Altruistic kidney donors in Israel

 The Forward has the story

Why Israel has more altruistic kidney donors than any other country in the world By Michele Chabin

"Israel is in the bottom half of countries when it comes to organs harvested after death, the type used in most transplants globally. ...

"But ...for more than a decade the number of Israelis who have donated kidneys while they are still alive and well has increased to the point that Israel is the worldwide leader in live donations per capita.

"That’s in large part thanks to the Jerusalem-based nonprofit ... Matnat Chaim, Hebrew for “gift of life,” which recruits and encourages individuals in good health to donate a kidney for purely altruistic reasons. 

"Of the more than 1,450 live kidney donations Matnat Chaim has facilitated, more than 80% percent were altruistic – donated by individuals who had no connection to the recipient. According to the group’s records, it made at least half of the matches between recipients and live donors in Israel from 2015 to 2022.

"Rabbi Yeshayahu Heber, whose life was saved by kidney from a live donor, founded Matnat Chaim in 2009 with his wife Rachel. Rabbi Heber, who died from COVID-19 in April 2020, had said he was moved to recruit volunteer donors after watching other kidney patients die for lack of transplants. 

"On Israel Independence Day this spring, Rachel Heber was awarded the prestigious Israel Prize in honor of the couple’s lifesaving work. 

...

Broadly speaking, the medical definition says that death occurs when the brain is no longer functioning, even if the heart is still beating. There are exceptions, but most ultra-Orthodox rabbis say death occurs when the heart stops beating and the person stops breathing.

“The problem is, if you wait until the heart stops, you can’t harvest the organs,” said Judy Singer, Matnat Chaim’s assistant director.

"For these reasons, Heber made it his mission to recruit live kidney donors.

"With other groups, including the Halachic Organ Donor Society and the Israel Transplant Authority, Matnat Chaim has convinced many religious Jewish communities to encourage members to donate altruistically. “Today, religious Jews, and haredim especially, are at the forefront of live kidney donations,” Singer said. “They say, I can’t donate an organ after death, but take my kidney and help someone now.”About 90% percent of Matnat Chaim’s kidney donors belong to the Modern Orthodox or ultra-Orthodox streams of Judaism.

“That number used to be 97%, but we’re always looking to increase the number of secular donors and Arab donors,” Singer said.

"The group has arranged for “many” Arab Israelis to receive transplants, she said, but did not share numbers for those recipients. Matnat Chaim is looking to work with an Arab group or individual to increase the number of Arab donors and recipients in the future, she added.

...

"According to the Ministry of Health, 656 transplants were carried out in Israel in 2022. Of those about half — 326 — came from living donors. By comparison in the U.S. that same year, about 15% of all organ donations came from living donors.

"Though transplant rates have been rising in both countries, many are still dying for lack of a donor. In Israel, 77 people died waiting for one in 2022."

 

Organ trafficking, and how to reduce it -- Frederike Ambagtsheer in Conversation

Frederike Ambagtsheer, who studies illegal markets for organs and transplants,  has some sensible thoughts on how to combat organ trafficking, not least by increasing the availability of legal, ethical transplantation conducted in high quality hospitals.

Here she is in The Conversation:

Illegal organ trade is more sophisticated than one might think - who’s behind it and how it could be controlled  by Frederike Ambagtsheer

"The organ trade involves a variety of practices which range from excessive exploitation (trafficking) to voluntary, mutually agreed benefits (trade).

"These varieties warrant different, data-driven responses.

"For example, organ sellers are reluctant to report abuses because organ sales are criminalised and sellers will be held liable. Although many can be considered human trafficking victims and be offered protection, this rarely occurs. Law- and policymakers should therefore consider decriminalising organ sales (removing penalties in the law) and offer organ sellers protection, regardless of whether they agree to provide evidence that helps to dismantle criminal networks.

"Countries should also allow medical professionals to safely and anonymously report dubious transplant activity. This information can support the police and judiciary to investigate, disrupt and prosecute those who facilitate illegal organ transplants. Portugal and the UK already have successful organ trafficking reporting mechanisms in place.

