may have actually fallen since the mid-1990s.

"He also raised questions about the effects of the drugs used for the process in Oregon and said the law would be widened. “As we saw in the Netherlands and Belgium, limits on who qualifies for an assisted death have been swept away,” he said.

“At a time when we have seen how fragile our healthcare system is, how underfunding puts pressure on services, when up to one in four Britons who would benefit from palliative care aren’t receiving it, and when our nation’s hospices are facing a massive shortfall in their income, I would suggest this should be the focus of attention, rather than discussing again this dangerous and ideological policy.”
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And here's the NYT on the controversy in Canada:

Death by Doctor May Soon Be Available for the Mentally Ill in Canada. The country is divided over a law that would allow patients suffering from mental health illnesses to apply for assisted death.  By Vjosa Isai  Dec. 27, 2023

"Canada already has one of the most liberal assisted death laws in the world, offering the practice to terminally and chronically ill Canadians.

"But under a law scheduled to take effect in March assisted dying would also become accessible to people whose only medical condition is mental illness, making Canada one of about half a dozen countries to permit the procedure for that category of people.
...
"There is still uncertainty and debate over whether assisted death will become available to the mentally ill early next year as scheduled. Amid concerns over how to implement it, Parliament has delayed putting it into place for the past three years and could delay it again."

Tuesday, July 18, 2023

Can Britain Fix Its National Health Service?

 The NYT has the story

A National Treasure, Tarnished: Can Britain Fix Its Health Service? As it turns 75, the N.H.S., a proud symbol of Britain’s welfare state, is in the deepest crisis of its history. By Mark Landler

"As it turns 75 this month, the N.H.S., a proud symbol of Britain’s welfare state, is in the deepest crisis of its history: flooded by aging, enfeebled patients; starved of investment in equipment and facilities; and understaffed by doctors and nurses, many of whom are so burned out that they are either joining strikes or leaving for jobs abroad.

...

"More than 7.4 million people in England are waiting for medical procedures, everything from hip replacements to cancer surgery. That is up from 4.1 million before the coronavirus pandemic began in 2020.

"Mortality data, exacerbated by long wait times, paints a bleak picture. In 2022, the number of excess deaths rose to one of the highest levels in the last 50 years, and those numbers have kept rising, even as the pandemic has ebbed.

"In the first quarter of 2023, more than half of excess deaths — that is, deaths above the five-year average mortality rate, before the pandemic — were caused by something other than Covid-19. Cardiovascular-related fatalities, which can be linked to delays in treatment, were up particularly sharply

...

"Seeking to solve the problem, Prime Minister Rishi Sunak last month announced a 15-year plan to recruit and train 300,000 nurses and doctors, budgeting 2.4 billion pounds (about $3 billion) for the first five years. But critics point out that the plan does not fund wage increases, the only surefire way to prevent workers from leaving.

...

"No mainstream politician proposes to privatize the N.H.S.: The specter of the inequitable U.S. health system still horrifies many Britons. And in some ways, the service remains a marvel, one of the world’s most comprehensive, taxpayer-funded health care providers — “free at the point of delivery,” in the words of its utopian motto. It still offers annual physical exams, mammograms, vaccinations and other services at a level that visiting Americans find impressive."

Wednesday, May 17, 2023

Human trafficking conviction in England, in kidney case-""the consent of the person trafficked is no defense."

 The BBC has the story, which is apparently the first such conviction for kidney trafficking under Britain's anti-slavery law. Reading the previous stories, it sounds like the young man in question was being deceived.  But even informed consent apparently wouldn't be a defense under British law...

Kidney-plot politician Ike Ekweremadu jailed By Tom Symonds

"A wealthy Nigerian politician, his wife and their "middleman" have been jailed for an organ-trafficking plot, after bringing a man to the UK from Lagos.

"Senator Ike Ekweremadu, 60, and his wife Beatrice, 56, wanted a new kidney for their 25-year-old daughter Sonia, the Old Bailey heard.

"The pair and Dr Obinna Obeta, 50, were previously convicted of conspiring to exploit the man.

"It is said to be the first such case under modern slavery laws.

...

"Lynette Woodrow, deputy chief crown prosecutor and national modern slavery lead at the Crown Prosecution Service (CPS), said it had been "our first conviction for trafficking for the purposes of organ removal in England and Wales".

"She said it highlighted an important legal principle which made it irrelevant whether the trafficking victim knew he was coming to the UK to provide a kidney.

"With all trafficking offences," Ms Woodrow said, "the consent of the person trafficked is no defence. The law is clear; you cannot consent to your own exploitation."


