Arguments against paying for plasma and other Substances of Human Origin (SoHO)

 Substances of Human Origin (SoHO) have a growing, often lifesaving role in modern medicine, from breast milk for premature babies, to kidneys for transplant, to blood and blood plasma, which the World Health Organization categorizes as an essential medicine for a wide variety of ailments and injuries.  However concern for protecting the donors of SoHO from exploitation has led to a considerable debate about whether donation must always be uncompensated, and motivated purely by altruism.
 

Two important cases are donation of kidneys and of blood plasma. Payment to donors of kidneys for transplant is banned almost everywhere, but a few countries (among which the U.S. is prominent) allow payment to plasma donors. Kidneys are in short supply, so patients with kidney failure very often die prematurely without receiving a transplant, but among high and middle income countries almost no one is today dying from a shortage of plasma and plasma products.  That isn’t because countries that don’t pay plasma donors generate sufficient supply for their domestic needs, it is because they can import plasma pharmaceuticals from countries that do pay donors, chiefly the U.S. which exports tens of billions of dollars of plasma products annually.
 

Here's an article arguing that payment for plasma and other SoHOs is always and everywhere wrong and should be stopped. (The  authors seem to agree with the WHO that countries should raise enough plasma domestically from unpaid donors, although no country has yet managed to do this.)  Furthermore, they suggest that companies that collect and process plasma must be nonprofits.

Prevention of Trafficking in Organs, Tissues, and Cells by Martin, Dominique E. PhD1; Capron, Alexander M. LLB2; Fadhil, Riadh A. S. MD3; Forsythe, John L. R. MD4; Padilla, Benita MD5; Pérez-Blanco, Alicia PhD6; Van Assche, Kristof PhD7; Bengochea, Milka MD8; Cervantes, Lilia MD9; Forsberg, Anna PhD10; Gracious, Noble MD11,12; Herson, Marisa R. PhD1; Kazancioğlu, Rümeyza MD13; Müller, Thomas PhD14; Noël, Luc MD15; Trias, Esteve MD16; López-Fraga, Marta PhD17 Transplantation, October 22, 2024. | DOI: 10.1097/TP.0000000000005212
 

“It is essential that all national laws “concerning the donation and human application” of human organs, tissues, and cells, as well as all derived therapies, conform to the principle of financial neutrality, prohibiting financial gain in the human body or its parts.9,70 Healthcare professionals, service providers, and organ, cell, and tissue procurement organizations, as well as other industry stakeholders involved in processing, manufacture, storage, and distribution of SoHOs and SoHO-based therapies, are all entitled to “reasonable remuneration” for their work and coverage of the costs associated with various sector activities.66,71 However, what may be considered a reasonable and proportionate remuneration in this context is ill defined. There have been reports of service providers and professionals generating disproportionate profits from such activities, creating potential financial conflicts of interest in service provision and potentially violating ethical norms and legal standards prohibiting trade in SoHOs.30
 

“Development of innovative therapies using human cells and tissues has increased, with the potential therapeutic value of these resources spurring commercial interests that, in some cases, has led to practices in which donated SoHOs are treated as commodities.30,72–75 Furthermore, some SoHOs may undergo substantial processing, resulting in these therapies being regulated outside the regulatory framework governing the transplantation of organs, tissues, and cells as such, and rather being considered as medicines, where commercial profits are expected and guide the production and distribution activities.74,75
 

“Mechanisms should be developed to ensure that strategies used in donor recruitment, which may involve actual or perceived financial incentives, are routinely disclosed and open to scrutiny.70 Transparency of practice is also required to enable scrutiny of the fees charged to cover costs of procuring, processing, storing, manufacturing, and distributing cells, tissues, and SoHO-based therapies and to assess the potential influence of financial interests on decision-making about the use of SoHOs in particular SoHO-based therapies, or distribution of SoHO-based therapies.74 These measures would furthermore help to facilitate equitable access to treatments for all patients.21
…
Box 1, first recommendation
“Recommendations for action to prevent trafficking in SoHOs
•    1. All countries should establish laws that prohibit payment for donation of SoHOs, trafficking in SoHOs, and trafficking in human beings to obtain SoHOs.
o    a. Legislation should prohibit activities that make the human body or its parts a source of financial gain exceeding the recovery of the costs of obtaining, processing, storing, and distributing those parts or the products made from them and of ensuring the sustainability, safety, and quality of donation and transplantation systems.”

