Social Choice & Fair Division: Theory & Applications, at the University of Tehran this weekend

 Mehdi Feizi (مهدی فیضی) writes to alert me to the upcoming conference, at the University of Tehran, on Social Choice & Fair Division: Theory & Applications

"The Tehran Economic Policy-Making Think-Tank (TEPT) at the University of Tehran and the Ferdowsi Center for Market Design (FCMD) at the Ferdowsi University of Mashhad invite applications for the 2024 Summer School on Social Choice and Fair Division (SCFD): Theory and Applications. The School will take place at the University of Tehran on September 6th and 7th and at the Ferdowsi University of Mashhad on September 8th. The SCFD2024 Summer School is aimed at advanced graduate students, post-docs, and junior faculty members. All courses are taught in English.

Topics and Speakers

The SCFD2024 Summer School will address the most important recent developments in social choice and fair division. It will be practice-orientated with a solid theoretical grounding, combining international policy relevance with a state-of-the-art high-level scientific program. At SCFD2024 Summer School, we have a collection of leading experts in their fields who strongly engage with policy-making institutions.

Keynote Speakers

Haris Aziz (University of New South Wales, Australia)

Fuhito Kojima (University of Tokyo, Japan)

François Maniquet (Université catholique de Louvain, Belgium)

Marcus Pivato (Université Paris 1 Panthéon-Sorbonne, France)

Arunava Sen (Indian Statistical Institute, India)

 

Lecturers

Inácio Bó (University of Macau, China)

Satya Chakravarty (Indira Gandhi Institute of Development Research, India)

Sinan Ertemel (Istanbul Technical University, Turkey)

Flip Klijn (Institute for Economic Analysis, Spain)

Alexander Nesterov (HSE University, Russia)

Kemal Yildiz (Bilkent University, Turkey)

Black markets for alcohol in Iran

 Prohibition (of alcohol) didn't work in the U.S. from 1920-1933, and it's not working in Iran today, despite "the Islamic Republic’s longstanding ban on the sale and consumption of alcohol, which is punishable by a penalty of up to 80 lashes and fines."

The NYT has the story:

Alcohol Poisonings Rise in Iran, Where Bootleggers Defy a Ban. Iran’s prohibition of the drinking and selling of alcohol has led to a flourishing underground market. But even officials have acknowledged a wave of hospitalizations and deaths in recent months.  By Farnaz Fassihi and Leily Nikounazar

"Rather than stopping drinking, the ban over time has led to a flourishing and  dangerous bootleg market. In the past three months, a wave of alcohol poisonings has spread across Iranian towns big and small, with an average of about 10 cases per day of hospitalizations and deaths, according to official tallies in local news reports.

"The culprit is methanol, found in homemade distilled alcohol and counterfeit brand bottles, apparently circulating widely, according to Iranian media reports and interviews with Iranians who drink, sell and make alcohol.

"The clerical rulers who took power after the 1979 revolution, instituting a theocracy, banned the consumption and selling of alcohol in accordance with Islamic rules prohibiting intoxication. Religious minorities are exempt. Over the decades, reports of methanol contaminations occasionally surfaced, but not in the scope and frequency seen in recent months....

"Even officials are now publicly acknowledging that the problem has escalated. Mehdi Forouzesh, Tehran’s chief coroner, said in a news conference in June that the number of hospitalizations and deaths from methanol poisoning had sharply risen. In only Tehran, he said, it had climbed by 36.8 percent since the beginning of March.

...

"Many Iranians love to drink, and nothing has dissuaded them from a tradition deeply rooted in ancient Persian culture. Homemade alcohol and imported bottles of liquor flow freely at many parties, weddings and social gatherings. Some upscale restaurants secretly serve patrons vodka in pots of tea."

Attack on Sharif University in Iran: an open letter

 I'm among the signers of yet another open letter protesting events in Iran, this one against violent attacks on peaceful protesters in Iranian universities, related in turn to official violence against women. (click to see all the signers...):

Statement in Condemnation of the Attacks on University Students in Iran

"The recent events surrounding the death of Mahsa Amini in police custody on September 16, 2022, have pained and astounded many Iranians within Iran and abroad, including many students and academics [1]. Mahsa’s death engendered a visceral reaction across Iran. Iranians have raised their voices in protest to demand justice, freedom, and equality for women and beyond [2,3].

"On the evening of October 2, 2022, in brutal response to a protest staged by students at the Sharif University of Technology, one of Iran’s leading universities, various anti-riot forces violently stormed the university campus and surrounding areas. They laid siege to the university’s campus, brutally attacking and arresting students and faculty en masse [4,5]. This attack is followed by attacks on other universities that are continuing as we write this letter, including an attack on Tabriz University.   

"This unspeakable violence against students is an assault on the sanctity of education, academe, and fundamental human rights. We, the undersigned members of the global community of academics, condemn this attack and severe acts of aggression against universities and students in Iran and demand the immediate release of all arrested students and faculty and their protection against further attacks and arrests. "

"To sign this petition, please fill out this google form:

https://forms.gle/8i2bQrTrTKU45jZD9 

For information, please reach out to: academics-supporting-iranian-students@googlegroups.com 

[1]https://www.theguardian.com/world/2022/oct/01/women-life-liberty-iranian-civil-rights-protests-spread-worldwide

[2]https://www.theguardian.com/world/2022/sep/30/iranian-protesters-are-part-of-a-worldwide-fight-for-womens-rights

[3]https://www.reuters.com/world/middle-east/iran-lawmakers-chant-thank-you-police-amid-growing-public-fury-over-womans-death-2022-10-02/ 

[4]https://www.bbc.com/news/world-middle-east-63111767

[5] https://www.bbc.com/persian/world-63113519

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

Here's a story about the attack on Sharif University, in the NY Times

‘Geniuses’ Versus the Guns: A Campus Crackdown Shocks Iran. Universities across Iran have erupted in protests after more than decade of being politically dormant, with students joining the unrest that has convulsed the country for the past three weeks.  By Farnaz Fassihi

"The scenes that unfolded at Sharif University on Sunday afternoon were some of the most shocking in the three weeks of protests led by women calling for an end to the Islamic Republic’s rule that have convulsed Iran since a 22-year-old woman, Mahsa Amini, died in the custody of the morality police. Security forces have cracked down violently on the protests but they continue."

