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."



Friday, January 12, 2024

Thursday, February 29, 2024

Education (and age) versus fertility in the U.S. marriage market

 Markets change over time, including the marriage market.  American marriages have become more assortative in recent years, and it appears that, in the 21st Century, women no longer pay a 'marriage penalty' (measured in spousal income) for graduate education.

The Human Capital–Reproductive Capital Trade-Off in Marriage Market Matching, by Corinne Low, Journal of Political Economy Volume 132, Number 2, February 2024

"Abstract: Throughout the twentieth century, the relationship between women’s human capital and men’s income was nonmonotonic: while college-educated women married richer spouses than high school–educated women, graduate-educated women married poorer spouses than college-educated women. This can be rationalized by a bidimensional matching framework where women’s human capital is negatively correlated with another valuable trait: fertility, or reproductive capital. Such a model predicts nonmonotonicity in income matching with a sufficiently high income distribution of men. A simulation of the model using US Census fertility and income data shows that it can also predict the recent transition to more assortative matching as desired family sizes have fallen."

Notable sentence about the ancien regime: "I provide a simple condition such that there always exists a man rich enough that he prefers a higher fertility but poorer woman to a richer and less fertile woman."


And here's an earlier paper on fertility (through IVF) and age of marriage in Israel:

Gershoni, Naomi, and Corinne Low. 2021. "Older Yet Fairer: How Extended Reproductive Time Horizons Reshaped Marriage Patterns in Israel." American Economic Journal: Applied Economics, 13 (1): 198-234.

"Abstract: Israel's 1994 adoption of free in vitro fertilization (IVF) provides a natural experiment for how fertility time horizons impact women's marriage timing and other outcomes. We find a substantial increase in average age at first marriage following the policy change, using both men and Arab-Israeli women as comparison groups. This shift appears to be driven by both increased marriages by older women and younger women delaying marriage. Age at first birth also increased. Placebo and robustness checks help pinpoint IVF as the source of the change. Our findings suggest age-limited fertility materially impacts women's life timing and outcomes relative to men."

Wednesday, February 28, 2024

Global pacemaker retransplantation

 There are innovative approaches to global health care.  Here is one, that involves reusing pacemakers recovered from deceased donors and refurbished for use in countries where pacemakers are too expensive for wide use.  Unlike some of what we encounter in kidney transplants across borders, the legal bans that have to be overcome may not come from the war against the poor.  A careful clinical trial is underway. There is also an unregulated black market...

Here's the encouraging story from

After death, a new life for refurbished pacemakers in low-, middle-income countries, February 23, 2024

"Lack of access to pacemakers is a major challenge to the provision of CV health care in low- and middle-income countries; however, postmortem pacemaker utilization could offer an opportunity to deliver this needed care, according to Thomas Crawford, MD, an electrophysiologist and associate professor of internal medicine at University of Michigan Health and the medical director of My Heart Your Heart, a cardiac pacemaker reuse initiative at the University of Michigan Cardiovascular Center


"Crawford: The need is great. Each year, somewhere between 1 million and 2 million people worldwide die due to a lack of access to pacemakers and defibrillators. There is literature reflecting this. When you query pacemaker implantation data for the United States, it is roughly 800 pacemakers per 1 million population. When you query countries like, for example, Nigeria, it says four pacemakers per million. Quite a difference.

"Per capita gross domestic product is such that, in many countries, a pacemaker costs more than a person’s annual income.


"Healio: What are the regulations around using a refurbished pacemaker?

"Crawford: Pacemaker reuse is illegal in all jurisdictions. The FDA states that pacemaker reuse is an “objectionable practice.” We know we can do it, but we need to develop partnerships with other entities to give us credibility. One of those methods to do this is by engaging the government. FDA issues export permits for this type of activity. We created a protocol where we reprocess the device, working with Northeast Scientific, which provides the pacemaker cleaning and sterilization. We have received permission from the FDA to export them. We have to put a sticker on them saying “not for use in the United States.” We are doing this in countries in which governments will allow it. One of the limitations is needing a government letter from each of the recipient countries. We have about 12 countries now, and the collection of countries we are working with is purely accidental. It is not a normal methodological process. A lot of it is through contact with individuals and opportunities that arise.

"Healio: You are leading a randomized controlled trial called Project My Heart Your Heart: Pacemaker Reuse. What is the study design, and what do you and your colleagues hope to learn?

