Can a family that has decided to end life support decide a loved one should be a living donor?

Transplantation is a field full of the kind of wrenching discussions that you might expect to find as hypotheticals in a philosophy class. The WSJ follows one such discussion:
The Difficult Ethics of Organ Donations From Living Donors

"The family proposed that doctors put Mr. Osterrieder under anesthesia and perform surgery to remove a kidney for transplant. Like any living donor, he would be expected to survive the procedure. Then, a few days later, the ventilator would be removed and he would be allowed to die.

“Just the feeling something good would come out of this helped us,” says Kim Shuster, 31, one of Mr. Osterrieder’s daughters.

"A labyrinth of federal and state rules and regulations, as well as those of individual transplant centers, guide organ procurement. The family met with the hospital’s ethics committee, spoke with doctors and talked among themselves. Everyone wanted to make sure the choice reflected Mr. Osterrieder’s wishes, but there was also discussion about how the family might feel if their decision made news and strangers, not to mention relatives, criticized them.

"Kathy Osterrieder says she, her children and son-in-law all agreed, “if any of us are not on board, we won’t do this.” Whatever happens, she told them, “we have to survive as a unit.”

"The ethics committee gave its approval, and the hospital reached out to the federally designated organ-procurement service that helps coordinate donations in the region. The organization’s leaders were moved. But when they put out a call to 14 different transplant centers to find a surgeon to perform the operation, “we could not find a surgeon who was willing,” says Kurt Shutterly, chief operating officer of the Center for Organ Recovery and Education, based in Pittsburgh.

"The surgeons didn’t feel it was ethical to remove Mr. Osterrieder’s kidney without his direct authorization, Mr. Shutterly recounts. They also worried, he says, that if a living donor died soon after the procedure, it might jeopardize an institution’s entire transplant program.
...
"Earlier this year, an Organ Procurement and Transplantation Network and UNOS working committee wrote a report about the ethical considerations of a type of “imminent-death donation,” in which a living donor through a surrogate donates an organ before the planned withdrawal of ventilator support. The committee found that, under certain circumstances, the practice may be ethical, but some people who read the report expressed significant enough concerns that the committee determined, for now at least, that it didn’t want to move forward with trying to change UNOS policy. The report is expected to be posted soon for public comment.

“It is powerful to think that someone at the end of life, who has suffered a lot of illness, would want to do something to help someone else by being a living donor,” says Peter Reese of the University of Pennsylvania, chairman of the OPTN/UNOS ethics committee.

"And yet, despite the fact that offering an organ is an exquisitely personal decision, transplantation is a highly communal process, from the involvement of many medical disciplines in the extraction of the organ to the decision about who receives it. “If all those people don’t agree and we try to push this forward, we run the risk of undermining the whole enterprise,” Dr. Reese says. “Organ transplantation requires public trust to a massive degree.”

Who finds sales of genetically modified food repugnant? (Hint: they are disgusted)

Here's a paper on a source of firm opposition to genetically modified food:

Sydney E. Scott, Yoel Inbar, and Paul Rozin
Evidence for Absolute Moral Opposition to Genetically Modified Food in the United States
Perspectives on Psychological Science May 2016 11: 315-324

Abstract

Public opposition to genetic modification (GM) technology in the food domain is widespread (Frewer et al., 2013). In a survey of U.S. residents representative of the population on gender, age, and income, 64% opposed GM, and 71% of GM opponents (45% of the entire sample) were “absolutely” opposed—that is, they agreed that GM should be prohibited no matter the risks and benefits. “Absolutist” opponents were more disgust sensitive in general and more disgusted by the consumption of genetically modified food than were non-absolutist opponents or supporters. Furthermore, disgust predicted support for legal restrictions on genetically modified foods, even after controlling for explicit risk–benefit assessments. This research suggests that many opponents are evidence insensitive and will not be influenced by arguments about risks and benefits.

A matching market for polygamy: SecondWife.com

Here is a (combinatorial?) site for plural marriage for Muslims: SecondWife.com

“then marry women of your choice, two or three, or four but if you fear that you shall not be able to deal justly, then only one”
- Quran 4:3

Repugnance and the social acceptance of kidney exchange (in French)

Here's an article, en français, that considers repugnance as central to the design (and public acceptance) of kidney exchange:

Brisset Nicolas, « Un marché sans marchandise ? Répugnance et matching market », Revue d'économie politique 2/2016 (Vol. 126) , p. 317-345 
URL : www.cairn.info/revue-d-economie-politique-2016-2-page-317.htm.

Here is its table of contents. (Google Translate is helpful but far from perfect in reading the article for those of us who are linguistically impaired...)

Plan de l'article

1. Introduction
2. Roth et la répugnance : le cas des organes
2.1. La solution marchande au manque d’organes
2.2. Le rejet de la solution marchande et la solution de Roth
3. Les critiques de la solution marchande
3.1. Motivation et effet d’éviction
3.2. Commerce de détresse et liberté du donneur
4. Donner corps à la répugnance
4.1. Conventions, marquage et incitation : du marchand et du non marchand
4.2. Don-contre-don et limite de la solution marchande
5. Conclusion

Here's more info on the author: Nicolas Brisset.