A Forum on Kidneys for Sale in Iran, in Transplant International

 Just published in Transplant International (which is the journal of the European Society for Organ Transplantation), is a paper describing the Iranian market for kidneys in the city of Mashad, and three commentaries on it.  

 Here's the original paper:

Kidneys for Sale: Empirical Evidence From Iran  by Tannaz Moeindarbari and Mehdi Feizi

And here are three short commentaries.

Kidneys for Sale? A Commentary on Moeindarbari’s and Feizi’s Study on the Iranian Model  by Frederike Ambagtsheer1, Sean Columb, Meteb M. AlBugami, and Ninoslav Ivanovski

Kidneys for Sale: Are We There Yet? (Commentary on Kidneys for Sale: Empirical Evidence From Iran) by Kyle R. Jackson, Christine E. Haugen, and Dorry L. Segev

Criminal, Legal, and Ethical Kidney Donation and Transplantation: A Conceptual Framework to Enable Innovation  by Alvin E. Roth, Ignazio R. Marino, Kimberly D. Krawiec and Michael A. Rees

***********

The commentary by Roth, Marino, Krawiec and Rees contrasts the legal Iranian market with the dangerous black markets that operate elsewhere, outside of regular medical institutions.

Here's a recent long article that pulls together much of the discussion on compensation for donors and on sale of kidneys and transplant black markets:

Organ Trafficking, Can the illicit trade be stopped? By Sarah Glazer,  CQ Researcher, June 24, 2022 – Volume 32, Issue 22

HT: Frank McCormick

Black market supply chains, Persian gulf stories

 Supply chains around the world are reacting to disruptions caused by Covid and other things. And those are mostly uncontroversial, uncontested legal supply chains.  For black markets things are even tougher. Here are two stories, about oil and arms, from the Persian gulf. Both are from the WSJ:

Smuggled Iranian fuel and secret nighttime transfers: Seafarers recount how it’s done  By Katie McQue

"The secret transfers usually take place at night to evade detection by regional coast guards. The ships anchor in the Persian Gulf just outside the territorial limits of the United Arab Emirates, and then, individually, small boats carrying smuggled Iranian diesel shift their loads to the waiting vessels, according to seafarers who have witnessed the trade.

“It is a big chain, with fishing boats sailing up to give diesel to a waiting tanker. It takes four to five days because boats come one by one,” said a 27-year-old Indian seafarer, who spoke on the condition of anonymity for fear of reprisals. He said he had been employed by a Dubai-based shipping company that smuggled Iranian fuel to Somalia.

...

"In addition to the nighttime transfers at sea, Iranian diesel bound for international markets is exported on tankers setting sail from Iran with the origin of the shipment forged to make it look as though it came from Iraq or the UAE, according to a third seafarer and three experts in security and energy affairs.

"Because of the profit margins, this trade was highly lucrative even before the United States pulled out of the nuclear deal. Iran has some of the world’s cheapest fuel prices thanks to very low production costs, heavy government subsidies and a weak currency. But the reimposed economic sanctions have given this business a further boost as smugglers seek to evade restrictions on Iranian oil exports. 

***********

Iran Navy Port Emerges as Key to Alleged Weapons Smuggling to Yemen, U.N. Report Says  By Benoit Faucon  and Dion Nissenbaum

"Thousands of rocket launchers, machine guns, sniper rifles and other weapons seized in the Arabian Sea by the U.S. Navy in recent months likely originated from a single port in Iran, according to a confidential United Nations report that provides some of the most detailed evidence that Tehran is exporting arms to Yemen and elsewhere.

"The draft report prepared by a U.N. Security Council panel of experts on Yemen said small wooden boats and overland transport were used in attempts to smuggle weapons made in Russia, China and Iran along routes to Yemen that the U.S. has tried for years to shut down. The boats left from the Iranian port of Jask on the Sea of Oman, the U.N. report said, citing interviews with the boat’s Yemeni crews and data from navigational instruments found on board."

An experimental study whose participants are compensated donors in the legal Iranian market for kidneys, by Kelishomi and Sgroi

 A recent working paper from Warwick reports an experiment and survey study whose participants are compensated kidney donors (and prospective donors) in the legal Iranian monetary market for kidneys.

Kelishomi, Ali Moghaddasi, and Daniel Sgroi. A Field Study of Donor Behavior in the Iranian Kidney Market. No. 1381. University of Warwick, Department of Economics, October 2021.

Abstract: Iran has the world’s only government-regulated kidney market, in which around 1000 individuals go through live kidney-removal surgery annually.  We report the results of the first field study of donor behavior in this unique and controversial market. Those who enter the market have low income, typically entering to raise funds.  They have lower risk tolerance and higher patience levels than the Iranian average.  There is no difference in rationality from population averages.  There is evidence of altruism among participants.  This might shed light on the sort of people likely to participate if other nations were to operate suchmarkets.

From the introduction:

"There is no doubt that the notion of paying for a kidney raises ethical concerns and some see this form of market transaction as incompatible with the “sacred value” of human life (Elias et al., 2015). However, given the apparent success of the Iranian kidney market and the existence  of long waiting lists, patient suffering and significant loss of life elsewhere, there has also been something of a re-evaluation of the potential for regulated organ markets in the developed world

...

