House flipping fraud in Florida

I received the following email from Eric Budish, the Chicago market designer:

"I came across a neat investigative journalism feature on a form of mortgage fraud called “house flipping” .

The newspaper reviewed 19mm Florida real-estate transactions, and found that 50,000 involved appreciation of 30%+ in less than 90 days. They investigate one fraud circle in depth, and have features on the local police, lenders, etc.

What makes the fraud tick is that the buyer can finance at the new price. So if A legitimately buys a house for 100, then immediately sells it to his buddy B for say 150, B can get a mortgage against the 150 (especially if his buddy C is a real-estate appraiser). Even if B makes a small down payment on the 150, together A and B have extracted 50 minus downpayment minus fees in cash from the transaction. B never intends to repay the 150, and B’s mortgage lender is severely under collateralized.

The reason I think this is all so interesting is that the fraud is only possible because houses are idiosyncratic, but not too idiosyncratic. If houses were perfect substitutes, then A, B and C couldn’t trick the mortgage lender about house values (50,000 flips is a lot, and likely an underestimate, but still less than 1% of transactions). If houses were substantially more idiosyncratic, then banks would never have gotten in the habit of financing 90%+ of the purchase price in the first place: in the event of foreclosure they’d have to worry about whether the right types of buyers would be in the market. Put differently, the housing market is not too thick, but not too thin."

Is fish-tossing repugnant?

Fishmongers in Seattle throw dead fish around the market, and it has apparently become not just a way of handling fish for sale, but a form of entertainment.

"Jeremy Ridgway, one of the managers at the market, said that he has done fish shows for the ministry of manpower in Singapore, for schoolchildren in Oklahoma and at countless other venues."

One of those other venues was a meeting in Seattle of the American Veterinary Medical Association, which decided to go ahead with "a plan to host a team-building program offered by the famous fish-throwers of Seattle's Pike Place Fish Market."

The organization People for the Ethical Treatment of Animals (PETA) finds this repugnant, and thinks such events should not be conducted.

Judge for yourself: Seattle's Pike Place fishmongers under fire .

Fly fishing

I spent last weekend in Jackson Hole Wyoming at a transplant conference. My friend Owen Phillips, the U. of Wyoming experimental economist who I first met when he visited Harvard in 2005, invited me to go fly fishing with him the next day. He hired a well recommended fishing guide, Mickey Brockman.

Fishing guides are licensed by the state, and work as subcontractors for businesses that hold outfitters' licenses (in Mickey's case, Westbank Anglers). So the arrangement is a bit like taxi drivers in cities where legal cabs require taxi medallions, except that fishing guides use their own equipment. Mickey's equipment includes a dory, which he rows facing forward, and a variety of fishing gear, including the barbless hooks that allow you to release the fish quickly after catching it. (He also packed lunch, which we ate looking up at the Grand Tetons, which sounds even better in French.)

Owen and I presented Mickey with a complicated task, since Owen is an expert angler with a lifetime of experience, and I was holding a fly reel for the first time. So, Mickey had to teach me the mechanics of casting, while keeping up a running list of likely targets for Owen to aim at.

It was an experience, and if you're in Jackson Hole and can't get Owen to take you, I certainly recommend Mickey.

(Thanks, Owen.)

To make the story long, we finished the day eating elk at Stiegler's (also recommended), which got us thinking about the market for elk: it turns out they are farm raised.

From Jackson Hole I flew to Stony Brook, Long Island, for a game theory conference. That tells you something about medicine and economics...

Regulatory capture in French electricity market

David Jolly reports in the NY Times: France Resists a Power-Monitoring Business

"Two weeks ago, the French Energy Regulatory Commission, the C.R.E., decided that Voltalis, a company that installs electricity management devices in homes and businesses and then manages their use, would have to, in effect, pay power producers for the power that it saves. "

Taxing a repugnant transaction, medical marijuana version

Steve Levitt's post When Taxpayers Welcome Taxes, is about a medical marijuana provider who lobbied to have his business taxed. Levitt speculates why:
"The real answer, I suspect, is that he is generating $19 million a year in revenues selling in a market (medical marijuana) that is barely legal. And DeAngelo probably suspects that taxation will increase the likelihood that his business remains legal, for two reasons. "

I'm inclined to agree. This reminds me of the similar case of legal brothels in Nevada.