"Crawford: The objective of the clinical trial is to determine if pacemaker reutilization can be shown to be a safe means of delivering pacemakers to patients in low- and middle-income countries without resources. The target enrollment is 270 patients, all from outside the United States, who each have a class I indication for pacing and who attest that they do not have the ability to purchase a device on their own. They must consent to be randomly assigned to receive either a brand-new pacemaker, which we purchase, or a reprocessed pacemaker, for which we provide the leads and accessories. Donated devices are inspected according to specific protocols that evaluate physical and electrical suitability, including battery longevity, for future use. Devices deemed to be acceptable are shipped to a third-party vendor, Northeast Scientific, for disassembly, cleaning and re-sterilization. There will be about 130 participants in each arm. We will follow those patients and report any adverse events. The countries that have contributed patients include Kenya, Nigeria, Paraguay, Sierra Leone and Venezuela. We hope to soon begin enrolling patients in Mexico and Mozambique.

"I have had clinicians outside the U.S. who tell me they removed a pacemaker device, cleaned it, reprocessed it and then implanted it in someone else — but the government does not know about it. This practice does happen and it is not regulated in any way; patients and physicians know about it and keep it quiet. The difference with what we are doing and these other efforts is we bring it to a much higher level, because that is what the FDA requires. "

Tuesday, February 27, 2024

Stanford Impact Labs announces support for kidney exchange in Brazil, India, and the U.S.

 Stanford Impact Labs has announced an investment designed to help the Alliance for Paired Kidney Donation (APKD) increase access to kidney exchange in Brazil, India, and the U.S.  Here are three related web pages...

1. Stanford Impact Labs Invests in Global Collaboration to Increase Access to Kidney Transplants.  $1.5 million over three years will support solutions-focused project led by Stanford’s Dr. Alvin Roth and the Alliance for Paired Kidney Donation (APKD)  by Kate Green Tripp

"Stanford Impact Labs (SIL) is delighted to announce a $1.5 million Stage 3: Amplify Impact investment to support Extending Kidney Exchange, a solutions-focused project established to increase access to lifesaving kidney transplants.

"The team, led by Stanford’s Dr. Alvin (Al) Roth, who shared the 2012 Nobel Prize in Economics for his work on market design, and the Alliance for Paired Kidney Donation (APKD) is working in close partnership with organ transplant specialists and medical centers in Brazil, India, and the U.S., including Santa Casa de Misericórdia de Juiz de Fora, the Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences (IKDRC-ITS), and Walter Reed National Military Medical Center.

"Over the course of the next three years, the team aims to increase the number of transplant opportunities available to patients who need them by creating and growing kidney exchange programs in Brazil and India, where millions of people suffer from kidney disease yet exchange is minimal; and explore the effects of initiating donor chains with a deceased donor kidney (DDIC) in the U.S., an approach which could unlock hundreds more transplants each year.


2. How Does Applied Economics Maximize Kidney Transplants? A project aimed at expanding kidney exchange and saving lives puts Nobel Prize-winning matching theory into practice.  by Jenn Brown   (including a video...)

"APKD uses open source software developed by Itai Ashlagi, Professor of Management Science and Engineering at Stanford University, to facilitate the matching process for its NEAD chains, and they currently average 5 non-simultaneous transplants per chain.

3. Extending Kidney Exchange

"In Brazil, our team has launched a kidney exchange program within Santa Casa de Misericórdia de Juiz de Fora and Hospital Clínicas FMUSP in São Paulo and aims to expand to facilitating exchanges between these centers and others with the ultimate goal of kidney exchange transitioning from a research project to an officially approved practice in Brazil.

"In India, our team has deployed kidney matching software and resources for growth to the Institute of Kidney Diseases and Research Center and Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS) to support kidney exchange programs. We aim to develop an evidence base for potential updates to organ transplantation laws that expand criteria for who can give and receive lifesaving kidneys.

"In the U.S., we are working with Walter Reed National Military Medical Center to test the use of deceased donor-initiated chains (DDIC) so as to generate hundreds of additional life-saving transplants each year that are not currently supported by today's practice of utilizing a deceased donor kidney to save the life of a single person on a transplant waitlist. "


Monday, February 26, 2024

Prison gangs, in Latin America and in the U.S.

 It's one thing to be able to capture and confine prisoners. When gangs are involved, it's quite another thing to control the prisons, or the ability of prisoners to continue to control gang activity outside of prison.

The NYT has the story, from Latin America:

In Latin America, Guards Don’t Control Prisons, Gangs Do. Intended to fight crime, Latin American prisons have instead become safe havens and recruitment centers for gangs, fueling a surge in violence. By Maria Abi-Habib, Annie Correal and Jack Nicas

"Inside prisons across Latin America, criminal groups exercise unchallenged authority over prisoners, extracting money from them to buy protection or basic necessities, like food.

"The prisons also act as a safe haven of sorts for incarcerated criminal leaders to remotely run their criminal enterprises on the outside, ordering killings, orchestrating the smuggling of drugs to the United States and Europe and directing kidnappings and extortion of local businesses.

"When officials attempt to curtail the power criminal groups exercise from behind bars, their leaders often deploy members on the outside to push back.

“The principal center of gravity, the nexus of control of organized crime, lies within the prison compounds,” said Mario Pazmiño, a retired colonel and former director of intelligence for Ecuador’s Army, and an analyst on security matters.