"Finally, a contested example of a possible solution to reduce organ scarcity and avoid black market abuses is to allow payments or other types of rewards for deceased and living organ donation to increase organ donation rates. To test the efficacy and morality of these schemes, strictly controlled experiments would be needed.

...

" In short, rather than exclusively focusing on stricter laws, a broader range of responses is needed that both address the root causes of the problem and that help to disrupt organ trading networks."

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Here are all my posts that mention Dr. Ambagtsheer's work, which I've followed for more than a decade.

NYC police officer receives a kidney through Kidneys for Communities (KFC:)

 Police magazine has the story of an anonymous living kidney donor who wanted his/her kidney to go to a first responder, facilitated by  Kidneys for Communities.

NYPD Officer Received Kidney Transplant with Aid of Nonprofit Group and PBA. Kidneys for Communities' Kidneys for First Responders initiative is designed to improve access to and facilitate living kidney donations by connecting those who want to help first responders with those who are in need of a lifesaving kidney donation.  July 7, 2023

"Kidneys for Communities, a national community-directed living kidney donation program, launched its Kidneys for First Responders initiative with its first kidney transplant recipient, New York City Police Officer Melissa Quinones, with assistance from the Police Benevolent Association of the City of New York.

******

And here's the KFC press release (doesn't that acronym already sound familiar?):

Kidneys for Communities Announces their ‘Kidneys for First Responders’ Initiative

"Kidneys for Communities’ Kidneys for First Responders initiative is designed to improve access to and facilitate living kidney donations by connecting those who want to help first responders with those who are in need of a lifesaving kidney donation"

"As Dr. Lloyd E. Ratner, who performed Quinones’ transplant, affirms, “The community-directed model, now available to interested communities and pioneered by Kidneys for Communities, is a common-sense approach to growing the pool of living kidney transplant donors. As more communities come on board, we expect it will shorten the critical waiting time for transplant recipients and save lives.”."

Compensating kidney donors: a call to action by Brooks and Cavanaugh in the LA Times

 Here's a clarion call for compensation of living kidney donors, from two nondirected kidney donors.  It's not the first, and very likely not the last, given the difficulty of modifying the existing law.  But it makes the case very clearly (and proposes that a tax credit spread over ten years might be the way to move foreward).

Opinion: A single reform that could save 100,000 lives immediately BY NED BROOKS AND ML CAVANAUGH, JULY 9, 2023 

"Never in the field of public legislation has so much been lost by so many to one law, as Churchill might’ve put it. The National Organ Transplant Act of 1984 created the framework for the organ transplant system in the United States, and nearly 40 years later, the law is responsible for millions of needless deaths and trillions of wasted dollars. The Transplant Act requires modification, immediately.

"We’ve got skin in this game. We both donated our kidneys to strangers. Ned donated to someone who turned out to be a young mother of two children in 2015, which started a chain that helped an additional two recipients. And Matt donated at Walter Reed in 2021, after which his kidney went to a Seattleite, kicking off a chain that helped seven more recipients, the last of whom was back at Walter Reed.

"Ned founded, and Matt now leads, an organization that represents nearly 1,000 living donors

...

"eight years ago, when Ned donated, the number of living kidney donors was 6,000. With all the work we’ve done since, the number of living donors is still about 6,000 annually. In the United States, nearly 786,000 people suffer from end-stage kidney disease, more people than can fit in the 10 largest NFL stadiums combined.

...

"More Americans die of kidney disease than of breast or prostate cancer, and one in three of us is at risk. This illness is widespread, but what makes it worse is the staggering financial burden borne by everyone. The head of the National Kidney Foundation testified in March that Medicare spends an estimated $136 billion, nearly 25% of its expenditures, on the care of people with a kidney disease. Of that, $50 billion is spent on people with end-stage kidney disease, on par with the entire U.S. Marine Corps budget.

...

"The National Organ Transplant Act prohibits compensating kidney donors, which is strange in that in American society, it’s common to pay for plasma, bone marrow, hair, sperm, eggs and even surrogate pregnancies. We already pay to create and sustain life

...

"The ethical concerns regarding compensation are straightforward. Nobody wants to coerce or compel those in desperate financial straits to do something they would not have done otherwise. The challenge, then — until artificial or nonhuman animal substitutes are viable options — is to devise a compensation model that doesn’t exploit donors.