HT: Dr. Jlateh Vincent Jappah

Saturday, January 14, 2023

The power of kidneys, altruism, and books. (And recommendation of a doctor in the UK)

 Here's a story, about kidneys and about books, in inews.co.uk:

‘It’s a gift with no conditions attached’: Why I donated my kidney to a person I’ll never meet. 250 people die each year in the UK because there are not enough kidneys available. So when GP Richard Armitage discovered altruistic donation was possible, he gave away an organ. By Tom Ough

"Despite being a GP, Richard Armitage had spent most of his career unaware that altruistic donations were possible. In this respect, Armitage, 34, was like many of his colleagues in the medical profession. That changed in 2017. Armitage, visiting the Nobel Laureate Museum Stockholm, bought a book by Alvin Roth, an economist who won a Nobel Prize in 2012. The book was Who Gets What — and Why: The New Economics of Matchmaking and Market Design, and in it Roth wrote how we allocate things within markets that aren’t dictated by money.

"Examples include the allocation of children to schools, doctors to hospitals, and kidneys to people with end-stage renal disease. Roth discussed what is known as non-directed altruistic kidney donations – in short, kidneys donated to strangers. Sitting on the plane home, Armitage read the book with fascination. When he returned to Nottingham he checked the NHS website to see whether non-directed altruistic kidney donation was possible in the UK. It was.

...
"In 2018 altruistic donors began being routinely added to the UK Living Kidney Sharing Scheme (UKLKSS), which oversees this sharing of organs by living donors. Apparently as a result of the move, in 2019 there was a 60 per cent rise in altruistic donations – from 124 to 183. Twenty-eight per cent of kidney transplants are now from living donors.
...
"It seemed a good application of the kind of moral philosophy that Armitage had discovered the same year, 2017, when he read Famine, Affluence and Morality. It is an influential essay in which Peter Singer, an Australian philosopher, argued that the West should be donating far more resources to humanitarian causes.
...
"All of Armitage’s intellectual discovery, including his reading of Roth’s writing on kidney donation, happened in one year, 2017 – also the year that Armitage finished his GP training. It marked the end of “a 10-year head-down slog” that began with the first day of medical school. “After I passed my last exam, it felt like I finally lifted my head up and asked: ‘But why am I doing this?’”

"And so Armitage’s first conversation with his regional kidney transplant centre was followed by an appointment with a Living Donor Nurse, who explained what donation would entail: the testing, the preparation, the surgery. Armitage was invited to speak to his loved ones and consider whether he was ready; it turned out he wasn’t.

"There were several hold-ups. At first, Armitage felt the beginning of his GP career was the wrong time to take weeks off work. Then Covid stalled the NHS’s kidney-sharing scheme. Armitage still wanted to donate his kidney, and successfully underwent a battery of investigations: a renal tract ultrasound scan, an electrocardiogram, chest X-ray, various fasted blood tests, and an X-ray of his kidney. As per the requirements of the donation scheme, Armitage met a clinical psychologist to discuss his state of mind, put the psychologist in touch with a loved one in order to independently assess his state of mind, and met a representative of the Human Tissue Authority to ensure that he was not donating his kidney under duress or for financial gain.
...
"Armitage spent several weeks in Ukraine as part of his work for the charity UK-Med, which sent British medics to deliver emergency healthcare. “That obviously meant I couldn’t continue with the donation process,” he says with some understatement. But when he got home, he told the donor team he was ready. “Can we crack on?”, he asked.

"The operation was on 23 November. Everything was in place; Armitage was part of a chain on which three people with end-stage renal disease were due a kidney.
...
"And just before he was discharged – three days after surgery, having convinced the hospital staff he was ready to take care of himself – he was informed that all the recipients in the chain now had working kidneys. “That was a very meaningful moment that made it all worthwhile,” says Armitage."

Friday, December 23, 2022

Postdoctoral opportunities in kidney exchange, in the U.K. with David Manlove and Daniel Paulusma

 David Manlove writes to invite applications for postdocs with him and Daniel Paulusma to work on kidney exchange.

"There are three positions available to work on algorithms and software for kidney exchange as part of the EPSRC-funded KidneyAlgo project: New Algorithms for UK and International Kidney Exchange (https://gow.epsrc.ukri.org/NGBOViewGrant.aspx?GrantRef=EP/X013618/1 and https://gow.epsrc.ukri.org/NGBOViewGrant.aspx?GrantRef=EP/X01357X/1).

 1. Postdoctoral Research Associate at Glasgow, working with David Manlove.  This position requires expert knowledge in the areas of algorithm design and analysis and/or operational research and combinatorial optimisation.  See https://www.dcs.gla.ac.uk/~davidm/adverts/RA-advert.html for further details.  The closing date is 31 January 2023.

 2.  Postdoctoral Research Associate at Durham, working with Daniel Paulusma.  This position has a focus on researching computational complexity aspects of fairness concepts from Cooperative Game Theory.  See https://durham.taleo.net/careersection/du_ext/jobdetail.ftl?job=22002075&lang=en&src=JB10200 for further details.  The closing date is 30 January 2023.