Matching markets--a short instructional video from the Core Project

Here's a short (4 minute) teaching video put together by the CORE Project ("Teaching Economics as if the last three decades had happened") from a much longer videotaped discussion on market design, matching markets, kidney exchange and repugnant transactions.




Here's a link to a CORE class that uses this video:

Introducing Unit 20: Innovation, information and the networked economy

Volatility in the political marketplace-Brexit

Will the United Kingdom of England, Scotland, Wales and Northern Ireland break up, following the 52% to 48% vote for the UK to leave the European Union? (Scotland and Northern Ireland voted to remain in the EU...).

Ken Rogoff has a characteristically well-written article (Britain’s Democratic Failure) arguing that such momentous decisions should be taken by super-majorities, not by a simple majority.

"The real lunacy of the United Kingdom’s vote to leave the European Union was not that British leaders dared to ask their populace to weigh the benefits of membership against the immigration pressures it presents. Rather, it was the absurdly low bar for exit, requiring only a simple majority. Given voter turnout of 70%, this meant that the leave campaign won with only 36% of eligible voters backing it.
This isn’t democracy; it is Russian roulette for republics. A decision of enormous consequence – far greater even than amending a country’s constitution (of course, the United Kingdom lacks a written one) – has been made without any appropriate checks and balances."

Scotland, of course, has voted in the past to remain part of the UK--might it vote differently in the future? By a similarly narrow margin?  

Airbnb and racial discrimination by hosts

The NY Times follows the story: Airbnb Vows to Fight Racism, but Its Users Can’t Sue to Prompt Fairness

"SAN FRANCISCO — Brian Chesky, chief executive of Airbnb, made a vow this month to root out bigotry from his business.

His online room-sharing company has recently been grappling with claims of discrimination, with several Airbnb users sharing stories on social media about how they were supposedly denied a booking because of their race. The issue came into the open in December, when a working paper by Harvard University researchers found it was harder for guests with African-American-sounding names to rent rooms through the site.

“This is a huge issue for us,” Mr. Chesky said at a company event in San Francisco in early June. “We will be revisiting the design of our site from end to end to see how we can create a more inclusive platform.”

But even as Mr. Chesky promised to stamp out racism from Airbnb, the company’s class-action litigation policy makes it tough — if not impossible — for customers to push the start-up to make any substantive changes on the issue. Airbnb requires that people agree to waive their right to sue, or to join in any class-action lawsuit or class-action arbitration, to use the service.

That clause, known as a class-action waiver, crops up whenever someone logs into Airbnb’s site. In March, the company updated its terms of service for new users, partly tohighlight that clause. Last month, Airbnb users were unable to log in and use their accounts until they agreed to the updated terms, including the class-action waiver language.

...

"For Airbnb, an effective response to discrimination claims is needed to blunt any fallout on its business. The company, valued at about $25 billion, has hosts in more than 34,000 cities and 191 countries and is positioning itself as an alternative to hotels. Airbnb recently raised $1 billion in debt to help finance its growth, according to a person familiar with the deal who spoke on the condition of anonymity because the transaction is not public. The credit facility wasreported earlier by Bloomberg.

Airbnb’s expansion depends partly on whether people of different nationalities and ethnicities feel welcomed to the platform in the same nondiscriminatory way that they are welcomed at international hotel chains. Two rival room-sharing services, Innclusive and Noirbnb, are now marketing themselves as services that provide inclusive and safe short-term rentals for people of any race or ethnicity.

Ms. Murphy, the Airbnb adviser, said the company recognized that eliminating discrimination was in its best interests. She said Airbnb’s relative youth — the company was founded in 2008 — meant it could deal with the issue in a more agile way than companies with entrenched cultures that may have needed the pressure of litigation to do the right thing.

“Airbnb is part of a new area of commerce, and the conditions for transactions are still developing,” she said. “That’s why it’s important to get it right.”

Repugnance watch: Nude photos as collateral for loans

The Guardian has the story: China's 'naked loans' force female students to bare all in return for more cash

"Shady internet lenders in China are reportedly coercing female college students to provide nude pictures of themselves as collateral – a loan-for-porn scheme that has prompted anger on the country’s internet.

Under the arrangement reported by state media this week, some college students have agreed to send photos of themselves naked, holding their identification cards, to potential lenders. In exchange, they became eligible for higher loan amounts – two to five times the normal sum, the state-run Beijing Youth Daily reported.

Lenders tell the students they will publish the photos online if the loans are not repaid on time, often at usurious interest rates.

According to state media, the loan scheme is taking place on JD Capital’s Jiedaibao website. Jiedaibao is a platform where individuals - often friends and acquaintances – can lend or borrow money, striking their own arrangements."

Repugnance watch: US ceases efforts to end global trade of polar bear parts

The Guardian has the story: US ceases efforts to end global trade of polar bear parts

"The US government has quietly dropped its campaign for an international ban in the trade of polar bear parts, which would have given the practice the same outlaw status as the elephant ivory market.

The US Fish and Wildlife Service has spent several years attempting to ban the overseas trade of polar bear skins, teeth, paws and other parts from Canada, which permits the hunting of the Arctic predators.

