Farmers in India petition to be allowed to sell organs

I (would like to) assume that this story from India only concerns sale of live kidneys for transplantation, but it isn't completely clear to me, given the mention of suicides due to debt:

Allow us to sell our organs to repay our debts, farmers tell PM

"Unable to repay bank loans and to highlight their miserable plight, a group of farmers from Haryana have sought permission from Prime Minister Manmohan Singh to allow them to sell their vital organs.

"The farmers' group who held a rally at Kurukshetra on Monday under the aegis of Bharat Kisan Union (Tikait), held placards displaying a rate list of their organs.

"Later, 33 farmers handed over a letter to the Kurukshetra Tehsildar to be forwarded to the Prime Minister, BKU's state unit chief Gurnam Singh said on Tuesday.

"We are left with no other option, but to sell our vital organs. Over 20,000 farmers have ended their lives across the country due to debt burden. At least, selling our organs would enable us to repay the debt and live for a few years more and feed our families," he said."

HT: Sangram Kadam

*****************
We'll be traveling in India in the coming days, so at least some of my blog posts will be from inventory...

Who volunteers for the volunteer army?

When I was young, the Viet Nam was was underway, and the way the American army got many soldiers was by conscription. But conscription ended in 1973, the Army has been an all volunteer force since then.

One reason it's interesting to look at who American soldiers are is because of the light it might shed on other debates, such as the one about whether living kidney donors should be compensated, and what would be the likely change in the pattern of donations should the law be changed to allow that.  One concern that arises is that, if kidneys could be bought and sold, the sellers would be the poorest of the poor, in desperation.

That isn't who end up in the American Army, it turns out. Here's a 2008 report from the Heritage Foundation that casts some light on the subject. It appears that being an American soldier is a good enough job that you have to have substantial human capital to be able to qualify.

Who Serves in the U.S. Military? The Demographics of Enlisted Troops and Officers
By Shanea Watkins, Ph.D. and James Sherk

"Based on an understanding of the limitations of any objective definition of quality, this report compares military volunteers to the civilian population on four demographic characteristics: household income, education level, racial and ethnic background, and regional origin. This report finds that:

1. U.S. military service disproportionately attracts enlisted personnel and officers who do not come from disadvantaged backgrounds. Previous Heritage Foundation research demonstrated that the quality of enlisted troops has increased since the start of the Iraq war. This report demonstrates that the same is true of the officer corps.
2. Members of the all-volunteer military are significantly more likely to come from high-income neighborhoods than from low-income neighborhoods. Only 11 percent of enlisted recruits in 2007 came from the poorest one-fifth (quintile) of neighborhoods, while 25 percent came from the wealthiest quintile. These trends are even more pronounced in the Army Reserve Officer Training Corps (ROTC) program, in which 40 percent of enrollees come from the wealthiest neighborhoods-a number that has increased substantially over the past four years.
3. American soldiers are more educated than their peers. A little more than 1 percent of enlisted personnel lack a high school degree, compared to 21 percent of men 18-24 years old, and 95 percent of officer accessions have at least a bachelor's degree.
4. Contrary to conventional wisdom, minorities are not overrepresented in military service. Enlisted troops are somewhat more likely to be white or black than their non-military peers. Whites are proportionately represented in the officer corps, and blacks are overrepresented, but their rate of overrepresentation has declined each year from 2004 to 2007. New recruits are also disproportionately likely to come from the South, which is in line with the history of Southern military tradition.

The facts do not support the belief that many American soldiers volunteer because society offers them few other opportunities."

HT: Volokh conspirators

Non-directed kidney donors are increasing (and are increasingly important)

Here's a story on the increasing number of non-directed kidney donors: Amid organ shortage, altruistic kidney donations increase but bring forth ethical debate

This line caught my eye:
 "It's difficult to pinpoint a single reason for the uptick, but more than 50 percent of altruistic donations ever performed -- 1,374 as of April -- came after 2009, when numbers of traditional living donors started falling."

I am only speculating, but I'm guessing that the relatively small drop in live kidney donation has to do with the recession: when times are hard, it's harder to arrange time for a kidney surgery, since we don't allow donors to be compensated, and aren't even as good as we should be at covering their costs.
As for the growth of non-directed donations since 2009, that's when the first non-simultaneous non-directed donor chain was reported in the New England Journal of Medicine, and that and other long chains since then may have garnered enough publicity (such as this and this) to spread the word to potential donors.

In any event, chains started by non-directed donors are an increasingly important part of kidney exchange today, for reasons explored here.

Ron Paul on paying organ donors

Ron Paul: End government control of organ transplants and compensate donors

"In his weekly Texas Straight Talk column — which has continued after his departure from Congress in January — Paul called for a repeal of he federal ban on compensating organ donors. Calling the support of the current system nonsensical, Paul asked, “If we trust the market to deliver food, shelter, and all other necessities, why should we not trust it to deliver health care- including organs?”"

