Nondirected liver donation in Canada--from the beginning

The Ottawa Citizen has the story:

The Gosling Effect: How one man (and his liver) forever changed Canadian health care. In 2005, Kevin Gosling became the first living Canadian to anonymously donate an organ to a stranger. It set a cascade of kindness into motion.  by Elizabeth Payne 

"It had been a long road for the then-46-year-old from Cornwall, Ont. For months, health officials wouldn’t take him seriously when he offered to donate the organ anonymously. We don’t do that here, he was told. Not only that, it had never been done before anywhere in Canada.

"Some top officials in Canada’s leading liver transplant program were adamantly opposed to Gosling’s proposal. They said it was unethical and immoral. They questioned his motives, even his sanity. But Gosling persisted, so far as to undergo months of physical and psychological testing and preparation.

"After more than a year and a half, everything was set to go.

...

"Gosling didn’t know much about the recipient. He only knew that it was a child.

...

"Gosling’s stubborn altruism and unwavering belief that he could make a life-changing difference to someone in desperate need almost single-handedly changed Canada’s health-care system.

"In the 19 years since that fateful day when transplant surgeons removed part of Gosling’s liver and transplanted it into the body of the very ill child, the Toronto General Hospital has completed more than 137 such operations involving people donating anonymously to strangers – more than any other hospital in the world.

...

"He was a pioneer in an area in which Canada is now a world leader – the act of anonymously donating part of a liver – a phenomenon that continues to be met with disbelief in some parts of the world.

...

"Gosling’s offer was turned down multiple times until he was eventually put in touch with the head of the multi-organ transplant program at University Health Network, one of only two hospitals in the country where living liver transplants are now routinely done. Along the way he met health officials who were adamantly opposed to the idea, even citing the Hippocratic oath. (Later, he was told by one staunch opponent that following Gosling’s case had made him change his mind.)"

HT: Colin Rowat

#############

See also:

Cattral, Mark S., Anand Ghanekar, and Nazia Selzner. "Anonymous living donor liver transplantation: The altruistic strangers." Gastroenterology 165, no. 6 (2023): 1315-1317.

and here are all my posts on nondirected donors: https://marketdesigner.blogspot.com/search/label/nondirected%20donor

Dealing with the harms of harm reduction

 Some of the jurisdictions that pioneered harm reduction measures to reduce drug overdose deaths are dealing with problems of public drug use.

The NYT has this story:

Bold Experiment or Safety Risk? Canada Is Divided on How to Stop Drug Deaths.  British Columbia’s partial retreat from an experiment to decriminalize drug possession reveals a political shift in Canada over combating the opioid crisis. By Vjosa Isai

"decriminalization, a policy introduced as a way of alleviating the opioid crisis, has instead been blamed for deepening it. Scenes of people openly using drugs on city streets have led several elected leaders, other critics and even some supporters to say that decriminalization is contributing to a sense of public disorder.

...

"In May, the federal government, which regulates controlled substances, approved a provincial request to reverse the policy and again make public drug use and possession in British Columbia a crime.

"The shift came not long after a similar experiment in Oregon ended in April, following a vote by the state Legislature to re-criminalize drugs amid soaring overdose deaths.

...

"practices, collectively known as harm reduction, are driven by a strategy meant to keep drug users alive rather than getting them to quit.

"Services that fall under this category include needle exchanges, safe injection sites, the distribution of naloxone, a drug used to reverse overdoses, and the testing of street drugs to reveal the presence of any other harmful substances.

...

"Safe injection sites, along with decriminalization, are among the harm reduction measures that have come under attack from critics who claim they lead to crime and perpetuate a cycle of drug abuse.

"In British Columbia, critics say the province should not have pursued decriminalization without also bolstering other services that drug users need, like housing and addiction treatment.

...

"Many residents, he added, complained of increased drug use on public transit, near schools and in entrances to businesses.

...

"Some frontline workers say harm reduction practices are being targeted to score political points at a time when death tolls are reaching new highs and different approaches are necessary to keep users alive."

Interviews by lottery at Queens University School of Medicine

 Overwhelmed by large numbers of applications, and concerned about fairness, Queens University will set admissions thresholds (on grades and exam scores) and then determine by lottery which applicants move to the interview stage.

