Controversial Markets: Public lecture at the Zurich Center for Market Design (video)

 A video of my April 13 lecture on Controversial Markets is now available at the Zurich Center for Market Design. (The talk proper is about an hour, and then includes some Q&A about compensation for donors, among other things, starting at around minute 56.)

Here's a direct link:

PhD-studentship at Durham University studying international kidney exchange

 Peter Biro forwards this announcement

PhD-studentship at Durham University in Cooperative Game Theory

Please find below details on a PhD-studentship in the Algorithms & Complexity Group (http://community.dur.ac.uk/algorithms.complexity/) at the Department of Computer Science of Durham University for the project: International Kidney Exchange: How to Ensure Stability?

The PhD-studentship provides full tuition fees and a maintenance grant for 42 months (£15,609 for 2021/2022) both for UK students and international students.

Deadline for applications: 10 May 2021 but the review of applications may close earlier if the PhD studentship is filled.

Starting date: 1 October 2021.

Project summary:  A kidney patient may have a willing donor, but a kidney transplant might not be possible due to blood- or tissue-type incompatibilities. However, patients and donors may be swapped after all patient-donor pairs are pooled together and one seeks to do this optimally (via a solution of a graph decomposition problem). We consider the situation where pools from multiple countries are merged. To keep an international kidney exchange program (KEP) stable, it is crucial that any proposed solutions will be accepted by all participating countries. The goal of this project is to research and improve stability of international KEPs using classical fairness concepts from Cooperative Game Theory. As such, the project has both a theoretical and experimental component.

The project involves a collaboration with the Mechanism Design Group, led by Dr Péter Biró, of The Centre for Economic and Regional Studies in Budapest (https://mechanismdesign.eu/).

Supervisory team: Prof. Daniel Paulusma (Durham, http://community.dur.ac.uk/daniel.paulusma/) and Prof. Matthew Johnson (Durham, http://community.dur.ac.uk/matthew.johnson2/)

Applications are welcomed from students with a first class degree or equivalent in Computer Science or Mathematics. Programming experience is essential.

To apply, please visit https://www.dur.ac.uk/study/pg/apply/. Applicants are encouraged to contact Daniel Paulusma at daniel.paulusma@durham.ac.uk<mailto:daniel.paulusma@durham.ac.uk> in advance of making an application.

The 1% Steps for Health Care Reform Project (including kidney exchange)

 The goal of the 1% Steps for Health Care Reform Project is to shift the way we think about health care spending in the US and offer a roadmap to policy makers of tangible steps we as a country can take to lower the cost of health care in the US. We want to leverage leading scholars’ work to identify discrete problems in the US health system and offer evidence-based steps for reform. We will continually update the project with new proposals that are based on the latest academic research.

Here is their full list of Policy Briefs.

Here's one on kidney exchange:

Expanding Kidney Exchange

Authors: Nikhil Agarwal, Massachusetts Institute of Technology; Itai Ashlagi, Stanford University; Michael Rees, The University of Toledo Medical Center; Alvin Roth, Stanford University

Here's one paragraph:

"Policy Proposal: This brief discusses three specific proposals for expanding kidney exchange. First, policy makers should eliminate financial disincentives for participating in kidney exchange platforms by including medical and administrative costs specific to kidney exchange in reimbursements from the Medicare program. Second, policy makers should direct the federal contractor UNOS (United Network for Organ Sharing) to allow kidney exchange chains to be initiated by deceased donors. Third, Medicare should pay for the costs of a global kidney exchange that allows exchanges involving patients in different nations."

And here's some discussion by Nikhil Agarwal with Zack Cooper:

Mike Rees wins transplant surgeon excellence award for innovations in kidney exchange

Mike Rees, who founded the Alliance for Paired Kidney Donation (APKD), received The American Association of Kidney Patients (AAKP)  2021 MEDAL OF EXCELLENCE AWARD at the American Society of Transplant Surgeons Winter Symposium (January 16),  during the ASTS Awards Ceremony.  In the two-minute video below, he accepts the award for his introduction of Nonsimultaneous Extended Altruistic Donor Chains, Standard Acquisition Charges, and Global Kidney Exchange (GKE).