"Given the nature of the debate it seems important to consider the characteristics of those likely to  come  forward  as  donors  if  a  market  is  established  and  to  ask  what  special  features  they may possess.  Since there is only one existent regulated market, this must involve a controlled examination of participants in the Iranian kidney market.  Our paper reports the outcome of an unprecedented first study of patient behavior in the Iranian kidney market in which we obtained direct access to donors before and after surgery. We provided full incentives where appropriate during our experimental treatments, providing incentive payments of around $50 (in terms of purchasing power parity) on top of a show-up fee of roughly $15.2 We also collected data that is similar to existing generic data on the Iranian population. This allows us to not only provide comparisons within our sample but also between our sample and Iranian averages where data is available.

...

" The study started in August 2017 (shortly after the end of sanctions between the UK and Iran) and live sessions continued until May 2019,with further telephone interviews and follow-up sessions continuing until February 2021.  78 subjects were first interviewed post-donation while the remaining 137 were interviewed pre-donation.  Of the pre-donation group 91 were contacted a second time to confirm their final status in February 2021.  35 had donated by this point with the remaining 56 dropping out of the market (30 for medical reasons and 26 through choice).  Following this process we were able to measure behavioral variables such as risk aversion, time preference (patience), altruism, rationality (consistency with GARP, the generalized axiom of revealed preference), and a wide variety of demographic and socioeconomic data.  Where feasible we incentivized answers and used the most prominent measures available.  We also examined why these patients enter the market and what alternatives might have been available to them.  We are able to compare our patient data with available data for typical Iranians to provide a benchmark (Falk et al., 2018)

...

"While the typical donor is in considerable financial difficulty, they are significantly more patient and exhibit lower tolerance for risk than an average Iranian (though conditional on entering the market those with lower patience are more likely to have donated during our study).   Those who go through with the process exhibit higher levels of altruism than those who drop out.   We find no difference in rationality between participants in the market and the subjects in a leading study of rationality from which we take our core measure  (Choi  et  al.,  2014).   We  would  argue  that  alternative  options  for  those  in  financial difficulty such as approaching a loan shark might be more appealing to the risk-loving (and perhaps more impatient) since this offers an immediate solution but replaces it with a serious and risky long-term liability, while the organ market is a difficult short-term prospect but does not result in higher levels of debt in the long run. Our findings on altruism are consistent with the idea that, while donors are being paid, they are nevertheless taking part in a difficult process that has the potential of saving a life, and this may also be important when considering alternatives."

#####

Update: here's the published paper

Kelishomi, Ali Moghaddasi, and Daniel Sgroi. A Field Study of Donor Behavior in the Iranian Kidney Market. European Economic Review, Volume 170, 2024

Laws and law enforcement for actions whose illegality is controversial (the case of 'honor killing')

Repugnant transactions and actions are sometimes banned with the full force of the law: consider  e.g. narcotics trafficking in the U.S., where our prisons are full of people convicted of drug crimes.   But sometimes, a legal ban comes with just a slap on the wrist: e.g., also in the U.S., prostitution is illegal almost everywhere, but mostly treated as a misdemeanor, not a serious crime. 

The punishment may not always fit the crime, but it tells us something about how legislators view the seriousness of the crime. 

So I was struck by the first sentences of this NY Times story about an "honor killing" in Iran:

A Daughter Is Beheaded, and Iran Asks if Women Have a Right to Safety
The so-called honor killing of a 14-year-old girl in Iran has shaken the country and forced an examination of its failure to protect women and children.

"Before he beheaded his 14-year-old daughter with a farming sickle, Reza Ashrafi called a lawyer.

"His daughter, Romina, was going to dishonor the family by running off with her 29-year-old boyfriend, he said. What kind of punishment, he asked the lawyer, would he get for killing her?

"The lawyer assured him that as the girl’s guardian he would not face capital punishment but at most 3 to 10 years in jail, Mr. Ashrafi’s relatives told an Iranian newspaper.

"Three weeks later, Mr. Ashrafi, a 37-year-old farmer, marched into the bedroom where the girl was sleeping and decapitated her.

Market design, in Farsi

Here's an article in Farsi, from an Iranian blog:

طراحی بازار؛ حیات جدید اقتصاددانان دنیا

امروزه اقتصاددانان تنها برای تحلیل بازار فراخوانده نمی شوند بلکه از آن ها برای طراحی بازارها نیز کمک می‌گیرند. این نخستین شماره از پرونده راهبرد معاصر در معرفی زوایایی کمتر شناخته شده از دانش اقتصاد است.

Google translate: "Market Design; The New Life of World Economists.  Today, economists are not only called upon to analyze the market, but also to help design markets."

The Iranian kidney market in Mashhad, by Mehdi Feizi and Tannaz Moeindarbari in Clinical Transplantation

Here's a new article in Clinical Transplantation:

Characteristics of kidney donors and recipients in Iranian kidney market: Evidence from Mashhad
Mehdi Feizi  Tannaz Moeindarbari
First published: 06 August 2019 https://doi.org/10.1111/ctr.13650

Abstract: The Iranian model of kidney transplantation is an example of a regulated living unrelated renal donation. In this paper, we collected and analyzed a unique dataset of 436 paired kidney donors and recipients, including their characteristics and the realized price of a kidney in Mashhad. As opposed to the global picture of kidney donation, we find that women are less likely to donate and more likely to receive a kidney. Moreover, the average price of a kidney amounts less than 2 years of work with the minimum level of wage.
***********

The article elicited a commentary by Gabe Danovitch, an eminent nephrologist at UCLA who speaks and writes frequently in opposition to compensation for donors:

COMMENTARY
Financial neutrality should replace the Iranian paid donor market
Gabriel Danovitch
First published: 16 July 2019 https://doi.org/10.1111/ctr.13665

He explains his opposition to markets in general this way: "the term “regulated market” is oxymoronic with respect to markets in general and specifically when it comes to human organs..."

