Surrogacy, and escrow accounts

 Surrogacy contracts involve a long term relationship, focused on a nine month pregnancy.  So commercial surrogacy depends on secure financial arrangements, which generally require funds to be held in escrow.  The WSJ article below documents that these escrow accounts are insufficiently regulated in some states, which can cause serious problems for surrogates and intended parents when the account holders are dishonest or careless.

Surrogacy Is a Multibillion-Dollar Business. Sometimes the Money Goes Missing.  "The growing industry has little regulation and many cases of financial abuse; escrow funds taken to pay gambling debts, buy bitcoin." By Ben Foldy
 

"Escrow companies, used in the majority of surrogacies, can handle millions of client dollars with almost no oversight, according to a Wall Street Journal review of court filings and interviews with parents and surrogates.

...

"The lack of regulation means that parents and surrogates frequently have little legal recourse and dim hopes of recovering lost funds. Already-pregnant surrogates must carry through with labor that they know they may not be paid for, while potentially being on the hook for medical bills they may not be able to afford. Parents face the prospect of messy litigation from unpaid surrogates. One couple whose surrogacy funds disappeared due to fraud before they were able to successfully transfer an embryo said they gave up hope for a pregnancy.

“Holding other people’s money is usually such a highly regulated industry,” said Andrew Bluebond, an attorney in Texas who helped Gallozzi look into what happened at SEAM. The surrogacy community’s relatively small size and intimate domain, Bluebond said, fostered a false sense of financial security.

“Rather than using the safeguards other industries use, they let their trust betray them,” he said. 

...

"Surrogacy has exploded into a multibillion-dollar industry, driven by increasing rates of infertility, expanded insurance coverage, the growing prevalence of LGBTQ families and an influx of couples from countries where the practice is illegal, including China. Last week, President Trump announced a deal aimed at lowering the price of medications used in IVF. 

There were around 10,850 transfers of embryos to surrogates in the U.S. in 2023 involving clinics reporting to the Society for Assisted Reproductive Technology, which says it represents clinics that perform around 95% of all procedures. That was up from 8,461 in 2021. The group’s data and other analyses expect an annual growth rate of about 15% over the coming years. About half of those embryo transfers resulted in successful deliveries.

Despite the growth, there are no federal laws regulating the financial or other aspects of surrogate pregnancies, and the practice is subject to a patchwork of state regulations. In Louisiana, for example, compensating surrogates is outlawed entirely. In a handful of other states, the contracts that often accompany surrogacy arrangements are legally unenforceable. 

...

"Last month, the nonprofit Society for Ethics in Egg Donation and Surrogacy, which functions as a kind of industry best-practices group in lieu of regulation, passed new guidelines for escrow accounts, although they have no binding power. The suggestions recommend escrow providers have relevant credentials, are subject to audits by certified accountants and have more than $10 million in bond coverage. " 

 

Regulating markets for antiquities, to more effectively compete with black markets (Kremer and Wilkening in JEP)

 Bans on illegally recovering, selling, and exporting archeological antiquities often result in black markets.  Michael Kremer and Tom Wilkening explore how markets might be regulated to be more effective.

Kremer, Michael, and Tom Wilkening. 2025. "Protecting Antiquities: A Role for Long-Term Leases?" Journal of Economic Perspectives 39 (3): 127–48. 

Abstract: In order to preserve cultural patrimony for future generations, most countries ban exports of antiquities. However, this may drive trade underground, particularly in low-income and low-state capacity contexts, and cause irreversible damage to cultural heritage. We argue that complementing export bans with fixed-duration, long-term leases can strengthen incentives for maintenance and revelation of antiquities, while preserving cultural patrimony. Allowing only leases rather than sales limits potential losses from corrupt deals between foreign collectors and government officials. Standardized contracts with set lease lengths, insurance requirements, and care requirements may also be necessary to limit corruption and establish a well-functioning market.

Market design podcast on NPR's Planet Money (with Alex Teytelboym)

 Alex Teytelboym comments throughout a program about market design on NPR's Planet Money:

 The episode focuses on the design of markets regulated by governments, and  touch on the regulation of fisheries, and on the spectrum incentive auction (about which they interviewed Glen Weyl instead of Paul Milgrom).

##########

Earlier related posts:

Monday, February 16, 2009  Sustainable fisheries

Sunday, January 30, 2011  Fishing as an endangered but protected transaction

Tuesday, July 24, 2018  Design of fisheries--EURO Excellence in Practice Award to Bichler, Ferrell, Fux, and Goeree

Friday, July 9, 2021 Fishery regulation involves onboard observers at sea--a very dangerous job

 ##########

 Monday, March 9, 2020 Paul Milgrom et al. on the incentive auction--two recent papers, and two pictures

 Monday, June 15, 2020  Paul Milgrom corrects the record on spectrum auctions and market design

 

 

 

 

The science and politics of vaping in the U.S

 The Washington Post has the story:

FDA lets Juul market vapes in the U.S. three years after trying to ban them
Federal regulators first announced a ban of Juul products in 2022, although a court order allowed them to stay on store shelves while the company filed an appeal.  By David Ovalle and Shannon Najmabadi
 

"The Food and Drug Administration has authorized Juul Labs to market its electronic cigarettes, years after the agency tried to ban the company’s products amid outcry over its role in fueling the popularity of vapes among young people.