New admissions process improves equitable access to the Queen’s MD Program

"Queen’s Health Sciences (QHS) is adapting its MD Program admissions process to create a more inclusive entry point for all applicants, minimize systemic barriers to becoming a doctor, and increase student diversity.

"The renewed medical student admissions process will launch this fall, for 2025 admissions, and includes a pathway for lower socioeconomic status (SES) applicants and adjustments to the current Indigenous pathway. A new comprehensive approach to support the recruitment of Black students will launch in a second phase of this admissions change.  

...

"The MD Program will set admissions thresholds for grade point average (GPA), Medical College Admission Test (MCAT), and Casper (a situational judgment test) at levels that align with the potential for predicting success in medical school, without concern for the number of applicants who meet these thresholds. While the MD Program already posts GPA thresholds, as part of this change, MCAT thresholds will be posted as well. All applicants who meet these thresholds will be entered into a lottery to determine who will be invited to interviews. "

HT: Jonah Peranson (of National Matching Services)

Plasma in Canada: payments and protests

 The local newspaper in Niagara on the Lake, a town in Ontario, Canada, covers the proposed opening next year of plasma collection centers that will pay for plasma.

Pay-for-plasma centre draws criticism from Health Coalition. The centre, which will pay residents to donate their blood plasma, is scheduled to open on Hespeler Road by early 2025, by Matt Betts

"The chair of the Waterloo Region Health Coalition is raising concerns about a pay-for-plasma centre slated to open on Hespeler Road in Cambridge by early 2025.

"Just as it sounds, residents can be compensated for donating their blood plasma.

"It's all part of an agreement between Spanish global healthcare company, Grifols, and the Canadian Blood Services.

"In September 2022, Canadian Blood Services announced our action plan in response to a global shortage of medications called immunoglobulins and plasma needed to make them," CBS said in an email to CambridgeToday.

"With funding from governments, Canadian Blood Services is opening 11 plasma donor centres in Canada and collecting more plasma ourselves. Our agreement with Grifols, a global healthcare company and leader in producing plasma medicines, is another part of that plan."

...

"paying for donations is banned in Ontario, Quebec and British Columbia. 

"However, CBS said its been in close discussions with the government and has an exemption.

...

"The agreement also complies with Ontario’s Voluntary Blood Donations Act, which has always contained an exemption for Canadian Blood Services, with implicit consideration of our agents, given our role as the national blood operator and supplier of blood products in Canada. Through our agreement, Grifols will operate under the Act as an agent of Canadian Blood Services."

"Per the agreement, Grifols must use plasma they collect in Canada to make immunoglobulins exclusively for patients in Canada, which reduces reliance on the global market, CBS said.

"But the whole operation doesn't sit right with Waterloo Region Health Coalition chair, Jim Stewart.

"It's a repugnant example of profit driven healthcare," Stewart said, questioning who's profiting in the end.

"What's next, paying people for their organs or embryos? This is just another example of Premier Doug Ford’s drive to privatize our healthcare system."

...

""These pay-for-donations centres really impact the homeless, people with low incomes and those with high levels of unemployment. This is going to dismantle the voluntary donor base and the sustainability of blood supply could be in jeopardy."

...

"While not confirmed by Grifols, Canadian Blood Resources and giveplasma.ca states qualified donors can earn up to $70 per donation and can donate twice in a seven day period."

#####

HT: Frank McCormick

Earlier:

Sunday, September 18, 2022

Canadian Blood Services to start paying Canadian plasma donors

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."

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:

Two former health secretaries join calls for new law on assisted dying

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.”

#########

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."

Transplant grand rounds in Manitoba, tomorrow on kidney exchange

 I'll be talking tomorrow to the transplant pros in Manitoba, about kidney exchange and transplants across borders, among other things.

Wednesday, Oct 4, 2023 | 1:15 PM CST

Sex work contracts are enforceable in small claims court, in Canada

 In Nova Scotia (where selling sex is legal but buying it is not), a sex worker sued a delinquent client for her fee and won (despite his argument that contracts requiring a party to commit a crime were unenforceable).