"Compensation models have been proposed in the past. A National Institutes of Health study listed some of the possibilities, including direct payment, indirect payment, “in kind” payment (free health insurance, for example) or expanded reimbursements. After much review, we come down strongly in support of indirect payment, specifically, a $100,000 refundable federal tax credit. The tax credit would be uniformly applied over a period of 10 years, in the amount of $10,000 a year for those who qualify and then become donors.

"This kind of compensation is certainly not a quick-cash scheme that would incentivize an act of desperation. Nor does it commoditize human body parts. Going forward, kidney donation might become partly opportunistic rather than mostly altruistic, as it is now. But would it be exploitative? Not at all."

...

Ned Brooks and ML Cavanaugh are living kidney donors, and Brooks is the founder of the Coalition to Modify NOTA.

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Here are all my posts that mention Ned Brooks, starting with this one:

Friday, February 26, 2016

A Freakonomics listener was inspired to become a non-directed kidney donor by the podcast on kidney exchange

The Ethics of Organ Markets | Glenn Loury & Sally Satel | The Glenn Show

Genn Loury interviews Sally Satel, starting with a discussion of political correctness in medicine, and moving on to include (just before minute 13)  kidney disease and carefully regulated compensation for kidney donors as a way to address the perennial shortage of kidney transplants.

 

  

"Satel: kidney transplantation is "the only arena in healthcare that's rationed...in a really direct way. ... "There's a lifeboat-ethics dimension to it."

Decreasing kidney discards--review, and a call for clinical trials

 A review of discarded kidneys from a large OPO revealed only modest margins for improved utilization.

Bunnapradist, Suphamai MD1; Rosenthal, J. Thomas MD1; Huang, Edmund MD2; Dafoe, Donald MD3; Seto, Tom PharmD4; Cohen, Aaron BS4; Danovitch, Gabriel MD1. Deceased Donor Kidney Nonuse: A Systematic Approach to Improvement. Transplantation Direct 9(6):p e1491, June 2023. | DOI: 10.1097/TXD.0000000000001491

"Background. A large number of procured kidneys continue not to be transplanted, while the waiting list remains high.

"Methods. We analyzed donor characteristics for unutilized kidneys in our large organ procurement organization (OPO) service area in a single year to determine the reasonableness of their nonuse and to identify how we might increase the transplant rate of these kidneys. Five experienced local transplant physicians independently reviewed unutilized kidneys to identify which kidneys they would consider transplanting in the future. Biopsy results, donor age, kidney donor profile index, positive serologies, diabetes, and hypertension were risk factors for nonuse.

"Results.  Two-thirds of nonused kidneys had biopsies with high degree of glomerulosclerosis and interstitial fibrosis. Reviewers identified 33 kidneys as potentially transplantable (12%).

"Conclusions. Reducing the rate of unutilized kidneys in this OPO service area will be achieved by setting acceptable expanded donor characteristics, identifying suitable well-informed recipients, defining acceptable outcomes, and systematically evaluating the results of these transplants. Because the improvement opportunity will vary by region, to achieve a significant impact on improving the national nonuse rate, it would be useful for all OPOs, in collaboration with their transplant centers, to conduct a similar analysis."

...

"One posited cause for continued high nonuse rates is that transplant physicians are overly conservative, content with doing a small number of cases relative to the need. Both the existence of a “weekend effect”8 and a paper by French investigators stating 62% of kidneys not transplanted in the United States would be transplanted in France9 are used in support of this contention. Mistaken reliance on kidney biopsies is an additional factor implicated in inappropriate kidney nonuse.10 An alternative explanation is that transplant physicians and surgeons have not been persuaded that it is safe to transplant high-risk kidneys into older recipients based on retrospective registry studies.

"With this background in mind, and with a strong desire to respond to the imperative of increasing the use of heretofore nontransplanted kidneys, we undertook an analysis of unused kidneys in our OPO service area. Goal one was to understand the interplay of factors causing nonuse including donor demographics and biopsies. Goal two was to use the information from goal one to devise a plan to increase the kidney utilization rate in our service area.