"The agency, after reviewing scientific data provided by the company, concluded that Juul’s electronic cigarette device and refillable cartridges in tobacco and menthol flavors can help adult cigarette users reduce smoking or switch to less harmful products, outweighing the risk to youth.

...

"The news comes a few days after the Vapor Technology Association, an industry group, said it launched a seven-figure ad campaign urging President Donald Trump to draw a distinction between vape products targeting youths and “safer, adult-focused alternatives” touted as smoking-cessation tools. Trump previously offered enthusiastic support for vaping and promised to protect the industry while campaigning in 2024.

...

"A 2024 Centers for Disease Control and Prevention survey found vapes were the most common tobacco product used by middle- and high-schoolers. About 1.6 million students use electronic cigarettes, according to the survey — and nearly 90 percent of those who vape prefer the flavored liquids, the survey reported.

Thursday’s Juul decision drew immediate outcry from public health groups that assert vapes are addictive and can harm the development of maturing brains."

Organ donation after circulatory death: the NYT recounts some disturbing cases

 The NYT has a disturbing story this morning about organ donation after circulatory death. These are cases in which a decision has been made to remove the patient from a ventilator, in anticipation that they are irreversibly dying.  If death (via cessation of heartbeat and breathing) occurs almost immediately after removal, the patient may still be a viable organ donor, and otherwise not.  Organ procurement organizations (OPOs) are not supposed to be involved until after death has been declared, but apparently in some small hospitals they get involved earlier, and have sometimes pressured physicians to proceed prematurely.

A Push for More Organ Transplants Is Putting Donors at Risk
People across the United States have endured rushed or premature attempts to remove their organs. Some were gasping, crying or showing other signs of life.  By Brian M. Rosenthal and Julie Tate, July 20, 2025

"Across the United States, an intricate system of hospitals, doctors and nonprofit donation coordinators carries out tens of thousands of lifesaving transplants each year. At every step, it relies on carefully calibrated protocols to protect both donors and recipients.
 

"But in recent years, as the system has pushed to increase transplants, a growing number of patients have endured premature or bungled attempts to retrieve their organs. ...  a New York Times examination revealed a pattern of rushed decision-making that has prioritized the need for more organs over the safety of potential donors.

...

"Most donated organs in the United States come from people who are brain-dead — an irreversible state — and are kept on machines only to maintain their organs. Most donated organs in the United States come from people who are brain-dead — an irreversible state — and are kept on machines only to maintain their organs. Circulatory death donation is different. These patients are on life support, often in a coma. Their prognoses are more of a medical judgment call.

"They are alive, with some brain activity, but doctors have determined that they are near death and won’t recover. If relatives agree to donation, doctors withdraw life support and wait for the patient’s heart to stop. This has to happen within an hour or two for the organs to be considered viable. After the person is declared dead, surgeons go in.

"The Times found that some organ procurement organizations — the nonprofits in each state that have federal contracts to coordinate transplants — are aggressively pursuing circulatory death donors and pushing families and doctors toward surgery. Hospitals are responsible for patients up to the moment of death, but some are allowing procurement organizations to influence treatment decisions.

"Fifty-five medical workers in 19 states told The Times they had witnessed at least one disturbing case of donation after circulatory death.

"Workers in several states said they had seen coordinators persuading hospital clinicians to administer morphine, propofol and other drugs to hasten the death of potential donors.

...

"Circulatory death donation used to be largely forbidden. That began to change in the 1990s, when a dying patient asked the University of Pittsburgh Medical Center to remove her life support and donate her organs. The hospital honored her wishes, then spent two years creating guidelines for future cases. Use of the practice gradually spread.

"Procurement organizations attributed the procedure’s recent growth to technological advances. Dozens of employees at the organizations said it was largely because of government pressure.

"Citing the number of Americans waiting for organs, H.H.S. said in 2020 that it would begin grading procurement organizations on how many transplants they arranged. The department has threatened to end its contracts with groups performing below average, starting next year. Many have raised their numbers by pursuing more circulatory death donors."

Prolific sperm donation and incest risk in the Netherlands

 The Guardian has the story:

‘Medical calamity’: dozens of Dutch sperm donors fathered at least 25 children.  Discovery that clinics have been breaking rules raises genetic risks in such a small, densely populated country  by Jon Henley 

"At least 85 sperm donors in the Netherlands have fathered 25 or more children, the national gynaecology and obstetrics organisation has said, after a new registration system showed fertility clinics have been breaking existing rules on sperm donation for decades.

"The NVOG said on Monday that some clinics had deliberately used sperm batches more than 25 times, exchanged sperm without the necessary paperwork or donors’ knowledge, and allowed the same donors to donate sperm at multiple clinics.

“The number of so-called ‘mass donors’ should be zero,” gynaecologist Marieke Schoonenberg told the TV show Nieuwsuur. “On behalf of the whole profession, we wish to apologise. We didn’t do things as they should have been done.”

"A law aimed at reducing the risk of involuntary incest and inbreeding should have barred donors from fathering more than 25 children in the Netherlands since 1992, but proved difficult to enforce because of strict privacy laws.