The international scope of kidney disease

 During the Covid-19 pandemic we've all become aware of the importance of public messaging--about wearing masks and other behaviors that reduce the spread of infection, etc.  For those of us interested in transplantation, communication about the prevalence and international scope of kidney disease is important

Here's an article from Kidney International (from a year ago) that focuses on just that:

A single number for advocacy and communication—worldwide more than 850 million individuals have kidney diseases by Kitty J. Jager, Csaba Kovesdy, Robyn Langham, Mark Rosenberg, Vivekanand Jha, Carmine Zoccali

"On a world scale the total number of individuals with chronic kidney disease (CKD), acute kidney injury (AKI), and those on renal replacement therapy (RRT) exceeds 850 million, a truly concerning figure that is twice the estimated number of people with diabetes worldwide and >20 times higher than the number of individuals affected by AIDS/HIV worldwide. Thus kidney diseases are one of the most common diseases worldwide.

"CKD is now an unquestionable global public priority.1,  2 Even though the prevalence of CKD and its impact on health has been mainly studied in economically developed countries, the burden of this disease is even greater in developing countries.3,  4 In 2016, this disease was 13th on the list of causes of death on a world scale,5 and in 2040, it is expected to be the 5th leading cause of years of life lost.6 In 2010, 2.6 million individuals were receiving some form of kidney replacement therapy worldwide, but an almost equal number might have died during the same year because of a lack of access to dialysis and transplantation.7 This scenario contrasts with that of other major chronic diseases, such as cardiovascular diseases and respiratory diseases, whose effects on mortality are declining."

HT: Mike Rees

NBER market design meeting today through Saturday on Zoom

The NBER market design conference is on Zoom this year, today through Saturday, starting each day at noon Eastern time (9am Pacific time).  I'll be speaking today at 2:45 EST (11:45 PST), about a new proposal for global kidney exchange using chains that begin overseas and end in the U.S., and about the background and history to this proposal, which initially met with considerable opposition.

2:45 pm	Mohammad Akbarpour, Stanford University Afshin Nikzad, University of Southern California Michael A. Rees, University of Toledo Medical Center Alvin E. Roth, Stanford University and NBER Global Kidney Chains

The full schedule, with links to papers, is here:

Market Design Working Group Meeting

Michael Ostrovsky and Parag A. Pathak, Organizers

October 22-24, 2020, on Zoom.us

 

Ned Brooks interviews me at the National Kidney Donor Organization virtual conference (video)

 For easy access, here's the video of my talk at the National Kidney Donor Organization virtual conference, about which I blogged this morning.  We talked about kidney exchange, global kidney exchange, and repugnant transactions...

Surgery Grand Rounds at UCSF. "Kidneys and Controversies: Kidney Exchange Within and Across Borders" Oct 21 (7am PST)

 Tomorrow at dawn I'll give a seminar to the surgeons at UCSF, about kidney exchange, and the controversies it has overcome, and is overcoming.

Surgery Grand Rounds | Kidneys and Controversies: Kidney Exchange Within and Across Borders

Date: October 21, 2020 Time: 7:00am-8:00am Place: Webinar

Rishwain Visiting Speaker: Alvin E. Roth, PhD

Al Roth is the Craig and Susan McCaw Professor of Economics at Stanford University and the George Gund Professor Emeritus of Economics and Business Administration at Harvard University. He shared the 2012 Nobel memorial prize in Economics. His research interests are in game theory, experimental economics, and market design. In the 1990’s he directed the redesign of the National Resident Matching Program (NRMP) and currently is a member of the Board of Directors. He has been involved in the design and organization of kidney exchange, which helps incompatible patient-donor pairs find life-saving compatible kidneys for transplantation. He is on the Advisory Board of the National Living Donor Assistance Center (NLDAC). His work on kidney transplantation led him to become interested in repugnant transactions, and more generally how markets, and bans on markets, gain or fail to gain social support.

The University of California, San Francisco School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.  CME Course MGR21045

UCSF designates this live activity for a maximum of 43 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

*The above credit is inclusive of credit for all Fiscal Year 2020-2021 Department of Surgery Grand Rounds.