Universities and price discrimination

According to Yale's president Richard Levin (interviewed in the WSJ), elite universities are more than ever able to charge different prices to different students:

"Four years of college at $200,000 strikes lots of people as indecent. "You're talking about sticker prices," Mr. Levin says. "The actual net price people pay, tuition minus financial aid, is basically not changed at all. If you look at the average net price for all of our students, it's actually declined over the last decade." That makes for an average cost of $18,000 per student per year now, compared to $19,000 a decade ago. Mr. Levin says the boom provoked "something of an arms race to give more financial aid," and opened private schools up to a larger -- and as a result stronger -- pool of students "that used to think that elite private schools were inaccessible to them." Yale may be "more affordable than ever," he says. But then Yale's president admits "this logic only applies to five schools" who offer "need blind" admissions."

The article ends by noting (in this time of recession and falling endowments) that universities are among our oldest self perpetuating institutions:
"For all the anxiety about the future for universities, it's hard to think of American institutions that have been as durable, surviving revolution, war and depression. At Yale, they like the refrain, "Older than the Republic." "

Gambling, in Russia

Gambling is sometimes regarded as a repugnant transaction, and sometimes as a tax on the willing. In Russia the pendulum has swung both ways. With the fall of communism, casinos became legal. Now they are becoming illegal, in all but some distant parts of Russia: Exiled by Russia: Casinos and Jobs

"The government is shutting down every last legal casino and slot-machine parlor across the land, under an antivice plan promoted by Vladimir V. Putin that just a few months ago was widely perceived as far-fetched. But the result will be hundreds of thousands of people thrown out of work.
And in a move that at times seems to have taken on almost farcical overtones, the Kremlin has offered the gambling industry only one option for survival: relocate to four regions in remote areas of Russia, as many as 4,000 miles from the capital. The potential marketing slogans — Come to the Las Vegas of Siberia! Have a Ball near the North Korean Border! — may not sound inviting, but that is in part what the government envisions. "

Credit markets, old and new: The Receivables Exchange

The WSJ reports CIT's Woes Prompt Surge In Activity At Receivables Exchange.

"The turmoil surrounding finance giant CIT Group Inc. (CIT) is driving a surge in new business for a New Orleans-based company that runs a market in receivables.
The Receivables Exchange, which lets small- and mid-sized companies auction their accounts receivable to buyers that include hedge funds and commercial banks, on Wednesday recorded its busiest day ever and is fielding a flood of calls from businesses searching for financing alternatives."

The Receivables Exchange is a new firm built a round the idea of disintermediating accounts receivable. Here's my earlier post.

Same sex marriage divides the Anglican Communion

Among American Episcopalians, and in the Anglican Communion worldwide, the issue of gay marriage has involved a contentious debate on what some regard as a repugnant transaction. That appears to be coming to a head.

Gay marriage approval sounds death knell for Anglican unity

"Bishops in the US dealt a death blow to hopes for unity in the worldwide Anglican Church when they approved in principle services for same-sex partnerships. The decision will finally split the Communion between Bible-based conservative evangelicals and liberal modernisers.
The bishops at the Episcopal General Convention voted by 104 to 30 to “collect and develop theological resources and liturgies” for blessing same-sex relationships, to be considered at the next convention in 2012.
The resolution notes the growing number of states that allow gay marriage, civil unions and domestic partnerships, and gives bishops in those regions discretion to provide a “generous pastoral response” to couples in local parishes. It was passed on Wednesday, hours after the Episcopal Church voted on Tuesday to allow the consecration of gay bishops. The motion passed by 99 to 45 among the bishops and by 72 per cent to 28 per cent among church deputies, made up of clergy and laity.
The decisions on gay consecrations and same-sex blessings end the uneasy truce agreed after the consecration of the openly gay Gene Robinson as Bishop of New Hampshire in 2003. "

Eugene Volokh on kidney transplantation and the law

Volokh writes:
"Should a Parent Be Required To Donate a Kidney to a Child Who Needs a Life-Saving Transplant?"
"A commenter asked this as a rhetorical question, suggesting, I think, that the answer must obviously be "no." But I don't see why, assuming that we're talking about a minor child of the parent. Parents are rightly seen as having duties to their children. These include the duties to work to support the child for 18 years (more controversially, that's extended even beyond 18 years in many child support decisions, but for now I set that aside); to care for the child; to bear a post-viability fetus, at least absent some substantial threat to the mother's life or health; and more.
Why wouldn't this also extend to the obligation to provide a life-saving transplant, at least when the risk is as low (not zero, but very low) as it is for kidney transplants? You bring a child into the world, and you incur major obligations to it; why shouldn't this be one of them?"