Former sex worker's victory in small claims court sets precedent, lawyer says. Decision clarifies that contracts for sex work are enforceable. by Moira Donovan · CBC News 

"A former sex worker in Nova Scotia has successfully sued a client in small claims court for non-payment of services. She and her advocates hope the decision will change the legal landscape for sex work in Canada.

"The case relates to an incident in January 2022 when Brogan, whom CBC News is only identifying by her first name because she is a survivor of human trafficking, spent an evening with a client.

"Afterward, the client refused to pay the agreed-upon fee.

"Brogan then turned to small claims court to recover the money — in what advocates believe is the first time such a case has come before the courts in Canada — and won a judgment that she was entitled to the unpaid amount, plus interest and costs.

...

"Brogan met the client in question, ... through a website called LeoList that's used by sex workers and their clients. After some discussion about rates and services, Brogan travelled to Samuelson's apartment, where she spent the evening.

...

"There was offer, there was an acceptance of the offer, there was certainty of terms, so all the hallmarks of an enforceable contract were there," said Jessica Rose, Brogan's lawyer.

"But the central question in the case was whether contracts for sex work are enforceable — a question that relates to the legislation governing sex work in Canada. 

"The Protection of Communities and Exploited Persons Act, which passed in 2014, is supposed to protect people from the risks involved in sex work. It amended the Criminal Code to remove the criminal penalty for individuals who sell their own sexual services, and eliminated criminal charges for those who support sex workers, such as drivers or security personnel.

"But aspects of that work remained criminalized, including the purchase of services.

"In this case, the defendant argued that contracts for sexual services were not enforceable because you could not have a contract in which one party — in this case, the client — had to do something illegal.

...

"adjudicator Darrel Pink concluded that because sex work is legal and the business arrangements supporting sex work are legal, it follows that the benefits of commercial law apply, including access to a civil claim — the same as any other service provider.

...

"Failure of the court to provide a remedy for a wrong or a breach of duty owed by a client would contribute to the very exploitation the legislation was designed to prevent," he wrote."

HT: Kim Krawiec

Canadian kidney exchange reaches 1000 transplants

 The May 2023 update from Canadian Blood Services shows that Canada's kidney paired donation program recently performed its 1,000th transplant.

Earlier:

Wednesday, December 8, 2010

National kidney exchange in Canada

Here's a recent announcement from Canadian Blood Services: Kidney Exchange Registry Goes National, Living Donor Paired Exchange becomes first Canada-wide organ donation registry

Medical aid in dying: access for children, and for mental illness

Two recent articles discuss whether there should be categorical limits on medical aid in dying (MAID).  In the Netherlands, the law now permits euthanasia for children in certain horrific situations, and in Canada, a debate continues about the status of patients with mental illness.

 From The Conversation:

Dutch government to expand euthanasia law to include children aged one to 12 – an ethicist’s view  by Dominic Wilkinson

"Ernst Kuipers, the Dutch health minister, recently announced that regulations were being modified to allow doctors to actively end the lives of children aged one to 12 years who were terminally ill and suffering unbearably.

"Previously, assisted dying was an option in the Netherlands in rare cases in younger children (under one year) and in some older teenagers who requested voluntary euthanasia. Until now, Belgium was the only country in the world to allow assisted dying in children under 12.

...

"Dutch paediatricians and parents had reported that in a small number of cases, children and families were experiencing distressing suffering at the end of life despite being provided with palliative care.

"That included, for example, children with untreatable brain tumours who developed relentless vomiting, screaming, and seizures in their dying phase. Or children with epilepsy resistant to all treatment with tens to hundreds of seizures a day.

"The study recommended improvements in access to palliative care for children, as well as altering regulation to provide the option of assisted dying in these extreme cases.

"It has been suggested that five to ten children a year might be eligible for this option in the Netherlands.

*********

From the NYT, an opinion piece:

Medical Assistance in Dying Should Not Exclude Mental Illness By Clancy Martin

"I am a Canadian, where eligible adults have had the legal right to request medical assistance in dying (MAID) since June 2016. Acceptance of MAID has been spreading, and it is now legal in almost a dozen countries and 10 U.S. states and Washington, D.C. To my mind, this is moral progress: When a person is in unbearable physical agony, suffering from a terminal disease, and death is near, surely it is compassionate to help end the pain, if the person so chooses.