"The limit was lowered to 12 in 2018, but the means to enforce it – a national register of donors and mothers with a code system ensuring sperm from the same donor cannot be used in more than 12 conceptions – came into force, retroactively, only in April.

“As a result, we now know, for the first time, the exact number of children per donor,” Schoonenberg said. Since 2004, when donors’ right to anonymity was lifted, the data showed there had been at least 85 “mass donors” (defined as at least 25 conceptions) in the Netherlands, she said.

"Most were biological father to between 26 and 40 children, Schoonenberg said, although several had between 50 and 75. Among them were at least 10 fertility doctors, including Jan Karbaat, who illegally fathered at least 81 children at his clinic.

"The most prolific donor was Jonathan Jacob Meijer, the subject of the Netflix documentary The Man with 1,000 Kids, who is known to have fathered at least 550 children worldwide. More than 100 of Meijer’s children were conceived in Dutch clinics.

"Ties van der Meer, of Stichting Donorkind, a foundation that helps children trace their donor fathers, said the findings were a “medical calamity”. The data meant there were probably at least 3,000 children in the Netherlands with 25 or more half-brothers and sisters, he said."

FDA Proposes Reducing Nicotine to Nonaddictive Level in Cigarettes: I see 5 possible futures

 Here's the FDA press release:

FDA Proposes Significant Step Toward Reducing Nicotine to Minimally or Nonaddictive Level in Cigarettes and Certain Other Combusted Tobacco Products
Agency Encourages Public Input on Proposal That Aims to Prevent Millions of Premature Deaths 

 " the U.S. Food and Drug Administration issued a proposed rule that, if finalized, would make cigarettes and certain other combusted tobacco products minimally or nonaddictive by limiting the level of nicotine in those products. If finalized, the United States would be the first country globally to take such a bold, life-saving action to prevent and reduce smoking-related disease and death. The FDA first announced its intent to propose such a ruleExternal Link Disclaimer in 2018, and today’s announcement is an important next step in the rulemaking processExternal Link Disclaimer. The agency intends to seek input on the proposal, including through public comment and the FDA’s Tobacco Products Scientific Advisory Committee"

#########

Here are some predictions of possible outcomes of this proposal.

1. (p>.5) No new regulation: We soon see Trump-branded, musk-flavored high-nicotine cigarettes.  (no lives saved)

Conditional on the proposals being enacted (i.e. p<.5)

2.  Cigarette makers find workarounds (nicotine supplements you can add to your smokes, new organic chemicals functionally equivalent to nicotine, etc. (few lives saved)

3. Black markets emerge: get your full-nicotine cigarettes at the same time you get your Mexican coca cola made with sugar instead of corn syrup. (some lives saved)

4. Smokers switch to non-combustables: Big Tobacco becomes Big vaping, chewing, and under-lip snus, snuff, and oral nicotine pouches. (maybe significant lives saved, but no decrease in nicotine addiction, and maybe substantial increase. Lung cancer down, oral cancers up.)

5. (low probability but we can hope): Smokers quit, and few young people start to smoke: tobacco use drops so low that deaths attributable to smoking drop below those attributable to alcohol or opioids.

Sports gambling presents problems for gamblers, athletes, and sports

 Sports betting has some potentially dire implications both for betters and for athletes and sports. Gamblers can find in-app gambling while the game is going on addictive."Prop" bets on the performance of particular athletes during the game, can also subject athletes to pressures that may be at odds with their incentives arising simply from the rules of the game. And this may open up sports to gambling and point-shaving scandals that have been vigorously suppressed in the past.

Here's a variety of headlines (in sufficient number that I won't summarize the accompanying stories, but you can click through to see them).

The Guardian:

‘A serious disease’: Congress weighs federal gambling crackdown amid growing concerns
With sports betting now legal in 38 states, experts worry that gambling addiction is on the rise  by Callum Jones 

NPR:

The president of the NCAA calls for a ban on 'prop bets' in college sports,  by Becky Sullivan
Becky Sullivan

The Atlantic:

Legalizing Sports Gambling Was a Huge Mistake. The evidence is convincing: The betting industry is ruining lives.  By Charles Fain Lehman

Paul Krugman's substack:

America the Addicted. Gambling — on sports, stocks and crypto — is the new opioids.  by Paul Krugman

Regulating emerging technologies

 Here's a recent RAND report, on the current diverse attempts to regulate emerging biotechnologies, focusing on organoids,* embryos, genes, and neurotechnology:

State-of-play and future trends on the development of oversight frameworks for emerging technologies
Part 2: Technology oversight report, by Sana Zakaria, Ioli Howard, Eva Coringrato, Anna Louise Todsen, Imogen Wade, Devika Kapoor, Alec Ross, Katarina Pisani, Chryssa Politi, Martin Szomszor, Salil Gunashekar, Dec 16, 2024 

"This RAND Europe study commissioned by Wellcome explores the current and future oversight frameworks for emerging technologies, focusing on organoids, human embryology, engineering biology and neurotechnology. 

...