Disclosure declaration – No one in a position to control the content of this activity has a relationship with an ACCME-defined commercial interest. Planners  Wen Shen, MD, Julie Ann Sosa, MD, MA, Lygia Stewart, MD, and Ryutaro Hirose, MD, have stated that they have no relationships to disclose. Speaker Roth has stated that he has no relevant relationships to disclose.

This activity is supported by the Department of Surgery’s Howard Naffziger Endowment Fund.

Join Webinar: https://ucsf.zoom.us/j/252447171?pwd=MWt0bG9vTjBSZEo1UnpidXRVWWU2UT09 

Auctions and Market Design Friday Seminar Series, organized by INFORMS (starting Oct 2)

 The auctions and market design section of INFORMS (the Operations Research and Management Science organization) is initiating a new seminar series,  every other week on Fridays, starting Oct 2.  I'll start the series off with a talk on contemporary kidney exchange, and there are talks scheduled through December, see below.

Auctions and Market Design Online Seminar Series

About the Seminar

The aim of this interdisciplinary seminar is to discuss pioneering and impactful work in the broad area of market design. Theoretical, computational, and experimental work as well as field studies will be featured. A wide range of applications, ranging from online advertising and labor markets to networks and platforms, will be presented. The seminar features research talks and expository talks to highlight trends in the field.

Organization

The seminar is organized by Ozan Candogan (Chicago Booth), Vahideh Manshadi (Yale), and Fanyin Zheng (Columbia).

The seminar will be bi-weekly on Fridays at 1-2 pm ET (10-11 am PT).

Email List

If this seminar interests you and you would like to be notified of upcoming speakers, you can join our email list.

Schedule

October 02 - Alvin Roth (Stanford University)

Title: Kidney Exchange: an Operations Perspective

October 16 - John Birge (University of Chicago)

Title: Increasing Efficiency in Electricity Market Auctions

October 30 - Jon Kleinberg (Cornell University)

November 13 - Winners of the Michael H. Rothkopf Junior Researcher Paper Prize

December 04 - Asuman Ozdaglar (MIT)

December 18 - Matthew Jackson (Stanford University)

Global Kidney Exchange supported by the European Society of Transplantation's committee on Ethical, Legal, and Psychosocial Aspects of Transplantation .

Quite some time ago, the European Society for Organ Transplantation (ESOT) charged its committee on Ethical, Legal, and Psychosocial Aspects of Transplantation (ELPAT) with the task of evaluating those aspects of global kidney exchange (GKE). GKE had been greeted in some quarters with a number of dramatic accusations (e.g. that it was a form of organ trafficking), and the ELPAT committee tried to consider each of them.  Interestingly, the committee included members who I surmise started with a wide range of views, from cautious support to active hostility to GKE.

The final report, just published in Transplant International,  (which is the official journal of ESOT) is one that I think the committee can be proud of.  While you can tell that some committee members retain reservations about GKE, they nevertheless all agreed on a report that finds all of the principal objections raised against GKE to be unfounded.  Together with the even more clearly stated support for GKE in the Lancet, I think that this may mark a turning point: it certainly marks that GKE is receiving growing (and well deserved) support. 

Global Kidney Exchange: opportunity or exploitation? An ELPAT/ESOT appraisal
Frederike Ambagtsheer  Bernadette Haase‐Kromwijk  Frank J. M. F. Dor  Greg Moorlock  Franco Citterio  Thierry Berney  Emma K. Massey
Transplant International, September 2020, 33, 9, 989-998.    

https://onlinelibrary.wiley.com/doi/full/10.1111/tri.13630       Here's the pdf

"Summary: This paper addresses ethical, legal, and psychosocial aspects of Global Kidney Exchange (GKE). Concerns have been raised that GKE violates the nonpayment principle, exploits donors in low‐ and middle‐income countries, and detracts from the aim of self‐sufficiency. We review the arguments for and against GKE. We argue that while some concerns about GKE are justified based on the available evidence, others are speculative and do not apply exclusively to GKE but to living donation more generally. We posit that concerns can be mitigated by implementing safeguards, by developing minimum quality criteria and by establishing an international committee that independently monitors and evaluates GKE’s procedures and outcomes. Several questions remain however that warrant further clarification. What are the experiences and views of recipients and donors participating in GKE? Who manages the escrow funds that have been put in place for donor and recipients? What procedures and safeguards have been put in place to prevent corruption of these funds? What are the inclusion criteria for participating GKE centers? GKE provides opportunity to promote access to donation and transplantation but can only be conducted with the appropriate safeguards. Patients’ and donors’ voices are missing in this debate." 