"But a debate has arisen in Canada because the law was written to include those living with severe, incurable mental illness. This part of the law was meant to take effect this year but was recently postponed until 2024."

Kidney transplants from donors who died from illegal drug use

 There was a time when the modal deceased kidney donor had suffered a head injury in an auto accident, but that time is long gone, due to increased auto safety and to the rise in drug overdose deaths.  Those latter deaths now constitute a large proportion of deceased donors, and here's a report from Canada confirming that those kidneys work well in their new owners.

Xie, Max Wenheng, Sean Patrick Kennan, Amanda Slaunwhite, and Caren Rose. "Observational Study Examining Kidney Transplantation Outcomes Following Donation From Individuals That Died of Drug Toxicity in British Columbia, Canada." Canadian Journal of Kidney Health and Disease 10 (2023): 20543581231156853.

"Abstract:

"Background: The illicit drug toxicity (overdose) crisis has worsened across Canada, between 2016 and 2021 more than 28 000 individuals have died of drug toxicity. Organ donation from persons who experience drug toxicity death has increased in recent years. 

"Objective: This study examines whether graft loss after kidney transplantation differed by donor cause of death. 

Design: Retrospective cohort. 

"Setting: Provincial transplant program of British Columbia, Canada. 

"Patients: Transplant recipients who received kidney transplantation from deceased donors aged 12 to 70 years between 2013 and 2019 (N = 1012). 

"Measurements: Transplant recipient all cause graft loss (graft loss due to any cause including death) was compared by donor cause of death from drug toxicity or other. 

"Methods: Five-year Kaplan-Meier estimates of all-cause graft survival, and 3-year complete as well as stratified inverse probability of treatment weighted Cox proportional hazards models were conducted. 

"Results: Drug toxicity death donors donated to 25% (252/1012) of kidney transplantations. Drug toxicity death donors were more likely to be young, white, males, with fewer comorbidities such as diabetes or hypertension but were more likely to have a terminal serum creatinine ≥1.5 mg/dL or be hepatitis C virus (HCV) positive. Unadjusted 5-year estimate of all cause graft survival was 97% for recipients of drug toxicity donor kidneys and 83% for recipients of non-drug toxicity donor kidneys (P < .001). Recipients of drug toxicity death donor kidneys had decreased risk of all cause graft loss compared to recipients of non-drug toxicity death donor kidneys (hazard ratio [HR]: 0.30, 95% confidence interval [CI]: 0.12-0.77, P = .012). This is primarily due to the reduced risk of all-cause graft loss for recipients of younger (≤35 years) drug toxicity death donor kidneys (HR: 0.05, 95% CI: 0.00-0.55, P = .015). 

"Limitations: Potential selection bias, potential unmeasured confounding. 

"Conclusions: Donation after drug toxicity death is safe and should be considered more broadly to increase deceased donor kidney donation."

...

"illicit drug toxicity remains the leading unnatural cause of death in BC accounting for more deaths than homicides, suicides, and motor vehicle incidents combined.

...

"The United States is also undergoing an opioid epidemic which began earlier than Canada and has recorded similar increases in organ donation from individuals that died of illicit drug toxicity.9-11 Studies in the United States have found that recipient survival after kidney transplantation from individuals who died from drug toxicity was similar for recipients of kidneys from donors that died of any other cause of death."

Canada experiments with decriminalization of opioids and other drugs in British Columbia

 From the CBC:

What you need to know about the decriminalization of possessing illicit drugs in B.C.  B.C. granted exemption by federal government in November 2022; pilot will run until 2026  by Akshay Kulkarni ·

"it is no longer a criminal offence to possess small amounts of certain illicit drugs in B.C. for people aged 18 or above.

"It's part of a three-year pilot by the federal government, which granted B.C. an exemption from the Controlled Drugs and Substances Act (CDSA) on May 31, 2022. 

...

"Under the exemption, up to 2.5 grams of the following four drug types can be legally possessed:

"Cocaine (crack and powder). Methamphetamine. MDMA. Opioids (including heroin, fentanyl and morphine).

"Fentanyl and its analogues were detected in nearly 86 per cent of drug toxicity deaths from 2019 until 2022, according to the latest report from the B.C. Coroners Service."

