Are embryos property?

 A Virginia judge has managed to make a repugnant legal argument about a repugnant transaction, since the relevant precedent he identifies has to do with the ownership of slaves.

Virginia judge rules human embryos are ‘chattel’ based on centuries-old slave laws  by Matthew Barakat, Associated Press

"Frozen human embryos can legally be considered property, or “chattel,” a Virginia judge has ruled, basing his decision in part on a 19th century law governing the treatment of slaves.

"The preliminary opinion by Fairfax County Circuit Court Judge Richard Gardiner – delivered in a long-running dispute between a divorced husband and wife – is being criticized by some for wrongly and unnecessarily delving into a time in Virginia history when it was legally permissible to own human beings.

“It’s repulsive and it’s morally repugnant,” said Susan Crockin, a lawyer and scholar at Georgetown University’s Kennedy Institute of Ethics and an expert in reproductive technology law.

...

"In a separate part of his opinion, Gardiner also said he erred when he initially concluded that human embryos cannot be sold.

“As there is no prohibition on the sale of human embryos, they may be valued and sold, and thus may be considered ‘goods or chattels,’” he wrote."

HT: Kim Krawiec

Artificial breast milk may be on the cellular agriculture horizon

 Cellular agriculture isn't just aspiring to produce meat; now breast milk is queueing up as a (still distant) possibility.

The New Yorker has the story:

Biomilq and the New Science of Artificial Breast Milk. The biotech industry takes on infant nutrition. By Molly Fischer

"New ventures in the world’s oldest food reflect our era’s enthusiasm for tech-based solutions to perennial human problems."

...

"The process of making breast milk in a human body begins during pregnancy, when hormonal changes prompt mammary cells to multiply. After delivery, two of the pregnancy hormones—estrogen and progesterone—drop off, while prolactin remains. This spurs the mammary cells to draw carbohydrates, amino acids, and fatty acids from the mother’s bloodstream, and to convert these raw materials into the macronutrients required to feed a baby. In Biomilq’s case, the mammary cells come from milk and breast-tissue samples provided by donors, and the cells multiply in vitro under the care of a team of scientists tasked with keeping them “happy.” The cells are then moved to a hollow-fibre bioreactor—a large tube filled with hundreds of tiny porous tubes that are covered in a layer of the lab-grown cells. As nutrients flow through the small tubes, the cells secrete milk components into the large tube, where they collect.

"Describing the results as “milk components,” not “milk,” is a crucial distinction. Biomilq has demonstrated that its technology can produce many of the macronutrients found in milk, including proteins, complex carbohydrates, and bioactive lipids, but it cannot yet create them in the same ratios and quantities necessary to approximate breast milk. Other elements of breast milk are beyond the scope of the company’s ambition. A mother’s antibodies, for example, are present in her milk, but they aren’t produced by the mammary cells, and, because Biomilq’s product will come from a sterile lab environment, it won’t offer any kind of beneficial gut bacteria.

...

"“It’s as fraught as abortion,” Jacqueline Wolf, an emeritus historian of medicine at Ohio University and the author of a history of breast-feeding and formula in the U.S., aptly titled “Don’t Kill Your Baby,” told me. “There’s almost nothing that raises more social issues than infant feeding.” Wolf dates the emergence of what became known as “the feeding question” to the eighteen-seventies, when mothers across the country began raising concerns about their milk supply. “The big change that was sparked by urbanization and industrialization was suddenly having to pay attention to a mechanical clock,” she said. Earlier infant-care manuals had advised feeding a baby when he showed signs of hunger. Now medical advice put infants on feeding schedules as rigid as railway timetables. But, as Wolf pointed out, “to build up a milk supply, you need to put the baby to the breast often, especially in the first few months.” The women complaining that they lacked sufficient milk were not, as one theory had it, suffering from the ill effects of too much education during puberty. Rather, they were following advice unwittingly engineered to fail.  

...

"By the nineteen-forties, most mothers were giving birth in hospitals, where orderly routine—babies in nurseries, bottles on schedules—often took priority over the personal attention required to initiate breast-feeding. 

...

"Commercial infant formula from brands such as Similac and Enfamil took off in the fifties—a modern amenity that sat comfortably alongside Betty Crocker cake mix and Cheez Whiz. (Formula had also made it easier for women to work outside the home.) At the same time, the decade saw the rise of some of breast-feeding’s most influential evangelists. The La Leche League was founded in 1956 by seven Catholic housewives in the Chicago suburbs who wanted to create a forum for breast-feeding mothers to share questions and advice. La Leche occupied a tricky cultural position, at once radical and conservative: on the one hand, it encouraged women to claim control of their bodies and to defy voices of institutional authority; on the other, the intended result of this rebellion was a world in which a mother’s place was unequivocally at home.

...

"Meanwhile, the alternative to breast-feeding—formula—began to take on a sinister light. An industry that had presented itself as a best friend to mid-century mothers showed a different face in its dealings abroad. New reports linked Nestlé’s aggressive marketing of formula to infant deaths in the Global South, making the case that the company’s product had been pushed on families who lacked the resources (such as clean water) to bottle-feed safely. Instead of a scientifically perfected modern convenience, formula became “The Baby Killer,” in the words of one influential pamphlet. A years-long global boycott of Nestlé ensued. In 1981, the World Health Organization adopted a resolution that aimed to ban the promotion of substitutes for breast milk. The U.S. was the only country in opposition. (Today, Nestlé stresses its compliance with W.H.O. code.)

...

"products intended to provide complete infant nutrition (that is, formulas) must clear more hurdles than other foods. A new product must, among other things, undergo what are essentially clinical trials, which can involve recruiting hundreds of babies to participate.

...

"The distribution of human breast milk has traditionally taken place at nonprofit milk banks, and recent attempts to introduce commerce into this transaction have stirred controversy. In 2014, a company called Medolac, selling shelf-stable human milk, announced that it would expand its milk-bank program in Black communities in Detroit. The plan was scrapped after backlash from community groups and activists, who called out the company for its low pay in comparison with its pricing and for reinforcing historical injustice. (At the time, the company denied allegations of exploitation.) Biomilq seems keen to avoid any impression of similar obliviousness. Egger told me that the company has encouraged employees to read Andrea Freeman’s “Skimmed,” an account of racial inequities perpetrated by the formula industry. And even as Biomilq describes itself as “women-owned” and “mother-centered,” it also notes that “lactation is not only for cisgender biological mothers.” 

********

Related posts on breast milk.

Blood money: plasma and ambivalence

 The Guardian has a long review of the book Blood Money, by Kathleen McLaughlin, who is dependent on blood plasma, but suggests reasons to be ambivalent about the American market for paid plasma.