"OneLegacy is the federally designated OPO for 7 counties in Southern California with a population of approximately 20 million. In 2019, which was chosen as the year of study because it was the last full year before the COVID-19 pandemic, OneLegacy served 10 centers with kidney transplant programs.11

"There were 1064 kidneys procured from 552 donors; 740 were transplanted and 324 were not transplanted. Forty-seven of the 324 (14.5%) were not offered for transplant because of absolute contraindications including cancers in the kidney, infections discovered during procurement, and abnormalities such as multicystic dysplastic kidneys. There were 5 surgical injuries (0.47%)—1 stripped ureter and 4 vascular injuries—all of which were determined to be nonrepairable by a transplant surgeon highly experienced with repair techniques. These kidneys were excluded from the study. The remaining 272 kidneys were offered for transplant and turned down by all local centers and, in turn, by all regional and national centers. Fourteen kidneys were provisionally accepted by and transported to nonlocal centers but, ultimately, not utilized due to prolonged cold ischemic times or findings on biopsies performed at the export center.

...

"One reason that the nonuse problem has proven intractable is that, even though it has been asserted that most nonused kidneys in the United States are safe to transplant, clinicians making the decisions in real time seem not to agree. Nor is there widespread enthusiasm for transplanting suboptimum kidneys into elderly recipients, despite papers promoting it,15 possibly because it is not entirely clear which older dialysis patients really benefit from transplantation.16

"The thought experiment of experienced local physicians reviewing procured but not transplanted kidneys appears to confirm this hypothesis. Despite French studies suggesting that 62% of kidneys not utilized in the United States would be transplanted in France, only 12% of kidneys were thus identified by our team of physicians, each of whom were highly motivated to reduce nonuse kidneys and highly knowledgeable about registry studies claiming safety of expanded donor criteria.10 If highly knowledgeable and experienced transplant physicians and surgeons—highly motivated to decrease nonuse—have not significantly changed kidney acceptance criteria, they are unlikely to be persuaded or respond to regulatory pressure to cause them to perform transplants that they feel would violate their responsibility to patients. Reducing the nonuse rate to ≤5% is unlikely under these conditions. Nonetheless, this experience does inform how improvement can occur.

"The alternative pathway to improvement in our service area is a more systematic prospective approach, in other words, an authentic clinical trial. The elements of such a trial would include codifying as precisely as possible the inclusion criteria for transplantable “suboptimal” donors, determining recipient criteria, extensive informed consent conversations, optimization of the organ offer process to minimize cold ischemia times, and outcomes tracking including quality of life and cognitive assessment. It should be decided in advance what will constitute an acceptable outcome for primary nonfunction and 1-y graft and patient survival."

Human trafficking conviction in England, in kidney case-""the consent of the person trafficked is no defense."

 The BBC has the story, which is apparently the first such conviction for kidney trafficking under Britain's anti-slavery law. Reading the previous stories, it sounds like the young man in question was being deceived.  But even informed consent apparently wouldn't be a defense under British law...

Kidney-plot politician Ike Ekweremadu jailed By Tom Symonds

"A wealthy Nigerian politician, his wife and their "middleman" have been jailed for an organ-trafficking plot, after bringing a man to the UK from Lagos.

"Senator Ike Ekweremadu, 60, and his wife Beatrice, 56, wanted a new kidney for their 25-year-old daughter Sonia, the Old Bailey heard.

"The pair and Dr Obinna Obeta, 50, were previously convicted of conspiring to exploit the man.

"It is said to be the first such case under modern slavery laws.

...

"Lynette Woodrow, deputy chief crown prosecutor and national modern slavery lead at the Crown Prosecution Service (CPS), said it had been "our first conviction for trafficking for the purposes of organ removal in England and Wales".

"She said it highlighted an important legal principle which made it irrelevant whether the trafficking victim knew he was coming to the UK to provide a kidney.

"With all trafficking offences," Ms Woodrow said, "the consent of the person trafficked is no defence. The law is clear; you cannot consent to your own exploitation."

HT: Dr. Jlateh Vincent Jappah

How much compensation for U.S. kidney donors would end the kidney transplant shortage?