However, the federal agency has said it won’t pursue the matter further at an international summit of the Convention on International Trade in Endangered Species of Wild Fauna and Flora (Cites), in September. Instead, the US will focus on the threat posed to polar bears from climate change.

...

"The US’s bid to ban the polar bear trade has garnered support from the UK, Germany and Russia but has been opposed by Canada, which insists that hunting is sustainable and an important cultural practice of the native Inuit people. Hunting can also generate income for communities, with tourists paying up to $50,000 for the chance to shoot a polar bear."

A skeptical view of the Iranian market for kidneys, from Shiraz

Here's an article (gated) from a recent issue of Transplantation, describing how the transplant program in Shiraz is discouraging patients from the (legal) market there for buying kidneys from living unrelated donors (they impose a six month waiting time for such transplants). Most patients who have transplants at Shiraz are receiving deceased donor kidneys.

Transplantation:

June 2016 - Volume 100 - Issue 6 - p 1165–1169

doi: 10.1097/TP.0000000000001164

In View: Around the World

Paid Living Donation and Growth of Deceased Donor Programs

Ghahramani, Nasrollah MD

Abstract

Abstract: Limited organ availability in all countries has stimulated discussion about incentives to increase donation. Since 1988, Iran has operated the only government-sponsored paid living donor (LD) kidney transplant program. This article reviews aspects of the Living Unrelated Donor program and development of deceased donation in Iran. Available evidence indicates that in the partially regulated Iranian Model, the direct negotiation between donors and recipients fosters direct monetary relationship with no safeguards against mutual exploitation. Brokers, the black market and transplant tourism exist, and the waiting list has not been eliminated. Through comparison between the large deceased donor program in Shiraz and other centers in Iran, this article explores the association between paid donation and the development of a deceased donor program. Shiraz progressively eliminated paid donor transplants such that by 2011, 85% of kidney transplants in Shiraz compared with 27% across the rest of Iran's other centers were from deceased donors. Among 26 centers, Shiraz undertakes the largest number of deceased donor kidney transplants, most liver transplants, and all pancreas transplants. In conclusion, although many patients with end stage renal disease have received transplants through the paid living donation, the Iranian Model now has serious flaws and is potentially inhibiting substantial growth in deceased donor organ transplants in Iran.

More on Chinese college admissions

Two stories in the NY Times shed some light on the high stakes game of college admissions in China.

China Tries to Redistribute Education to the Poor, Igniting Class Conflict

China Threatens Jail Time for College Entrance Exam Cheaters

Kidney black market arrests at Apollo hospital in Delhi

Each morning when I manage this blog I erase spam comments, and many of them relate to kidney sales. You can see typical ones on the Google+ page of the (apparently mis-spelled) Appollo Hospital in India.
So I noted with interest this recent story about arrests connected to that hospital.


Kidney Racket: At Least 3 Recipients, 5 Donors Traced
Delhi | Press Trust of India |

"NEW DELHI:  Delhi Police have traced at least three recipients and five donors in connection with the international kidney racket linked to Apollo Hospitals in Delhi, even as the investigators sought legal opinion regarding slapping charges on them.

Five persons, including two personal secretaries of a nephrologist in Apollo Hospital, have been arrested in connection with the kidney racket which is believed to have its ramifications in countries including Sri Lanka and Indonesia, an official privy to the investigation said.

Till this afternoon, three of the recipients were traced in Kolhapur, Jammu and Kashmir and Ghaziabad.

Prima facie the recipients shelled out over Rs. 40 lakh for each transplant, of which not even 10 per cent reached the donor, the official said.

He further said, the police have traced over five donors, including three women, who are presently admitted in a hospital in Delhi.

During investigation it came to light that the gang members used to prepare forged papers to establish the relationship between donors and recipients, to adhere to the law.

The police have come across five cases in Apollo Hospital, in which the donors were shown as wife, brother, father or brother-in-law (2 cases) of recipients, the official said, adding that while average time of hospital stay for the donors was six days, for the recipients it was 12 days.

Meanwhile, the police have sought legal opinion in slapping charges on the donors and recipients under relevant provisions of law. Lawyers have been consulted for the purpose, the official said.

The accused arrested so far in the case include Aditya Singh and Shailesh Saxena, who worked as personal secretaries of Apollo Hospital doctors for 3-4 years, and three touts identified as Aseem Sikdar, Satya Prakash and Devashish Moulik.

The touts used to lure financially poor people from West Bengal, Uttar Pradesh and other parts of the country for donating kidney. Mr Moulik landed in the police net following a fight with his wife, whose kidney he had sold off.

Medical tests of recipient and donor were conducted and once the compatibility match was done, operations were conducted at Apollo Hospital in southeast Delhi.

"We are cooperating and providing all information required to help the police in their investigation pertaining to the alleged kidney sale racket," said a press statement by Indraprastha Apollo Hospital."