‘It’s gamified’: inside America’s blood plasma donation industry. In her new book Blood Money, Kathleen McLaughlin uses a personal lens to examine an industry that rewards mass plasma donation  by David Smith

"So who is the typical blood seller and why do they do it? McLaughlin had expected to find the poorest of the poor but, it transpires, most of them are screened out because a plasma donor must have a permanent address.

“What I found instead was a lot of people who, say, 25 years ago would have been middle class, and they just don’t make enough money for that lifestyle any more. I get the sense that one of the biggest demographics is college students. We’re talking about like big public universities where there are a lot of students who don’t come from wealthy backgrounds; I’ve talked to people who use this money to buy books, to pay to go out for a night, for ‘beer money’.

“You will also find people in communities like Flint, Michigan, where I spent a lot of time, who used to be able to expect to have this very normal American middle-class lifestyle and wages and benefits no longer keep pace with that. There are people doing it to buy groceries and to pay for housing. There are also people who are selling plasma to take a vacation."

...

"And whereas donating blood for free is lauded, donating it for money is stigmatised. “If you think about blood donation, it’s something that we consider quite heroic. If you go to the Red Cross and donate blood, you’re saving a life, you’re not getting paid for it.

“But somehow this practice of donating plasma for pay comes with a pretty heavy stigma. A lot of the people I interviewed who do sell plasma had not told their families that they do it because they were afraid of what their families would think: there would be some kind of judgment or their families would be worried about their health or concerned that they don’t have enough money.

‘The stigma is entirely linked to the fact that we stigmatise poverty in the United States. We look down on it. We don’t respect people who aren’t wealthy in the same way that we respect wealthy people. It’s been interesting for me to see the way that people view selling plasma as being somehow problematic and that’s definitely contributed to the fact that this industry is kind of hidden.”

"Still, should we make a moral judgment about the blood industry? It is not, after all, pushing an addictive substance like opioids, but rather is helping the health of people in America and around the world, McLaughlin included. She replies: “We need to ask ourselves that. From my perspective as someone who depends on this substance, what people are doing is incredibly altruistic.

“I also think a lot of people are being financially coerced to do it and, the way the system is set up, you get paid more per donation for each donation you make. It’s gamified in such a way that people are encouraged to donate quite often and because it is a hidden industry, most Americans haven’t really considered if this is who we want to be.

“If you know that there are potentially millions of Americans who have sold their plasma to pay for things like groceries and vacations, are you OK with that? For me, it’s more a matter of getting people to think about it, that our economic situation is such that this is part of our fabric now and are we comfortable with being that way or do we want to think more deeply about how we can make this more feel more of a choice for people?”

"She adds: “The industry itself isn’t necessarily the problem. The problem is that we have let this industry become a part of people’s incomes. I don’t know that that’s the kind of society we want to be.”

“It’s these places where people are economically fragile, not necessarily desperately poor. The kind of fragility that we didn’t have 25 or 30 years ago when there were more social-safety protections.”

The market for (and marketing of) baby formula

 The Lancet has a series of articles on baby formula.  It begins with this editorial, and is followed by three articles:

Unveiling the predatory tactics of the formula milk industry, The Lancet, Published: February 07, 2023 DOI:https://doi.org/10.1016/S0140-6736(23)00118-6

"For decades, the commercial milk formula (CMF) industry has used underhand marketing strategies, designed to prey on parents' fears and concerns at a vulnerable time, to turn the feeding of young children into a multibillion-dollar business. The immense economic power accrued by CMF manufacturers is deployed politically to ensure the industry is under-regulated and services supporting breastfeeding are under-resourced. These are the stark findings of the 2023 Breastfeeding Series, published in The Lancet today."

******

VOLUME 401, ISSUE 10375, P472-485, FEBRUARY 11, 2023 Breastfeeding: crucially important, but increasingly challenged in a market-driven world, by Prof Rafael Pérez-Escamilla, PhD  Cecília Tomori, PhD Sonia Hernández-Cordero, PhD Phillip Baker, PhD Aluisio J D Barros, PhD MD France Bégin, PhD Donna J Chapman, PhD Laurence M Grummer-Strawn, PhD Prof David McCoy, PhD Purnima Menon, PhD Paulo Augusto Ribeiro Neves, PhD Ellen Piwoz, PhD Prof Nigel Rollins, MD Prof Cesar G Victora, PhD MD Prof Linda Richter, PhD on behalf of the 2023 Lancet Breastfeeding Series Group†  Open Access Published: February 07, 2023 DOI:https://doi.org/10.1016/S0140-6736(22)01932-8

"When possible, exclusively breastfeeding is recommended by WHO for the first 6 months of life, and continued breastfeeding for at least the first 2 years of life, with complementary foods being introduced at 6 months postpartum.9 Yet globally, many mothers who can and wish to breastfeed face barriers at all levels of the socioecological model proposed in The Lancet's 2016 breastfeeding Series."

 VOLUME 401, ISSUE 10375, P486-502, FEBRUARY 11, 2023 Marketing of commercial milk formula: a system to capture parents, communities, science, and policy by Prof Nigel Rollins, MD  Ellen Piwoz, ScD Phillip Baker, PhD Gillian Kingston, PhD Kopano Matlwa Mabaso, PhD Prof David McCoy, DrPH  Paulo Augusto Ribeiro Neves, PhD  Prof Rafael Pérez-Escamilla, PhD  Prof Linda Richter, PhD  Prof Katheryn Russ, PhD  Prof Gita Sen, PhD  Cecília Tomori, PhD  Prof Cesar G Victora, MD  Paul Zambrano, MD  Prof Gerard Hastings, PhD  on behalf of the 2023 Lancet Breastfeeding Series Group  Open Access Published:  February 07, 2023 DOI:https://doi.org/10.1016/S0140-6736(22)01931-6

"Despite proven benefits, less than half of infants and young children globally are breastfed in accordance with the recommendations of WHO. In comparison, commercial milk formula (CMF) sales have increased to about US$55 billion annually, with more infants and young children receiving formula products than ever. "

 VOLUME 401, ISSUE 10375, P503-524, FEBRUARY 11, 2023 The political economy of infant and young child feeding: confronting corporate power, overcoming structural barriers, and accelerating progress by Phillip Baker, PhD Julie P Smith, PhD Prof Amandine Garde, PhD Laurence M Grummer-Strawn, PhD Benjamin Wood, MD Prof Gita Sen, PhD Prof Gerard Hastings, PhD  Prof Rafael Pérez-Escamilla, PhD  Chee Yoke Ling, LLB  Prof Nigel Rollins, MD Prof David McCoy, DrPH  on behalf of the 2023 Lancet Breastfeeding Series Group†  Open Access Published: February 07, 2023 DOI:https://doi.org/10.1016/S0140-6736(22)01933-X

"The first and second papers in this Series8,  9 present several reasons for the global rise of CMF in human diets, including the CMF industry's exploitation of parental anxieties; ubiquitous marketing; and absent or inadequate protection and support for breastfeeding within health-care systems, work settings, and households. In this Series paper, we look further upstream and examine the root causes of low worldwide breastfeeding rates10 to understand why so many women and families are prevented from making and implementing informed decisions about feeding and caring for infants and young children; why so many policy makers and health-care professionals are co-opted by CMF marketing and other commercial forces; and why so many countries have not prioritised and implemented policies to protect, promote, and support breastfeeding. It is important to note that we use the terms women and breastfeeding throughout this Series for brevity, and because most people who breastfeed identify as women; we recognise that not all people who breastfeed or chestfeed identify as women."