“That’s where let’s say the management positions are, the command positions,” he added. “It is where they give the orders and dispensations for gangs to terrorize the country.”


I wrote a related post in November (see below) about a Brazilian prison gang, and received an illuminating email from Professor David Skarbek of Brown University, saying

"I enjoyed your blog post about the PPC Brazilian prison gang. I thought that you might be interested to know that the same phenomenon exists in the US as well. I'm attaching a piece I published in the American Political Science Review on the Mexican Mafia in Southern California."

Here's the link to that article:

Skarbek, David. "Governance and prison gangs." American Political Science Review 105, no. 4 (2011): 702-716.

Abstract: How can people who lack access to effective government institutions establish property rights and facilitate exchange? The illegal narcotics trade in Los Angeles has flourished despite its inability to rely on state-based formal institutions of governance. An alternative system of governance has emerged from an unexpected source—behind bars. The Mexican Mafia prison gang can extort drug dealers on the street because they wield substantial control over inmates in the county jail system and because drug dealers anticipate future incarceration. The gang's ability to extract resources creates incentives for them to provide governance institutions that mitigate market failures among Hispanic drug-dealing street gangs, including enforcing deals, protecting property rights, and adjudicating disputes. Evidence collected from federal indictments and other legal documents related to the Mexican Mafia prison gang and numerous street gangs supports this claim.



Tuesday, November 21, 2023

Sunday, February 25, 2024

Mark Satterthwaite interviewed by Sandeep Baliga (video)

After listening to this interview with the great Mark Satterthwaite, I now understand the independent origins of the Gibbard-Satterthwaite theorem, and the collaborative origins of the Myerson-Satterthwaite theorem. 
In the final ten minutes or so of the interview, Mark describes worthwhile future research directions (and methods:), starting just after minute 28:30, particularly about appropriately matching patients to medical specialists.


Earlier interviews by Sandeep Baliga:

Saturday, February 24, 2024

Foreign surrogacy in Denmark is becoming less restrictive

 Above the Law has the story:

Denmark Passes New Pro-Surrogacy Regulations. The new rules in Denmark focus on two areas of surrogacy.  By ELLEN TRACHMAN  February 14, 2024

 "On February 5, 2024, the Danish government announced new surrogacy-supportive rules scheduled to come into effect on January 1, 2025. The rules address parentage for families formed by surrogacy — including commercial (compensated) surrogacy outside of Denmark — as well as for families formed by altruistic (noncompensated) surrogacy within Denmark.


"In Denmark, compensated surrogacy is illegal, and altruistic surrogacy has traditionally fallen into a legal gray area, pushing most hopeful parents who want to have a genetic connection to their child, but who are unable to carry a pregnancy themselves, to go abroad. The Danish government estimates that about 100 children are born to Danish parents each year by surrogacy outside of Denmark, while about five children each year are born within Denmark in altruistic surrogacy arrangements.


"Denmark has a history of denying parental rights to the intended parents of children born by surrogacy abroad. But on December 6, 2022, the European Court of Human Rights ruled against Denmark in K.K. and Others v. Denmark. In that case, a married heterosexual couple had twins with the assistance of a Ukrainian surrogate. Under Ukrainian law, both Danish intended parents were recognized as parents of the child, and the surrogate was not a parent of the child.


"The ECHR found that Denmark’s refusal to recognize the parent-child relationship between the mother and child was a human rights violation — not a violation of the mother’s human rights, but of the two children, to have a recognized legal relationship with their mother.

To its credit, Denmark is reacting to the ECHR’s definitive ruling. In the announcement by the Danish government last week, the government made it clear that the country’s new rules are intended to go beyond the minimum requirements of the ECHR to merely not violate the human rights of Danish children.  (The bare minimum requirement would be to just allow stepparent adoptions.) Instead, the Danish government’s new rules go farther to protect children and their parents.


"The new rules permit Danish family courts to quickly make a decision on parenthood in the case of a foreign surrogacy agreement, even permitting a court ruling to be made prior to the family’s return to Denmark. The rules also require that the court assess the best interest of the child, but with a presumption that it is, of course, in the child’s best interest to have a timely recognition of their parents.

"Moreover, the court decisions are permitted to be retroactive to the birth of the child, permitting parents to have access to parental leave work benefits, inheritance rights, and all other benefits of that legal relationship. And, in contrast to a stepparent adoption, the new rules will allow recognition of the parent-child relationship with the mother or nongenetic parent even if parents have separated, or if one parent died before they had a chance to apply for parenthood.


"In a stated attempt to address the risk of child trafficking, the rules require that at least one intended parent be genetically related to the child. Additionally, the surrogate is required to confirm in a notarized declaration after the birth that she wishes to transfer parenthood of the child to the intended parents."