Pollak on Marriage Markets

Here's a new NBER paper on marriage by Bob Pollak:

Marriage Market Equilibrium

Robert A. Pollak

NBER Working Paper No. 22309
Issued in June 2016
NBER Program(s):   CH   LS 

The standard Beckerian analysis of marriage market equilibrium assumes that allocation within marriage implements agreements made in the marriage market. This paper investigates marriage market equilibrium when allocation within marriage is determined by bargaining in marriage and compares that model with the standard model. When bargaining in marriage determines allocation within marriage, the marriage market is the first stage of a two-stage game. The second stage, bargaining in marriage, determines allocation within each marriage. This analysis is consistent with any bargaining model with a unique equilibrium as well as with Becker's "altruist model," the model that underlies the Rotten Kid Theorem. Marriage-market participants are assumed to rank prospective spouses on the basis of the allocations they foresee emerging from bargaining in marriage. The first stage game, the marriage market, determines both who marries and, among those who marry, who marries whom (assortative marriage). When bargaining in marriage determines allocation within marriage, the appropriate framework for analyzing marriage market equilibrium is the Gale-Shapley matching model, not the Koopmans-Beckmann assignment model. These models have different implications for who marries, for who marries whom, and for the Pareto efficiency of marriage market equilibrium.

The regulated market for the resale of grave sites (and the black market of unregulated sales)

Benjamin Kay points me to a 2013 story in The Forward about the resale market for unused grave sites: Black Market for Jewish Grave Sites Grows on Web .

"A black market in Jewish graves is hiding in plain sight on the classified pages.

"Defunct Jewish burial societies have been selling cemetery plots at bargain basement prices through classified ads on Craigslist and in the print edition of the Forward — even though New York and New Jersey state laws bar these sales.

"Each sale of a New York grave by a burial society on the open market could be punishable by up to six months in jail, according to the state’s top cemetery regulator, though no one has ever been prosecuted. New Jersey law carries no such penalties, but still prohibits the sales.
...
"Only cemeteries are generally allowed to sell cemetery plots on the open market in New York and New Jersey. But in the two states’ Jewish cemeteries, mutual aid societies, called landsmanschaften, own huge inventories of empty graves. Founded at the turn of the past century by Jewish immigrants from the same town or region in Europe, the societies bought up large tracts of cemetery land, erected stone gates lined with the names of the societies’ officers and readied plots for their dues-paying members.

"Today, many of those societies and congregations have disappeared, leaving behind empty, unclaimed graves.

"As the societies have withered away, control of the organizations and their assets has passed down within families. The officers who now run the landsmanschaften — often the children or grandchildren of earlier officers — have found themselves responsible for cemetery land worth hundreds of thousands of dollars."

Market design at the University of Chicago

Chicago is making a home for market design. ..

Mohammad Akbarpour and Eric Budish's market design class at University of Chicago

Podcast about Who Gets What and Why (now in paperback)

Here's an interview about Who Gets What and Why, now in paperback.

The marijuana business in the U.S.: legal in some states, but still illegal under Federal law.

The Guardian suggests that Canada may soon find commercial opportunities in marijuana :
Will Canada become America's cannabis capital?
Plans to legalise recreational marijuana in Canada have those south of the border worried they’ll lose their lead in the emerging pot industry

"He may be the chief executive of Denver’s largest marijuana dispensary, ground zero for America’s fastest growing industry, but Andy Williams struggles with a lot of financial hurdles.

The First Bank of Colorado closed the accounts of everyone in the family business, Medicine Man Technologies, including children who have no part in the industry. Williams can’t take on any investment and needs to fund expansion through personal loans from friends and family.

Customers can only pay in cash; banks refuse to hold his money and everyone from employees to contractors need to accept cash payments. Employees, who can’t prove their income as a result, often struggle to get loans and mortgages.

Furthermore, section 280E of the US tax code prohibits the deduction of expenses related to controlled substances for tax purposes, and Williams predicts that he gives the internal revenue service an additional $600,000 each year as a result of business expenses that can’t be written off.

While recreational marijuana legalisation is well on its way in states like Colorado, it remains illegal at the federal level, stifling the growth and innovation of the industry’s first movers.

Meanwhile, north of the border, Canadian prime minister Justin Trudeau has vowed to legalise recreational marijuana consumption on a federal level, opening the door to investment, less restrictive tax policies and banks that can treat the marijuana industry like any other. While legalisation hasn’t yet taken place in Canada, when it inevitably does American marijuana businesses may suddenly find themselves at a disadvantage. "

Second Workshop on “Marketplace Innovation” June 15, 2016 NYU Stern

Marketplace Innovation Workshop

Second Workshop on “Marketplace Innovation”

June 15, 2016
NYU Stern
In conjunction with the 2016 Informs Revenue Management Conference