**********

Among my previous posts on milk are some noting that there are shortages of human breast milk, and that in many places the sale of breast milk is banned (in some places out of concern that poor mothers would sell their milk instead of feeding their children, and in some places out of concerns that the sale of breast milk is repugnant even from mothers who produce milk in excess to their children's needs.)  

Thus (in different times, places, and circumstances) there is repugnance both to the sale of mothers' milk and to the sale of substitutes for it.

Compensation for participating in clinical trials

 Here's an opinion piece from Medpage Today:

It's Time to Pay Clinical Trial Participants More — Accelerating trial enrollment can catalyze access to much-needed medications  by Gunnar Esiason 

He writes:

"Most people I know with cystic fibrosis have participated in at least one, if not several clinical trials. 

...

"Participating in a trial can be like working for a company that hasn't invested in its employees in a long time. In this case, the employees are clinical trial participants. The pay is low despite the time required to participate in research and the growing number of trials that need participants.

"From 2019-2022, the number of registered clinical trials grew by 25%opens in a new tab or window globally -- yet participant pay remains arbitrary and inconsistentopens in a new tab or window between studies. It's almost like mismatched supply and demand curves, where participants are in high demand but unwilling to participate.

"Increasing trial participant pay might be a path toward alleviating the participant supply crunch in trials hungry for patients. One key benefit of increasing pay for patients could be substantial: namely, speeding up clinical trials through a more competitive enrollment process.

...

"More than 80% of clinical trials fail to enroll on time, leading to costs of anywhere from $600,000 to $8 million per dayopens in a new tab or window and making trials take up to twice as longopens in a new tab or window.

"And yet it has been shownopens in a new tab or window that moderately increasing pay can motivate participation without being an "unjust inducement." In other words, patients are encouraged to participate -- but not coerced to do so.

"If increasing participant pay can accelerate trial enrollment, then a safe and effective drug can reach the market faster and therefore reduce the amount of time products remain in the pre-revenue stage. The return on investment for study sponsors who increase participant pay should be clear from a business perspective.

"From a patient perspective, even a marginal improvement in time to accessing new drugs is something worth celebrating. For patients, we pay the cost of delays with our health."

*********

Some earlier related posts:

Monday, February 22, 2021

Ethical Payment in Human Infection Challenge Studies in the American Journal of Bioethics

Monday, March 1, 2021

Compensating challenge vaccine trial participants: further discussion in the American Journal of Bioethics

Thursday, October 29, 2020

Paying participants in challenge trials of Covid-19 vaccines, by Ambuehl, Ockenfels, and Roth

"we note that increasing hourly pay by a risk-compensation percentage as proposed in the target article provides compensation proportional to risk only if the risk increases proportionally with the number of hours worked. (Some risky tasks take little time; imagine challenge trials to test bulletproof vests.) "

Sunday, November 1, 2020

What do we know about the effects of payments to participants in challenge trials for vaccines, and other public spirited activities?

Donate blood or organs to pay a traffic fine or shorten a prison term?

I spend a lot of my time thinking and writing about repugnant transactions and controversial markets, and some of that intersects with my work on blood and organ donation and transplantation (particularly on the controversial issue of compensation for donors, and how that might intersect with varieties of coercion). But today's post is about two proposals that mix all these things together. (My guess is that many people will find them differently repugnant: think of them as a quick test of your own views.)

In Argentina, a municipal judge proposes blood donation to pay traffic fines, and in Massachusetts several legislators co-sponsor a bill to allow bone marrow (blood stem cell) donation or organ donation to reduce prison sentences.

First, blood donation and traffic fines:

 Mario Macis points me to this story in La Nacion, about a city in the Argentine province of Salta:

En una ciudad de Salta las multas de tránsito se pueden pagar con una donación de sangre  [In a city of Salta, traffic fines can be paid with a blood donation]  (English from Google Translate)

"In the city of Tartagal, Salta, it is possible to pay a traffic ticket with a blood donation . The measure, taken two months ago, generates both support and questioning.

...

"The judge of the Court of Misdemeanors of the Municipality of Tartagal, Farid Obeid , proposed in a ruling last August that those who had traffic fines could pay them with their own blood donation or from third parties on behalf of the offenders.

"It was then determined that donations be made in hospitals, voluntarily and only once; that is to say that repeat offenders cannot opt ​​for blood donation.

...

"The ruling received support and criticism, the latter basically from the health sector. Oscar Torres, president of the Argentine Association of Hemotherapy, Immunohematology and Cellular Therapy , sent a letter to the Deliberative Council of Tartagal indicating that the measure removes the "spirit of solidarity and altruism from blood donation" 

Here's a related story about the ongoing debate (also using Google translate):

Controversy over an unusual municipal project: they claim that fines can be paid with blood. "This controversial project was presented to the Deliberative Council of Tartagal, and criticism has already begun"

***********

And here's the new bill proposed in Massachusetts (don't hold your breath waiting for it to be passed into law). It's in English, so the phrase about the necessary "amount of bone marrow and organ(s) donated to earn one’s sentence to be commuted" isn't a translation error; I think it's just awkward (i.e. not meant to be chilling). (But the discussion of donated "organ(s)" makes me think of Kazuo Ishiguro's novel "Never Let Me Go"). 

Bill HD.3822, 193rd (Current), An Act to establish the Massachusetts incarcerated individual bone marrow and organ donation program

"Section 170. (a) The Commissioner of the Department of Corrections shall establish a Bone Marrow and Organ Donation Program within the Department of Correction and a Bone Marrow and Organ Donation Committee. The Bone Marrow and Organ Donation Program shall allow eligible incarcerated individuals to gain not less than 60 and not more than 365 day reduction in the length of their committed sentence in Department of Corrections facilities, or House of Correction facilities if they are serving a Department of Correction sentence in a House of Corrections facility, on the condition that the incarcerated individual has donated bone marrow or organ(s). 

...