Here's their introduction:

"In 2017, Rees et al. [1] introduced “Global Kidney Exchange” (GKE), an international kidney exchange program that facilitates cross‐border exchanges between immunologically incompatible donor–recipient pairs in high‐income countries (HIC) and biologically compatible but financially impoverished donor–recipient pairs in low‐ to middle‐income countries (LMIC). GKE aims to overcome immunologic barriers in the developed world and poverty barriers in the developing world. The underlying rationale is that financial barriers prevent transplantation much more frequently than organ scarcity. The number of patients dying annually worldwide from end‐stage kidney disease due to inadequate financial resources far exceeds the number of patients in developed countries placed on kidney transplantation waitlists [1-3]. GKE has the potential to expand the genetic diversity of the donor pool which may help to transplant difficult‐to‐transplant, highly immunized patients [1]."

As they debunk the main arguments that have been made against GKE, I thought that some of these remarks were among the most interesting:

"Removing financial barriers to organ donation is an internationally agreed objective, enshrined, among others, in the World Health Organization’s (WHO) Guiding Principles on Human Cell, Tissue and Organ Transplantation and in the CoE Convention [13, 15]. These organizations highlight that prohibition of organ payments does not preclude reimbursing expenses incurred by the donor, including the costs of medical procedures [13, 17]. Given that countries’ legislation vary in their approach to what constitutes illicit payment versus legitimate reimbursement, it is doubtful whether GKE violates the nonpayment principle under all circumstances. For example, the University of Minnesota’s legal team vetted GKE and agreed to proceed. Other hospital legal teams have followed suit [1]."

...

"“[e]xploitation occurs when someone takes advantage of a vulnerability in another person for their own benefit, creating a disparity in the benefits gained by the two parties” [9]. It is hard to see, however, that this description of exploitation can be readily applied to GKE. Primarily, it is not clear that there is a significant disparity in benefits between recipients. Each patient receives a kidney transplant, and as Minerva et al point out, benefits are arguably greater for LMIC recipients, who get the additional benefit of their follow‐up care being paid for [33]. The same is true for the donors, who each obtain the desired benefit of their intended beneficiary receiving a transplant. Rather than there being a morally troubling disparity in benefit, GKE appears to offer either roughly equal benefit, or greater benefit for those who are allegedly exploited."

"It is also unconvincing to consider GKE exploitative on other grounds. Rather than failing to protect the vulnerable, it seems that GKE addresses specific vulnerabilities by offering protection to those who are (i) vulnerable to death from kidney failure or (ii) vulnerable to losing a loved one due to kidney failure. It is similarly unconvincing to suggest that GKE treats people merely as a means to an end. Instead, one can see that participants in LMIC are respected as individuals, with measures put in place to protect their welfare and to ensure that their participation is voluntary."

...

The claim that donors and recipients in LMIC are too poor or vulnerable to voluntarily engage in GKE is also debatable and could be seen as paternalistic. First of all, the risk that voluntariness is undermined does not apply specifically to GKE or to LMIC alone, but applies to living donation more generally [35].

...

"The proclamation that countries have to be self‐sufficient was first declared by the 2008 DoI and the WHO [73, 74] and has rapidly gained momentum since [75-77]. The argument to ban GKE because of the need to achieve self‐sufficiency raises various implications however. First of all, it implies that the need for countries to become self‐sufficient is more important than the lives that can be immediately saved through GKE. Is achievement of self‐sufficiency so important that it overrides life‐saving alternatives? Who has the authority to decide which approach should get priority? Why is it required that countries become self‐sufficient in organ donation and transplantation, while it is universally accepted for countries to rely on global exchanges of all other types of goods and services?

 ***********************

The ESOT/ELPAT committee apparently operated under rules that prevented them from investigating some claims that required evidence, so they included some questions for us in their paper, which we answer in the comment that appeared in the same issue of TI. (For example, there was some confusion about what escrow meant in connection with the money provided for the foreign donor and recipient's medical expenses after their return home...)