Organized by Ramesh Johari, Ilan Lobel, Costis Maglaras, and Gabriel Weintraub

Program

8:30 – 9:00 AM: REGISTRATION AND BREAKFAST
9:00 – 9:15 AM: INTRODUCTION
Dean Peter Henry, NYU Stern School of Business
9:15 – 10:15 AM: SESSION 1: KEYNOTE ADDRESS
“Kidney Exchange: Where We Are and Where We May Be Going,”
Alvin Roth, Craig and Susan McCaw Professor of Economics and
2012 Nobel Memorial Prize Recipient in Economic Sciences,
Stanford University
10:15 – 10:30 AM: BREAK
10:30 – 12:00 PM: SESSION 2: RIDE-SHARING AND ON-DEMAND PLATFORMS
Talks: “Operations in the On-Demand Economy: Staffing Services with
Self-Scheduling Capacity,” Martin Lariviere, John L. and Helen
Kellogg Professor of Managerial Economics & Decision Sciences,
Kellogg School of Management
“Surge Pricing at Uber,” Garrett Van Ryzin, Head of Dynamic
Pricing Research, Uber; Paul M. Montrone Professor of Private
Enterprise, Columbia Business School
“Smarter Tools for (Citi)Bike Sharing,” David Shmoys,
Laibe/Acheson Professor of Business Management and Leadership,
Cornell University
12:00 – 1:30 PM: LUNCH (ROOM 5-50, 5TH FLOOR)
2
1:30 – 2:30 PM: SESSION 3: EMPIRICS OF PRICING
Talks: “Monitoring Costs and the Design of Online Marketplaces,”
Kostas Bimpikis, Associate Professor of Operations, Information
and Technology, Stanford GSB
“Price Floors and Preferences: Evidence from a Minimum Wage
Experiment,” John Horton, Assistant Professor of Information,
Operations and Management Sciences, NYU Stern School of Business
2:30 – 2:45 PM: BREAK
2:45 – 4:15 PM: SESSION 4: TRUST AND REVIEWS
Talks: “The Welfare Impact of Consumer Reviews: A Case Study of the
Hotel Industry,” Greg Lewis, Senior Researcher, Microsoft
“Provably Trustworthy Dark Pools,” David Parkes,
George F. Colony Professor of Computer Science and Area Dean for
Computer Science, Harvard University
“The Effect of Online Reviews on Physician Demand: A
Structural Model of Patient Choice,” Mor Armony,
Associate Professor of Information, Operations, & Management
Sciences, NYU Stern School of Business
4:15 – 4:45 PM: BREAK
4:45 – 5:45 PM: SESSION 5: DIGITAL ADVERTISING AND AUCTIONS
Talks: “Online Mechanisms for Repeated Auctions and Ad Selection,”
Vahab Mirrokni, Principal Researcher, Google
“Bundling Over Time and Martingale Auctions,” Santiago
Balseiro, Assistant Professor, Decision Sciences, Duke University

White House Organ Summit--video and links. Deceased donor chains planned at Walter Reed

Here's a video of the plenary talks/announcements at the White House Organ Summit yesterday. I give the last brief talk, from minute 43-48. (5 minute talks are hard:). I report on the plan to start some nondirected donor kidney exchange chains with deceased donor kidneys at Walter Reed, which has some flexibility in the allocation of deceased donor kidneys.



Here's the accompanying White House FACT SHEET: Obama Administration Announces Key Actions to Reduce the Organ Waiting List

Here's the text of my five-minute speech (which I wrote out in advance, to stay on script and keep on time):

"White House Organ Summit: Deceased Donor Chains

I’m Al Roth, an economist at Stanford.

Most people waiting for transplants are waiting for kidneys. And kidneys are special, because healthy people have two and can remain healthy with one. So kidneys can be donated by living as well as deceased donors.  Each year in the U.S. we transplant over 5,000 living donor kidneys, along with over 11,000 deceased donor kidneys.

Kidney transplantation is also special: it is both the best treatment for kidney failure, giving recipients many more years of life—and it is also the cheapest treatment. The American health care system saves over $250,000 in five years after a transplant, because dialysis is much more expensive than transplantation and post-transplant care.

          I’m going to tell you now about how some living donor kidney transplants are organized, as background for one of the quite concrete announcements we have today.

Sometimes a person is healthy enough to donate a kidney but can’t give to the patient he loves, because kidneys have to be biologically compatible. This opens up the possibility of kidney exchange (and exchange is where economists come in). Kidney exchange is a kind of matching market in which patient-donor pairs can donate compatible kidneys to one another so that each patient gets a compatible kidney. For example, if you and I are healthy enough to donate a kidney, but can’t donate to the patient we love, maybe my kidney is compatible with your patient and yours with mine, and so a simple exchange between two patient-donor pairs can make two additional transplants possible. In the last 10-15 years, kidney exchange has become a standard part of American medicine, resulting in thousands of additional transplants.

          Sometimes a non-directed donor comes forward—an altruistic donor who wishes to donate a kidney, and doesn’t have a particular patient in mind. These donors can spark chains of transplants that help patient-donor pairs in the kidney exchange pool, and patients on the deceased donor waiting list who don’t have a living donor. Some of these chains can produce many transplants, ever since we have learned to organize them as Non-simultaneous chains, in which the non-directed donor initiates a chain by giving to a patient-donor pair whose donor then gives to another pair, etc., most often ending with a donation to someone on the waiting list who doesn’t have a living donor.  These chains can be long because they don’t have to be conducted simultaneously since every pair receives a kidney before giving one, so that they don’t risk giving a kidney and not getting one.  Mike Rees who is here today organized the first non-simultaneous chain, which had twenty people--ten donors and ten transplant recipients--in the picture that was eventually published in People Magazine.