"The Bone Marrow and Organ Donation Committee shall also be responsible for promulgating standards of eligibility for incarcerated individuals to participate and the amount of bone marrow and organ(s) donated to earn one’s sentence to be commuted. Annual reports including actual amounts of bone marrow and organ(s) donated, and the estimated life-savings associated with said donations, are to be filed with the Executive and Legislative branches of the Commonwealth. All costs associated with the Bone Marrow and Organ Donation Program will be done by the benefiting institutions of the program and their affiliates-not by the Department of Correction. There shall be no commissions or monetary payments to be made to the Department of Correction for bone marrow donated by incarcerated individuals."

Simultaneous HT to Ron Shorrer, Kim Krawiec, Akhil Vohra

Incentives for deceased organ donation, in Asia

 Here's a discussion, in an Asian context, of providing incentives to families to consent to deceased donation.

Introducing Incentives and Reducing Disincentives in Enhancing Deceased Organ Donation and Transplantation by Kai Ming ChowMBChB⁎ Curie AhnMD† Ian DittmerMBChB‡ Derrick Kit-SingAuLMCHK§ IanCheungMBBS║ Yuk LunChengMBChB¶ Chak SingLau MBChB Deacons Tai-KongYeungMBBS║ Philip Kam-TaoLi MD Seminars in Nephrology,  Available online 27 December 2022

*Department of Medicine and Therapeutics, Carol and Richard Yu PD Research Centre, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong

† Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea

‡Department of Renal Medicine, Auckland City Hospital, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand

§Centre for Bioethics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong

║Cluster Services Division, Hospital Authority, Kowloon, Hong Kong

¶Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong

#Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pok Fu Lam, Hong Kong, China

Summary: Despite the effectiveness of solid organ transplantation, progress to close the gap between donor organs and demand remains slow. An organ shortage increases the waiting time for transplant and involves significant costs including patient morbidity and mortality. Against the background of a low deceased organ donation rate, this article discusses the option of introducing incentives and removing disincentives to deceased organ donation. Perspectives from ethics, general public opinion, and the health care profession are examined to ensure a comprehensive appraisal and illustrate different facets of opinion on this complex area. Special cultural and psychosocial considerations in Asia, including the family based consent model, are discussed.

This sentence caught my eye:

"After suggestion by Economics Nobel Laureate Alvin Roth for the community to unite to remove disincentives to kidney donation, the transplant community and academia have been having more discussion and analysis. That, in part, hinges on the estimates of the economic welfare gain for the society as a whole."

...

"PERSPECTIVES OF ASIAN SOCIETY

"It is widely recognized that deceased organ donation rates in Asian countries have been significantly lower than that in Western countries.

...

"No one disputes the social and cultural beliefs in the decision to donate organs. 

...

"An example of honoring the principles of reciprocity in incentivizing organ donor registrations is the organ allocation priority policy. Israel became the first country in 2008 to enact legislation incorporating such incentives based on individuals’ willingness to donate into their organ procurement system.26,42,43 The policy provides an incentive or motivation by the reciprocal altruistic dictum that “each partner helping the other while he helps himself,”42 granting priority on organ donor waiting lists to those individuals who registered as organ donors by signing a donor card for at least 3 years. Subsequent observations in Israel, as analyzed 5 years after introduction of the new policy, included an increase in the authorization rate of next of kin of unregistered donors, as well as a two-fold higher likelihood of next-of-kin authorization for donation when the deceased relative was a registered donor.44

"How does the concept of reciprocity apply for Asian societies? Will the results from Israel be replicated in Asia? Although social exchange theory should be a universal normal applicable to all human relationships, cultural influence or patterns might differ. Previous research on reciprocity across different cultural contexts, indeed, has shown that East Asians tend to reciprocate in kind and emphasize more on equity-based theory than Americans.45 Viewed through such a lens of “to give is to take,” it is relevant to quote another similar example in Taiwan, where incentives were provided to deceased organ donors’ families. In brief, after a person has become a deceased organ donor in Taiwan, up to three of his or her blood relatives will be granted priority to receive a deceased donor organ should they be on the waiting list for transplantation.46

"At the heart of the issue is the family based consent that is unique and vital, albeit not exclusive, in Confucian tradition within Chinese societies. It is important to note that organ donation is more often a family based consent process in Chinese culture than those “from a Western cultures”. As such, family priority right provided in the Israel or Chinese model would be more likely to motivate organ donation within a family based ethical culture.47 As in any discussion of culture's influence on organ donation decision, we must be mindful that East Asians tend to favor family centered decision making.

...

"If the concept of reimbursing funeral expenses for deceased organ donors is explored further then these four tenets are suggested as a guide: Tenet 1: the overarching principle is to appreciate and recognize the altruistic behavior of organ donors, and not the next of kin. Tenet 2: the second priority of reimbursing funeral expenses is to motivate the passive-positive public to sign up for organ donation. Tenet 3: the ultimate beneficiary from an incentive system is society, with an improved deceased organ donation rate. Government and charitable organizations, but not organ recipients, should be the source of payment. Tenet 4: as a token of expressing gratitude to the deceased organ donors, funeral expenses reimbursement preferably should be offered to those who have expressed the wish to donate (donor registration); they should have been provided the option to decline the offer."

NPR on black markets for kidneys from Nepal, for India

Here's an 8-minute video from National Public Radio about the black market for kidneys, trafficked from Nepal to India.  Some of the people interviewed indicate that they were duped; others decline to cooperate with prosecutors against the black market recruiters. A particular Indian hospital is named. Frank Delmonico makes an appearance near the end.  

(The video doesn't discuss any of the larger issues about the causes and consequences of the shortage of organs for transplant that make black markets busy and profitable, or how these might be addressed through legal and ethical efforts to increase the availability of transplants.)

.

HT: Frank McCormick

**********

Here's a post on the legal market for kidneys in Iran.

Monday, June 27, 2022

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

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Here's an article from earlier this week in the Washington Monthly

We Have to Make Organ Donors Whole. by Sally Satel, January 17, 2023 

"I’m alive because of kidney donations, but there wouldn’t be an organ shortage if we made it easier for those willing to literally give a piece of themselves. New York is taking a good first step."

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related earlier post:

Sunday, January 1, 2023

New York State's Living Donor Support Act (LDSA, S. 1594) was signed by Governor Hochul on Dec. 29

Moral certainties versus moral tradeoffs

 An article and a commentary in PNAS raise the possibility that  economists and psychologists and moral philosophers concerned with morally contested transactions may be able to engage in more useful discussions. A problem is that economists mostly think about tradeoffs while many moral philosophers (or at least those who write about medical ethics) often think of morality as involving absolutes. (This is clearly illustrated in discussions about repugnant transactions, such as those involving compensation of donors of blood plasma or kidneys, for example.)