(One wonders how the market for nephrologists works, and for medical specialists and subspecialists generally.  Someone should study that...)
**********

The article on Mashhad includes some very interesting description of the market there:

"Since the first live kidney transplant in Mashhad on 2 April 1985 until December 2017, more than 2500 people have had a kidney transplant in the Montaserie Organ Transplantation Hospital. It is operating as a center for dialysis and the only center in Mashhad and neighboring regions for transplantation of kidney, liver, and bone marrow. According to the latest reports, more than 7000 people from different age groups are now waiting for a kidney in Mashhad.

"In Mashhad, approximately 60 individuals refer to the IKF every week to sell their kidney. Of these donors, about 15 individuals are actively pursuing the process, while the rest are dissuaded due to various reasons. Out of these individuals, about one‐fifth are medically approved for kidney donation, after the 3 or 4 weeks of examinations.

"From the demand perspective, every end stage renal disease (ESRD) patient aged below 70 in Khorasan Razavi Province without having a willing related donor is referred through a nephrologist's letter to the IKF in Mashhad to enter the kidney waiting list according to their blood type. These patients can be entered in the waiting list of hospitals to receive a kidney from a deceased donor as well.

"From the supply perspective, each potential kidney donor, between 22 and 40 years old, should register at the IKF after undergoing the preliminary medical tests and bringing the notarized consent of him/herself and his/her family, including both parents for singles, only the spouse for married men, and the spouse and both parents for married women.
...
There are four different matching lines for each blood type, and the IKF usually pair each donor with a renal patient with the matching blood type in the waiting list based on a first come, first‐served basis. Nevertheless, this is not the only way of matching, and both sides can also publically advertise and find each other outside the IKF matching system. However, they have to register there and do the required paperwork and medical tests, as the transplantation centers only accept donors referred by the IKF, as a market maker.

"A renal patient should pledge in cash half the official price of a kidney to the IKF following the initial registration of the waiting list. Once a patient is matched to a donor and they both agree upon a price, the patient pays the remaining price of a kidney to the IKF via a cheque. After carrying out the transplantation, the IKF transfers all the amount of money received from the patient to the donor. However, the IKF neither receives any financial interest nor benefits from any monetary transactions, as it is a charity after all. Although there is no official ceil price, the IKF in Mashhad informally tries its best to convince and incentivize the donor not to ask a high price.
...
"Almost all kidney donors mostly face severe and urgent financial needs, for example, paying off debts (especially home rentals and blood money) and even living expenses, especially for single‐mother households. Thus, financial issues constitute the most frequent and primary motive for living unrelated donors in Iran.
...
"According to this law, compensated kidney donation in Iran is only possible between two individuals from the same nationality with the legal residence permits, especially refugees in Iran from Afghanistan.

"Since there is a large number of Afghan refugees in Mashhad, the IKF has formed a limited market for them. At the main kidney market for Iranians, donors do not have to wait to find a match, as there are always patients looking for a compatible kidney, especially those with a rare blood type such as AB. However, at the kidney market for Afghans, there is no patient in a queue to get a kidney and donors have to stay on the waiting list to find a suitable recipient.

"Moreover, for Afghan citizens, the amount of money a patient should pay to compensate a donor is determined not based on the official price of a kidney in Iran, but rather in a wholly agreed manner. In 2014, the total cost of kidney transplantation was about 6329 USD. While the government pays all kidney transplantation costs for Iranian patients and donors, Afghan renal patients should pay the hospital fees and other costs related to transplantation, which is estimated about 350 million IRR, almost 8650 USD, and reaches about 800 million IRR, almost 19 775 USD, with the cost of kidney purchase.
...
[Among Iranians] "Not only donors tend to be financially motivated for donation, but also recipients are not wealthy, as 47% of them are unemployed."

Official and unoffical Iranian kidney marketplaces--online prices

The Journal of Urology has published an in-press short paper about an informal website that seems to operate alongside the official Iranian monetary market for kidneys. (Thanks to Jim Brooks for the pointer.)

 Donor Willingness to Accept for Selling a Kidney for Transplantation: Evidence from Iran  by Mehdi Feizi and Tannaz Moeindarbari

"The Iranian model of kidney donation, established in 1988, is a state-funded system of living  renal  transplant  where  the  government  pays  for  all  transplant-related  expenses.  The Iranian Kidney Foundation, IKF hereafter, is in charge to match recipients and compensated donors. On the supply side, each donor registers at the local IKF after conducting preliminary medical  tests.  On  the  demand  side,  any  ESRD  patient  could  enter  the  kidney  waiting  list according to his/her blood type. A renal patient is matched to a donor, basically with the same blood type, based on the first come, first served.

"Both sides could also find each other outside the IKF, say in an online kidney matching website. However, since the transplant is exclusively possible through an official letter from the IKF,  they  have to register there."
***********
The article goes on to analyze prices asked and offered for kidney donation at the online kidney website that they refer to, http://www.koliee.ir/ .  It's in Farsi, but when I ask Google to translate it, their home page looks pretty interesting.  (It seems to offer the opportunity to search for kidneys by price as well as blood type.)

It contains some cautionary sentences:

"If you want to reach your goal without problems on this website, refuse to pay any money before the operation. Also, carry out kidney donation only through the Association for the Protection of Nephrology in your city."

It would be interesting to understand how websites like this interact with the official kidney market.