Euthanasia in Canada

 The NYT columnist Ross Douthat considers the medical aid in dying policies in Canada, and warns us that conservative politics is what protects us against the slippery slope that might lead us down the Canadian path.

 What Euthanasia Has Done to Canada

"In recent years, Canada has established some of the world’s most permissive euthanasia laws, allowing adults to seek either physician-assisted suicide or direct euthanasia for many different forms of serious suffering, not just terminal disease. In 2021, over 10,000 people ended their lives this way, just over 3 percent of all deaths in Canada. A further expansion, allowing euthanasia for mental-health conditions, will go into effect in March 2023; permitting euthanasia for “mature” minors is also being considered.

...

"The rules of civilization necessarily include gray areas. It is not barbaric for the law to acknowledge hard choices in end-of-life care, about when to withdraw life support or how aggressively to manage agonizing pain.

"It is barbaric, however, to establish a bureaucratic system that offers death as a reliable treatment for suffering and enlists the healing profession in delivering this “cure.” And while there may be worse evils ahead, this isn’t a slippery slope argument: When 10,000 people are availing themselves of your euthanasia system every year, you have already entered the dystopia.

"Indeed, according to a lengthy report by Maria Cheng of The Associated Press, the Canadian system shows exactly the corrosive features that critics of assisted suicide anticipated, from health care workers allegedly suggesting euthanasia to their patients to sick people seeking a quietus for reasons linked to financial stress.

...

"in the Canadian experience you can see what America might look like with real right-wing power broken and a tamed conservatism offering minimal resistance to social liberalism. And the dystopian danger there seems not just more immediate than any right-authoritarian scenario, but also harder to resist — because its features are congruent with so many other trends, its path smoothed by so many powerful institutions.

...

"without a potent conservatism, the cultural balance tilts too much against these doubts. And the further de-Christianization proceeds, the stronger the impulse to ... rationalize the new order with implicit reassurances that it’s what some higher power wants.

"It’s often treated as a defense of euthanasia that the most intense objections come from biblical religion. But spiritual arguments never really disappear, and the liberal order in a dystopian twilight will still be infused by some kind of religious faith.

"So I remain a conservative, unhappily but determinedly, because only conservatism seems to offer a stubborn obstacle to that dystopia"

*********

Update, January 14: in a followup column, Douthat responds to supporters of Canada's euthanasia policies,* and summarizes his position with this concluding sentence: 

"And if euthanasia is kept within limits or rolled back from its advances, I suspect it will be the old taboos and Christian prohibitions that make the difference, not a libertarianism that so quickly and easily yields to pagan destinations."

*See in particular

Canadian Euthanasia as Moral Progress. Individual liberty, the common good, and human dignity. by Richard Hanania

Here's a summary paragraph:

"First, I will show that the MAID program is currently small, and likely represents cases of the most extreme suffering given the data that we have. I then go on to refute arguments against MAID that have appeared in the popular press. Sometimes, these arguments are simply false, as when it is claimed that it will eventually lead to large numbers of healthy young adults killing themselves with state sanction. Other times, the arguments may be correct but actually make the case for euthanasia. It is true, for example, that some people might feel “pressured” to commit suicide because they don’t want to be burdens on their families or the government. I don’t think there’s anything wrong with this — in practically every other kind of situation, it is usually considered pro-social to care about the impact your life has on others. This gets to the point that my support for euthanasia does not simply rest on libertarian and utilitarian grounds, but also on the idea that people should behave in ways that consider the common good and that, yes, preserve human dignity. The state’s interest in saving costs, as long as it’s going to pay for healthcare, is also legitimate, although I won’t dwell on that here."

Canadian Blood Services to start paying Canadian plasma donors

 CBC news has the story, which seems to mark a turning point in a long struggle with repugnance for paying donors.

Canadian Blood Services signs agreement with private company to boost national plasma supply.  Some advocates calling for the resignation of Canadian Blood Services leaders over agreement. by Stephanie Dubois 

"Canadian Blood Services (CBS) is partnering with a private healthcare company to boost Canada's national blood plasma supply, the organization announced Wednesday.

...

"CBS has signed an agreement with Grifols, a company headquartered in Spain, which specializes in producing plasma medicines, the national blood collection organization said in a news release.