The PNAS article is   

Guzmán, Ricardo Andrés, María Teresa Barbato, Daniel Sznycer, and Leda Cosmides. "A moral trade-off system produces intuitive judgments that are rational and coherent and strike a balance between conflicting moral values." Proceedings of the National Academy of Sciences 119, no. 42 (2022): e2214005119. https://doi.org/10.1073/pnas.2214005119

"Significance: Intuitions about right and wrong clash in moral dilemmas. We report evidence that dilemmas activate a moral trade-off system: a cognitive system that is well designed for making trade-offs between conflicting moral values. When asked which option for resolving a dilemma is morally right, many people made compromise judgments, which strike a balance between conflicting moral values by partially satisfying both. Furthermore, their moral judgments satisfied a demanding standard of rational choice: the Generalized Axiom of Revealed Preferences. Deliberative reasoning cannot explain these results, nor can a tug-of-war between emotion and reason. The results are the signature of a cognitive system that weighs competing moral considerations and chooses the solution that maximizes rightness.

"Abstract: How does the mind make moral judgments when the only way to satisfy one moral value is to neglect another? Moral dilemmas posed a recurrent adaptive problem for ancestral hominins, whose cooperative social life created multiple responsibilities to others. For many dilemmas, striking a balance between two conflicting values (a compromise judgment) would have promoted fitness better than neglecting one value to fully satisfy the other (an extreme judgment). We propose that natural selection favored the evolution of a cognitive system designed for making trade-offs between conflicting moral values. Its nonconscious computations respond to dilemmas by constructing “rightness functions”: temporary representations specific to the situation at hand. A rightness function represents, in compact form, an ordering of all the solutions that the mind can conceive of (whether feasible or not) in terms of moral rightness. An optimizing algorithm selects, among the feasible solutions, one with the highest level of rightness. The moral trade-off system hypothesis makes various novel predictions: People make compromise judgments, judgments respond to incentives, judgments respect the axioms of rational choice, and judgments respond coherently to morally relevant variables (such as willingness, fairness, and reciprocity). We successfully tested these predictions using a new trolley-like dilemma. This dilemma has two original features: It admits both extreme and compromise judgments, and it allows incentives—in this case, the human cost of saving lives—to be varied systematically. No other existing model predicts the experimental results, which contradict an influential dual-process model."

Here is their first example:

"Two countries, A and B, have been at war for years (you are not a citizen of either country). The war was initiated by the rulers of B, against the will of the civilian population. Recently, the military equilibrium has broken, and it is certain that A will win. The question is how, when, and at what cost.

"Country A has two strategies available: attacking the opposing army with conventional weapons and bombing the civilian population. They could use one, the other, or a combination of both. Bombing would demoralize country B: The more civilians are killed, the sooner B will surrender, and the fewer soldiers will die—about half from both sides, all forcibly drafted. Conventional fighting will minimize civilian casualties but maximize lives lost (all soldiers).

"More precisely: If country A chooses not to bomb country B, then 6 million soldiers will die, but almost no civilians. If 4 million civilians are sacrificed in the bombings, B will surrender immediately, and almost no soldiers will die. And, if A chooses an intermediate solution, for every four civilians sacrificed, approximately six fewer soldiers will die.

"How should country A end the war? What do you feel is morally right?"

**********

Here is the followup commentary:

Lieberman, Debra, and Steven Shenouda. "The superior explanatory power of models that admit trade-offs in moral judgment and decision-making." Proceedings of the National Academy of Sciences 119, no. 51 (2022): e2216447119.

"We make “moral” decisions each day (should I stay and help my graduate student with her thesis thereby delaying dinner for my children? And if I do stay, how long is acceptable until the trade-off tips in favor of my children—30 min? An hour? Longer?). There are costs associated with every act, and part of the human condition is that we seek to balance our duties to everyone in our social network.

"Moral judgments, as the above example illustrates, lead to intermediate, compromise solutions. For this reason, the value of moral dilemmas like the trolley problem that yield only binary outcomes is limited to the superficial exploration of normative theories within philosophy—not the underlying mental software driving moral cognition

...

"As a philosophical tool, the trolley problem playfully probes certain (limited) contours of moral decision-making. But, as a methodology imported from philosophy into cognitive science to illuminate moral cognition, the translation is impoverished because it yields only binary, extreme solutions and prevents moral trade-offs or compromise judgments. "

Sell a kidney to save a life? by Dylan Walsh, in WIRED.

 Martha Gershun alerts me to this story which appeared this morning in WIRED, in which the author, a kidney transplant recipient (24 years ago), considers the history of the long debate about whether kidney donors might be compensated, to end the shortage of life-saving kidney transplants.  It's very well written, and contains some details (e.g. dialog between Al Gore and Barry Jacobs) that I hadn't seen before.  It's well worth reading the whole thing.

Would You Sell One of Your Kidneys? Each year thousands die because there aren’t enough organs for transplants, and I may be one of them. It’s time to start compensating donors. by Dylan Walsh

Here's the first sentence:

"WHEN WE WERE teenagers, my brother and I received kidney transplants six days apart. "

Here's some history of transplantation itself:

"In 1963, the world’s preeminent kidney transplant surgeons met in DC to discuss the state of the field. They were few in number and dispirited. Roughly 300 operations had been performed by then, with only 10 percent of patients surviving more than six months, according to one account. The procedure remained no more than “highly experimental,” in the words of even its fiercest proponents. But the prevailing gloom lifted when two little-known surgeons from Denver, Thomas Starzl and Thomas Marchioro, presented results from a series of transplants they’d performed. They had managed to flip the outcomes: 10 percent failure, 90 percent success. A euphoric shock spread through the crowd, which quickly gave way to skepticism. The results were studied, confirmed, and eventually replicated. "

Here's a bit about the origins of the legal ban on compensating donors (the 1984 National Organ Transplant Act, or NOTA):

"In 1967, one study found that roughly 8,000 people were eligible for a kidney transplant; only 300 received one.

"IT TOOK ABOUT a decade for someone of enterprising disposition to step into this gap. H. Barry Jacobs was a Virginia doctor who lost his license to practice medicine in 1977 for attempting to defraud Medicare. He spent 10 months in jail and shortly after his release turned his energies to the unregulated business of organ brokering. His company, International Kidney Exchange Ltd., was built around the fact that most of us are born with two kidneys but can function with one. If one kidney is removed, the other grows larger and works harder, filtering more blood to cover as best it can for its emigrant twin. This redundancy supported Jacobs’ straightforward business model. He would connect people who wanted to sell one of their kidneys, for a price of their choosing, with people who needed one. As a mi"ddleman, Jacobs would charge a brokerage fee to the recipients.