 3. Research Software Engineer at Glasgow, working with David Manlove.  This position requires excellent programming skills and substantial prior software development experience.  See https://www.dcs.gla.ac.uk/~davidm/adverts/RSE-advert.html for further details.  The closing date is 31 January 2023.

 Please do pass this email on to anyone who you feel might be interested."

Thursday, July 14, 2022

Allegations of organ trafficking for kidney transplants--in England and India

 From time to time there are stories of prosecutions for organ trafficking in connection with kidney transplants.

Here's a story developing in England. (Early reports were that the alleged donor/seller/victim was a child, but apparently he's not a minor):

From the BBC:

Ike Ekweremadu: Nigerian senator faces London organ-harvesting trial

"A prominent Nigerian senator and his wife who are accused of plotting to harvest a man's kidney in the UK will face trial at the Old Bailey.

"Ike Ekweremadu, 60, and Beatrice Nwanneka Ekweremadu, 55, are alleged to have transported a 21-year-old man from Nigeria to London.

"Prosecutors allege the couple planned to have his kidney removed so it could be given to their daughter.

...

"The alleged victim is said to have refused to consent to the procedure after undergoing tests at the Royal Free Hospital in Hampstead."

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Not long ago I participated in an online conversation including Professor Janet Radcliffe Richards, who recalls that her view that bans on kidney sales are ill-conceived arose from news in the 1980's about a case involving Turkish sellers (here's an LA Times story from then):

London Kidneys-for-Cash Scandal Prompts Action to Ban Sale of Organs BY ROBERT BARR JULY 16, 1989

"“The concept of organs being bought and sold for money is entirely unacceptable in a civilized society,” Health Minister Roger Freeman told a House of Commons committee during debate on proposed legislation outlawing organ sales. The bill is expected to pass Parliament later this month.

"Not all lawmakers agree.

“The bill will cause death where there could be life, and to prolong suffering where we could provide relief,” said Sir Michael McNair-Wilson, a Conservative Parliament member awaiting a kidney transplant.

...

"Neil Hamilton, who cast the only vote against the bill in committee, said he had pondered the dilemma facing one Turk who allegedly sold a kidney.

“His daughter was suffering from a medical problem which threatened her life, but it could not be solved in Turkey without money,” Hamilton said. “If he did not get the money for the operation, his daughter would die.”

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The situation in India is complex, since there is or was something of a long tradition of kidney sales, which are against the law, and are guarded against by authorization committees that have to approve each living donor transplant. Recently, kidney exchange has become legal in India, but the law only allows close family to be the intended donor in an incompatible patient-donor pair. Below is a report of a case where it's alleged that an attempted donor was paid, and also illegally claimed to be a family relation.

Here's the Hindustan Times story:

Ruby Hall Clinic kidney transplant ‘malpractices’ probe handed over to crime branch

"Earlier on Wednesday, police officials probing the case told Magisterial court that more cases of kidney transplants based on the relationship claims have been unearthed during the interrogation of agents Ravindra Rodge and Abhijit Gatane. Both have been arrested by the police. These two agents having donated their kidneys earlier and also played the role of middlemen in at least four kidney transplants where alleged malpractices were involved.

...

"The case pertains to a kidney swap procedure, also known as paired kidney exchange, between the Moshi man and the Kolhapur woman posing as his wife, and a mother-daughter duo from Baramati."

And here's the story in the Indian Express:

Two middlemen arrested in Pune kidney transplant malpractice case. The other accused in the case, including Ruby Hall Clinic doctors, the patient who received the kidney, and the unrelated donor who was passed off as his wife--are yet to be arrested.

"Police have arrested the two middlemen over the alleged malpractices in a kidney transplant conducted at Pune’s Ruby Hall Clinic in March in which an unrelated woman was allegedly presented as the organ receiver’s wife and promised Rs 15 lakh in return.

...

"Among the 15 people named in the FIR are the hospital’s managing trustee, Dr Purvez K Grant, deputy medical director Dr Rebecca John, legal advisor Manjusha Kulkarni, nephrologist Dr Abhay Sadre, urologists Dr Bhupat Bhati and Dr Himesh Gandhi and transplant coordinator Surekha Joshi. The police also booked the two middlemen, the patient—from Pimpri Chinchwad’s Moshi area—who received the kidney, his wife, their three family members, the woman from Kolhapur who was allegedly passed off as the patient’s wife to become the donor."

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Among the most vigorous opponents of paying kidney donors--e.g. among some of those who think it's a crime against humanity--there's also opposition to extending the scope of legal, ethical, unpaid kidney donation and transplantation, particularly in poor countries.  One reason for this is the intuition that more transplantation will cause more paid transplantation.  The cases reported above, although rare, help to support this view.

But a much stronger case can be made that it is the unavailability of transplants that causes exploitative black markets, and that increasing the availability of legal transplants will reduce the demand for illegal ones.