"Key Findings:

Lack of specific frameworks for organoids

• There is an absence of specific regulatory frameworks for organoids, with current oversight relying on broader stem cell and biomedical regulations. Emerging mechanisms, such as Japan's consent-to-govern approach, are gaining traction to address ethical challenges, particularly around donor consent and privacy concerns.

Challenges in human embryology oversight

• Existing frameworks, like the UK's Human Fertilisation and Embryology Act, are outdated and not designed for new technologies such as AI in embryo selection. Disparate national regulations complicate international collaboration, and there is a need for frameworks to adapt to scientific advancements and public interest.

Fragmented oversight in engineering biology

• The global landscape features disparate oversight mechanisms, creating obstacles for international collaboration. There is a need for alignment across diverse applications and jurisdictions, with potential solutions including cross-sector collaboration and international biosecurity measures.

Neurotechnology oversight gaps

• Current regulations do not address the unique challenges posed by neurotechnologies, such as data privacy and dual-use concerns. Ethical guidelines, like Chile's neurorights, offer proactive models, but there is a need for stronger post-market surveillance and international guidelines to prevent misuse.

Priority considerations for future oversight

• The report outlines eight priority considerations, including developing interconnected oversight networks, ensuring equity, harmonizing international governance, fostering public involvement, and integrating adaptive and anticipatory strategies into oversight frameworks."
  

#########

* "Organoids are three-dimensional structures that are derived from stem cells and are capable of self-organising into structures that mimic the key functional, structural and biological complexity of an organ."

Regulating nicotine is a cat and mouse game

 Attempts to regulate (and tax) cigarettes and related nicotine-addicting products are a cat and mouse game. Many laws regulate "tobacco," "nicotine," or "flavorings," and all of these have close substitutes that might fall outside of the law, such as synthetic (non-tobacco) nicotines, and coolants other than menthol that might not be considered flavorings.  California legislators are amending laws to fill those gaps.

California’s Visionary Tobacco Bill—Will the FDA Follow?  by Sven E. Jordt, PhD1,2; Sairam V. Jabba, DVM, PhD, JAMA, 2024

"The state of California has been a consistent leader in tobacco control, with one of the lowest smoking rates in the nation. On September 28, 2024, Gavin Newsom, governor of California, signed Assembly Bill 3218, which will further strengthen tobacco control in the state.1 The signed legislation will close 2 loopholes left open by California’s 2022 legislation that restricts sales of most flavored tobacco products, including menthol cigarettes and youth-appealing flavored e-cigarettes. The tobacco industry immediately exploited these loopholes to continue selling flavored tobacco products in the state. Similar loopholes remain in the legislation of other states and in federal regulations. Are other states and the US Food and Drug Administration (FDA) set to follow California’s example, or will California’s advance result in an even wider divide in tobacco control in the US?

...

"The tobacco industry argued that California’s flavor ban does not apply to non-menthol cigarettes because the cooling sensations imparted by odorless cooling agents do not represent a banned “characterizing flavor,” meaning a distinguishable taste, aroma, or both. However, current scientific definitions of the term flavor, also adopted by the flavor chemical industry, include the entire range of sensations perceived during product consumption, including physical traits such as cooling sensations.4 In California’s new bill, legislators adopted this definition, clarifying the term characterizing flavor to include “a cooling sensation distinguishable by an ordinary consumer during the consumption of a tobacco product.”

...

"The second loophole addressed by California’s new bill pertains to emerging e-cigarette products in which nicotine is replaced with chemical analogues such as 6-methyl nicotine.5,6 In both state and federal regulatory statutes, a tobacco product is narrowly defined as being derived from tobacco or nicotine. Manufacturers claim that this definition does not apply to products containing 6-methyl nicotine, because its chemical formula differs from that of nicotine. Manufacturers advertise that FDA review of their products is not required, flavor bans do not apply, and that the products are exempt from tobacco taxes, offering them in youth-appealing flavors such as rainbow fruit, blue razz ice, or strawberry apple lemon.5,6 California’s new legislation closes this loophole by extending the legal definition of nicotine, adding “and includes nicotinic alkaloids and nicotine analogs.”

New rules for evaluating transplant centers

 Historically, transplant centers ('hospitals') have been primarily evaluated on the one year graft survival on the transplants that they do.*  Now Medicare announces it will test a new model, that will emphasize the number of transplants conducted ("achievement"), in addition to somewhat less emphasis on the ratio of deceased donor kidneys accepted or rejected ("efficiency") and graft survival ("quality").

Medicare Program; Alternative Payment Model Updates and the Increasing Organ Transplant Access (IOTA) Model.  A Rule by the Centers for Medicare & Medicaid Services on 12/04/2024 

"a. Proposed IOTA Model Overview

"End-Stage Renal Disease (ESRD) is a medical condition in which a person's kidneys cease functioning on a permanent basis, leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life.[2]

"The best treatment for most patients with kidney failure is kidney transplantation. Nearly 808,000 people in the United States are living with ESRD, with about 69 percent on dialysis and 31 percent with a kidney transplant.[3]

"Relative to dialysis, a kidney transplant can improve survival, reduce avoidable health care utilization and hospital acquired conditions, improve quality of life, and lower Medicare expenditures.[4 5]

"However, despite these benefits of kidney transplantation, evidence shows low rates of ESRD patients placed on kidney transplant hospitals' waitlists, a decline in living donors over the past 20 years, and underutilization of available donor kidneys, coupled with increasing rates of donor kidney discards, and wide variation in kidney offer acceptance rates and donor kidney discards by region and across kidney transplant hospitals.[6 7] 

...