They also have a list of "our other websites" (again, in translation). The first one deals with surrogacy:

 Rental uterus

 My card

 Kidney donation

 The purse

 Amateur crafts

 Toggle Finder

 Mbti test

 Hello

 Buy and Sell a Loan

 Gnocard

PBS asks: should the U.S. follow Iran in allowing a market for kidneys for transplant?

PBS asks the question
Iran pays kidney donors. Should the U.S. follow?

You can read the transcript or watch the video at the link.

HT: Mohammad Akbarpour

An anthropologist (Dr. Elham Mireshghi) looks at the market for kidneys in Iran

Elham Mireshghi completed her Ph.D. in Anthropology at UC Irvine in 2016. Her dissertation is
Kidneys on Sale? An Ethnography of Policy, Exchange, and Uncertainty in Iran

Here's the abstract:
"Since 1997, Iran has implemented the world’s only program for living paid kidney donation. The program has been developed and administered by a non-profit NGO – the Kidney Patient Foundation (KPF). Though sanctioned by Shi‘a Muslim jurists and celebrated in the West as the “Iranian Model,” the program has been rife with moral unease and uncertainty in Iran. While organ donation after death is valorized, undergoing transplantation for cash is stigmatized. Furthermore, there is little agreement among policy actors that facilitating paid organ giving is a good idea. In this dissertation, I examine kidney “selling” both at the level of the exchange – where I analyze the experiences of kidney givers and recipients – and at the level of institutional and bureaucratic process, legal and scientific reasoning, and practical and ethical negotiation, to explain how Iran came to uniquely sanction and bureaucratically routinize kidney selling. I disentangle the dense threads of moral reasoning and experience among a range of actors - from donors and recipients to doctors, policy activists, and Islamic jurists – that undergird the policy’s development and implementation. I have conducted ethnographic field research (2011-2013), including observation inside medical and Islamic institutions in Tehran and Qom, and indepth interviews of kidney givers and patients, KPF personnel, doctors and legal scholars and jurists. I have also analyzed Islamic legal texts, as well as visual and textual media.

"My analysis brings together analytic approaches within the anthropology of public policy, medicine, morality, and exchange, while also contributing to a growing interest in Iranian Studies to venture beyond themes of repression and resistance. I consider Iran’s living kidney giving program within the context of Iran’s post-revolution medical modernization projects, its haphazard economic liberalization, and ongoing commitment to social welfare, alongside an examination of the role of Islamic jurists and other “experts” in policy making. I elucidate the socio-economic conditions and aspirations that motivate kidney givers, and the “medical imaginary” that facilitates their decision as well as the legal reasoning of jurists. Lastly, I offer an alternative to the “commodity paradigm” in examining exchanges involving money that can contribute to bioethical discussions of organ sales."



Here's a paragraph describing the reduction in waiting time for a kidney transplant resulting from the market:

"The culmination of these regulations has resulted in a much shorter wait for kidney transplants in Iran than is the case in, for example, the United States, where paid donation is prohibited and most organs from unrelated donors come from cadavers and brain-dead individuals. This has often been touted as one of the most important outcomes of permitting kidney sales. In the US, if one does not find a donor among family or friends or an “altruist” living stranger, then the wait can take nearly four if not more years. In Iran, the wait can be a little over a year, if not less; though celebratory reports on what is now called the “Iranian Model” often claim that there is no waiting list at all .... If a patient chooses non-living donation, then much like the US the wait can take much longer than a year. "

Much of her interaction was with a social worker who was reluctant to enroll kidney sellers:
"Management was not unaware of Ms. xxx’s principled opposition to kidney selling and her attempts at talking people out of it. Ms. xxx explained to me once that she framed her activities as a benefit for the organization in the form of counseling for sellers. It would garner legitimacy for a program that had frequently come under domestic and international scrutiny, she argued. So management and Ms. xxx shared an interest in counseling prospective donors while assuring that a certain number made it to the list. For management, the interest had to do with protecting the organization’s credibility while also assisting in the treatment of suffering kidney patients. For Ms. xxx, it had to do with ensuring that fewer young men and women fell into what she called the “sick cycle of disease and poverty” (what she deemed to be the likely result of kidney selling) while also maintaining her employment."

One aspect of her work concerns the religious rulings that permit the Iranian kidney market.

Here's a quote from Ayatollah Makarem Shirazi  about what can be sold:
“The severing of an organ from a living person and the transplantation of that to someone whose kidneys have both decayed (fasid) is permissible on the condition that the owner (sahib) of the organ consents, and his life (jan) is not put into danger; and caution requires that if money is received in exchange, that it be in exchange for the permission to proceed with the taking (giriftan) of the organ, and not the organ itself.”

 I blogged about this part of Dr. Mireshghi's work earlier here:

Friday, June 5, 2015

The Shi'a religious jurisprudence behind Iran's legal market for kidneys

Kidney donor/sellers in Iran face social stigma--2 papers

The first of these two recently published papers is a report compiling interviews taken some time ago:

Coercion, dissatisfaction, and social stigma: an ethnographic study of compensated living kidney donation in Iran
Sigrid Fry‑Revere,  Deborah Chen,  Bahar Bastani,  Simin Golestani,  Rachana Agarwal, Howsikan Kugathasan, and Melissa Le
International Urology and Nephrology, https://doi.org/10.1007/s11255-018-1824-y, Online, February 2018

Abstract: "This article updates the qualitative research on Iran reported in the 2012 article by Tong et al. “The experiences of commercial kidney donors: thematic synthesis of qualitative research” (Tong et al. in Transpl Int 25:1138–1149, 2012). The basic approach used in the Tong et al. article is applied to a more recent and more comprehensive study of Iranian living organ donors, providing a clearer picture of what compensated organ donation is like in Iran since the national government began regulating compensated donation. Iran is the only country in the world where kidney selling is legal, regulated, and subsidized by the national government. This article focuses on three themes: (1) coercion and other pressures to donate, (2) donor satisfaction with their donation experience, and (3) whether donors fear social stigma. We found no evidence of coercion, but 68% of the paid living organ donors interviewed felt pressure to donate due to extreme poverty or other family pressures. Even though 27% of the living kidney donors interviewed said they were satisfied with their donation experience, 74% had complaints about the donation process or its results, including some of the donors who said they were satisfied. In addition, 84% of donors indicated they feared experiencing social stigma because of their kidney donation."