Monday, June 20, 2022

Report of a SARS-CoV-2 human challenge trial. In Britain.

 The May issue of Nature Medicine reports what I am pretty sure was the first covid challenge trial. It was a small one, designed to track how the viral load develops after infection, to see how quickly tests detect infection, and to check procedures to pave the way for subsequent challenge trials.  Recall that a challenge trial, also called a human infection trial, is one in which the participants are deliberately exposed to the disease, and then reside in the hospital under close medical observation and care.

Killingley, B., Mann, A.J., Kalinova, M., Boyers, A., Goonawardane, N., Zhou, J., Lindsell, K., Hare, S.S., Brown, J., Frise, R. and Smith, E., 2022. Safety, tolerability and viral kinetics during SARS-CoV-2 human challenge in young adults. Nature Medicine, 28(5), May, 1031-1041.

"36 volunteers aged 18–29 years without evidence of previous infection or vaccination were inoculated with 10 TCID50 of a wild-type virus (SARS-CoV-2/human/GBR/484861/2020) intranasally in an open-label, non-randomized study (ClinicalTrials.gov identifier NCT04865237; funder, UK Vaccine Taskforce). After inoculation, participants were housed in a high-containment quarantine unit, with 24-hour close medical monitoring and full access to higher-level clinical care."

...

"Written informed consent was obtained from all volunteers before screening and study enrollment. Participants were given a donation of up to £4,565 to compensate for the time and inconvenience of taking part in the study (including at least a 17-day quarantine). This was calculated using the National Institute for Health Research (NIHR) formula and the UK national living wage."

Two of the volunteers were found to have previous antibodies, and of the remaining 34, 53% (18 people) were infected with the disease after 5 days.  

Here's a schematic of how the trial proceeded, starting with almost 27,000 people who volunteered online to participate in the trial, from which the final 36 participants were chosen.




In contrast, the Phase 3 clinical trial of the Pfizer vaccine had almost 22,000 people in the vaccine group and in the placebo group, and reported after four months that only 8  participants in the vaccinated group had contracted the disease, compared to 162 in the placebo group.  So the vaccine was 95% effective (only 5% of the 170 infections were in the vaccinated group).

Big (Phase 3) vaccine trials aren't comparable to small preliminary trials, so my point here is just that in the challenge trial the rate of infection of unvaccinated volunteers in 5 days is more than fifty times that rate over four months in the traditional clinical trial, in which participants go about their lives and get infected by chance.  That's one of the reasons that challenge trials offer the possibility of fast and efficient testing.

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When the study was completed, in 2021, the NY Times published a column with the headline

Britain Infected Volunteers With the Coronavirus. Why Won’t the U.S.?,  By Kate Murphy Oct. 14, 2021

It ended with the following paragraph:

"As one participant in Britain’s Covid human challenge trial put it: “You know the phrase ‘one interesting fact about yourself’ that strikes terror into everyone? That’s now solved forever. I did something that made a difference.”

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Of course challenge trials are controversial in lots of ways. See some discussion here of the ethics of paying challenge participants. 

Thursday, October 29, 2020

Paying participants in challenge trials of Covid-19 vaccines, by Ambuehl, Ockenfels, and Roth

"we note that increasing hourly pay by a risk-compensation percentage as proposed in the target article provides compensation proportional to risk only if the risk increases proportionally with the number of hours worked. (Some risky tasks take little time; imagine challenge trials to test bulletproof vests.) "

Saturday, October 30, 2021

Economic warfare: how to staff it?

 The Financial Times has a story about how the UK Ministry of Defense runs an economic warfare unit, which needs to be staffed differently than other military specialties. (The U.S. armed forces have very limited ability to recruit people with specialized skills from civilian occupations, except for doctors and lawyers.)

Secretive MoD ‘banking’ unit helps UK wage economic warfare. Taskforce set up to disrupt Isis six years ago turns its attention to new ‘grey zone’ threats such as cyber  by Helen Warrell 

"A taskforce of former bankers and financiers is helping the UK military sharpen its skills in economic warfare as a bulwark against growing threats including terrorism, cyber attacks and disinformation campaigns.

"The secretive unit — established by Britain’s Ministry of Defence six years ago to disrupt Isis’ commercial activities in Iraq and Syria — is staffed by a handful of former City professionals with expertise in commodity markets and international money flows.

...

"The taskforce, made up predominately of reservists with City experience, has worked with special forces, intelligence agencies and the army’s 77th Brigade information warfare unit to weaken adversaries by limiting their access to finance. 

...

"Bankers are able to enter the armed forces in a number of ways, from applying for a post as a military “regular” through the army’s officer selection board and undergoing training at Sandhurst, to working more flexibly in pro bono roles.

"The MoD is also considering reforms to its policies on reservists, including relaxing age and fitness requirements and bringing in a new “lateral” entry regime which would allow industry experts to transfer directly into senior military ranks rather than working their way up the hierarchy.