Here's his column in full:

***Please note: This is the temporary home for my weekly column until my personal web page is up and running.***

Let Market Forces Solve Organ Transplant Crisis

Ten-year old cystic fibrosis patient Sarah Murnaghan captured the nation’s attention when federal bureaucrats imposed a de facto death sentence on her by refusing to modify the rules governing organ transplants. The rules in question forbid children under 12 from receiving transplants of adult organs. Even though Sarah’s own physician said she was an excellent candidate to receive an adult organ transplant, government officials refused to even consider modifying their rules.

Fortunately, a federal judge intervened so Sarah received the lung transplant. But the welcome decision in this case does not change the need to end government control of organ donations and repeal the federal ban on compensating organ donors.

Supporters of the current system claim that organ donation is too important to be left to the marketplace. But this is nonsensical: if we trust the market to deliver food, shelter, and all other necessities, why should we not trust it to deliver healthcare—including organs?

It is also argued that it is “uncompassionate” or “immoral” to allow patients or insurance companies to provide compensation to donors. But one of the reasons the waiting lists for transplants is so long, with many Americans dying before receiving a transplant, is because of a shortage of organs. If organ donors, or their heirs, were compensated for donating, more people would have an incentive to become organ donors.

Those who oppose allowing patients to purchase organs should ask themselves how compassionate is it to allow those people to die on the transplant waiting list who might otherwise have lived if they were able to obtain organs though private contracts.

Some are concerned that if organ donations were supplied via the market instead of through government regulation, those with lower incomes would be effectively denied access to donated organs. This ignores our current two-tier system for allocating organs, as the wealthy can travel overseas for transplants if they cannot receive a transplant in America. Allowing the free market to alleviate the shortage of organs and reduce the costs of medial procedures like transplants would benefit the middle class and the poor, not the wealthy.

The costs of obtaining organs would likely be covered by most health insurance plans, thus reducing the costs directly borne by individual patients. Furthermore, if current federal laws distorting the health care market are repealed, procedures such as transplants would be much more affordable. Expanded access to health savings accounts and flexible savings accounts, combined with generous individual tax deductions and credits, would also make it easier for people to afford health care procedures such as transplants.

There is also some hypocrisy in the argument against allowing market forces in organ transplants. Everyone else involved in organ transplantation procedures, including doctors, nurses, and even the hospital janitor, receives compensation. Not even the most extreme proponent of government-provided health care advocates forcing medical professionals to provide care without compensation. Hospitals and other private institutions provide compensation for blood and plasma donations, and men and women are compensated for donations to fertility clinics, so why not allow compensation for organ donation?

Sarah Murnaghan’s case shows the fallacy in thinking that a free-market system for organ donations is less moral or less effective than a government-controlled system. It is only the bureaucrats who put adherence to arbitrary rules ahead of the life of a ten-year old child. It is time for Congress to wake up and see that markets work better in all aspects of health care, including organ donation, just as they work better in providing all other goods and services.

Permission to reprint in whole or in part is gladly granted, provided full credit is given.

Egg donation in Israel at a new, higher price

Egg donors to be compensated with NIS 19,000

"The Knesset's Labor, Welfare and Health Committee approved raising compensation sum to egg donors to NIS 19,000 ($5200) due to lack of donors.

"Since the bill to allow women to donate eggs in Israel was approved over a year and a half ago, only seven women had donated eggs, and were given NIS 10,000 ($2800). The Health Ministry requested to raise the compensation total in order to increase the number of donors due to severe shortage of eggs."

Compensating kidney donors with charitable contributions--Choi, Gulati and Posner

Organ shortages remain despite the increase in live donation that has accompanied kidney exchange. But it is illegal to pay donors, so there's an ongoing discussion of other ways to induce a greater supply.  Here's a proposal by Choi, Gulati and Posner...

Altruism Exchanges and the Kidney Shortage

Stephen J. Choi 

New York University School of Law

G. Mitu Gulati 

Duke University - School of Law

Eric A. Posner 

University of Chicago - Law School
January 16, 2013

University of Chicago Institute for Law & Economics Olin Research Paper No. 630
NYU Law and Economics Research Paper No. 13-03 
Abstract:      
Not enough kidneys are donated each year to satisfy the demand from patients who need them. Strong moral and legal norms interfere with market-based solutions. To improve the supply of kidneys without violating these norms, we propose legal reforms that would strengthen the incentive to donate based on altruistic motives. We propose that donors be permitted to donate kidneys in exchange for commitments by recipients or their benefactors to engage in charitable activity or to donate funds to charities chosen by donors. And we propose that charities be permitted to create Altruism Exchanges, which would permit large numbers of altruists to make charitable exchanges with each other, including but not limited to kidney donations. Altruism Exchanges would solve two significant problems with the current system of voluntary kidney donations: the risk of default and the lack of liquidity.