##########

They also suggest that there is widespread human trafficking in SoHO, although they acknowledge that there isn’t a lot of data to support this:

“since 2010, there have been few empirical studies of organ trafficking, with more recent studies often consisting of qualitative interviews or surveys with individuals who participated in organ trafficking or were victims of human trafficking for organ removal several years earlier.7,32,52 Legal case analyses have focused primarily on seminal cases that detail activities that occurred in the early 2000s.33,38 Much of what is known about current trafficking activities is gleaned from sporadic media reports, which make clear the global prevalence of organ trafficking.”

#########
 

Earlier:

Wednesday, August 28, 2024  WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood, by Krawiec and Roth

Monday, April 22, 2024 Plasma donation in the EU: compensated and uncompensated

Saturday, November 4, 2023  The EU proposes strengthening bans on compensating donors of Substances of Human Origin (SoHOs)--op-ed in VoxEU by Ockenfels and Roth

Practical market design makes policy recommendations (which can violate NBER publication policy)

The National Bureau of Economic Research (NBER) publishes a widely read series of working papers, before publication in refereed journals. They also distribute a list of papers that have been published in medical journals, since those journals don't allow prepublication in working papers.  For both these series the NBER has a rule against papers that make policy recommendations.

This is sometimes a problem for the field of market design, since practical market design is about finding ways to improve the operation of markets, which is a kind of policy advice. I encountered this recently with the two papers described below, published in medical journals, which apparently are too policy related: the policy being to save more lives by arranging more transplants, in this case of hearts and kidneys respectively. (Medical journals have their own conventions, but aren't opposed to advice on medical practice...)

I received the following email from the NBER, accompanied by a line of explanation for each paper.

The email began:

"I apologize for my belated response about your journal articles; while the subject matter is clearly vital, after review of the full-text, we determined that your articles make policy recommendations that are too specific for NBER’s policy on working papers (which we apply to papers in the article list)."

 It then continued by highlighting the offending sentences in each article:

1. Alyssa Power MD*, Kurt R. Sweat MA*, Alvin Roth PhD, John C. Dykes MD, Beth Kaufman MD, Michael Ma MD, Sharon Chen MD, MPH, Seth A. Hollander MD, Elizabeth Profita MD, David N Rosenthal MD, Lynsey Barkoff NP, Chiu-Yu Chen MD PhD, Ryan R. Davies MD, Christopher S. Almond MD, MPH, “Contemporary Pediatric Heart Transplant Waitlist Mortality,” Journal of the American College of Cardiology, Vol 84, no. 7, August 13, 2024: 620-632.https://www.sciencedirect.com/science/article/pii/S0735109724075624

"Policy language:  A more flexible allocation system that accurately reflects patient-specific risks and considers transplant benefit is urgently needed."

2. Vivek B. Kute, Himanshu V Patel, Subho Banerjee,Divyesh P Engineer, Ruchir B Dave, Nauka Shah, Sanshriti Chauhan ,Harishankar Meshram , Priyash Tambi  , Akash Shah, Khushboo Saxena,Manish Balwani , Vishal Parmar, Shivam Shah, Ved Prakash ,Sudeep Patel, Dev Patel, Sudeep Desai, Jamal Rizvi , Harsh Patel, Beena Parikh, Kamal Kanodia, Shruti Gandhi, Michael A Rees,  Alvin E Roth,  Pranjal Modi “Impact of single centre kidney-exchange transplantation to increase living donor pool in India: A cohort study involving non-anonymous allocation,”Nephrology, September 2024,https://onlinelibrary.wiley.com/doi/10.1111/nep.14380

"Policy language: We suggest stepwise progress to achieve multicentre, regional, State and then a National program. Ideally, there should be engagement by the National Organ & Tissue Transplant Organization and the World Health Organization. 

While we recommend simultaneous surgery for mDRPs in a single exchange, sometimes logistical aspects have necessitated non-simultaneous exchanges"

##########

Earlier posts:

Thursday, August 8, 2024  Pediatric Heart Transplants: rethinking the waitlist, by Power, Sweat...Almond et al.

 Wednesday, September 18, 2024 More on non-anonymous kidney exchange in India

Peter Singer interview in the NYT

 The NYT interviews the eminent philosopher:

Peter Singer Wants to Shatter Your Moral Complacency  By David Marchese

Q. "I think of you as being best known for your work on animals and ethics, which flows out of utilitarian principles — that the right action is the one that produces the most good. But you’re also seen as one of the godfathers of effective altruism. Can you explain what effective altruism is and how it builds on utilitarianism?