 Here's a paper with a forbidding title but an important message (and an eye-catching first paragraph...:)

McCormick, Frank, Philip J. Held, Glenn M. Chertow, Thomas G. Peters, and John P. Roberts. "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

"Abstract:

Objectives: The aim of this study was to show how the US government could save approximately 47 000 patients with chronic kidney failure each year from suffering on dialysis and premature death by compensating living kidney donors enough to completely end the kidney shortage.

Methods: Supply and demand analysis was used to estimate the number of donated kidneys needed to end the kidney shortage and the level of compensation required to encourage this number of donations. These results were then input into a detailed cost-benefit analysis to estimate the economic value of kidney transplantation to (1) the average kidney recipient and their caregiver, (2) taxpayers, and (3) society in general.

Results: We estimate half of patients diagnosed with kidney failure each year—approximately 62 000 patients—could be saved from suffering on dialysis and premature death if they could receive an average of 1½ kidney transplants. However, currently there are only enough donated kidneys to save approximately 15 000 patients. To encourage sufficient donations to save the other 47 000 patients, the government would have to compensate living kidney donors approximately $77 000 (±50%) per donor. The value of transplantation to an average kidney recipient (and caregiver) would be approximately $1.5 million, and the savings from the recipient not needing expensive dialysis treatments would be approximately $1.2 million.

Conclusions: This analysis reveals the huge benefit that compensating living kidney donors would provide to patients with kidney failure and their caregivers and, conversely, the huge cost that is being imposed on these patients and their families by the current legal prohibition against such compensation."

and here's the first paragraph:

"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."

Kidney transplants from donors who died from illegal drug use

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

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

"Abstract:

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

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

Design: Retrospective cohort. 

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

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

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

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

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

"Limitations: Potential selection bias, potential unmeasured confounding. 

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

...

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

...

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

The economics and politics of compensating kidney donors, by McCormick and Held

Political feasibility is an unavoidable consideration in any discussion of compensating kidney donors.  McCormick and Held take the latest a stab at it. 

How to End the Kidney Shortage. Few if any of these news stories lamenting the kidney shortage or touting hightech breakthroughs mention that we already have a solution to the shortage: compensating kidney donors to induce more supply  By Frank McCormick and Philip J. Held, SPRING 2023 • REGULATION (CATO Institute).

"A crucial question remains: what level of compensation should the government offer to kidney donors? The answer is a political judgment call that involves the tradeoff between the number of patients saved from premature death and the probability of getting a particular law or regulation changed.

Evaluating kidney patients and donors without consideration of race

 Somewhere in the history of nephrology, a patient's race was included as a factor in estimating their kidney function.  This has at various times been important for various kinds of treatment, including of course preventive treatment, as well as starting dialysis, and entry and perhaps priority on kidney transplant waitlists. And it has also been important for evaluating the quality of deceased donor kidneys that can be offered for transplantation. There have been important recent changes in this, and more may be on the way. The current issue of JAMA devotes a number of articles to that, linked below.

Viewpoint Redressing the Harms of Race-Based Kidney Function Estimation Dinushika Mohottige, MD, MPH; Tanjala S. Purnell, PhD, MPH; L. Ebony Boulware, MD, MPH Audio: Race-Neutral Estimates of Kidney Function: Enhancing Equity Video: Race-Neutral Estimates of Kidney Function: Enhancing Equity Time to Abolish Metrics That Sustain Systemic Racism in Kidney Allocation John S. Gill, MD, MS; Burnett Kelly, MD, MBA; Marcello Tonelli, MD, SM Medical News & Perspectives Race-Based Equations Delayed Black Patients From Getting Onto Kidney Transplant Lists—An Unprecedented New Policy Seeks to Undo the Damage Jennifer Abbasi PREVIOUSLY PUBLISHED JAMA | Research Association of Estimated GFR Calculated Using Race-Free Equations With Kidney Failure and Mortality by Black vs Non-Black Race Orlando M. Gutiérrez, MD, MMSc; Yingying Sang, MS; Morgan E. Grams, MD, MHS, PhD; et al JAMA | Opinion Race-Free Estimation of Kidney Function: Clearing the Path Toward Kidney Health Equity L. Ebony Boulware, MD, MPH; Dinushika Mohottige, MD, MPH; Matthew L. Maciejewski, PhD JAMA Network Open | Research Association of the Estimated Glomerular Filtration Rate With vs Without a Coefficient for Race With Time to Eligibility for Kidney Transplant Leila R. Zelnick, PhD; Nicolae Leca, MD; Bessie Young, MD, MPH; et al Audio Race-Neutral Estimates of Kidney Function: Enhancing Equity Video

Join the conversation. Follow JAMA on Twitter.