The average non-directed chain produces five transplants. That is, if someone offers to donate a kidney to start a chain - someone offering to help a stranger with this amazing gift of a kidney and a life free from dialysis - then on average, that one donor's gift will start a chain which produces 5 transplants

With that in mind, earlier this year, several eminent surgeons and I published an article in the American Journal of Transplantation noting that deceased donor kidneys are almost all non-directed. So we proposed that we should occasionally start non-directed donor chains with deceased donor kidneys – which are non-directed donor kidneys that today are used to produce just a single transplant. Carefully done, this could substantially increase the number of transplants for all patients –both those waiting without a living donor and those waiting for a kidney exchange.

Today, surgeons at Walter Reed who are here today have announced that they are going to pilot this idea through the military share program, which gives them the flexibility to allocate certain deceased donor kidneys to the benefit of veterans and service members. This new initiative at Walter Reed may soon show us how to move forward on a larger scale in using some deceased donor organs to start chains of multiple transplants.

To summarize, kidney chains can play an important role in increasing transplants. Since the first long non-simultaneous non-directed donor chain was organized by Dr Rees in 2007, thousands of kidney exchange transplants have been accomplished, more than half through non-directed donor chains. These save both lives and money by increasing the number of transplants. So we should take good care of our non-directed living donors—and there is growing consensus that we should at least figure out ways to reimburse all donors for their financial costs, including lost wages. And we should, in gratitude to our deceased donors, make the best use possible of their non-directed donation.

I’d like to personally thank Walter Reed for their initiative in pioneering the use of deceased donor kidneys to start kidney exchange chains that will increase donations and benefit both those waiting for deceased donors and those waiting for exchange with other patient donor pairs. Starting kidney transplant chains with deceased donor kidneys has the potential to be a very significant innovation."

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

Here's a link to my post on our AJT article (by Melcher, Roberts, Leichtman, Roth, and Rees) advocating for starting kidney exchange chains with deceased donor kidneys:

Monday, April 11, 2016

Using deceased donor kidneys to start living donor kidney exchange chains

**********

Here's the announcement from the DoD:

Walter Reed Announces Pilot Program as Part of Organ Summit

"BETHESDA, Md., June 13, 2016 — Walter Reed National Military Medical Center officials today announced a pilot program to pioneer kidney paired donation chains started via the military share program, in which families of active duty military service members donate one of their kidneys to patients listed for transplant at the medical center’s campus here.

...

""We are excited to participate in this initiative, which has the potential to increase organ allocation for our patients,” Navy Capt. (Dr.) Eric Elster, professor and chairman of surgery at the Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center said. “While it will require overcoming logistical barriers, we in military medicine excel at such challenges."

Walter Reed surgeons perform an average of 25 transplants per year on patients from across the country, and the medical center also maintains a living donor kidney transplant program that participates in national paired kidney exchanges.

Army Maj. (Dr.) Jason Hawksworth, transplant chief at Walter Reed, said his team “looks forward to contributing to the innovative initiative that may exponentially increase the availability of life-saving transplants on patients throughout the nation."

According to the Scientific Registry of Transplant Recipients, a regulatory body that tracks transplants, Walter Reed has the best organ transplant outcomes in the greater Washington-Baltimore region."

White House organ summit today

I'm catching an early flight from Boston to DC this morning. I expect there may be more to report later...

White House summit on increasing organ donation
"The White House will host an Organ Summit. At the summit, the administration and private entities will announce a new set of actions that will build on the administration’s previous accomplishments to improve outcomes for individuals waiting for organ transplants and improve support for living donors. This event will be webcast live at www.whitehouse.gov/live. The event will take place Monday, June 13, from 10:30 am-12:30 pm EDT."

Update: see the next post.

Head transplants--could they be feasible? Repugnant?

The NY Times has the story: Doctor’s Plan for Full-Body Transplants Raises Doubts Even in Daring China

"The idea for a body transplant is the kind of thinking that has experts around the world alarmed at how far China is pushing the ethical and practical limits of science. Such a transplant is impossible, at least for now, according to leading doctors and experts, including some in China, who point to the difficulty of connecting nerves in the spinal cord. Failure would mean the death of the patient.

The orthopedic surgeon proposing the operation, Dr. Ren Xiaoping of Harbin Medical University, who assisted in the first hand transplant in the United States in 1999, said he would not be deterred. In an interview, Dr. Ren said that he was building a team, that research was underway and that the operation would take place “when we are ready.”

His plan: Remove two heads from two bodies, connect the blood vessels of the body of the deceased donor and the recipient head, insert a metal plate to stabilize the new neck, bathe the spinal cord nerve endings in a gluelike substance to aid regrowth and finally sew up the skin.

Whether or not he performs the operation, leading medical experts have condemned the plan.

“For most people, it’s at best premature and at worst reckless,” said Dr. James L. Bernat, a professor of neurology and medicine at the Geisel School of Medicine of Dartmouth College.

Dr. Huang Jiefu, a former deputy minister of health in China, said in an interview in November that when the spine is cut, the neurons “cannot be reconnected, so it’s scientifically impossible.”

“Ethically it’s impossible,” Dr. Huang added. “How can you put one person’s head on another’s body?”