A. "Sure. Effective altruism is the view that firstly, we ought to try to make the world a better place. Doesn’t mean that we all have to become saints, but it should be an important goal for people to think, What can I do to make the world better? And to think about that in a global way, not just for me and my family and those close to me but for people anywhere in the world and, indeed, for beings capable of suffering who are not of our species. Effective altruism developed into a kind of a social movement to encourage people to do that, and effective altruists have done a lot of research to try to find which are the most effective charities in different areas. What is the connection with utilitarianism? I think if you are a utilitarian, you ought to be an effective altruist. Because if you’re a utilitarian you ought to want to reduce suffering and increase happiness, and given that we all have limited resources, surely we should be using those resources as effectively as possible to do as much good as we can."

######

Earlier: Singer is one of the founding editors of the Journal of controversial ideas (which has a large, diverse and distinguished editorial board):

Friday, May 21, 2021  Journal of controversial ideas

and he defends sensible views on kidney exchange:

Saturday, November 2, 2019

Video Interview: Peter Singer on Global Kidney Exchange

Peter Singer discusses Global Kidney Exchange, and his recent article in the Lancet, in this interview on the Practical Ethics blog at Oxford.

Behavioral market design (in the JEP)

 The Fall 2024 Journal of Economic Perspectives has three papers on behavioral market design:

Symposium: Behavioral Incentive Compatibility

6.	Evaluating Behavioral Incentive Compatibility: Insights from Experiments
	David Danz, Lise Vesterlund, and Alistair J. Wilson
	Full-Text PDF | Additional Information

 

Incentive compatibility is core to mechanism design. The success of auctions, matching algorithms, and voting systems all hinge on the ability to select incentives that make it in the individual's interest to reveal their type. But how do we test whether a mechanism that is designed to be incentive compatible is actually so in practice, particularly when faced with boundedly rational agents with nonstandard preferences? We review the many experimental tests that have been designed to assess behavioral incentive compatibility, separating them into two categories: indirect tests that evaluate behavior within the mechanism, and direct tests that assess how participants respond to the mechanism's incentives. Using belief elicitation as a running example, we show that the most popular elicitations are not behaviorally incentive compatible. In fact, the incentives used under these elicitations discourage rather than encourage truthful revelation.

 

7.	Behavioral Incentive Compatibility and Empirically Informed Welfare Analysis: An Introductory Guide
	Alex Rees-Jones
	Full-Text PDF | Additional Information

A growing body of research conducts welfare analysis that assumes behavioral incentive compatibility—that is, that behavior is governed by pursuit of incentives conditional on modeled imperfections in decision-making. In this article, I present several successful examples of studies that apply this approach and I use them to illustrate guidance for pursuing this type of analysis.

 

8.	Designing Simple Mechanisms
	Shengwu Li
	Full-Text PDF | Additional Information

It matters whether real-world mechanisms are simple. If participants cannot see that a mechanism is incentive-compatible, they may refuse to participate or may behave in ways that undermine the mechanism. There are several ways to formalize what it means for a mechanism to be "simple." This essay explains three of them, and suggests directions for future research.

Realistic college application advice, by Ali and Shorrer in the AER

 Here's a nice paper modeling the advice that high school guidance counselors traditionally give about college applications, reflecting the fact that colleges' admissions decisions are correlated, and applications are often limited. 

Hedging When Applying: Simultaneous Search with Correlation by S. Nageeb Ali and Ran I. Shorrer, American Economic Review (Forthcoming)

Abstract: Applicants to schools, colleges, and jobs hedge by applying to a broad range of options, including reaches, matches, and safeties. We develop a simultaneous-search framework that rationalizes this practice. In this framework, the admissions process is correlated across schools so that if an applicant is rejected by one school, she is more likely to be rejected by more selective schools. We find that an applicant then optimally targets both safeties and reaches. We characterize how the optimal portfolio varies with the applicant’s beliefs, risk attitudes, and application costs, and offer an algorithm that delivers the optimal portfolio in polynomial time.

And here are the opening paragraphs:

"An applicant to schools, colleges, or jobs typically does not know if or where her applications would be accepted. To hedge her bets, she might target some places she deems safeties, others she views to be matches for her qualifications, and some that are reaches. Hedging is common; indeed, this strategy is generally recommended to college applicants by guidance counselors and advisers.

'Why hedge? Intuitively, an applicant might see admissions decisions as being correlated across schools. For instance, in US college and graduate admissions, an applicant might not know where she stands in the pool, what her letters of recommendation say, or how schools assess her essay. An applicant’s prospects are correlated also in centralized admissions protocols in which the applicant has to first specify a portfolio of schools and then take a single exam that determines where she is admitted. Such protocols have featured in China, Ghana, Kenya, Mexico, Turkey, and the UK. Finally, “single tie-breaking” matching procedures, in which a single lottery is used to allocate overdemanded seats, necessarily also correlates admissions decisions. In all these cases, if one school rejects an applicant, then it is more likely that other schools would also do so. This force might impel her to apply broadly."