 HT: Alexander Berger

New in Iran: Donate one of your kidneys to be exempted from military service

There's a new development regarding kidney donation and sales in Iran. Google translate renders the headline Donate one of your kidneys to be exempted from military service

I am assured on good authority that the story says that kidney donors will be exempted from military service.

Here's how Google Translate renders the story:

"Acting Human Resources department Stadkl Armed Forces exemptions from military service the soldiers announced the donor organ. According to ISNA, General Moussa Kamali on donor exemption from military service, said the donor organ to make it happen efficiency, We'll exempt him from military service. According to him, for example, people who donate one of his kidneys has been the inclusion of medical waivers are exempt from military service. Stadkl Armed Forces Acting Human Resources department stating Srfdashtn donation card member, was not the reason for exemption from military service, said those who donate their organ, even during military service are exempt from military service."


Here's the article in Farsi: http://www.alef.ir/vdcgnu9qzak9774.rpra.html?187850 for those who can make your own translation.

HT: Mohammad Akbarpour

Economic rewards to motivate blood donations, by Lacetera, Macis and Slonim

This just out in Science: Economic rewards to motivate blood donations. It suggests that old conclusions need to be revisited based on new evidence.

"The position and guidelines of the World Health Organization (WHO) and several national blood collection agencies for nearly 40 years have been based on the view that offering economic incentives to blood donors is detrimental to the quantity and safety of the blood supply (1). The guidelines suggest that blood should be obtained from unpaid volunteers only (2). However, whether economic incentives positively or negatively affect blood donations (and other prosocial activities) has remained the subject of debate since the positions were established (2–8).

"Evidence consistent with the WHO position came originally from uncontrolled studies using nonrandom samples and, subsequently, from surveys and laboratory studies indicating that economic incentives can “crowd out” (decrease) intrinsic motivations to donate and can attract “worse” donors (9). This evidence arguably affected policies, such as bans on compensation for blood and organ donations in many countries.
...
"With a few early exceptions based on small, nonrepresentative samples (12), field trial evidence on how economic incentives affect blood donations has been absent. But field-based evidence from large, representative samples has recently emerged. The results are clear and, on important questions, opposite to the uncontrolled studies, surveys, and laboratory evidence preceding them."
...
"Conclusion

"In light of the recent evidence, it is time to re-examine policy guidelines for increasing and smoothing blood supply, including whether incentives can play a role. There are efforts under way from different parts of society toward using rewards to increase donations. The U.S. 9th Circuit Court of Appeals' 2012 ruling legalizing compensation for bone marrow donations through apheresis was initiated by private individuals (32). A company prompted a 2010 European Court of Justice ruling that allowed importation of blood products obtained from compensated donors (33). Researchers and clinicians have noted that some WHO guidelines (e.g., emphasis on exclusive use of nonremunerated donors and centralizing blood collection organizations) are unintentionally adversely affecting blood collection in sub-Saharan Africa (34).

"In addition to economic incentives, policy-makers should consider nonpecuniary rewards (e.g., symbolic and with social recognition) and various appeals. Debates on ethical issues around giving rewards for donations (35) should be encouraged. But there should be little debate that the most relevant empirical evidence shows positive effects of offering economic rewards on donations."

5 Are Convicted in Kosovo Organ Trafficking

Here's the story from the NY Times: 5 Are Convicted in Kosovo Organ Trafficking

"Five people were convicted Monday in Pristina, the capital of Kosovo, in connection with an elaborate organ-trafficking network that lured poor people to the country to sell their kidneys and other organs to wealthy transplant recipients from Israel, the United States, Canada and Germany. Organs sold for as much as $130,000 each.
"The defendants, all Kosovars, were tried before a panel of two European Union judges and one Kosovar judge. A special prosecutor for the union, Jonathan Ratel, called the case a landmark because doctors had been convicted.
...
“The sole and driving motive for this exploitation of the poor and the indigent was the opportunity for obscene profit and human greed,” Mr. Ratel, the prosecutor, said Monday. “In every sense this was a cruel harvest of the poor.”
...
"According to the indictment in the case, traffickers in the network promised payments of up to $26,000 to poor people in Turkey, Moldova and Russia to persuade them to travel to Kosovo and donate an organ. They were asked to sign false documents saying they were donating to a relative for humanitarian reasons.

"Two dozen donors were taken in by the scheme; many were never given any compensation and were released without adequate medical care."
...
"Mr. Ratel said the Dervishis were aided by Dr. Yusuf Sonmez, whom he called a notorious international organ trafficker. Dr. Sonmez is a fugitive and may be in South Africa, Mr. Ratel said."