Here's an excerpt from the discussion of social stigma:  

"Some donors had a general sense that people had negative impressions of donors. One donor pointed out, “When people find out that you have donated, they start looking at you in a different way. They start keeping their distance.” Another donor explained what he thought was going through
people’s heads: “Oh, he sold his kidney, he’s not a good person.”
***********
and here's a paper with reports from an internet survey:

The Social Stigma of Selling Kidneys in Iran as a Barrier to Entry: A Social Determinant of Health
Mohammad Mehdi Nayebpour  Naoru Koizumi
World Medical and Health Policy, Volume10, Issue1, March 2018,
Pages 55-64
"Abstract
Iran is the only country in the world currently with a legalized compensated kidney donation system, in which kidney sellers are matched with end‐stage renal disease patients through a regulated process. From a practical point of view, this model provides an abundance of kidneys for transplantation as opposed to the American model that relies on altruistic donation. The major concern about adopting the Iranian model is the possibility of exploitation. A large body of literature exists on this topic, but few have focused on its cultural aspects. This paper sheds light on the cultural implications of the Iranian model by providing empirical evidence on the social stigmas against kidney sale in Iran. We claim that these stigmas act as barriers to entry to the supply market of kidneys. Due to the conditions created by social stigmas, kidney sellers are forced to consider not only monetary rewards but also cultural factors. Thus, they tend to be more cautious and try to avoid impulsive decisions. Such social stigmas act as unofficial regulatory forces to keep kidney sale as the last resort for the poor, to diversify the supply market by age, and to stretch the decision‐making process in the absence of a mandatory waiting period for transplantation."

from the discussion:
"Our survey demonstrated that an immense amount of negative stigma is directed toward kidney sellers in Iran from society. Comparison of our findings to those reported by Ghods et al. (2001), who studied the actual characteristics of kidney sellers, reveals stark differences between perception and reality. Ghods et al. interviewed 500 kidney sellers in Iran in 2001 (Ghods et al., 2001). The study reports that only 6 percent of them were actually illiterate (while 71 percent of our respondents thought kidney sellers are illiterate), 88 percent had elementary to high school degree (while only 22 percent of our respondents thought kidney sellers have a high school education), and 6 percent had university degrees and above (6 percent of our respondents thought kidney sellers have above high school education). This gap between the actual profile and the perception of kidney sellers indicates that while Iranians benefit from the current policy, they have a grave stigma against it. The other important gap between perception and reality appears in question 5. About 15 percent of people consider that kidney sellers are drug addicts and 56 percent are not sure whether kidney sellers are drug addicts or not. This particular perception is stunning, since by law kidney sellers undergo a series of strict medical tests before becoming eligible for selling. "

More debate about legalizing kidney sales

There's nothing new in this debate, but here is more on compensating kidney donors.  As far as I can see, the weakest argument against compensating donors is that the illegal black markets for kidneys work badly...

From Gizmodo:
Should You Be Allowed to Sell Your Kidney?

Gabe Danovitch, a distinguished transplant nephrologist and an active opponent of compensation for donors, is quoted saying this about markets:
"Any attempt at so-called regulating… a market, by definition, is not regulated. Markets don’t like regulations. Let’s say we were to allow a regulated market, and a donor would get $30,000. I’m just throwing this out. Why wouldn’t Singapore say you can get 50? In Doha you can get 80? And why wouldn’t the donors go around the world to get the best price? If we were to do that in the United States, it would be a disaster."

This argument strikes me as strange: is the problem with compensating donors  that it might open up competition for American transplant centers??

Danovitch also makes an argument that, as a nephrologist who evaluates potential donors, he couldn't trust them as much if they were getting paid.
**************

On a related matter, this from the LA Times
'Kidney for sale': Iran has a legal market for the organs, but the system doesn't always work

The Iranian kidney market--Associated Press

The Associated Press has a nice story on the Iranian market in which donors can be compensated for kidneys. Here's the version in the Denver Post

In Iran, unique system allows payments for kidney donors

Some interesting paragraphs:

"Iran started kidney transplants in 1967 but surgeries slowed after the 1979 Islamic Revolution and the storming of the U.S. Embassy in Tehran, in part due to sanctions. Iran allowed patients to travel abroad through much of the 1980s for transplants — including to America. But high costs, an ever-growing waiting list of patients and Iran’s grinding eight-year war with Iraq forced the country to abandon the travel-abroad program.

"In 1988, Iran created the program it has today. A person needing a kidney is referred to the Dialysis and Transplant Patients Association, which matches those needing a kidney with a potential healthy adult donor. The government pays for the surgeries, while the donor gets health coverage for at least a year and reduced rates on health insurance for years after that from government hospitals.

"Those who broker the connection receive no payment. They help negotiate whatever financial compensation the donor receives, usually the equivalent of $4,500. They also help determine when Iranian charities or wealthy individuals cover the costs for those who cannot afford to pay for a kidney.

"Today, more than 1,480 people receive a kidney transplant from a living donor in Iran each year, about 55 percent of the total of 2,700 transplants annually, according to government figures. Some 25,000 people undergo dialysis each year, but most don’t seek transplants because they suffer other major health problems or are too old.