"The IOTA Model will be a mandatory model that will begin on July 1, 2025, and end on June 30, 2031, resulting in a 6-year model performance period comprised of 6 individual performance years (“PYs”). The IOTA Model will test whether performance-based incentives paid to, or owed by, participating kidney transplant hospitals can increase access to kidney transplants for patients with ESRD, while preserving or enhancing quality of care and reducing Medicare expenditures. CMS will select kidney transplant hospitals to participate in the IOTA Model through the methodology proposed in section III.C.3.d of this final rule. As this will be a mandatory model, the selected kidney transplant hospitals will be required to participate. CMS will measure and assess the participating kidney transplant hospitals' performance during each PY across three performance domains: achievement, efficiency, and quality.

"The achievement domain will assess each participating kidney transplant hospital on the overall number of kidney transplants performed during a PY, relative to a participant-specific target. The efficiency domain will assess the kidney organ offer acceptance rate ratios of each participating kidney transplant hospital relative to a national ranking or the participating kidney transplant hospital's past organ offer acceptance rate ratio. The quality domain will assess the quality of care provided by the participating kidney transplant hospitals via a composite graft survival ratio. Each participating kidney transplant hospital's performance score across these three domains will determine its final performance score and corresponding amount for the upside risk payment that CMS would pay to the participating kidney transplant hospital, or the downside risk payment that would be owed by the participating kidney transplant hospital to CMS. The upside risk payment will be a lump sum payment paid by CMS after the end of a PY to a participating kidney transplant hospital with a final performance score of 60 or greater. Conversely, beginning in PY 2, the downside risk payment will be a lump sum payment paid to CMS by any participating kidney transplant hospital with a final performance score of 40 or lower. There is no downside risk payment for PY 1 of the model.

...

"The three performance domains will include: (1) an achievement domain worth up to 60 points, (2) an efficiency domain worth up to 20 points, and (3) a quality domain worth up to 20 points.

"The achievement domain will assess the number of kidney transplants performed by each IOTA participant for attributed patients, with performance on this domain worth up to 60 points. The final performance score will be heavily weighted on the achievement domain to align with the IOTA Model's goal to increase access to kidney transplants to improve the quality of care and reduce Medicare expenditures. The IOTA Model theorizes that improvement activities, including those aimed at reducing unnecessary deceased donor discards and increasing living donors, may help increase access to kidney transplants."

###########

CMS gives a high level overview here: Increasing Organ Transplant Access (IOTA) Model

and later today there's a webinar you can register for:

"The CMS Innovation Center will be hosting a welcome webinar to present an overview of the model on December 18, 2024, from 2 to 3 p.m. ET. Register to attend: https://cms.zoomgov.com/webinar/register/WN_hvGDyZTxQ5eNhX1OBolevA
 

########

*see Wednesday, October 2, 2024 Regulation of Organ Transplantation and Procurement (Chan and Roth in the JPE)

That paper suggests desirable regulations  would coordinate transplant and OPO incentives, and link them both to the health outcomes of all patients attributable to a given transplant center (and not just those patients who were transplanted). 

#########

quick update (from the Q&A following the webinar): 

this is viewed as an experiment on roughly half the transplant centers, but there isn't currently a commitment about what to do after the projected 6 years of the experiment.

. all transplant patients are considered, but payments are only for Medicare fee for service patients

achievement: . each center's target for annual transplants will be it's average number over the three years ending a year before the beginning of the experiment...(at least that was the answer for the first year).

    . both deceased and living donor outcomes will be included in the achievement metric.

quality: .the first year will consider one-year graft survival, and year n will consider graft survival for the first n years.

OPOs: there are no requirements for OPOs within the IOTA model 

risk adjustment: not for year 1, they are hoping to have risk adjustment measures in subsequent years.

. 

The market for (ethical) pornography

 Will regulation, lawsuits and competition for creators increase the supply of ethical porn?

Wired has the story:

The Sticky Dilemmas of Pornhub’s Next Chapter
Videos of minors. Illegal data collection. Lack of oversight. Lawsuits. Problems have dogged the popular porn site for years. Is its promise of transparency enough for a reset? By Jason Parham

"Kekesi empathized with the performers. It’s part of her job. As vice president of brand and community at Pornhub, the monstrously popular adult entertainment site, she puts in plenty of face time with creators, as well as fans of the platform, the press, and critics. 

...

"She was thrust into the role in 2023, following a particularly turbulent period for the company. On some level, Pornhub has always been controversial—it comes with the territory—but the problems of the platform in recent years represented an existential threat.

"Rumblings began in 2019, when the owners of the GirlsDoPorn and GirlsDoToys websites were charged in a sex trafficking conspiracy for deceiving and forcing women to perform in adult films, which they then uploaded online, including to platforms like Pornhub. In March 2020, Senator Ben Sasse of Nebraska urged the US Department of Justice to open an investigation into Pornhub, citing incidents from “the past year,” including the GirlsDoPorn case. A New York Times column by Nicholas Kristoff that December brought even more attention to accusations that Pornhub hosted videos depicting sexual abuse, including of children. At first Pornhub denied any wrongdoing, but reaction swiftly snowballed.