In any event, the large number of co-authors to our comment (21!) is another expression of the broad and international support that GKE is achieving.

Global Kidney Exchange Should Expand Wisely
Alvin E. Roth  Ignazio R. Marino  Obi Ekwenna  Ty B. Dunn  Siegfredo R. Paloyo  Miguel Tan  Ricardo Correa‐Rotter  Christian S. Kuhr  Christopher L. Marsh  Jorge Ortiz  Giuliano Testa  Puneet Sindhwani  Dorry L. Segev  Jeffrey Rogers  Jeffrey D. Punch  Rachel C. Forbes  Michael A. Zimmerman  Matthew J. Ellis  Aparna Rege  Laura Basagoitia  Kimberly D. Krawiec  Michael A. Rees 

Transplant International, September 2020, 33, 9,  985-988. https://onlinelibrary.wiley.com/doi/full/10.1111/tri.13656   Here's a link to the pdf 

Here's the full first paragraph:

"We read with great interest and appreciation the careful consideration and analysis by Ambagtsheer et al. of the most critical ethical objections to Global Kidney Exchange (GKE). Ambagtsheer et al. conclude that implementation of GKE is a means to increase access to transplantation ethically and effectively.1,2 These conclusions by their European Society of Transplantation (ESOT) committee on Ethical, Legal and Psychological Aspects of Transplantation (ELPAT) represent a step forward toward a greater understanding and an open, honest debate about GKE. Taken together with the strong endorsement of GKE by Minerva et al. in Lancet  and the positive position statement of the American Society of Transplant Surgeons (ASTS), Ambagtsheer et al. successfully dispel previously raised doubts 5-13 to which we have previously responded .2,14-17"

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

Here are all my posts on global kidney exchange (GKE)

Global kidney exchange between Abu Dhabi and Kerala (India)

Here is an article in the newspaper Malayalam Manorama, in Malayalam, the language spoken in Kerala, about a global kidney exchange between hospitals in Abu Dhabi in the United Arab Emirates, and in Kerala in India.

The url hints at the story: the exchange was between a Kerala hospital and a UAE hospital that both used kidney exchange software provided by Mike Rees's organization, the Alliance for Paired Kidney Donation (APKD), to identify the exchange, which was performed in India:

https://www.manoramaonline.com/global-malayali/gulf/2020/08/05/alliance-for-paired-kidney-donation-uae.html

നൽകാൻ ആളുണ്ടായിട്ടും വൃക്ക ലഭിക്കാത്തവർക്ക് ആശ്വാസം

 

The article says SEHA Kidney Care Staff( Anan Purushothaman, Sheenamma Varghese , Siddiq Anwar) with Dr Mike Rees from Alliance For Paired Donation helped find a compatible  kidney donor in India via the “Global Kidney Paired Exchange”. Dr Feroz Aziz then successfully transplanted the two pairs.

Kim Krawiec, through a friend fluent in Malayalam, gives the following summary:

"The article goes on to say that Najla was in want of a kidney donor. Even though she had 3 of her relatives who were ready to donate none of them were compatible. She was asked to get in touch with the organisation called Alliance for Paired Kidney Donation, where they find donors all around the world using the latest technology. With the help of this organisation and the latest technology, not to mention the doctors and nurses she was able to find a compatible donor. At the same time Najma's mother was able to donate her kidney to the Abu Dhabi donor's husband. Now all are well and back to normal life."

Surrogacy and global kidney exchange receive popular support even where banned, in PNAS by Roth and Wang

Popular repugnance contrasts with legal bans on controversial markets
Alvin E. Roth and  Stephanie W. Wang
PNAS first published July 29, 2020 https://doi.org/10.1073/pnas.2005828117

reviewed by Nicola Lacetera and Mario Macis

Abstract: We study popular attitudes in Germany, Spain, the Philippines, and the United States toward three controversial markets—prostitution, surrogacy, and global kidney exchange (GKE). Of those markets, only prostitution is banned in the United States and the Philippines, and only prostitution is allowed in Germany and Spain. Unlike prostitution, majorities support legalization of surrogacy and GKE in all four countries. So, there is not a simple relation between public support for markets, or bans, and their legal and regulatory status. Because both markets and bans on markets require social support to work well, this sheds light on the prospects for effective regulation of controversial markets.