...

"Grifols will help CBS meet national targets for plasma supply by both collecting paid-for plasma and by turning Canadian plasma into immunoglobulins —a form of specialized medications called plasma protein products– for Canadian patients. 

...

"Health Canada says on its website there's currently "not enough plasma collected in Canada to meet the demand," and most of the plasma products distributed by CBS and Héma-Quebec are purchased from U.S. manufacturers and made from U.S. paid-donor plasma. "

Canadian Blood Services in talks around paid donations of plasma

Canadian Blood Services in talks around paid donations of plasma as supply dwindles. by Christopher Reynolds

"Canadian Blood Services is in talks with companies that pay donors for plasma as it faces a decrease in collections.

"The blood-collection agency issued a statement on Friday saying it is in “ongoing discussion with governments and the commercial plasma industry” on how to more than double domestic plasma collection to 50 per cent of supply.

"Canadian Blood Services has previously cautioned that letting companies trade cash for plasma - a practice banned in British Columbia, Ontario and Quebec - could funnel donors away from voluntary giving.

"The bulk of the non-profit agency's supply currently comes from abroad, including via organizations that pay donors."

HT: Frank McCormack

************

The Globe and Mail adds some detail:

Canadian Blood Services eyes getting plasma from paid donors amid supply challenges by Chris Hannay

"Industry observers say the most likely commercial partner for CBS is Grifols, an international pharmaceutical company headquartered in Spain. The company purchased a large-scale plasma processing facility in Montreal in 2020, and in January bought an existing for-profit plasma donation centre in Winnipeg.”

***********

See my full set of posts on plasma in Canada

Fentanyl by prescription: a Vancouver experiment

 Part of the problem of black markets, particularly for drugs (but not just for drugs) is that customers are dealing with criminals who are neither as honest nor as skilled as pharmacists. This means that drug buyers don't know what they are getting, and can overdose, sometimes fatally, when the mixture they have purchased contains drugs or quantities of drugs that they don't know about.  As fentanyl has started to show up mixed into heroin, and to replace it, this seems to have been one of the big causes of inadvertent overdoses.

In Vancouver, an experiment is underway to make drugs safer by having pharmacists dispense them, in prescribed dosages. (Not everyone thinks this is a good idea.)

The NYT has the story:

Fentanyl From the Government? A Vancouver Experiment Aims to Stop Overdoses. A city on the forefront of harm reduction has taken the concept to a new level in an effort to address the growing toxicity of street drugs.  By Stephanie Nolen

"the breadth of Vancouver’s services and interventions is almost unimaginable in the United States, less than an hour’s drive to the south. Supervised injection sites and biometric machines that dispense prescription hydromorphone dot the city center; naloxone kits, which reverse overdoses, are available free in every pharmacy; last year, a big downtown hospital opened a safer-use site next to the cafeteria, to keep patients who are drug users from leaving in order to stave off withdrawal.

"And since April, Chris... has received pharmaceutical-grade fentanyl through the dispensary, which sells to those who can pay and provides free drugs through the program’s operational budget to those who cannot.

"The new program aims to provide a safer alternative to the fentanyl available on the streets, where the supply is increasingly lethal and is responsible for most of the overdose epidemic that was declared a public health emergency here six years ago.

"Dr. Christy Sutherland, a board-certified addiction medicine specialist who set up the program, said its goal was, first, to keep people from dying, and, second, to help bring stability to their lives so that they may think about what they might want to change."

Harm reduction for drugs: an experiment in British Columbia

 Here's a news story in the Guardian, and the policy paper from British Columbia about the new efforts on harm reduction there.

Canada to decriminalize some drugs in British Columbia for three years. Policy aims to stem record number of overdose deaths by easing a fear of arrest by those who need help

Here's the official report of the Provincial Health Officer of British Columbia. I think the choice of cover picture does a good job of capturing the tension between treating drug users as criminals or as patients.

STOPPING THE HARM. DECRIMINALIZATION OF PEOPLE WHO USE DRUGS IN BC

Decriminalizing personal drug use

 The WSJ has the story

Some Cities Turn to Decriminalizing Drugs as Overdoses Climb. Toronto follows Vancouver and the state of Oregon in seeking to make it legal to carry small amounts of heroin, fentanyl and other drugs for personal use.  By Vipal Monga

"Canada’s largest city is the latest jurisdiction aiming to decriminalize drug possession as it faces a surging overdose epidemic.