"In Canada, where Pornhub is based, a parliamentary committee launched an investigation into the allegations. Visa and Mastercard suspended payment processing. Dozens of women sued Pornhub’s parent company, then called MindGeek and since renamed Aylo Holdings, alleging it had created and profited from a “bustling marketplace for child pornography, rape videos, trafficked videos, and every other form of nonconsensual content.”

...

"Pornhub has taken steps to address at least some of these problems. Following the Times article, it scrubbed the site of all “unverified content,” Kekesi said. Now anyone who wants to upload content to Pornhub has to not only verify their own identity; they also must supply proof of consent for everyone who appears in the scene, including documentation, IDs, and other paperwork. Pornhub also started issuing annual “transparency reports,” which it now does twice a year, publishing its content moderation practices. 

...

"Already, 12 US states have instituted age-verification laws around porn consumption. Because PornHub doesn’t want to open itself to litigation under these new laws, it went on the offensive, blocking all access to its site in those states regardless of age.

...

"In general, though, porn is more accessible than ever. Platforms like OnlyFans customize desire for a small fee. The riskier side of the social media site X operates in the vein of the former Backpage.com, where creators use the app to promote their work, engage with fans, and find gigs. That has also meant more competition for Pornhub. Kekesi never says it outright, but this is likely why the company has made a noticeable effort to appease the concerns of adult creators. “We are catching up and trying to be more visible and more present with the creator community,” she said."

America Has an Organ Shortage. Could Paying Donors Close the Gap? Podcast from BYU radio.

 Here's a podcast on the shortage of organs for transplant, and on the controversies about compensating organ donors, and plasma donors.

America Has an Organ Shortage. Could Paying Donors Close the Gap?   Top of Mind with Julie Rose | BYU radio
 

"There are more than 100,000 people on the waitlist for an organ transplant. Every day 17 of them die. Most organs for transplant come from deceased donors. But the organs in highest demand for transplantation are kidneys and livers – both of which can be donated while a person is still alive. So, we could save thousands of lives each year if more people were willing make a living organ donation. Some advocates say giving donors money would increase organ donations enough to eliminate the entire waitlist. But federal law makes it illegal to buy or sell organs. Ethicists have real concerns about coercion and exploitation, too. In this podcast episode, we're exploring America's organ shortage and asking whether paying donors could close the gap.  
Guests:
David Galbenski, liver transplant recipient and co-founder of the Living Liver Foundation (https://livingliver.org/)

Elaine Perlman, kidney donor, Executive Director of Waitlist Zero and leading advocate for the End Kidney Deaths Act (http://waitlistzero.org/)

Kathleen McLaughlin, journalist and author of Blood Money; The Story of Life, Death, and Profit Inside America's Blood Industry

Al Roth, Nobel-prize winning economist, Stanford University, expert in market design and game theory (https://marketdesigner.blogspot.com/)"

I'm interviewed at the end of the podcast, starting at minute 39:

x

Kim Krawiec interview about WHO demands for national self sufficiency in blood donation and kidney exchange

 The University of Virginia takes note of the recent Krawiec & Roth paper I blogged about in August.

Here is their interview with Kim about the paper:

WHO Stifles International Blood and Organ Donations, Argue Professors. Professor Kimberly Krawiec, Nobel Prize Winner Alvin E. Roth of Stanford Argue World Health Organization Policies Need Revision

Here are the first two Q&As

"What motivated you to critique the WHO principles of self-sufficiency and nonremuneration in organs and blood? ​

"The severe shortage of both blood products and transplantable organs, especially kidneys, was our motivation and has motivated much of our other work, both together and separately. In the United States alone, the organ transplant waiting list is approximately 100,000 people, and if current trends continue, it will only grow in the coming years.

"Shortages of blood products present a similar challenge. Although wealthy countries are typically able to satisfy domestic whole blood needs, the vast majority of low- and middle-income countries (LMIC) are not. As a result, in many LMIC, shortages of blood for transfusion contribute to maternal death, death from traffic accidents and complications from childhood anemia. Moreover, even wealthy countries experience seasonal shortages of whole blood or deficiencies in some blood components, such as platelets, which are harder to collect and have a shorter shelf life.

The shortage of plasma-derived medicinal products (PDMPs) is particularly severe and entirely preventable. PDMPs are life-saving treatments for multiple acute and chronic conditions for which there are no alternative treatments. Yet these life-saving therapies are unavailable to much of the world’s population. The United States, one of the few countries to pay plasma donors, supplies 70% of the world’s plasma needs, with Germany, Austria, Hungary, Czechia and Latvia (which also permit some form of payment for plasma donors) supplying another 20% of the world total. In other words, a handful of countries supply plasma to the rest of the world, including other wealthy countries. Meanwhile, LMIC who can neither collect and process their own nor afford to purchase blood products on the open market (or are prevented from doing so under the terms of the foreign aid that supports their health system) simply do without, to the detriment of their citizens.