"Some 8 to 10 percent of those who do apply are rejected due to poor health and other concerns. The average survival rate of those receiving a new kidney is between seven to 10 years, though some live longer, according to Iranian reports.
...

"Poverty around the world drives black market kidney sales, a lucrative business the World Health Organization estimated represented at least 5 percent of all transplants in 2005, though it acknowledges that figure is only a guess. The U.N. health agency’s guiding principles on organ transplantation call for banning organ sales, though it allows for “reimbursing reasonable and verifiable expenses,” including the loss of income by a living donor."

Organ transplantation in Iran

Robert Gutman draws my attention to this article from the English language Iranian Financial Tribune:  Sunday, April 23, 2017 Strides in Organ Transplant

I'm not sure where the claim in the first sentence of 50,000 organ transplant "surgeries" comes from, but the rest of the article (which seems to talk about a total closer to 5,000 transplants) is an interesting view of the situation in Iran.


"Over 50,000 organ transplant surgeries were conducted during the last fiscal year that ended on March 20.

Around 2,500 kidney, 802 liver, 119 heart, 30 pancreas and several intestine and lung as well as 1,040 bone marrow transplants were performed in Iran during the period, said Seyyed Mohammad Kazemeini, head of the Organ Transplant Management Office at the Health Ministry.

“This impressive number of transplant surgeries has helped save many lives as well as more than $1.8 billion in foreign exchange, as patients would otherwise have paid huge amounts for the medical help abroad. Some were even treated free,” the official was quoted as saying by ISNA.

However, he regretted that insurance companies still refuse to cover expenses of organ transplants despite a government directive last year.

“Insurance companies are not complying and the Health Ministry has to draw on its own resources to provide free services for some patients,” he said and hoped the ministry’s support would continue.

“During this year’s New Year holidays (March 21- April 2), 93 transplants were performed,” which shows the preparedness of the medical fraternity.

Iranian organ transplant teams are capable of providing assistance and training to neighboring countries, he said.

Last year a team of experts from Mashhad, capital of the northeastern Khorasan Razavi Province, carried out 47 renal transplants in Afghanistan, and medical teams from Shiraz, capital of the southwest Fars Province, conducted 20 operations in Pakistan and Tajikistan.

Shiraz University of Medical Sciences is known for its accomplishments in liver transplants and the hospitals under its coverage are among the top medical centers in the world with regard to the number of surgeries performed. On average, 500 liver transplants and 300 kidney surgeries are annually undertaken in Shiraz, which also has the distinction of performing the first kidney transplant in Iran in 1968 at the prestigious Namazi Hospital.

A specialized hospital is now planned to be established in Shiraz for organ transplants.

Iran ranks third worldwide in organ donation and is the only country in the world that has addressed the shortage of transplant organs through a legal payment system since 1988 when living non-related donation (LNRD) was legalized,  making it the only country where organ sale is legal.

There are currently 46 organ transplant centers in the country and 25 facilities for organ donation.

  Increase in Brain-Dead Organ Donation

According to Kazemeini, people’s tendency to donate organs of brain-dead patients in their families has increased significantly.

“Last year, 57% of transplant kidneys were donated by brain-dead patients,” he said.

In the past organ donation or sale by living people was predominant. The acceptance of organs of brain-dead patients has improved remarkably due to legal and religious decrees and widespread awareness campaigns on the issue.

Organ transplant is a medical procedure in which an organ is removed from one body and placed in the body of a recipient, to replace a damaged or missing organ.

Today, over 1.4 million people have voluntary organ donation cards in the country. On average, 700 organ donations (nine per million people) are made annually according to official statistics.

Organs that have been successfully transplanted include heart, kidney, liver, lung, pancreas, intestine, and thymus. Worldwide, kidneys are the most commonly transplanted organs, followed by liver and heart. Organ donors may be living, brain dead, or dead via circulatory death.

In the fiscal year that ended in March 2016, from among the 8,000 people confirmed as brain dead at Iranian hospitals, 1,400 kidneys (and 2,300 organs) were donated.

Kidney transplants account for nearly 75% of all organ replacement surgeries while liver and heart transplants comprise 22% and 3% of the total number. More than half of all transplanted kidneys (56%) were from brain-dead donors and 44% were from living people.

Kazemeini had earlier pointed to Iran’s top position in the field of kidney transplant in the Middle East. On average, 3,000 kidney transplants are conducted every year and Iranian surgeons have transplanted over 35,000 kidneys so far."

Mohammad Akbarpour on Iran's kidney market

My colleague Mohammad Akbarpour at Stanford GSB is featured in their newsletter.  

He thinks about kidney transplantation from a number of different angles...here's a snippet.

Is It Ever OK to Sell (or Buy) a Kidney?

"Iran’s paid kidney market emerged after the country’s revolution at the end of the 1970s. In the early ’80s, foreign sanctions against the government inhibited its ability to get dialysis machinery. The number of Iranians needing a kidney transplant, however, kept increasing, so in 1988 the government organized a system that regulated and funded kidney transplantation. Their system included compensation for donors.

Officials euphemistically described the money given to each donor as a “gift,” says economist Mohammad Akbarpour, an assistant professor of economics at Stanford Graduate School of Business, who, has been working with several colleagues to study Iran’s market and unpaid kidney exchange markets globally. “They were paying for it, but using different words,” says Akbarpour. The system worked so well that the kidney transplant wait list in Iran was nearly eliminated by 1999.

“We have this discussion in the West about what would happen if you have a paid market for kidneys,” says Akbarpour. “The expectation has been that poor people will be selling their kidneys to rich people. But the debate has been largely based on speculations, as opposed to evidence.”

Akbarpour looked at five years’ worth of data about kidney sales and transplantation in the country, and his preliminary findings show that the average wealth of those buying kidneys is almost exactly the same as the average wealth of Iranians. Most of the payment for each transplant comes from the patient, not the government.