Finding donors for transplants

In a second article in the NY Times, David Bornstein explored the search for organ donors:
Finding Organ Donors Concealed in Plain Sight

He talked to lots of people exploring different approaches, including incentives and outreach, and kidney exchange chains (and his article is full of interesting links, if you're interested...)

Death in California isn't the same anymore

The NY Times has the story: Who May Die? California Patients and Doctors Wrestle With Assisted Suicide

"On Thursday, California became the fourth state in the country to put in effect a law allowing assisted suicide for the terminally ill, what has come to be known as aid in dying. Lawmakers here approved the legislation last year, after Brittany Maynard, a 29-year-old schoolteacher who had brain cancer, received international attention for her decision to move to Oregon, where terminally ill patients have been allowed to take drugs to die since 1997.

Oregon was the first state to pass an assisted suicide law, and was followed by Washington and Vermont. Under a Montana court ruling, doctors cannot be prosecuted for helping terminally ill patients die, as long as the patient makes a written request. With the California law, 16 percent of the country’s population has a legal option for terminally ill patients to determine the moment of their death, up from 4 percent.

In the states with assisted suicide laws, the number of people who request and take medication to hasten dying has steadily increased. In Oregon, for example, 16 people ended their lives under the law in 1998, and by 2015, that number had grown to 132.

The California legislation is strict, intended to ensure that patients have thought through the decision and are making it voluntarily. Patients must make multiple requests for the medication and have a prognosis of less than six months to live.

Many hospitals have not yet released policies for dealing with the law. And no doctor, health system or pharmacy will be required to comply with a patient’s request. Doctors who object to the practice are not even required to refer patients who request the medication to another physician.

Roman Catholic and other religious health systems have said they will not participate. “We are crossing a line — from being a society that cares for those who are aging and sick to a society that kills those whose suffering we can no longer tolerate,” José H. Gomez, the Catholic archbishop of Los Angeles, said in a statement Wednesday."

Wife swapping: it's hard to make binding contracts for repugnant transactions

Yannai Gonczarowski writes:

"A week ago, the following question was asked on a popular Israeli web forum that discusses legal questions: The author says that he and his wife agreed with their neighbor and his wife that they will exchange partners for a day: the neighbor will be with the author's wife for one day, and after the neighbor's wife returns from her current trip abroad, she will be with the author for a day. As you can already imagine, the author writes that the first part happened, but when the neighbor's wife returned from abroad, the neighbor and his wife denied any such agreement and ignored the author's messages. The author says that he has text messages on his phone to prove the agreement and that he spent a considerable amount of money on beverages for the intended day with the neighbor's wife, and asks the readers of the web forum whether he has a cause for legal action against the neighbor and his wife for violating the agreement.

A link to the question on the web forum (the actual Hebrew text is somewhat more colorful/offensive): http://www.lawforums.co.il/SingleMessage.aspx?MessageID=1186029

Indeed, in repugnant markets (at least ones in which an altruist donor beginning a "chain" is unlikely...) simultaneity is key."

On Patients Who Purchase Organ Transplants Abroad--Many or few?

An article in the American Journal of Transplantation:

On Patients Who Purchase Organ Transplants Abroad
by F. Ambagtsheer,*, J. de Jong,W. M. Bramer and W. Weimar

The international transplant community portrays organ trade as a growing and serious crime involving large numbers of traveling patients who purchase organs. We present a systematic review about the published number of patients who purchased organs. With this information, we discuss whether the scientific literature reflects a substantial practice of organ purchase. Between 2000 and 2015, 86 studies were published. Seventy-six of these presented patients who traveled and 42 stated that the transplants were commercial. Only 11 studies reported that patients paid, and eight described to what or whom patients paid. In total, during a period of 42 years, 6002 patients have been reported to travel for transplantation. Of these, only 1238 were reported to have paid for their transplants. An additional unknown number of patients paid for their transplants in their native countries. We conclude that the scientific literature does not reflect a large number of patients buying organs. Organ purchases were more often assumed than determined. A reporting code for transplant professionals to report organ trafficking networks is a potential strategy to collect and quantify cases.
++++++++

Update: here's the published version...
Volume 16, Issue 10, October 2016, Pages 2800–2815

College admissions--and censorship--in China (during the approach to the Gaokao college entrance exam)

David Yang writes:

Just want to share a post I saw on China’s social media today. 

This week is China’s college entrance exam (Gaokao), and a high-profile social media account featured your book and the matching algorithm in a post about the college admission system in China. See picture #1: the title of the post reads “One algorithm that solves the challenges of college admission”, and you can see the cover of your book below. The abstract reads: “Rarely is economics this useful and pragmatic — a classic algorithm can potentially lead China’s college admission system out of trouble, solving the lose-lose situation currently faced by students and universities.”

And when you click on the article, you see Picture #2, which is a signal that the article has been censored and content deleted. College admission system in China has been fiercely debated and it is become quite a sensitive topic!

Transplantation interviews Dr Lloyd Ratner

It's gated, but here's a link.
Lloyd E. Ratner, MD, MPH: Professor of Surgery and Director of Renal & Pancreatic Transplantation at Columbia University, and Treasurer of the American Society of Transplant Surgeons

Some interesting bits:

"

Transplantation: Together with a team at Johns Hopkins, you have been the first to perform laparoscopic donor nephrectomies. Would you mind sharing aspects of your personal journey leading to this surgical success with us?