"How do current WHO policies on organ and blood donation contribute to this problem?

"WHO policy mandates both national (or sometimes only regional) self-sufficiency and an absence of remuneration for both blood products and transplantable organs — what we refer to in the paper as “the twin principles.” These twin principles are unhelpful separately and unworkable together. Their effect on blood products is particularly stark — no country that fails to compensate donors is self-sufficient in plasma collection and few LMIC collect sufficient supplies of whole blood.

"The self-sufficiency mandate presents a real hurdle to progress in transplantation, especially for smaller countries and LMIC. This is especially the case because some of the most exciting and promising developments for increasing the availability of transplants have been in kidney exchange, a mechanism that leverages in-kind exchange, rather than financial compensation, to encourage and facilitate donation among those with willing but incompatible partners. But kidney exchange works best when a large pool of patient-donor pairs can engage with one another. So, requiring that transplantation be contained within national boundaries unnecessarily limits access to transplants that could be achieved only by cross-border exchange."

Regulation of Organ Transplantation and Procurement (Chan and Roth in the JPE)

 Here's a new paper (in final form, online ahead of print) on how organ transplants are regulated.  The paper uses an experiment to make several points about the design of current regulations.  One of them is that transplant centers are incentivized to be risk averse, since they are measured only by the outcomes of the transplants they perform, and not on the outcomes for patients they decline to transplant (so they are reluctant to transplant risky kidneys or risky patients).

Regulation of Organ Transplantation and Procurement: A Market-Design Lab Experiment by Alex Chan and Alvin E. Roth, Journal of Political Economy, online ahead-of-print .

 Abstract: We conduct a lab experiment that shows that current rules regulating transplant centers (TCs) and organ-procurement organizations (OPOs) create perverse incentives that inefficiently reduce both organ recovery and beneficial transplantations. We model the decision environment with a two-player multiround game between an OPO and a TC. In the condition that simulates current rules, OPOs recover only the highest-quality kidneys and forgo valuable recovery opportunities, and TCs decline some beneficial transplants. Alternative regulations that reward TCs and OPOs together for health outcomes in their entire patient pool lead to behaviors that increase organ recovery and appropriate transplants.

Here's what transplants look like in our experimental environment:

And our results are robust to big changes in parameters:

Kidney exchange in Brazil: prelude

 Yesterday I flew home from a busy visit to Brazil, with Mike Rees and Dr. Gustavo Ferreira.  

On Wednesday we all traveled to the capital, Brasilia, meeting with government ministries and agencies about how to move kidney exchange forward there.

Our most promising meeting on Wednesday was with the company that organizes the hospitals associated with Brazil's Federal universities. We talked about research possibilities

Wednesday Aug 7: Brazilian Hospital Services Company

Our most important meeting was on Thursday with the Ministry of Health  We talked about how clinical trials of kidney exchange in Brazil could help guide changes in Brazil's organ transplant laws and regulations.

Thursday: Brazil Ministry of Health, August 8 2024

On Friday we traveled to Juiz de Fora where we participated in a transplant symposium at the Santa Casa hospital there

On Saturday we had an exciting finish to the trip, but it's not my story to tell yet, so I'll blog again after there is an official announcement.

Earlier:

Tuesday, February 27, 2024

Stanford Impact Labs announces support for kidney exchange in Brazil, India, and the U.S.

Surrogacy in Israel

In Israel, where commercial surrogacy is legal, surrogates are more and more coming from educated and religious communities. 

Haaretz has the story:

Married, Educated, Not in It for the Money: The New Profile of Israeli Surrogate Mothers. Who are the Israeli women who wish to be pregnant and give birth for others? The answer to that question has changed dramatically over the past decade  by Ronny Linder

""I'm a little tired of women telling me how disadvantaged all surrogates are, so I thought of starting a thread just for surrogates, with: name + our occupation + town. I'll go first." This is what one moderator of an open Facebook surrogacy group wrote, about a year ago – and the responses came pouring in: a computer programmer from Tekoa, a sociolinguistics Ph.D. from Kfar Sava, a school principal from Jerusalem, a postgraduate student of gender studies from Hatzeva, a lawyer from Gush Etzion, an oncology nurse from Mevasseret Zion and so on and on.

"The post and the responses to it, written in reaction to the prevalent perception that views surrogacy as bearing the potential for exploitation of disadvantaged women who must "hire out" their uteruses for money, largely reflects the great transformation, over a few short years, in the profile of surrogate mothers and of the entire field in Israel. 

...

"Since the surrogacy law was legislated in 1996, almost 1,300 children have been born in Israel through surrogacy procedures. In recent years, the number has averaged around 80 children per year. Data collected by the Health Ministry about surrogate mothers between 2022 and 2023, reveals the changes in the profiles of women who choose to take on the task, as compared with the last study, in 2010. That study, which reviewed surrogate mothers during the years 1996-2010, was conducted by Etti Samama as part of the work for her doctoral thesis in health-system management at Ben-Gurion University. To compile recent data, Adam Ringel and Eti Dekel, for many years the national supervisor of the surrogacy law, collected information from 246 cases – 90 percent of the cases filed with committee in the last couple of years. 

...