"Our main result is that (unlike prostitution) the laws banning surrogacy and GKE do not seem to reflect popular demand. Neither do these bans reflect that opponents of legalization feel more strongly than supporters.

...

"All three transactions are the subject of current debate in at least one of the countries we surveyed.¶¶ Based on the results of our surveys, we do not see entrenched popular resistance to either surrogacy or GKE (or simple kidney exchange) where it is presently illegal, and thus, we anticipate that efforts to lift or circumvent current restrictions are likely to be increasingly successful, while efforts to legalize or decriminalize prostitution where it is presently illegal may face greater opposition from the general public.

"Understanding these issues is important, not just for the hundreds of Spanish couples stranded outside of Spain while they look for a way to bring their surrogate children home and not just for the people in need of kidney exchange but for whom it is out of reach in Germany or in the Philippines. These issues are also of importance to social scientists in general and economists in particular. When markets enjoy social support, when they are banned, and when, in turn, bans are socially supported are questions that touch upon many transactions, particularly as social and economic interactions are increasingly globalized.

"Our findings suggest that the answer to these questions may not be found in general public sentiment in countries that ban markets or legalize them. Rather, we may have to look to the functioning of particular interested groups, perhaps with professional or even religious interests, that are able to influence legislation in the absence of strong views (or even interest) among the general public about the markets in question."

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

Here's the published citation:

Roth, Alvin E. and Stephanie W. Wang, “Popular Repugnance Contrasts with Legal Bans on Controversial Markets,” Proceedings of the National Academy of Sciences (PNAS),  August 18, 2020 117 (33) 19792-19798; https://doi.org/10.1073/pnas.2005828117 

Kidney Exchange: an Operations Perspective by Ashlagi and Roth

Here's a survey that puts some emphasis on the many changes in the design of kidney exchange operations and processes that have moved it from its small beginnings to its current situation facilitating annual transplants in the thousands, and might help to scale it up further, since the supply of transplants is still far short of the need. 

Kidney Exchange: an Operations Perspective
Itai Ashlagi and Alvin E. Roth
May 2020

Abstract: Many patients in need of a kidney transplant have a willing but incompatible living donor. Kidney exchange programs arrange exchanges among such incompatible patient-donor pairs, in cycles and chains of exchange, so each patient receives a compatible kidney. Kidney exchange has become a standard form of transplantation in the United States and a few other countries, in large part because of continued attention to the operational details that arose as obstacles were overcome and new obstacles became relevant. We review some of the key operational issues in the design of successful kidney exchange programs. Kidney exchange has yet to reach its full potential, and the paper further describes some open questions that we hope will continue to attract attention from researchers interested in the operational aspects of dynamic exchange.


Here's the concluding paragraph:

"Looking back, kidney exchange has accomplished a lot, but not nearly enough. The number of people waiting for a kidney transplant is growing, despite the growth of exchange. But there is room for kidney exchange to continue to grow and to increase the availability of transplants further, by designing international kidney exchanges, by starting chains with deceased donor kidneys, and by introducing other market design innovations that have yet to be explored or even conceived."

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

Now online in Management Science, Ahead of Print

Kidney Exchange: An Operations Perspective

Itai Ashlagi , Alvin E. Roth 

Published Online: 

2 Jul 2021 https://doi.org/10.1287/mnsc.2020.3954

Kidney exchange, in French, in Forbes

Here's a short interview in French about kidney exchange, in Forbes France:

Alvin Roth, Lauréat Du Prix Nobel D’Economie Veut Revolutionner Les Dons De Reins
Philippe Branche   10 janvier 2020

Here's one bit:

Are you currently working with politicians, legislators or medical administrators to resolve this problem ? 