"Toronto’s board of health this month said it would seek permission from Canada’s federal government to allow drug users to carry small amounts of drugs for personal use, including heroin, fentanyl and cocaine, without fear of prosecution. The exemption wouldn’t cover drug trafficking, which would remain a criminal offense.

"City officials hope that decriminalization will make it easier for people to get help. They say it could also make it easier for drug users to get jobs and stable housing because they won’t have criminal records.

...

"The new policies and proposals come as officials say they are seeking ways of handling an overdose epidemic that has swept across North America. Drug users are dying in record numbers as an increasingly toxic drug supply overwhelms the black market.

“The current approaches to drug policy and regulation are not working,” said Dr. Eileen de Villa, medical officer for Toronto, during a presentation to the city’s board of health on Dec. 6."

Cannabis in Canada

It's not so easy for a heavily regulated legal market to compete with an unregulated black market.  The NY Times has the story:

After ‘Green Rush,’ Canada’s Legal Pot Suppliers Are Stumbling. Most marijuana producers in Canada are still reporting staggering losses two and a half years after legalization.  By Ian Austen

"When Prime Minister Justin Trudeau’s government’s legalized marijuana in 2018, a primary goal was to create a more equitable justice system — not a major new business sector.

"Investors, however, thought otherwise, and in the time leading up to legalization, a “green rush” swept the Toronto Stock Exchange. Money poured into companies starting up to service not only the Canadian market, but also eyeing other opportunities, particularly the U.S. market, where more states were embracing legalization.

...

"Even with a slight recovery propelled by the spreading legalization in the United States — New York legalized marijuana last month, and voters in four states backed legalization in November — one marijuana stock index is still down about 70 percent from its peak in 2018.

"Two and a half years after legalization, most marijuana producers in Canada are still reporting staggering losses.

"And a major new competitor is looming: Mexico’s lawmakers legalized recreational pot use last month. So the business climate for Canada’s growers could become even more challenging."

A non-simultaneous liver exchange chain at UCSF, and a brief history of liver exchange

 Living donor liver transplants are relatively uncommon in North America compared to Asia.  Liver exchange might help change that. Here are some reports of recent and not so recent liver exchanges, including a non-simultaneous exchange chain  at UCSF, and a simultaneous chain in Canada.  Expect more in the near future.

 (Non-simultaneous chains have become the backbone of kidney exchange in the U.S., so we may start to see longer chains of liver exchange as well.)

Here's the most recent report of a short non-directed donor chain:

Expanding living donor liver transplantation: Report of first US living donor liver transplant chain  by Hillary J. Braun  Ana M. Torres  Finesse Louie  Sandra D. Weinberg  Sang‐Mo Kang  Nancy L. Ascher  John P. Roberts, American Journal of Transplantation, First published: 10 November 2020 https://doi.org/10.1111/ajt.16396

Abstract: "Living donor liver transplantation (LDLT) enjoys widespread use in Asia, but remains limited to a handful of centers in North America and comprises only 5% of liver transplants performed in the United States. In contrast, living donor kidney transplantation is used frequently in the United States, and has evolved to commonly include paired exchanges, particularly for ABO‐incompatible pairs. Liver paired exchange (LPE) has been utilized in Asia, and was recently reported in Canada; here we report the first LPE performed in the United States, and the first LPE to be performed on consecutive days. The LPE performed at our institution was initiated by a nondirected donor who enabled the exchange for an ABO‐incompatible pair, and the final recipient was selected from our deceased donor waitlist. The exchange was performed over the course of 2 consecutive days, and relied on the use and compliance of a bridge donor. Here, we show that LPE is feasible at centers with significant LDLT experience and affords an opportunity to expand LDLT in cases of ABO incompatibility or when nondirected donors arise. To our knowledge, this represents the first exchange of its kind in the United States."