"At the time, Al Gore, then a member of the US House of Representatives, was developing the National Organ Transplant Act, which centered on establishing a repository to match organ donors with those in need of a transplant. Upon hearing of Jacobs’ plan, Gore also took up the question of compensation. Jacobs appeared before the Subcommittee on Health and the Environment on October 17, 1983, and spoke with truculence. He talked about one doctor who had testified before him “sitting on his butt” and failing to seriously address the problem of organ shortages. He interrupted and challenged his questioners. His testimony, above all, highlighted the likely abuses in an unregulated organ market.

“I have heard you talk about going to South America and Africa, to third-world countries, and paying poor people overseas to take trips to the United States to undergo surgery and have a kidney removed for use in this country,” Gore said. “That is part of your plan, isn't it?”

“Well, it is one of the proposals,” Jacobs said.

...

"This exchange gave public force to a debate that had been unfolding in the dimmer theater of academia ever since transplantation first became possible. ...Proponents of an organ market had historically invoked the crisp—some say cold—logic of utilitarianism. A properly designed market, they suggested, would provide economic surplus to both the organ donor, in the form of money, and to the recipient, in the form of a longer, healthier life. Opponents of a market typically crafted their dissents from the gossamer realm of ethics."

There's more, both personal and policy.  

Good luck to all who need a kidney and to those who donate them. Maybe we'll make some more progress in 2023.

New York State's Living Donor Support Act (LDSA, S. 1594) was signed by Governor Hochul on Dec. 29

 Frank McCormick forwards this email:

From: Elaine Perlman

Sent: Thursday, December 29, 2022 5:44 PM

Subject: Governor Hochul Has Signed the Living Donor Support Act!

 "Hello!

I am delighted to inform you all that the New York State's Living Donor Support Act (LDSA, S. 1594) was signed by Governor Hochul today.

 New York is becoming the best state for organ donation!

 Thank you for your advocacy in support of this legislation. The LDSA will save more New Yorkers' lives.

 Waitlist Zero's Executive Director Josh Morrison wrote the legislation. State Senator Rivera from The Bronx and Assembly Member Gottfried from Manhattan sponsored the bill.

 This spring, a team from the NKDO, NKF, DOVE, LiveOn New York, and Waitlist Zero lobbied for the bill's passage in Albany. Soon after, the LDSA was unanimously passed by both houses.

 This new law creates the opportunity for New York's living donors to avoid going into debt to donate. Living donors will be reimbursed for their lost wages and out-of-pocket expenses. New York will be the first state in the country to offer this opportunity for donation to be cost neutral for donors.

 Currently the Federal Government only reimburses when both the recipient and donor make less than 350% of the poverty line (around $47,000). The LDSA will reimburse the lost wages of donors who make up to $125,000 as well as the costs of donation (travel, childcare, etc).

 In addition, the LDSA will ensure that all potential recipients will be educated about transplantation.

 There are currently 8,569 people on New York's transplant wait lists, 7,234 of whom are awaiting a kidney. With the LDSA, we anticipate that far more New Yorkers will benefit from a living organ donation.

Here is the press release.

On Tuesday, January 3rd from 4-5pm ET, we will have a virtual celebration and toast the passage of the LDSA! Here is our zoom link.

Please share this good news far & wide!

Best,

 Elaine

Director, Waitlist Zero "

***********

Because the National Living Donor Assistance Center (NLDAC) is a payer of last resort, the NY law will replace NLDAC for NY donors who do meet the means test, and so it will also allow the NLDAC budget to go further.

********

Update: Frank McCormick writes to alert me that, like the authorization for NLDAC,  the NY State law (https://www.nysenate.gov/legislation/bills/2021/S1594) "requires that the Program shall be payer of last resort..." I hope that this doesn't turn into a competition to be the payer of last resort in a way that might cause some NY donors to fall between the cracks, and not be reimbursed either by NLDAC or the State of New York.

Compensation for kidney donors, reconsidered in Value in Health

Here's a paper and a commentary in the journal Value in Health, focusing on the possibility of reducing deaths from kidney failure by offering some form of  regulated compensation to kidney donors. They point out that the potential effects of such a policy are very much greater than than we have so far achieved through uncompensated donation and kidney exchange

McCormick, F., Held, P.J., Chertow, G.M., Peters, T.G. and Roberts, J.P., 2022. Projecting the Economic Impact of Compensating Living Kidney Donors in the United States: Cost-Benefit Analysis Demonstrates Substantial Patient and Societal Gains. Value in Health. Volume 25, Issue 12, December 2022, Pages 2028-2033

Their paper begins as follows:

"Losing the War Against Kidney Failure

"Economics Nobel Laureate Alvin Roth has played a crucial role in developing paired kidney donation, which is currently saving >1100 US patients with kidney failure per year from suffering on dialysis and dying prematurely. Nevertheless, Professor Roth often points out that this is a victory in a war that we are losing.1 The number of patients diagnosed with kidney failure each year in the United States is not only much greater than the number who receive kidney transplants; it is rising at a faster rate.2,3 Thus, the number of patients diagnosed with kidney failure who are fated to suffer on dialysis for an average of 4 to 5 years while their health steadily deteriorates until they die prematurely has trended upward and is now >100 000 per year.

"How to Win the War

"Many researchers have argued that the government can substantially increase kidney donations and transplants by compensating living kidney donors.4, 5, 6, 7 Indeed, there is virtually unanimous agreement in the transplant community that the government should remove all financial disincentives to kidney donation.8 This study extends that line of reasoning to its logical conclusion by asking (1) how many patients diagnosed with kidney failure each year could avoid suffering on dialysis and premature death by receiving one or more kidney transplants and (2) what level of government compensation of donors would be needed to induce this number of donations."

**********

The paper was preceded in the issue by this commentary:

Garrison, Louis P. "Paying for Kidneys: Reflections on Welfare Economics, Political Economy, and Market Design." Value in Health 25, no. 12 (2022): 1925-1928.

The commentary begins this way*:

"British philosopher Janet Radcliffe Richards at the University of Oxford has written: “If you die through mistakes in moral reasoning, you are just as dead as if you die through mistakes in medicine.”1 The aim of the authors of this thought-provoking cost-benefit analysis is to estimate and inform us about the cost to American society of the limits—perhaps owing to mistakes in both moral and economic reasoning—on the ability of healthy individuals to donate or supply their second or “extra” kidney to those who have kidney failure.2 The 1984 National Organ Transplant Act makes it unlawful to share anything of value between organ donor and recipient, prohibiting exchange for “valuable consideration” (meaning, specifically, payments beyond “reasonable” expenses for removal, implantation, etc)."