Alvin Roth: I am, but not with great success. I recently spoke to decision makers in several countries: India, China, Germany, Canada and of course the United States. In October, renowned bioethicist Peter Singer expressed strong support for the Global Kidney Exchange Program, so that recently the idea of ​​expanding kidney exchange to include international exchanges has gained momentum. I also recently debated with a member of the Bundestag, the German parliament. In Germany, kidney transplantation from a living donor is legal, but a patient can only receive a kidney from an immediate family member, and therefore the literal interpretation of the law makes it impossible to exchange kidneys. German law provides that monetary exchanges of parts of the human body are illegal and, apparently, it is to avoid any possibility of payment for a kidney that the limitation to family members is applied. A minimal amendment to German law could allow immediate family members to make an indirect donation, via the kidney exchange system, which would preserve the confidence that the donor was not paid to make an exchange. By designing this market in this way, we are trying to expand the database and reduce the waiting time for sick people.

Global kidney exchange: continued controversies, perhaps moving towards resolution

As 2019 came to a close, several articles reminded us that global kidney exchange (GKE), while gaining increasing acceptance, still is regarded as repugnant in some quarters.

Here's an article in Forbes:
Why The Global Kidney Exchange Remains Controversial by Christine Ro, Dec. 15

"The GKE has been philanthropically funded so far, but it’s possible that US health insurance companies might assume the expenses in the future. The exchanges are cost-effective on the rich-country side because the costs of medical care are smaller in lower-income countries. As well, dialysis is an unusual medical procedure in that every US citizen is entitled to it. Kidney transplants work out to be much cheaper than years of dialysis.

"This lopsided cost-effectiveness is one of the main sources of controversy around the GKE. One argument is that, to use the example of the first GKE match, the US ultimately benefits much more than the Philippines. If the Filipino pair is already a match, but the first US pair isn’t, the Americans are receiving a kidney matching service (kickstarting a daisy chain) that the Filipinos didn’t need. What the Filipinos did require was payment of their expenses. If they had the financial resources, they wouldn’t need an exchange program at all. They, or their medical system, could have covered the costs of the transplant.
...
"The medical team involved in the first Filipino match are adamant that it was positive. In an impassioned letter to the editor of the American Journal of Transplantation, they write:

“Let us be clear: without GKE, the Filipino husband was never going to receive his spouse’s kidney. Without GKE, the husband was going to die, the wife was going to lose her spouse, and their son was going to be fatherless.”

“No alternative existed for this Filipino pair and millions more like them. GKE did not exploit this Filipino couple—it provided the mechanism for the wife to literally save her husband’s life. They could not afford dialysis.”

“For 3 years on Father’s Day, the couple’s child has written our team to thank us for saving his daddy’s life.”

********

The Forbes article also links (without pointing it out) to the recent robust defense of GKE in the Lancet (see Global Kidney Exchange in the Lancet, by Minerva, Savulescu and Singer ).

And I've written earlier about other, welcome support.

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

But in Spain, the National Transplant Organization has organized opposition against allowing patients and donors from poor countries to participate in kidney exchange.  So I was glad  to see a Spanish healthcare blog questioning their reasoning:

From the Spanish blog Avances en gestión clínica (Advances in Clinical Management):

¿Nobel de Economía o traficante de órganos? ["Nobel economist, or organ trafficker?"]
by Pedro Rey, Dec. 30

It turns out that isn't meant to be an inflammatory headline, rather it is a reaction to the inflammatory announcements that issued from the Spanish ONT (National Transplant Organization) in connection with global kidney exchange.  Below, for example, is one of many such stories, using just such words:

La ONT frena la entrada en Europa de «una nueva forma de tráfico de órganos» propuesta por un nobel de Economía  ["The ONT slows the entry into Europe of "a new form of organ trafficking" proposed by a nobel economist"

Beatriz Domínguz Gil, directora de la ONT, denuncia que la iniciativa de Alvin Roth es «una nueva forma de tráfico de órganos, pero presentada como una iniciativa buena y ética» 

[  "Beatriz Domínguz Gil, director of the ONT, denounces that Alvin Roth's initiative is "a new form of organ trafficking, but presented as a good and ethical initiative"]
******
Coming back to Professor Rey and his question ¿Nobel de Economía o traficante de órganos?. He points out that while the Spanish ONT is a world leader in recovering deceased donor organs, it doesn't have the same kind of leadership in living organ donation or in kidney exchange.  He says, in part (via Google translate):