“We’re really not trying to throw middle-aged bankers out of the back of aircraft [on military operations],” the taskforce member explained. “It’s about using their professional skills.”

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See also 

Tuesday, December 1, 2020

Tuesday, October 19, 2021

Challenge trials in Britain and (not) in the U.S.

 The NY Times has an excellent piece on Covid vaccine challenge trials, and the different traditions (and repugnance) in Britain and the U.S.

Britain Infected Volunteers With Covid. Why Won’t the U.S.? By Kate Murphy

"In an age of masking, compulsive hand sanitizing and plexiglass dividers, it seems inconceivable that for more than 40 years people enthusiastically signed up — and were often put on a waiting list — to have respiratory viruses, including coronaviruses, dripped into their noses.

"They were volunteers at the Common Cold Unit, set up in 1946 by the British government’s Medical Research Council.

...

"the Common Cold Unit established and refined a model for so-called human challenge studies that paved the way for the first Covid-19 human challenge study just completed in Britain, where young, healthy and unvaccinated volunteers were infected while researchers carefully monitored how their bodies responded.

"Then, as now, there were those who decried deliberately infecting or “challenging” healthy volunteers with disease-causing pathogens. It violates the medical principle of “do no harm.” The trade-off is a unique opportunity to discover the causes, transmission and progression of an illness, as well as the ability to more rapidly test the effectiveness of proposed treatments.

...

"“The key benefit of human challenge studies is that they are controlled — everyone gets the same virus, the same amount and they are in the same environment,” said Dr. Christopher Chiu, professor of infectious diseases at Imperial College London and chief investigator in Britain’s Covid challenge study.

...

"In the United States, the regulatory hurdles to conduct challenge studies mean there are precious few, mostly for finding better treatments for malaria, cholera and influenza. Ethicists and regulators are more comfortable approving clinical trials where subjects are given a treatment, say a drug or vaccine, to see if it helps improve a condition volunteers already have, or could prevent them from developing later.

...

"Dr. Fauci’s office said the institute has no plans to fund Covid-19 human challenge trials in the future. Many bioethicists support that decision. “We don’t ask people to sacrifice themselves for the good of society,” said Jeffrey Kahn, director of the Johns Hopkins Berman Institute of Bioethics. “In the U.S., we are very much about protecting individual rights and individual life and health and liberty, while in more communal societies it’s about the greater good.”

"But Josh Morrison, a co-founder of 1Day Sooner, which advocates on behalf of more than 40,000 would-be human challenge volunteers, argues it should be his and other people’s right to take risks for the greater good. “Most people aren’t going to want to be in a Covid challenge study, and that’s totally fine, but they shouldn’t project their own choices on other people,” he said."


HT: Axel Ockenfels

Wednesday, September 8, 2021

Participating in a Covid challenge trial: a participant's experience

 The WSJ's Jenny Strasburg has another story on British challenge trials of Covid-19:

Researchers Infect Volunteers With Coronavirus, Hoping to Conquer Covid-19. So-called challenge trials have long been used to study infections, but so far only the U.K. is doing them for Covid-19   By Jenny Strasburg

"On March 8, 23-year-old Jacob Hopkins, a U.K. university student, watched researchers enter his quarantine room’s airlocked entrance at London’s Royal Free Hospital. They wheeled a cart carrying a big red box, like a picnic cooler, labeled “biohazard.”

...

"A few days after the virus was dripped into his nose, he was shivering with a mild case of Covid-19, with the antiviral remdesivir pumped through a thin tube inserted into his arm. He spent 19 days in quarantine and said he felt fully recuperated a month later. He will ultimately be paid about £6,000, equivalent to $8,300, for that time, a year of follow-up tests and phone calls, and a parallel study he agreed to. Trial payments are based on U.K. living wages and go through ethical review."

...

"All volunteers are 18 to 30 years old and screened for known risk factors. They are isolated in quarantine suites with full-time medical care and specialized air systems to contain the virus. Researchers hope to publish peer-reviewed initial findings from the first phase of the challenge trials by this autumn.

...

"Researchers hope trial data will shed light on the durability of immune protection and how Covid-19 affects breathing, heart function, smell and concentration even before symptoms show. They say the model could test new vaccines and treatments head-to-head, eliminating weaker candidates before expensive, large-scale trials. Transmission data could help authorities prioritize who gets booster doses.

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As an observer of repugnant/controversial transactions, I've been following the challenge trial discussion, including in particular about appropriate payments for participants.  There's a part of the medical ethics literature that worries that payments to volunteers might be 'coercive,' particularly to poor volunteers, and that payments should therefore be as small as possible, e.g. minimum wage payments for time spent, and that some things (such as risk) should not be compensated. My colleagues and I have been among those pointing out that there can also be ethical (as well as practical) issues involved in paying too little (or in providing too little post-trial medical care and insurance).