LR: When first introduced in 1995, laparoscopic live donor nephrectomy was a novel, radical, and controversial concept. However, there was an antecedent history of about 10 years, which I witnessed. When I was a general surgery resident at Long Island Jewish Hospital, the Chairman of Urology and pioneer of endourology, Dr. Arthur Smith, was the first person to propose a minimally invasive nephrectomy for disease. Smith’s idea was to place a percutaneous nephrostomy tube into the kidney and allow a tract to form. Then, when the tract was sufficiently fibrosed, he proposed that a Resect-o-scope (like that used for TURPs or TURBTs) be passed through the tract and the kidney be resected from the inside out. Jerry Weinberg, a GU resident who worked with Smith eventually published the first experimental series of minimally invasive nephrectomies in a large animal model. In that series, Weinberg and Smith thrombosed the renal vessels radiologically, then fragmented the kidney with ultrasound, and finally removed the fragments laparoscopically.

During my transplant fellowship at Washington University, Ralph Clayman, with the assistance of his fellow Lou Kavoussi, performed the first laparoscopic nephrectomy for disease. In that first case, Clayman had the renal vessels thrombosed by interventional radiology followed by a laparoscopic nephrectomy. This initial case took approximately 12 hours. However, within 1 year, Clayman had reduced the operating time to approximately 4 hours, no longer requiring radiologic thrombosis of the renal vessels.

As part of a faculty position that I took subsequently at Johns Hopkins University, I directed a satellite renal transplant program at Bayview Medical Center (formerly Baltimore City Hospital). Together with Lou Kavoussi, the newly recruited Chief of Urology, we decided to perform laparoscopic live donor nephrectomies. Our goal was to remove logistical and financial disincentives to living kidney donation by reducing pain, length of stay, and recovery while improving cosmesis. In the mean time, Clayman’s group demonstrated in a large animal model that laparoscopically procured kidneys could be successfully transplanted. Finally, after identifying the right patients, Kavoussi and I performed the first laparoscopic donor nephrectomy in February 1995. The donor went home on postoperative day 1 and was back to work as a welder within 2 weeks. The recipient was discharged after an uneventful hospitalization with a creatinine of 0.8 mg/dL. From there, dissemination and adoption of the laparoscopic donor nephrectomy operation was largely patient driven.

Back to Top

Transplantation: Donor nephrectomies were discussed controversially in the 1990s. Can you share early challenges of outcomes and responses of the public, health professionals, and patients with us?

LR: The first manuscript describing the initial case report and technical aspects of the operation was flat-out rejected. After a rebuttal, the manuscript was accepted without revisions. A large portion of the transplant community could not conceive how we could do this laparoscopic operation safely. When we presented our data, people angrily stood up and told us that we were “amoral and that we were going to kill people.” I had nightmares every night for 2 years. ... Transplantation: You have been a pioneer in paired kidney exchanges. How do you envision a further expansion? LR: I believe that kidney-paired donation has not yet reached its maximal potential. The most attention has been paid to optimizing allocation algorithms. However, logistical and financial issues remain important, under-addressed obstacles. These need to be dealt with before we can expect further expansion. Additionally, compatible pair participation in KPD is the most effective way to increase the desperately needed blood group O donors. However, this represents a major paradigm shift, where living donors are converted from a private resource to a shared or public resource. This will take years to gain widespread acceptance. Finally, I think that consideration should be given to using deceased donor organs to kick off living donor chains."

NBER Market Design meeting at Stanford, October 28-29 2016 (submission deadline August 1)

Here's the memo

From:  Michael Ostrovsky and Parag Pathak

To:  NBER Market Design Working Group

The National Bureau of Economic Research workshop on Market Design is

a forum to discuss new academic research related to the design of

market institutions, broadly defined. The next meeting will be held at

Stanford University on October 28-29, 2016.

We welcome new and interesting research, and are happy to see papers

from a variety of fields. Participants in the past meeting covered a

range of topics and methodological approaches.  Last year's program

can be viewed at:  http://conference.nber.org/confer/2015/MDf15/program.html

The conference does not publish proceedings or issue NBER working

papers - most of the presented papers are presumed to be published

later in journals.

There is no requirement to be an NBER-affiliated researcher to

participate.  Younger researchers are especially encouraged to submit

papers.

If you are interested in presenting a paper this year, please

upload a PDF version by August 1, 2016 to this link:

http://papers.nber.org/confsubmit/backend/cfp?id=MDf16

Preference will be given to papers for which at least a preliminary

draft is ready by the time of submission. Only authors of accepted

papers will be contacted.

For presenters in North America, the NBER will cover the travel and hotel

costs. For speakers from outside North America, while the NBER will not

be able to cover the airfare, it can provide support for hotel accommodation.

There are a limited number of spaces available for graduate students

to attend the conference, though we cannot cover their costs. Please

email ostrovsky@stanford.edu a short nominating paragraph.

Please forward this announcement to any potentially interested

scholars.  We look forward to hearing from you.