"we may find it worrying that Spanish morals have slowed, before 28 countries, the development of an idea that could benefit many patients and reduce the economic burden to keep them on dialysis for a long time.To solve this problem, a public and serious debate that clarifies the specific interests of an ONT that has based its prestige on the proven effectiveness in transplants from deceased donors and not so much in cross-transplants and, even less, living transplants, would be desirable."
********

Professor Rey goes on to note that we shouldn't naively assume that problems in dealing with cross border issues, especially between rich and not so rich countries, can be easily navigated.  I agree, and I'm confident that the GKE chains that have been conducted so far will pass close scrutiny, and point the way towards finding global solutions to the global problem of kidney failure.

I hope this is an indication that in the coming year, some of the early, hysterical reactions to GKE in Spain may continue to give way to more reasoned discussion, that will let legitimate concerns be expressed and addressed, and separated from other personal and professional motivations that may have obscured the initial reception of GKE in Europe.

Kidney exchange explained in 1 minute (video), and a BBC story

Here's a link to a 1 minute BBC video that was recorded when I was in Berlin recently, discussing how changes in the German transplant law (which presently allows only immediate family members to donate a kidney to someone) could be minimally modified to allow kidney exchange also.

 (a short ad comes on first--my part is only 48 seconds:-)


Here's an accompanying story that somewhat confusingly (it seems to me)  mashes together discussions of kidney exchange, global kidney exchange, and compensation for donors.

How an economist helped thousands get a new kidney By Ian Rose, BBC News
Berlin
...
"Roth, working with Tayfun Sönmez and Utku Unver, has revolutionised kidney donation around the world by using an economic theory to make kidneys more available.
...

"German exchange change?
"We meet in Berlin as Nobel laureates and other luminaries gather to discuss the future of healthcare. Alvin Roth is there in part because Germany is one of the only major industrialised countries where kidney exchange is not lawful.

"I think that the bureaucratic rules and regulations for kidneys as for every market have to be revisited from time to time in the in the light of new developments, and should be modernized and adapted to current capabilities," he says.

"When contacted about the issue the German Health Ministry tells me that they are planning to organise a public debate on the issue but have no schedule for that yet.

"Prof Roth says he understands the concerns behind the German ban. "They're worried about organ trafficking.

"They're worried that if I showed up and wanted to give you a kidney, it would mean that you had paid me and it may be I was a poor and desperate person. But on the other hand, if your brother shows up and wants to give you a kidney, they're not worried about that."
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update:
The BBC publishes in many languages, and so you can read the story in Chinese, Indonesian, Turkish, Spanish, Portuguese, and here's a site that has translated it to Hungarian.

Video Interview: Peter Singer on Global Kidney Exchange

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

Video Interview: Peter Singer on The Global Kidney Exchange Programme
Published November 1, 2019 | By Katrien Devolder

"In this interview with Katrien Devolder, Peter Singer defends the Global Kidney Exchange (GKE) programme, which matches donor–recipient pairs across high-income, medium-income, and low-income countries. The GKE has been accused of being a form of organ trafficking, exploiting the poor, and involving coercion and commodification of donors. Peter Singer refutes these claims, and argues that the GKE promotes global justice and reduces the potential for people in need of kidneys in low-income and medium-income countries to be exploited."

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Earlier post and link to the Lancet article:

Thursday, October 31, 2019

Global Kidney Exchange in the Lancet, by Minerva, Savulescu and Singer

And you can find all my posts on global kidney exchange here.

Update: and here's the press release for the Lancet article, from Princeton's University Center for Human Values:
Peter Singer makes the case for Global Kidney Exchange Program
Thursday, Oct 31, 2019

"Professor Peter Singer is one of three bioethicists who have published an argument in The Lancet, one of the world’s leading medical journals, in favor of a Global Kidney Exchange program that matches donors and recipients across low and middle-income (LMIC) countries with pairs in high income countries.

Singer co-authored the paper  with Oxford University Professor Julian Savulescu and  Francesca Minerva, a postdoctoral fellow at the University of Ghent, in Belgium.

The three argue that, far from representing a form of organ trafficking, as some critics have suggested, a Global Kidney Exchange program would reduce suffering and save the lives of rich and poor patients alike."