Tonya Ingram (1991-2022), health activist, died while waiting for a kidney

 Tonya Ingram, a poet and health activist who testified in Congress about the long waiting list for kidney transplants, died last month while still waiting.  Saturday's New York Times had a moving column about her activism, her struggle and her long wait.

Tonya Ingram Feared the Organ Donation System Would Kill Her. It Did. By Kendall Ciesemier (Ms. Ciesemier is a writer, a producer and an organ recipient.) Jan. 28, 2023

Here's her obit in the LA Times:

Tonya Ingram, an inspiring L.A. poet and ‘lupus warrior,’ died waiting for a kidney by Jireh Deng, JAN. 23, 2023

Market design isn't only about trying to allocate scarce resources effectively, it's also about working to make them less scarce.

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

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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.

Fifty Years of a National Program for the Treatment of Kidney Failure

 This JAMA viewpoint tells the story:

Fifty Years of a National Program for the Treatment of Kidney Failure, by Kevin F. Erickson,  Melandrea Worsley, andWolfgang C. Winkelmayer, JAMA. Published online December 19, 2022. doi:10.1001/jama.2022.23873

"Fifty years ago, on October 30, then-President Richard Nixon signed the Social Security Amendments of 1972, which created the End-Stage Renal Disease (ESRD) program. In extending Medicare benefits to people with kidney failure regardless of their age, this landmark legislation availed universal health care coverage for most persons with kidney failure.

...

"In the 1950s kidney transplant had emerged as a treatment option. By the early 1960s, innovations in dialysis machines and vascular access made it possible to treat chronic uremia with dialysis. These technological breakthroughs transformed kidney failure from a terminal illness into a treatable chronic condition. Although the first long-term dialysis center opened in 1962, most patients with kidney failure could not afford dialysis.

...

"For individuals with kidney failure, the ESRD program was transformative. By 1980, there were 58 000 patients receiving lifesaving treatment through the program, with enrollment growth averaging 22% per year. Enrollment growth spanned wide ranges of age, sex, and race, reflecting benefits across broad segments of the US population.4 Currently, more than 700 000 patients with kidney failure have Medicare coverage.

...

" In 2019, Medicare’s fee-for-service program spent $37 billion on the care of patients with kidney failure, accounting for more than 7% of overall Medicare expenditures.

...

"Despite past efforts to maintain quality and limit cost growth, major care gaps remain. Since the ESRD program’s inception, proponents of home dialysis have deplored the underuse of these modalities. Meanwhile, near-universal dialysis coverage may incentivize overtreatment with dialysis. Increasing evidence suggests that some of the sickest patients who start dialysis could instead benefit from active conservative management. A growing body of evidence also suggests that some patients who are new to dialysis may be able to safely undergo a hemodialysis regimen that includes fewer than the standard 3 treatments per week. Near-universal access to kidney failure treatment contrasts sharply with widespread limitations in access to preventive chronic kidney disease (CKD) care. This contrast is particularly poignant as it relates to racial disparities. Black patients face faster rates of CKD progression due, in part, to limited access to CKD care.9 In 2019, 33% of all patients receiving dialysis were Black individuals.

...

"the 2019 Advancing American Kidney Health initiative built on prior efforts to create a dialysis–focused alternative payment model (APM) through 6 new kidney care APMs that encourage home dialysis, kidney transplant, and advanced CKD care. It remains unclear whether dialysis-focused value-based payment initiatives will address outstanding cost and quality gaps. To date, substantial improvements in quality have not been observed.

...