Here are some earlier posts focusing on articles I've coauthored about compensation for participation in challenge trials:

Thursday, October 29, 2020

Paying participants in challenge trials of Covid-19 vaccines, by Ambuehl, Ockenfels, and Roth

"we note that increasing hourly pay by a risk-compensation percentage as proposed in the target article provides compensation proportional to risk only if the risk increases proportionally with the number of hours worked. (Some risky tasks take little time; imagine challenge trials to test bulletproof vests.) "


Sunday, September 5, 2021

Australia and England swap millions of vaccine doses

Barter can increase efficiency. The Financial Times has the story:

Australia strikes deal to ‘swap’ 4m vaccine doses with UK  by William Langley and Oliver Barnes 

"The UK will send 4m Covid-19 vaccine doses to Australia in a swap deal aimed at accelerating Canberra’s stuttering rollout and bolstering British supplies later in the year when ministers are pushing for a booster campaign. 

"The first batch of 292,000 BioNTech/Pfizer doses will arrive in Australia in the coming days, with the remainder due by the end of the month, Prime Minister Scott Morrison said on Friday. 

"Australia will return an equivalent 4m doses before the end of the year, according to the UK health department.

"The deal is designed to speed up Australia’s vaccination rollout, which has been one of the slowest in the world, and Morrison said it would allow the government to bring forward its prospective reopening date.

"It reflects the UK’s calculation that it does not currently need all its stockpiled doses, which expire in a matter of months if not used, while allowing London to boost supplies later this year in anticipation of a broad booster campaign and the vaccination of 12 to 15-year-olds."


Tuesday, August 31, 2021

Challenge trials for Covid-19 Delta variant

 Before the development of the first Covid vaccines, there was a good deal of discussion about the appropriateness of testing vaccines with human challenge trials, i.e. with tests in which volunteers were deliberately exposed to Covid so that the vaccine effectiveness could be more readily assessed.  Now, with the Delta variant spreading, those issues are once again live.

Only England has authorized challenge trials. Here's a story from the WSJ:

Researchers Ready Lab-Grown Covid-19 Delta Variant for Human Trials. U.K. company is growing the highly contagious variant under tight lab controls for use in challenge studies  By Jenny Strasburg

"While the rest of the world is trying to stamp out the Covid-19 Delta variant, British researchers are making progress growing a carefully controlled batch in a lab that they hope to use to infect volunteers in studies.


"The effort marks a new phase in the U.K.’s human challenge trials, the only Covid-19 studies in the world intentionally exposing participants to the virus with the goal of developing new vaccines and treatments. 
...
"Two Covid challenge trials sponsored by Imperial College London and the University of Oxford started earlier this year in the U.K. They so far have exposed more than 40 healthy, young volunteers under isolated medical supervision to the original Wuhan strain that circulated widely in 2020.

"Since then, the highly transmissible Delta variant has come to dominate infections globally, rendering vaccines less effective and boosting case numbers across the U.K., U.S. and elsewhere. Delta’s fast rise led researchers and U.K. challenge-trial partner hVivo Services Ltd. to focus on trying to grow the variant in the lab.
...
"It took U.K. researchers and government advisers almost a year to plan and gain approval from a U.K. ethics committee and medicines regulators to start the controversial challenge trials for which the Delta strain could eventually be used. The government provided funding; so did the London-based Wellcome Trust, a large healthcare-focused charitable foundation.
...
"The challenge trials faced pushback from some U.K. academics and foreign researchers, as well as from some government officials, who considered them unsafe or otherwise unethical, people involved in the process say. Delays have caused friction among partners. hVivo, part of London-listed pharma-services company Open Orphan ORPH 3.08% PLC, had hoped to use the Covid-19 challenge-trial model by now to test antivirals and other products for drug companies, executives have told industry peers. A U.K. government spokesman said the pace of the challenge studies has reflected appropriate caution, and the trials have been safe.

"Challenge trials have been used for decades to study viruses and other pathogens by deliberately exposing volunteers and studying the body’s response. While scientists in the U.S. and Europe also pushed to do Covid-19 challenge studies, only the U.K. has moved forward."
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Monday, August 9, 2021

Criminalizing the clients of sex work makes the client population riskier to sex workers (study in the UK)

 Here's a  recent study that suggests that criminalizing the clients of prostitutes results in the client population becoming more risky.

Quashing demand or changing clients? Evidence of criminalisation of sex work in the UK, by Marina Della Giusta, Maria Laura Di Tommaso, Sarah Jewell, and Francesca Bettio, July 2021


Abstract: The use of regulation of sex work is undergoing sweeping changes across Europe and client criminalisation is becoming very widespread, with conflicting claims about the intended and actual consequences of this policy. We discuss changes in demand for paid sex accompanying the criminalization of prostitution in the United Kingdom, which moved from a relatively permissive regime under the Wolfenden Report of 1960, to a much harder line of aiming to crack down on prostitution with the Prostitution (Public Places) Scotland Act 2007 and the Policing and Crime Act of 2009 in England and Wales. We make use of two waves of the British National Survey of Sexual Attitudes and Lifestyles (NATSAL2, conducted in 2000-2001 and NATSAL3, conducted in 2010-2012) to document the changes in both the amount of demand for paid sex and in the type of clients that have taken place across the two waves, and their possible implications for policies that frame prostitution as a form of crime.