Tales from the Organ Trade: documentary on kidney black markets

Tales from the Organ Trade investigates the black market of organ trafficking
A documentary filmmaker investigates the organ trade and questions her beliefs.

Should people be allowed to sell their organs?

That question lingers in Tales from the Organ Trade , a documentary by Toronto’s multiple award-winning filmmaker Ric Bienstock, making its North American premiere at Hot Docs , April 28, 29 and May 2.

The film won Best Sign of the Times Doc Award from New Zealand's documentary festival, where it had its world premiere last week.

Narrated by David Cronenberg, it’s an unflinching look at international organ trafficking, capturing, for the first time, the point of view of all participants in one operation.

Kidney disease is skyrocketing and transplant is the only way to survive for hundreds of thousands of people. With the desperately poor willing, and opportunistic surgeons able, there’s little hope of containing the spread, Bienstock says.

...

Globally it’s illegal to buy organs, a position Bienstock agreed with at first.

“I expected it to be a very black and white story when I set out,” she says. “Then I realized there was a lot of moral ambiguity.”

The film focuses on a trafficking ring run out of a Kosovo clinic, involving a Turkish surgeon, an Israeli facilitator and a Canadian prosecutor — and a Toronto man who purchases a kidney from a woman in Moldova.

...

Most disquieting is the footage from the Philippines, where donating a kidney is almost a rite of passage for young men. Viewers may find themselves actually hoping one wannabe donor finds a buyer — a young man trying to lift his family out of poverty. Another young donor gets sick and discovers he has kidney disease, after it’s too late for him and the unknown recipient.

...

Bienstock confesses to feeling sadness, not relief, for the man whose kidney is rejected due to the film crew’s presence. “He really wanted to buy that house in the country and he’ll never be able to,” she says.

The Philippine men, primarily labourers, also have scars that take months to heal, and no follow-up health care.

“That is why (some) are arguing for regulation,” Bienstock says. “It should be done properly. People who donate should be at the peak of their health.”

...

"“People are finding their way to these illegal operations when they are desperate enough,” Bienstock says. “We need to find a solution and we need to be open to think uncomfortable thoughts.”

Glenn Cohen on Transplant Tourism: purchasing organ transplants internationally

Transplant Tourism: The Ethics and Regulation of International Markets for Organs

I. Glenn Cohen 

Harvard Law School
April 20, 2013

Journal of Law, Medicine and Ethics, Vol. 41, No. 1, 2013 
Abstract:      
“Medical Tourism” is the travel of residents of one country to another country for treatment. In this article I focus on travel abroad to purchase organs for transplant, what I will call “Transplant Tourism.” With the exception of Iran, organ sale is illegal across the globe, but many destination countries have thriving black markets, either due to their willful failure to police the practice or more good faith lack of resources to detect it. I focus on the sale of kidneys, the most common subject of transplant tourism, though much of what I say could be applied to other organs as well. Part I reviews some data on sellers, recipients, and brokers in these markets. Part II discusses the bioethical issues posed by the trade - I skeptically evaluate some of the typical arguments for prohibiting the trade but suggest a different kind of argument that might work better. Part III focuses on potential regulation to deal with these issues. The definitive version of the article can be downloaded from the Journal's website as hosted by Wiley-Blackwell.


 And see his related blog post here: http://blogs.law.harvard.edu/billofhealth/2013/04/24/transplant-tourism-hard-questions-posed-by-the-international-and-illicit-market-for-kidneys-new-article-i-wrote/

Fewer Israelis seeking transplants abroad: more live donations at home

New laws have limited transplants overseas, and have provided some payments to living donors in Israel.  Haaretz has the story (may be gated):
"Law meant to prevent organ trafficking passed in 2008 also means the number of transplants within the country, as well as the percentage of Haredi men seeking to donate for altruistic reasons, is on the upswing; more women serve as live donors than men."


"The number of Israelis seeking kidney transplants abroad is plummeting, in the wake of a 2008 law meant to prevent organ trafficking.

"In 2007, 143 Israelis received kidney transplants abroad, but according to Health Ministry statistics, that number took a nosedive to 35 in 2011.

"The sharp decline comes as a result of more stringent guidelines for transplants; since the law was passed, HMOs have approved funding for kidney transplants abroad only from cadavers in the United States, Russia and Latvia.

"While transplants abroad have dropped, the new Organ Transplant Law has also led to a 50-percent increase in kidney transplants from live donors in Israel. A new study conducted at Beilinson Hospital and at Tel Aviv University found that the law, which both prohibits the sale of organs but also – in a first-time ruling – allows live donors to receive monetary compensation, has led to a significant change in the mix of such donors. Haredi men are now seeking, via the law, to donate kidneys for altruistic reasons. In these cases, the donors are not related to the patients.