"In summary, during its first 50 years the US ESRD program has provided critical access to lifesaving care for many patients with kidney failure while it has undergone a series of reforms as policy makers aim to control costs and maintain quality. Challenges in balancing cost and quality will persist as the program enters the second half-century of its existence."

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."

It's not so easy to become a living kidney donor: report from the Cleveland Clinic

 It's not so easy to become a living kidney donor.  Here's a report on the pipeline at the Cleveland Clinic:

Cholin, Liza K., Jesse D. Schold, Med MStat, Susana Arrigain, Emilio D. Poggio, John R. Sedor, John F. O’Toole, Joshua J. Augustine, and Alvin C. Wee. " Characteristics of Potential and Actual Living Kidney Donors: A Single Center Experience, Transplantation (2022).

It's concerning to see that 164 donor candidates were rejected at this center for being "ABO or crossmatch incompatible."  Were they told about the possibility of kidney exchange?

 

"There was a mean of 2.8 and median of 1 (1, 3) potential donors for every 1 transplant candidate that did not receive a kidney. There was a mean of 5.9 and median of 2 (1, 5) potential donors for every 1 transplant candidate that received a kidney."

HT: Frank McCormick

Deceased donor organ discards on weekends, in the the Annals of Transplantation

 Hospital resources and physician incentives can be stressed on weekends, and there is historical evidence that organ discards are higher on weekends.  Here's a study suggesting that is still a thing.

Yamamoto, T., A. Shah, M. Fruscione, S. Kimura, N. Elias, H. Yeh, T. Kawai, and J. F. Markmann.  Revisiting the "Weekend Effect" on Adult and Pediatric Liver and Kidney Offer Acceptance. Annals of Transplantation. 2022 Nov;27:e937825. DOI: 10.12659/aot.937825. PMID: 36329622.

"BACKGROUND: Weekends can impose resource and manpower constraints on hospitals. Studies using data from prior allocation schemas showed increased adult organ discards on weekends. We examined the impact of day of the week on adult and pediatric organ acceptance using contemporary data.

"MATERIAL AND METHODS: Retrospective analysis of UNOS-PTR match-run data of all offers for potential kidney and liver transplant from 1/1/2016 to 7/1/2021 were examined to study the rate at which initial offers were declined depending on day of the week. Risk factors for decline were also evaluated.

"RESULTS: Of the total initial adult/pediatric liver and kidney offers, the fewest offers occurred on Mondays and Sundays. The decline rate for adult/pediatric kidneys was highest on Saturdays and lowest on Tuesdays. The decline rate for adult livers was highest on Saturday and lowest on Wednesday. In contrast, the decline rate for pediatric livers was highest on Tuesdays and lowest on Wednesdays. Independent risk factors from multivariate analysis of the adult/pediatric kidney and liver decline rate were analyzed. The weekend offer remains an independent risk factor for adult kidney and liver offer declines, but for pediatric offers, these were not significant independent risk factors.

"CONCLUSIONS: Although allocation systems have changed, and the availability of kidneys and livers have increased in the USA over the past 5 years, the weekend effect remains significant for adult liver and kidney offers for declines. Interestingly, the weekend effect was not seen for pediatric liver and kidney offers.

Josh Morrison profiled in Vox

 Josh Morrison, the founder of WaitlistZero and 1DaySooner, is an unusually energetic and effective effective altruist.   

Here's a profile in Vox:

Josh Morrison took risks for science, and he thinks you can, too. From kidney donations to human challenge trials for Covid-19 vaccines, Josh Morrison shows the vast good any individual can do. By Muizz Akhtar

"Morrison first became familiar with this kind of direct public health participation when he read about kidney donations in the New Yorker when he was a law student in 2009. In the piece, people explained why they gave their kidneys to strangers in need — though there was slight risk to donors, the reward and benefit for the recipients was more than worth it. Two years later, he donated a kidney himself.

...

“The basic logic of my work in general is to try to use a sort of identity politics to get better political decision-making,” Morrison told me. “So with kidney donation, the theory is if kidney donors are more empowered in the political system as a sort of identity group, then the system will treat donors better and that will mean more people donate.”

HT: Frank McCormick

**********

I've mentioned Josh Morrison in many of my posts...