"The language of ‘prostitute’ and ‘prostitution’ is typically aligned with abolitionist perspectives that see the sale of sex as entailing women’s exploitation and objectification, both by those who manage and create the opportunity for the sexual transaction as well as by those clients who make the purchase and maintain the demand. The language of ‘sex workers’ and ‘sex work’ has typically been preferred by those who emphasize women’s agency in entering into commercial sex transactions (albeit under conditions of constraint) and who call for the regulation of the sale of sex as akin to the sale of non-sexual labor or services. We deliberately use the two terms interchangeably in our work...

...

"Germany, the Netherlands and Greece have moved towards acknowledging prostitution as a regular job on one side, and Sweden, Norway, Finland, France and Ireland have hardened their stance instead aiming to eradicate prostitution as a form of violence on the other side. In the first group of countries, the consideration of sex work as legitimate labor has led to shifting bans on outdoor and indoor prostitution subject to compliance with regulations (Netherlands since 2000, Germany since 2002). Sex workers are entitled to a number of employment related protections under the law and local authorities required to ensure that brothels are suitably licensed and operating in accordance with relevant health and safety requirements. The abolitionist model, conversely, seeks to prohibit prostitution, facilitate exit and punish clients and has applied in varying degrees in the United States and, more recently, Sweden, Norway and Finland. In Sweden it is an offence, punishable by a fine or imprisonment for up to six months, to obtain a casual sexual relationship for payment. Both outdoor and indoor prostitution are prohibited, although only the clients will be criminalized.

...

"The evidence we bring indicates that the increased stigmatization of prostitution that has taken place in the UK over the period 2000-2012, during which prostitution was progressively criminalized, does not support the expectations of a significant reduction in demand as the policy intended and corresponds to a change in the type of clients that are observed through successive waves of the British National Survey of Sexual Attitudes and Lifestyles (NATSAL henceforth). We conclude that this provides further support for the idea that demand for sexual services might be inelastic to both the market price and the implicit price of stigma, whereby criminalization is not likely to be conducive to decreases in demand as is hoped for. Rather, it might jeopardize the working conditions and safety of existing prostitutes thus raising the welfare cost of abolitionism. 


Sunday, February 21, 2021

Human infection challenge trials for Covid vaccine to move forward in UK

 The BBC has this story:

Covid-19: World's first human trials given green light in UK

"Healthy, young volunteers will be infected with coronavirus to test vaccines and treatments in the world's first Covid-19 "human challenge" study, which will take place in the UK.

"The study, which has received ethics approval, will start in the next few weeks and recruit 90 people aged 18-30.

"They will be exposed to the virus in a safe and controlled environment while medics monitor their health.

...

"The Human Challenge study is being delivered by a partnership between the UK government's Vaccines Taskforce, Imperial College London, the Royal Free London NHS Foundation Trust and the company hVIVO, which has pioneered viral human challenge models.Clive Dix, interim chair of the Vaccines Taskforce, said: "We have secured a number of safe and effective vaccines for the UK, but it is essential that we continue to develop new vaccines and treatments for Covid-19.

"We expect these studies to offer unique insights into how the virus works and help us understand which promising vaccines offer the best chance of preventing the infection."

...

"Initially, the study will use the virus that has been circulating in the UK since the pandemic began in March, which is of low risk to healthy adults, to deliberately infect volunteers.

"In time, a small numbers of volunteers are likely to be given an approved vaccine and then exposed to the new variants, helping scientists to find out the most effective jabs - but this phase of the study has not yet been given the go-ahead."


HT: Tom Darton

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And here's a story from the NY Times, which touches on the issue of compensation for participants (and the associated debate about whether that is repugnant):

U.K. Approves Study That Will Deliberately Infect Volunteers With Coronavirus. Researchers hope to learn things about how the immune system responds to the coronavirus that would be impossible outside a lab.  By Benjamin Mueller

"After being exposed to the virus, the participants will be isolated for two weeks in the hospital. For that and the year’s worth of follow-up appointments that are planned, they will be paid 4,500 pounds, or about $6,200. The researchers said that would compensate people for time away from jobs or families without creating too large an economic incentive for people to participate."