"The payment of donors under the new law, amounting to thousands of shekels, began in August 2010, covering all live organ donors in Israel from May 2008. At the same time, statistics provided by the National Transplant Center showed a steep increase of 64 percent in the number of live kidney donors in 2011 (117 transplants) as compared with 2010 (71). The number of transplants in 2012 (108) was at a similar level.

Compensation for kidney donors: once again under discussion

The American Journal of Transplantation published the following article, by a large group of authors called the Working Group on Incentives for Living Donation:
"Incentives for Organ Donation: Proposed Standards for an Internationally Acceptable System"
Volume 12, Issue 2, pages 306–312, February 2012

Some idea of the content of their recommendations can be gotten from the following Table:

Table 2.  Guidelines for development of a regulated system of incentives for deceased and living donation

(1) Each country implementing a system of incentives should have a legal and regulatory framework for the process.

(2) The entire process must be transparent and subject to government and international oversight.

(3) The incentive should be provided by the state or state-recognized third party. Under well-defined, transparent and regulated circumstances, prospective recipients may help fund a charity that supports the program. There is no direct payment from the recipient to the donor and supporting the charity will not result in advancement on the waiting list.

(4) Allocation of the organ(s) should be performed according to the single recognized system of that country (similar to UNOS in the United States) using a predefined and transparent algorithm so that everyone on the list has an opportunity to be transplanted. Kidneys would be allocated to the number 1 person on the list (as determined by defined and transparent criteria).

(5) There should be a plan for administration and for rigorous oversight to ensure that criteria for evaluation, acceptance, allocation and provision of the incentive to the donor (or donor family) are being followed.

(6) The donation should be anonymous and nondirected.

(7) No other solid organ donor incentive plan would be legal.

(8) There should be legislation to govern wrongdoing and how centers would be censured, including criminal sanctions and fines, if wrongdoing is identified.

The  article drew the following replies in the Letters to the Editor

“Proposed Standards for Incentivesfor Organs Donation” Are Neither International nor Acceptable

F. Delmonico, G. Danovitch, A. Capron, A. Levin and J. Chapman, Council, Declaration of Istanbul Custodian Group, Montreal, QUE, Canada

The Philippines Is Not the Site forIncentivized Organ Donation

B. Padilla, D. Bayog, N. L. Uy, I. Gueco, L. Nazareno-Rosales, A. Chua, L. Almazan-Gomez, D. Bonzon, B. Balmores and E. Cabral

"The report on the proposed “international standards” for financial incentives for organ donation in the February issue of the AJT (1), stated that “until there are trials, we have no means of knowing under precisely what circumstances such a proposal would best succeed”. Permit us to report that a regulated system of incentives for living organ donors was already implemented in the Philippines from 2002 to 2008. The program offered a sizable “gratuity package” while mandating systems and procedures for transparency, creation of ethical guidelines, monitoring of transplant facilities and a donor registry, much like what this article proposes. The reality was different from the intended outcomes. The black market was not eliminated and organ brokers continued to be involved (Roberto Tanchanco et al., unpublished cohort study, 2011) (2). A regulation that transplants to foreigners should comprise no more than 10% of total transplants proved unenforceable and transplant tourism flourished (3). Donors were not protected, as there was failure of informed consent, lack of economic improvement in the donors’ lives and poor rate of medical follow-up (Roberto Tanchanco et al., unpublished cohort study, 2011) (2). A study limited to the donors within the government-regulated program reported better economic outcomes, but this was hardly convincing as poor follow-up allowed reporting of data in only 81 of 164 participants (Romina Danguilan et al., unpublished cross-sectional study, 2010).

Thus, our experience leads us to believe that the Matas article underestimates the problems related to the approach they recommend. A system of incentives for living unrelated donors which is difficult to differentiate from a disguised organ market is totally inappropriate for a country like the Philippines, where many patients have a potential related donor but cannot afford to pay for a transplant, where the deceased donor program is still very infantile, where the poor have been exploited in organ trafficking before and a large sector of the population remains vulnerable."


A Realistic Proposal—Incentives MayIncrease Donation—We Need Trials Now!

A. Matas, J.A.E. Ambagtsheer, R. Gaston, T. Gutmann, B. Hippen, S. Munn, E. T. Ona, J. Radcliffe-Richards, A. Reed, S. Satel, W. Weimar and R. Danguilan

"To the Editor:

The shortage of organs is a critical problem for patients with organ failure, and has led to a polarizing discussion. Some, including us, have suggested that a regulated system of incentives might increase donation and alleviate the crisis (1,2). Others, championed by Chapman, Danovitch, Padilla and Delmonico, have passionately opposed this option (3–6).