"The data indicate a fundamental change in the socio-economic status of women who choose to become surrogates. In terms of education, while in 2010 the majority of surrogate mothers had a high school education (70 percent), nearly one fifth (18 percent) had less than 12 years of schooling, and only 7 percent had academic degrees. Less than a decade and a half later, however, the picture has been transformed: 65 percent of surrogate mothers have an academic degree, and only about one fifth have only a high school education (14 percent) or less than 12 years of schooling (8 percent). The proportion of those with academic degrees among surrogates is significantly higher than that group's share of the population, which is 38 percent.

"A similarly changed picture emerges in terms of employment: In 2023, only 2.5 percent of surrogates were unemployed, compared with 25 percent in 2010. No less interesting is the finding regarding geographical dispersal of surrogates, as compared with the general public: In recent years, almost half (45 percent) of them come from kibbutzim, moshavim and organized communities – compared with just 12 percent in 2010.

...

"An absolute majority of surrogates come from [the world of] religious Zionism, on the one hand, or are secular women from kibbutzim and other organized communities, on the other," Ringel elucidates. "These two groups are seemingly worlds apart, but in the world of surrogacy, you see the resemblance between them. These are independent, strong women, with a fully developed values-based worldview, who are looking to do something big for others, who see surrogacy as a calling, as female empowerment and as the ultimate giving."

"What happened between 2010 and 2024 that led to such dramatic change in the profile of surrogate mothers? Experts in the field ascribe the change mainly to the opening up of the option for married women to become surrogates, beginning in 2010 – a move that significantly increased the pool of potential surrogates and also changed their socio-economic backgrounds.

"This is indeed a transformation: in 2010, all surrogates were unmarried women, 75 percent of them divorced, the rest single (and a few widows). In contrast, in 2022-2023, 80 percent of surrogates were married or in relationships, and only 20 percent were divorced or single.

...

 "There was always an altruistic element with surrogates, but ever since married and more affluent women entered the picture – the economic part became more of a bonus, rather than the main motive," Dekel points out."

Growth pains for legal marijuana, in Germany and New York

Transitioning from a thriving black market for marijuana to a regulated legal market isn't so easy.

The Guardian has the story from Germany, where so far clubs, but not shops, have been legalized:

Cannabis legalisation hampered by most German of substances: red tape. Activists say the rollout of laws permitting recreational use of the drug has been hampered by a ‘bureaucratic monster’  by Deborah Cole

"Joints now mingle openly with pints among fans watching the European football championship in host nation Germany, which in the spring became the first big EU country to legally allow personal recreational use of cannabis.

"That is, provided the fan is over 18, only carrying a small amount of the narcotic, not smoking in the stands of a stadium and not in possession of more than three plants at their officially registered home.

...

"The hotly disputed law passed by Olaf Scholz’s three-party coalition, which took effect in April, legalised cultivating up to three plants for private consumption, the possession of 50g (1.75oz) of cannabis at one time at home and 25g in public.

...

"A key phase began on 1 July with the establishment of registered cannabis clubs, which proponents say are vital to assuring the smooth path towards legal weed and supplanting the underworld street trade.

...

"In order to thwart drug tourism, members must have lived in Germany for six months, sign up to a club for a minimum of three months and have a clean criminal record for narcotics.

"Clubs are dependent on fee-paying members to start operating but are not allowed to advertise, said Marten Knopke of the Cannabis Social Club Leipzig, thus robbing them of a key source of capital needed to rent offices and land for growing purposes. Consumption on club premises is also verboten.

“We are subject to more restrictions than any alcohol company,” Knopke said, echoing a frequent complaint from the cannabis scene about drinking, which kills more than 60,000 people in Germany each year. “The government has also made it really difficult for us to stand up to the hidden [narcotics] market.”

...

“There are no shops where you can buy, meaning they [foreign tourists]" will end up buying something on the underground market, which is very dangerous in Berlin,” because of contaminated drugs and the role of the mafia in the trade, he said."

********

And here's the New York Times on New York:

The Real Problem With Legal Weed, By Charles Fain Lehman

"When New York legalized recreational marijuana in 2021, the future seemed bright. ...

"Three years later, things are not going to plan. Gov. Kathy Hochul has called New York’s legalization rollout “a disaster.” Mayor Eric Adams has spent months demanding that Albany fix the current system. “What happened?” The New Yorker recently asked in a feature on the collapse of the state’s marijuana “revolution.”

...

"There are around 140 recreational dispensaries operating statewide — about one for every 148,000 New Yorkers. Instead of shopping legally, New Yorkers tend to get their weed from the illegal shops that now blanket the state. Estimates suggest that there are anywhere from 2,000 to 8,000 in New York City alone, with uncounted more from Ithaca to Oneonta. Recent crackdowns have temporarily sealed more than 400 stores — only a small fraction of the total in the city.

"These shops undercut the legal stores, offering the same high at a fraction of the price. And they attract crime: There were 736 robbery complaints at unlicensed shops last year, according to the New York Police Department. Shootings are not uncommon, including the killing of a 36-year-old man captured on video last April.

"They also sell to teenagers, as The Times has reported. Teachers, prevention experts and pediatricians have raised the alarm about high schoolers smoking or vaping marijuana at school."