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Related posts on challenge trials:   https://marketdesigner.blogspot.com/search/label/challenge

Saturday, June 22, 2019

Richard Branson on Kidney Exchange

Richard Branson, the founder of Virgin Group, has a blog post about kidney exchange:

A new hope for those in need of a transplant

"Unfortunately, living donation isn’t always straightforward. Depending on the country, 40% or more of recipients are incompatible with their intended donors. In some places, that means potential donors are simply turned away, forcing those in desperate need of a transplant to wait until another compatible donor turns up.
"You don’t have to know much about the organ donation system to realise that doesn’t make much sense. That’s why I was interested to learn about Kidney Exchange Programs (KEPs). KEPs increase the number of transplants by pooling and matching pairs of donors and recipients.
"The matching process allows one previously incompatible donor-recipient pair, say a kidney patient and a family member willing to donate, to be matched with another pair. Under a KEP, donors are then swapped, resulting in two new compatible pairs. It can sound a little complicated but this video provides a clear explanation.
"I was pleased to learn that the UK Living Kidney Sharing Scheme (UKLKSS) has become the largest operating KEP in Europe, allowing pairs to match in two and three-way swaps.
...
"The unfortunate news is that most countries don’t have schemes like this. The UK is one of only three countries in Europe running an advanced KEP program, with other countries that do have schemes limiting them by only allowing two-way exchanges or by prohibiting altruistic donors.
It’s barriers like these that mean countries are missing out on saving thousands of lives. I urge policy makers in countries without KEPs to learn more about the programmes and consider the difference they could make.
"If more countries developed KEPs, just imagine what this could mean in the future. Through greater international cooperation, kidneys could be exchanged between countries meaning the lives of even the hardest-to-match patients could be saved.Fortunately, it is thanks to the fantastic work of organisations like the European Network for Collaboration on Kidney Exchange Programmes (ENCKEP), that some of this research is already being done.
ENCKEP brings together clinicians, economists, and policy makers to explore the legislative, medical, financial and ethical issues that surround greater collaboration on KEPs. Their latest report provides an overview of their work to date."

Sunday, January 27, 2019

Black market kidney transplants to UK patients? An inflammatory article in the Daily Mail

There seems to be good evidence that kidneys for transplantation are bought and sold in some parts of the world. However I'm not aware of any good data on how much of this trade involves people from wealthy countries, as opposed to internal commerce in less well resourced countries.

 Here's a scare headline from the British tabloid newspaper the Daily Mail:
REVEALED: Hundreds of Britons who buy KIDNEYS on the black market from overseas traffickers charging £30,000 in a bid to avoid NHS waiting lists are coming back with deadly diseases such as HIV and hepatitis

It turns out that the "hundreds"  in the National Health Service data are 400, over a period of 16 years, which averages out to 25 Britons a year.

"Around three million Britons have chronic kidney disease, with the biggest causes uncontrolled diabetes and high blood pressure. It contributes to 45,000 early deaths every year.

NHS figures show almost 400 UK residents have received follow-up support after a transplant abroad over the past 16 years. But medics say the true number is likely to be higher because most are advised by brokers not to tell the NHS what they have done."

I don't know what kinds of health data the NHS collect, but in principle it would be easy to track all patients who return to the UK with a transplant from overseas, because such patients immediately need to get prescriptions for daily immunosuppressive drugs. (However I don't think we track these data in a centralized way in the U.S.)


HT Frank McCormick
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Here some of what I've gleaned in the past:

Monday, December 17, 2018 

Australia's parliament reports on organ trafficking

Australia's parliament has published a report on organ trafficking in Australia. They didn't find much trafficking there, but recommend that data be more vigorously collected. They report that only one case of (attempted) paid organ donation has come to the attention of the authorities, but that it was successfully prevented, and the intended recipient died. The report ends with a case study of an anatomical exhibit using human cadavers.

Wednesday, October 4, 2017 

Kidney black markets are persistent

Black markets in kidneys--like those for narcotic drugs--have resisted attempts to abolish them.

Sunday, September 17, 2017

Sunday, January 15, 2017

Black markets for kidney transplants--arrests in Israel

"In the last two years, the ring reportedly arranged for 14 transplants in four countries; Turkey, Bulgaria, Thailand and Philippines"

Friday, August 19, 2016


Interview with a kidney buyer and seller in Syria

Here's an interview with a displaced person in Syria (an internal refugee) and the Syrian woman to whom he sold his kidney:
The woman in need of a kidney and the man willing to sell one to her: ‘I’m at the end of the line’

Tuesday, June 21, 2016

Wednesday, June 8, 2016


On Patients Who Purchase Organ Transplants Abroad--Many or few?

An article in the American Journal of Transplantation:
On Patients Who Purchase Organ Transplants Abroad
by F. Ambagtsheer,*, J. de Jong,W. M. Bramer and W. Weimar
"We conclude that the scientific literature does not reflect a large number of patients buying organs. Organ purchases were more often assumed than determined. A reporting code for transplant professionals to report organ trafficking networks is a potential strategy to collect and quantify cases."