Delmonico et al., representing the Declaration of Istanbul [DoI] Custodial Group (DICG) now write that our proposed guidelines for a regulated system are not acceptable (4). Our proposal, as stated in the manuscript, was presented as a basis for discussion (7). Rather than suggesting modifications or improvements, the DICG simply condemns it.

Their condemnation rests on two arguments. First, that others have suggested that “sales,”“brokering” and “organ markets” are wrong, and that we have “departed from the consensus.” Yet we clearly state our opposition to exploitation and unregulated markets, and instead suggest a government-regulated system with explicit limits to prevent the abuses all parties decry. But even the supposition that we have no right to challenge “the consensus” is suspect. When, in moral debate, is majority opinion the final argument? If it were, homosexuals would still be criminals and women still subordinate to their husbands and excluded from public life–both once widely held majority views enshrined by law.

And where does this so-called consensus come from? The DICG refers to the World Health Organization (WHO) and the DoI. Yet, the WHO has updated its Guiding Principles (most recently supporting reimbursement of costs and of emotionally or legally related donors vs. previous stance banning all but genetically related donors and any payment). The draft of the DoI was written by a Steering Committee including Chapman and Delmonico, but no proponent of incentives (8). The summit was by invitation only, and invitees were invited based on their stance on this issue (Danovitch, personal communication). The few proponents of incentives were vastly, and vociferously, outnumbered. Why are these “consensus” documents immune from challenge?

Second, the DICG is incorrect that our proposal is “belied by the reality of markets.” Again, they conflate “unregulated markets” with the government sponsored regulated systems we propose. As we state: (a) each system would be limited (donors and recipients) to citizens of that country, and (b) the organ would be allocated to the #1 person on the list (i.e. not the rich buying from the poor). Each government-regulated system would be based on donor and recipient protection, regulation, transparency and oversight.

Finally, we resent the innuendo in the suggestions that our manuscript was prompted and “funded in part by Filipino organizations that have favored organ sales to foreigners” and that the authors would accept “permitting the poor and vulnerable in any community to part with a kidney for the wealthy sick.” These are cheap shots unworthy of a discussion so important to our patients. It may be that there is no place for a regulated system of incentives. But that decision should be made after dispassionate, reasoned discussion and ideally after being informed by hard data.

In a second letter, Padilla (another member of DICG) et al., suggest that our proposed system would not work in the Philippines (6). We recognize that there have been mixed evaluations of the programs implemented in both the Philippines and Iran (9). However, neither system of incentives meets the guidelines we have proposed. Moreover, the very fact that successes have been reported suggests that the systems could indeed work and should be improved upon rather than abandoned. We did not state that our system would work in every country, but presented guidelines detailing how systems should be designed in order to be acceptable. Each country would need to have appropriate regulation and oversight and to be able to address wrongdoing."

(Not so) New discussion of monetary incentives for organ donation

Update: a comment correctly points out that I somehow linked to an old story below:(
I'll follow with some more up to date material tomorrow...
a.r.

NBC news has the story, on the latest, cautious support for amendments to the 1984 National Organ Transplant Act that prohibit even experiments designed to understand the effect of monetary incentives on organ donation:
Docs push for tests of cash rewards for organs: Medical group wants to go beyond altruism to motivate cadaver donors

Most people who donate organs after death need no reward beyond altruism, but others could use a little nudge, according to the nation’s doctors.

That’s why the AMA has waded into the controversial waters of offering financial incentives for cadaver organ donations, a proposition that can’t even be examined without modifying the National Organ Transplantation Act.What’s not so clear to the American Medical Association is what kind of incentives — and in what amounts — might encourage potential organ donors and their family members to follow through.

That’s the 1984 federal law that prohibits payment or any kind of “valuable consideration” for organ donation.

This month, the AMA voted to move forward with plans to amend the law to allow pilot studies to settle the incentive issue.

“We can speculate, but unless you actually study it, you don’t know,” said Dr. Joseph Annis, an AMA board member. “What’s standing in the way right now is NOTA.”

The federal law is aimed at preventing human organs from becoming a commodity, of course, said Dr. Gerald Wilson, a South Carolina surgeon and member of the AMA delegation that introduced the issue.

“People are concerned about the possibility that we’re buying organs,” Wilson said.

But even some of the harshest critics of payment for living organ donations — a separate hot-bed issue — say that studying incentives for donation after death should be acceptable in a nation where nearly 100,000 people remain on a waiting list for organs and nearly 10 percent die before a transplant becomes available.

Living donations raise most concern “Those of us who worry about financial incentives corrupting organ donations worry most about living donations,” said David Rothman, director of the Center on Medicine as a Profession at Columbia University.