“It’s not just rich people who can buy a kidney in Iran,” he says. “Even poor people find the money for it, because it’s so valuable. There are also charities they can tap.”

But one suspected consequence of a cash market for kidneys did turn out to be true: Poor people sell kidneys far more than any other economic group. In Iran, most kidneys come from those whose incomes are in the bottom 25% of earners."

Opposition to kidney sales in Iran

Afshin Nikzad points me to the following story in Farsi, and provides the translation below. He writes:

http://donya-e-eqtesad.com/SiteKhan/1136026/

"I edit/copy parts of the article from google translate (since it didn't give a great translation) : 

The 78 years old residing in America in an interview with US media said he had been in America for a kidney transplant and doctors had told him he should stay on the waiting list for a kidney transplant from brain death or that of one of his two children. All catch. But he found a third way through his Iranian birth certificate: buying a kidney in Iran. In his interview he talked about the youth in Iran who from the poverty and desperation were lined up to speak to him for selling their kidney.

Doctor, "Ali Husseini,” the head of the Transplantation Society of the Middle East in response to the letter, said: "Buying and selling kidney with strangers is dirty and inhumane and is banned even in countries like India and Pakistan" He also said “among all the thousands seller in the country there is not a single a rich person, all were poor and sold the kidney from poverty and desperation; undoubtedly they  have not donated their kidney.”

Dr. Mohammad Reza Ganji, head of the Iranian Society of Nephrology said “… In the past two years  63% of the transplants have been from brain-dead (that is two thousand and six hundred transplants), and this is statistically significant in the world."

The Iranian market for kidneys

The AP has published this descriptive story about the Iranian market for kidneys:
IN IRAN, UNIQUE SYSTEM ALLOWS PAYMENTS FOR KIDNEY DONORS BY NASSER KARIMI AND JON GAMBRELL

Some paragraphs from the story:

"The AP gained rare access to Iran's program, visiting patients on dialysis waiting for an organ, speaking to a man preparing to sell one of his kidneys and watching surgeons in Tehran perform a transplant. All of those interviewed stressed the altruistic nature of the program - even as graffiti scrawled on walls and trees near hospitals in Iran's capital advertised people offering to sell a kidney for cash.
...
Iran started kidney transplants in 1967 but surgeries slowed after the 1979 Islamic Revolution and the storming of the U.S. Embassy in Tehran, in part due to sanctions. Iran allowed patients to travel abroad through much of the 1980s for transplants - including to America. But high costs, an ever-growing waiting list of patients and Iran's grinding eight-year war with Iraq forced the country to abandon the travel-abroad program.

In 1988, Iran created the program it has today. A person needing a kidney is referred to the Dialysis and Transplant Patients Association, which matches those needing a kidney with a potential healthy adult donor. The government pays for the surgeries, while the donor gets health coverage for at least a year and reduced rates on health insurance for years after that from government hospitals.

Those who broker the connection receive no payment. They help negotiate whatever financial compensation the donor receives, usually the equivalent of $4,500. They also help determine when Iranian charities or wealthy individuals cover the costs for those who cannot afford to pay for a kidney.

Today, more than 1,480 people receive a kidney transplant from a living donor in Iran each year, about 55 percent of the total of 2,700 transplants annually, according to government figures. Some 25,000 people undergo dialysis each year, but most don't seek transplants because they suffer other major health problems or are too old.

Some 8 to 10 percent of those who do apply are rejected due to poor health and other concerns. The average survival rate of those receiving a new kidney is between seven to 10 years, though some live longer, according to Iranian reports.

In the United States, about a third of kidney donations come from living donors. The average kidney from a deceased donor lasts 10 years, while one from a living donor averages about 15 years, according to Dr. David Klassen of the United Network for Organ Sharing, or UNOS, which oversees the U.S. transplant system. Recipients of living-donor kidneys in the U.S. fare better in part because they haven't been on dialysis as long before their transplant."

A skeptical view of the Iranian market for kidneys, from Shiraz

Here's an article (gated) from a recent issue of Transplantation, describing how the transplant program in Shiraz is discouraging patients from the (legal) market there for buying kidneys from living unrelated donors (they impose a six month waiting time for such transplants). Most patients who have transplants at Shiraz are receiving deceased donor kidneys.

Transplantation:

June 2016 - Volume 100 - Issue 6 - p 1165–1169

doi: 10.1097/TP.0000000000001164

In View: Around the World

Paid Living Donation and Growth of Deceased Donor Programs

Ghahramani, Nasrollah MD

Abstract

Abstract: Limited organ availability in all countries has stimulated discussion about incentives to increase donation. Since 1988, Iran has operated the only government-sponsored paid living donor (LD) kidney transplant program. This article reviews aspects of the Living Unrelated Donor program and development of deceased donation in Iran. Available evidence indicates that in the partially regulated Iranian Model, the direct negotiation between donors and recipients fosters direct monetary relationship with no safeguards against mutual exploitation. Brokers, the black market and transplant tourism exist, and the waiting list has not been eliminated. Through comparison between the large deceased donor program in Shiraz and other centers in Iran, this article explores the association between paid donation and the development of a deceased donor program. Shiraz progressively eliminated paid donor transplants such that by 2011, 85% of kidney transplants in Shiraz compared with 27% across the rest of Iran's other centers were from deceased donors. Among 26 centers, Shiraz undertakes the largest number of deceased donor kidney transplants, most liver transplants, and all pancreas transplants. In conclusion, although many patients with end stage renal disease have received transplants through the paid living donation, the Iranian Model now has serious flaws and is potentially inhibiting substantial growth in deceased donor organ transplants in Iran.