*It also includes this great parenthetical aside:

"(As an aside, our health economics and outcomes research field should pay more attention to “market design:” a good place to start is a visit to the blog of Roth30.)"

**********

The commentary also refers to the symposium I blogged about below at the University of Chicago, which you can follow on video:

Friday, July 15, 2022

The Future of Living Donor Kidney Transplantation (videos)

On May 7, 2022 the University of Chicago hosted a Symposium on "The Future of Living Donor Kidney Transplantation: Evolving National Perspectives in Kidney Transplant "

HT: Philip Held

Two illegal (former) kidney transplant networks analyzed: the Netcare -and Medicus cases, by Ambagtsheer and Bugter

 There aren't many successful prosecutions resulting from illegal organ trafficking, despite the fact that the prevalence of illegal kidney transplants is estimated by many sources to be high.  Here's a paper that tries to understand the nature of the black market supply chain for kidneys, by examining two prosecutions that led to convictions, connected to a hospital in Kosovo and another in South Africa.

Ambagtsheer, F., Bugter, R. The organization of the human organ trade: a comparative crime script analysis. Crime, Law and Social Change (2022). https://doi.org/10.1007/s10611-022-10068-5

Abstract: "This study fills critical knowledge gaps into the organization of organ trade utilizing crime script analysis. Adopting a situational crime prevention approach, this article draws from law enforcement data to compare the crime commission process (activities, cast and locations) of 2 prosecuted organ trade cases: the Medicus case and the Netcare case. Both cases involved transnational criminal networks that performed kidney transplants from living donors. We further present similarities and differences between illegal and legal living donor kidney transplants that may help guide identification and disruption of illegal transplants. Our analysis reveal the similar crime trajectories of both criminal cases, in particular the extensive preparations and high degree of organization that were needed to execute the illegal transplants. Offenders in the illegal transplant schemes utilized the same opportunity structures that facilitate legal transplants, such as transplant units, hospitals and blood banks. Our results indicate that the trade is embedded within the transplant industry and intersects with the transport- and hospitality sector. The transplant industry in the studied cases was particularly found to provide the medical infrastructure needed to facilitate and sustain organ trade. When compared to legal transplants, the studied illegal transplant scripts reveal a wider diversity in recruitment tactics and concealment strategies and a higher diversity in locations for the pre-operative work-up of donors and recipients. The results suggest the need for a broader conceptualization of the organ trade that incorporates both organized crime and white collar crime perspectives."

***

"Although reliable figures of the trade’s scope are lacking, the World Health Organization (WHO) has estimated that approx. 5000 illegal transplants are performed annually (WHO, 2007). The organ trade is reported to rank in the top 5 of the world’s most lucrative international crimes with an estimated annual profit of $840 million to $1.7 billion (May, 2017). While illegal organ transplants have been reported to take place in countries across the globe, knowledge of the trade’s operational features remains scarce (Pascalev et al., 2016)

...

"At the time of writing, only 16 convictions involving organ trade have been reported to the case law database of the United Nations Office on Drugs and Crime, which is far less than would be expected based on global estimates of the problem (UNODC, 2022). The Organization for Security and Co-operation in Europe (OSCE) has reported 9 additional cases (OSCE, 2013). All reported cases had cross-border features and most involved the facilitation of living donor kidney transplants.

...

"In 2014 the Council of Europe established a new convention against ‘Trafficking in Human Organs’ which calls for a broad prohibition of virtually all commercial dealings in organs. Accordingly, sales that occur with the consent of donors are considered to be ‘trafficking’ regardless of the circumstances involved (Council of Europe, 2015)"

...

[Netcare]"Israeli and Romanian donors were promised $20,000 for their kidneys, the Brazilian donors were promised between $3,000 and $8,000. Most donors were recruited in Brazil by 2 retired military officers (Ambagtsheer, 2021; De Jong, 2017; Scheper-Hughes, 2011). 

Payments and reimbursements: Payments took place throughout all stages of the crime commission process. Patients paid Perry/his company up to $120,000 prior to their travel and transplant. Perry, and later also Meir, subsequently paid Netcare. Netcare in turn disbursed payments to various actors in the scheme, including the transplant surgeons and the blood bank. ... Occasionally, additional payments were made directly in cash to the surgeons by Perry, his company, or his agents. Perry also paid an escort/fixer (Rod Kimberley) and a nephrologist. Kimberley paid low-tier offenders in the scheme, including the interpreters. Kimberley additionally covered the costs of recipients’ and donors’ accommodations and he gave donors pocket money upon arrival in South Africa as an advance to their kidney payment. All donors received the promised amount in cash after their operations. 

...

"Contrary to donors in the Netcare case, none of the Medicus’ donors received the promised amount. Some did not receive payment at all but were promised payment only if they recruited new prospective kidney sellers. Withholding payments to kidney sellers in order for them to recruit new prospective kidney sellers is a tactic in organ trafficking schemes to sustain the transplant program (De Jong, 2017).

...

"The cases diverge with respect to the locations and legal embeddedness. Contrary to the Medicus case where transplants were organized in one clinic that was not licensed to conduct transplants, transplants in South Africa were facilitated in at least 5 hospitals across the country that were legally mandated to perform transplants."

Blood Money, by John Dooley and Emily Gallagher

 Are paid plasma donors being exploited? Here's a paper that suggests not, but rather that the payments that plasma donors receive can improve their financial well being not merely by providing additional income, but also by helping them avoid going into expensive debt.

 Dooley, John and  Emily Gallagher, Blood Money (October 11, 2021). Available at SSRN: https://ssrn.com/abstract=3940369 or http://dx.doi.org/10.2139/ssrn.3940369

Abstract: "Little is known about the motivations and outcomes of sellers in remunerated markets for human materials. We exploit dramatic growth in the number of commercial blood plasma centers in the U.S. to study the individuals who sell plasma. We find sellers tend to be young and liquidity constrained with low incomes and credit scores; they also report less access to traditional bank credit. Plasma centers absorb demand for non-traditional credit. The opening of a nearby plasma center reduces payday loan inquires and transactions by 13–18% among young borrowers. Meanwhile, foot traffic increases by over 9% at both essential and non-essential goods establishments when a new plasma center opens nearby. Our findings suggest that, at least in the short-term, constrained households use the discretionary income from plasma centers to smooth consumption without appealing to high-cost debt."

HT: Mario Macis

Update: here's the published version

John M Dooley, Emily A Gallagher, Blood Money: Selling Plasma to Avoid High-Interest Loans, The Review of Financial Studies, 2024;, hhae018, https://doi.org/10.1093/rfs/hhae018

Reforming kidney care, by Drs. Ben Hippen and Thao Pascual.

 Ben Hippen is a transplant nephrologist who I encountered not too long after I started to think about kidney transplants. I've always found it enlightening to listen to him. And he's changed where he sits, most recently by taking a position with Fresenius, the big dialysis provider.