“A tightly controlled study that looks strictly at cadaveric donations — you’re getting a qualified, ‘It’s OK.’”

Rothman acknowledged that critics who oppose financial incentives for deceased donation fear that it's the first step on a slippery slope to payment for living organs.

Critics also worry that the prospect of even modest payments could lead patients' families to withhold vital medical information that could lead to rejection of an organ, or to prematurely withdraw care from a patient.

Ideally, the AMA hopes to determine whether cash contributions, payment for funeral expenses or even donations to a charity of the deceased’s choice might motivate family members to allow donation after death.

More than a decade ago, Pennsylvania approved a law to pay $300 toward funeral expenses for families of organ donors, but the rule was never enacted because of the NOTA restrictions.

The number and design of studies and where they might be conducted is not clear, Annis and Wilson said. Wilson, however, noted that the an organ procurement agency in his state, Life Point Inc. of South Carolina, may be interested in conducting a pilot study.

It’s not the first time this issue has been raised. The AMA first argued for studying motivations for cadaveric organ donation in 2002. The issue has been the subject of heated debates since then, both inside and outside the organ donation community.

The United Network for Organ Sharing, or UNOS, the nation’s organ allocation agency, is divided on the issue, said Dr. Benjamin Hippen, a North Carolina kidney transplant specialist.

‘It definitely doesn't go far enough’ Hippen, a member of UNOS ethics committee, believes in incentives for living and deceased donors alike and said the AMA’s intent to study the issue is only a necessary first step.

“It definitely doesn’t go far enough, in my view,” Hippen said.

Efforts to increase cadaver donations actually have succeeded, he said. In the past five years, the percentage of deceased people eligible to donate organs who actually do so has risen from about 50 percent to nearly 70 percent, according to UNOS. In some places, the percentage may be even higher.

“It begs the question: If you’ve only got 20 percent more you get organs from, is it 20 percent who could be swayed? “ Hippen said.

Only well-conducted studies can answer that question. AMA officials said they’re not sure when they’ll begin serious lobbying to change NOTA, certainly not before a new president takes office.

"The politicians have their hands full," Annis said.

Meanwhile, critics like Rothman welcome a cautious approach.

"Would I line up to oppose this bill? No," he said. "Would it worry me? Yes."

Anti-economics (If Michael Sandel Ruled the World)

If I ruled the world: Michael Sandel

The first sentence of the first paragraph: "If I ruled the world, I would rewrite the economics textbooks."

The first sentence of the second paragraph: "Consider the case for a free market in human organs—kidneys, for example."

Economics is important...sounds like someone should study it...

surrogacy

Here are three NPR stories on surrogacy, highlighting some of the legal issues around it.

http://www.npr.org/2012/04/13/150498711/surrogacy-aides-spring-from-murky-legal-waters

http://www.npr.org/2012/04/13/150563803/ties-that-bind-when-surrogate-meets-mom-to-be

http://www.npr.org/2012/04/14/150586618/legal-debate-over-surrogacy-asks-who-is-a-parent

HT: Steve Leider

"Kidney ethics" in Hebrew and in Israel

The phrase "מוסר כליות" (musar claiot) in Hebrew could be literally translated as "kidney ethics," but is an idiom that means something like "a guilty conscience" or maybe "remorse". It's the headline of this story in Haaretz magazine, about the grey market for organs in Israel...

This is the kind of thing that Jay Lavee wrote about trying to fix, in his op-ed that I blogged about yesterday.

Ht: Ran Shorrer

Jay Lavee on organ transplantation policy in Israel

An op-ed by Jay Lavee, the Israeli transplant surgeon at the heart of recent dramatic revisions of transplant law and policy in Israel: Saving lives locally

Ads for kidneys in Iran

An article in Haaretz describes the market for kidneys ("kidney bazaar" בזאר הכליות) in Iran, and includes this picture of ads written on a wall  in Tehran.

"Qasemi Mustafa, head of Kidney Patients Support Association in Iran, said the average sum received by the donors ranged around $ 6,000 [paid by the recipient]. The Government adds that another thousand dollars."

HT: Ran Shorrer

Here's a closely related story in the Guardian: In the only country where the organ trade is legal, the streets near hospitals have been turned into a 'kidney eBay'

"Iran is the only country where the selling and buying of kidneys is legal. As a result, there is no shortage of the organs – but for those trying to sell a kidney, there is a lot of competition.
... "Competition means that some ads have been torn down. Some have added their information to ads by other donors. Others have placed their ads on people's doors or simply written them in marker pen on trees where they think they will catch people's attention.