The paper says this about the timing of the surgeries:

"Other centers reporting LPE have performed the donor and recipient operations in four operating rooms simultaneously4, 5 which can be logistically challenging, but addresses concerns regarding simultaneity and equalizing risk. In our case, we performed the operations on sequential days. In doing so, we accepted the risk that, given a good outcome in Recipient 1 on the first day, Donor 2 (the “bridge” donor) might opt out of living donation at the last moment. Reappropriating terminology from the kidney paired exchange (KPE) literature, a bridge donor is defined as someone who donates more than 1 day after their intended recipient received a transplant.12 A recent paper discussing the feasibility of LPE in the United States emphasized that, in the early days of KPE, there was concern that the bridge donor might back out at the last minute and break the chain.13 As a result, kidney donor operations were initially attempted simultaneously. However, a 2018 review of 344 KPE chains between 2008 and 2016 revealed that only 5.6% of bridge donors broke the chain and the majority of these donors developed a medical issue during their time as a bridge donor that prohibited them from completing donation.12 Ultimately, because this occurrence was so infrequent, the authors concluded that simultaneous donor operating rooms for chains are unnecessary and may actually deter potential donors based on logistical issues. "

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And here's a report from Canada of a non-directed donor chain of liver exchange with all surgeries conducted simultaneously (also with the NDD donating to an incompatible patient-donor pair whose donor donated to a patient on the deceased donor waiting list).

Living donor liver paired exchange: A North American first  by Madhukar S. Patel  Zubaida Mohamed  Anand Ghanekar  Gonzalo Sapisochin  Ian McGilvray  Blayne A. Sayed  Trevor Reichman  Markus Selzner  Jed A. Gross  Zita Galvin  Mamatha Bhat  Les Lilly  Mark Cattral  Nazia Selzner, American Journal of Transplantation, First published: 10 June 2020 https://doi.org/10.1111/ajt.16137 

Abstract: Paired organ exchange can be used to circumvent living donor‐recipient ABO incompatibilities. Herein, we present the first case of successful liver paired exchange in North America. This 2‐way swap required 4 simultaneous operations: 2 living donor hepatectomies and 2 living donor liver transplants. A nondirected anonymous living donor gift initiated this domino exchange, alleviating an ABO incompatibility in the other donor‐recipient pair. With careful attention to ethical and logistical issues, paired liver exchange is a feasible option to expand the donor pool for incompatible living liver donor‐recipient pairs.

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Here's a 2014 report from S. Korea:

Section 16. Update on Experience in Paired-Exchange Donors in Living Donor Liver Transplantation For Adult Patients at ASAN Medical Center by  Jung, Dong-Hwan1; Hwang, Shin1; Ahn, Chul-Soo1; Kim, Ki-Hun1; Moon, Deok-Bog1; Ha, Tae-Yong1; Song, Gi-Won1; Park, Gil-Chun1; Lee, Sung-Gyu, Transplantation: April 27, 2014 - Volume 97 - Issue - p S66-S69, doi: 10.1097/01.tp.0000446280.81922.bb

"Between January 2003 and December 2011, approximately 2,182 adult LDLT cases were included in this study. During this period, 26 paired-exchange donor LDLT cases were performed (1.2%).

"Results: Of the 26 paired-exchange donor LDLT cases, 22 pairs were matched due to ABO-incompatibility, and 4 pairs were matched because of cascade allocation of unrelated donors or relatively small graft volume to the recipients. A total of 28 living donors were included in the 26 paired-exchange donor LDLT cases because of inclusion of two dual-graft transplants. Elective surgery was performed in 22 cases, and urgent operation was performed in 4 cases. The overall 1-year and 5-year patient and graft survivals were both 96.2% and 90.1%, respectively.

"Conclusions : Our experience suggests that the paired-exchange donor program for adult LDLT seems to be a feasible modality to overcome donor ABO incompatibility."

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Here's a story of a liver exchange in Texas, between an incompatible pair and a compatible pair.

Saturday, December 28, 2019 A liver exchange in San Antonio, Texas

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Here's a liver exchange in Hong Kong between an incompatible pair and a compatible pair.

Friday, April 4, 2014 An unusual liver exchange in Hong Kong

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Here's a report from two major liver transplant centers in Hong Kong and S. Korea. The Korean team reported 16 donor exchanges conducted over a 6-year period.

Friday, April 9, 2010 Liver exchange