Here's a snippet of his professional history from his cv:

Current positions:

•Senior Vice President, Global Head of Transplant Medicine, Fresenius Medical Care. Sept 2021

•Clinical Professor of Internal Medicine, University of North Carolina, Chapel Hill School of Medicine. (Non-tenure track appointment) April 2015-present.

Past Positions:

•General and Transplant Nephrologist, Metrolina Nephrology Associates, P.A, Charlotte, North Carolina. 2005-2021

•Attending General and Transplant Nephrologist, Transplant Center, Carolinas Medical Center, Charlotte, North Carolina. 2005 - 2021

•Medical Director, FKC Baxter Street Hemodialysis Unit (in-center and home therapies).2009-2021.

Here are some of his current thoughts, with his colleague Dr. Pascual, in Medpage Today on how to advance kidney care and transplantation.

The Kidney Transplant Ecosystem Is Ripe for Reform— Here are the policies and payment systems that need to change  by Benjamin Hippen, MD, and Thao Pascual, MD

"A centralized data repository of patients' clinical evaluations, laboratory, and radiologic testing accessible by multiple transplant centers could reduce the time, expense, and waste of redundant or obsolete testing.

...

"Quality outcomes for transplant programs should be pegged to the patient outcome that really matters: Receiving a successful kidney transplant in the shortest period of time. A recent survey of patients with kidney disease regarding tradeoffs between being transplanted earlier and waiting for a "better organ" confirms that a wide majority of patients prioritize being transplanted sooner. "Transplant soon and well" should be the mantra for regulators and policy makers when considering nephrologist and dialysis provider-facing metrics to achieve the right outcomes for patients. 

...

"several reforms can be made to the transplant ecosystem to make it easier for transplant centers to be more aggressive in their organ acceptance behaviors. Changing the organ offer system to use the approach of "simultaneously expiring offers" can streamline organ placement timelines, placing higher-risk organs with more risk-tolerant centers more quickly and efficiently. Aligned with the goal of getting patients to transplant faster, regulators and payors (public and private) should prioritize shortening time to transplant over sky-high 1-year patient and graft survival thresholds. The lowest performing third of transplant centers are conferring longer and better survival rates to patients compared to any maintenance dialysis therapy. We should seek to remove regulatory and financial barriers to transplant centers seeking to safely make use of every gift of life. If we expect transplant centers to transplant higher-risk organs, we should recognize that it may cost more to perform those transplants successfully. The payment system for transplants should account for these higher costs so that transplant centers are not faced with losing money when transplanting higher-risk organs.

"A key component of the kidney transplant ecosystem is the generosity of living donors, and we should do more to support their decision to give the gift of life. This means protecting living donors from insurer efforts to exclude them from life or disability insurance coverage because of their donation. In addition, enhancing education efforts to increase living donor kidney transplants can help bridge the gap between organ need and supply. One pending solution to these challenges is the passage of the Living Donor Protection Act (H.R.1255/S.377). The bill would prohibit discrimination by insurers based on an individual's status as a living organ donor. Employers can also do their part through adjusting their paid leave policies for employees who become living donors, by joining the AST Living Donor Circle of Excellence."

"Benjamin Hippen, MD, is senior vice president and head of transplant medicine and emerging capabilities at Fresenius Medical Care. Thao Pascual, MD, is associate chief medical officer at U.S. Renal Care. They are both members of Kidney Care Partners."

********

As a long time, thoughtful  observer of kidney care and transplantation, Dr Hippen's point of view has shifted over time. Below are some (much) earlier blog posts featuring some of his earlier thoughts.

Wednesday, March 16, 2011

How not to assign kidneys

Saturday, April 9, 2011

Should there be a donor kidney market? Latest version of a familiar debate

Sunday, July 26, 2015

Ben Hippen on the economics of transplantation and dialysis

Canadian Blood Services to start paying Canadian plasma donors

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

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

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

...

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

...

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

...

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

Non-directed organ donors and NLDAC financial support

For some years I've been a member of the advisory group of the National Living Donor Assistance Center (NLDAC) which is authorized to offer federally funded financial support (for travel, and now also for lost wages and childcare expenses) to needy donors whose recipients also cannot afford to offer such support. As kidney exchange has grown, so have the number of non-directed donors, who don't have a particular recipient in mind. In a recent email, NLDAC has defined how these donors can qualify for financial assistance.

"Defining Non-Directed Donors

"Eligibility for NLDAC depends primarily on the recipient's household income. This is because the Organ Donation and Recovery Improvement Act requires NLDAC to assess the recipient's ability to reimburse their donor before providing reimbursement with federal funding. Most donors have a particular recipient in mind, and that person is allowed to reimburse their expenses, if they are willing and able to do so. NLDAC provides reimbursement when the recipient cannot afford to provide it. Some donors do not have a recipient to ask for help, though. A non-directed donor is a living donor with no intended recipient. These donors can apply to NLDAC without recipient information because there is no identified recipient. Non-directed donors are eligible for NLDAC regardless of their eventual recipient's information, as long as the donor meets the residency requirements and applies on time. 

"Let's consider some examples:

"Tina heard on the news that there are 5,000 people waiting for a kidney transplant in her state. She called a transplant center and asked that they give her kidney to anyone who needs it, if she is approved to donate. Tina is a non-directed donor because she has no intended recipient. 

"Anthony read about a stranger's search for a living kidney donor on Facebook. Though he doesn't know the person, he would like to be evaluated as a potential donor for them. He is a directed donor because he has an intended recipient, even though he doesn't know them personally. 

"Jacqueline wants to donate to a member of her church without revealing her identity to the recipient. She is a directed donor because she has an intended recipient, though she wants to remain anonymous. 

"Esther wanted to donate to her husband, but they are not a good match. Through kidney paired donation, she donates to a stranger, and the stranger's loved one donates to her husband. Because Esther has an intended recipient who received a transplant through her donation, she is a directed donor. 

"Devin was being evaluated as a potential living donor to his uncle when his uncle received a deceased donor transplant. Devin decided he was still willing to donate even though his uncle no longer needed his organ, and asked the transplant center to give his kidney to anyone on the waitlist. Devin is now a non-directed donor because he does not have an intended recipient anymore. 

"Which of these donors can apply to NLDAC without their recipient's information? Tina and Devin, because they are donating without an intended recipient. Anthony, Jacqueline, and Esther can apply with their intended recipient, and NLDAC will keep the donor and recipient's information private. Esther would apply with her originally intended but incompatible recipient, her husband."

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

All my posts on NLDAC:  https://marketdesigner.blogspot.com/search?q=nldac&max-results=20&by-date=true