"At the heart of the capital, near the Charity Association for the Support of Kidney Patients (CASKP), the number of ads has made the streets of Tehran into a sort of kidney eBay.
...
"Iran's controversial kidney procurement system, which has been praised by many experts and criticised by others, allows people to sell and buy kidneys under the state-regulated surveillance of two non-profit organisations, the CASKP and the Charity Foundation for Special Diseases. These charities facilitate the process by finding potential vendors and introducing them to the recipients, and are charged with checking the compatibility of a possible donation and ensuring a fair trade.

"After the transplant, the vendor is compensated by both the government and the recipient. In an interview with the semi-official Mehr news agency, the CASKP's director, Mostafa Ghassemi, estimated the total official price list to be around 7m rials, of which 1m is paid by the government. Iranians are not allowed to donate kidneys to non-citizens.

"In 2010, a total of 2,285 kidney transplants took place in the country, of which 1,690 kidneys were supplied from volunteers and 595 from those clinically brain-dead," he said. According to Mehr, the majority of people selling kidneys are aged 20-30. Despite the state control, bureaucracy and time-consuming procedures have left the door open for non-official direct negotiations, making the Iranian system more like a kidney market.

"Dr Benjamin Hippen, a transplant nephrologist with the Carolinas medical centre in North Carolina, US, has studied successes, deficiencies and the ambiguities of the Iranian system.

"Making a judgment about whether the 20-year-old system as a whole has been successful was complicated, he said. "The majority of those selling kidneys in Iran are disproportionately poor, and information about the long-term outcomes for sellers is quite limited. Too, it is increasingly clear that there are many different systems, rather than a single unified system in Iran.

"That said, Iran appears to have successfully addressed the shortage of organs, incentives for organs have not substantially attenuated the growth and development of organ procurement from deceased donors, and reported outcomes for recipients have been favourable."

"Comparing Iran with Pakistan, where organ trafficking is nominally illegal but still occurs, Hippen, who is an associate editor of the American Journal of Transplantation, said: "It seems to me that if Iran had not developed a system of incentives, the situation there today would look very much like the state of affairs in countries such as Pakistan."

"In the US, more than 100,000 people were estimated to be on the waiting list for kidney transplants in 2010 – waiting lists were eliminated in Iran in 1999.

"Hippen has pointed out that "since 1999, more than 30,000 US patients with kidney failure have died waiting for an organ that never arrived".

"Arguing in favour of allowing people to sell their kidneys, Sue Rabbitt Roff, a senior research fellow at the University of Dundee, said last year that it was time to "pilot paid provision of live kidneys in the UK under strict rules of access and equity".

Incentives for blood donation (and seminar by Bob Slonim today at Stanford)

Bob Slonim is visiting at Stanford this quarter, and will be giving a seminar today: here's the announcement.

Mon, Oct 8, 3:30PM - 5:00PM

Bob Slonim Sydney (visiting Stanford)

Blood Donation Registry: A lab and natural field experiment

GSB E-103

There's no paper to link to yet...
****************

Over at MR, Alex Tabarrok wrote a little while ago about the earlier work of Bob and his colleagues on blood donation:

"Mario Macis, Nicola Lacetera, and Bob Slonim, the authors of the most important work on this subject (references below), write to me with the details:

The decision to donate blood involves complex motivations including altruism, civic duty and moral responsibility. As a result, we agree with Buttonwood that in theory incentives could reduce the supply of blood. In fact, this claim is often advanced in the popular press as well as in academic publications, and as a consequence, more and more often it is taken for granted.

But what is the effect of incentives when studied in the real world with real donors andactual blood donations?

We are unaware of a single study of real blood donations that shows that offering an incentive reduces the overall quantity or quality of blood donations. From our two studies, both in the United States covering several hundred thousand people, and studies by Goette and Stutzer (Switzerland) and Lacetera and Macis (Italy), a total of 17 distinct incentive items have been studied for the effects on actual blood donations. Incentives have included both small items and gift cards as well as larger items such as jackets and a paid-day off of work.  In 16 of the 17 items examined, blood donations significantly increased (and there was no effect for the one other item), and in 16 of the 17 items studied no significant increase in deferrals or disqualifications were found.  No study has ever looked at paying cash for actual blood donations, but several of the 17 items in the above studies involve gift cards with clear monetary value.

...

Goette, L., and Stutzer, A., 2011: “Blood Donation and Incentives: Evidence from a Field Experiment,” Working Paper.

Lacetera, N., and Macis, M. 2012. Time for Blood: The Effect of Paid Leave Legislation on Altruistic Behavior. Journal of Law, Economics and Organization, forthcoming.

Lacetera N, Macis M, Slonim R 2012 Will there be Blood? Incentives and Displacement Effects in Pro-Social Behavior. American Economic Journal: Economic Policy 4: 186-223.

Lacetera N, Macis M, Slonim R.: Rewarding Altruism: A natural Field Experiment, NBER working paper.

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