Volokh has earlier written, in the Harvard Law Review, an article titled
MEDICAL SELF-DEFENSE, PROHIBITED EXPERIMENTAL THERAPIES, AND PAYMENT FOR ORGANS.

He argues there that there may be a right to self defense (similar the right to use lethal force against an attacker) that would invalidate bans on experimental medical treatments, and bans on the sale of kidneys for transplant. That is, he argues that a person at risk of dying from kidney failure is being denied her right of self defense--medical self defense--when she is legally prevented from trying to buy a kidney.

Here's a relevant paragraph, which follows some other analogies:
"Olivia is dying of kidney failure. A kidney transplant would likely save her life, just as an abortion would save Alice’s, lethal self-defense might save Katherine’s, and an experimental treatment might save Ellen’s. But the federal ban on payment for organs sharply limits the availability of kidneys, so Olivia must wait years for a donated kidney; she faces a 20% chance of dying before she can get one. Barring compensation for goods or services makes them scarce. Alice and Ellen would be in extra danger if doctors were only allowed to perform abortions or experimental treatments for free. Katherine likely wouldn’t be able to defend herself with a gun or knife if weapons could only be donated. Likewise, Olivia’s ability to protect her life is undermined by the organ payment ban."

HT: Steve Leider

Organ tranplants and law in Japan

Japanese transplant law and practice are in flux. Recent news stories convey different parts of the story.

Japan’s Parliament Eases Rules on Organ Transplants, Death Law
July 13 (Bloomberg) -- Japan’s parliament approved legislation to ease restrictions on organ transplants in a move that backers say will save thousands of lives.
The upper house today approved a bill passed in the lower chamber last month that eliminates the need for a written will for organ donations. The new rules also accept a lack of brain function as a legal definition of death.
Doctors performed 11 heart transplants in Japan last year, according to the Japanese Circulation Society, compared with more than 2,000 in the U.S. The 12-year-old limitations lawmakers voted to end today had forced Japanese to travel overseas for transplants “as a last resort to survive,” according to a joint statement from medical groups including the Japan Society for Transplantation.
Each year, about 400 Japanese die because they aren’t able to get a heart transplant, while 2,000 pass away without a new liver, according to statistics presented to lawmakers last year by the society.

Travelling overseas--to the U.S.--for a heart transplant isn't an easy thing to arrange:An organ in U.S. won't be cheap

" Japanese who traveled to the United States to get new hearts were charged as much as about $1.63 million for the operation in 2008, or five times higher than in previous years, medical sources well-versed in organ transplants said Thursday.
...The average fee charged to 42 Japanese who went to the U.S. for heart transplants between 1998 and 2008 rose to about ¥80 million last year, compared with between ¥30 million and ¥70 million in the past, they said.
One child patient was charged as much as ¥160 million for the operation last year, while another was required to put down a deposit of ¥400 million in March, the sources said.
In the U.S., the only country that accepts Japanese for heart transplants, nationals are charged $300,000 on average in hospital and physician fees for the operation, they said, adding that the figure does not include pre- and posttreatment fees."

Japan lifts ban on children donating organs
"Japan lifted a ban Monday on organ donations from children, reversing a restriction that created such a dearth of small organs in the country that young patients were forced to seek transplants abroad.
The law will allow children, defined as those under 15, who are brain dead to donate their organs — a sea change in this country, where organ donating is sensitive because of Buddhist beliefs consider the body sacred and reject its desecration."

Kids under 15 can give organs
"The bill, known as Plan A, which won Lower House approval last month, allows brain-dead children under age 15 to be an organ donor with the family's consent and recognizes brain death as legal death.
google_protectAndRun("render_ads.js::google_render_ad", google_handleError, google_render_ad);
...The current transplant law, enacted 12 years ago, forbids brain-dead people under age 15 from becoming an organ donor. Supporters of Plan A had aimed to revise the law to increase the self-sufficiency of domestic organ availability, but some lawmakers argued brain death is too sensitive an issue and thus should not be universally recognized as actual death. " (HT: Jun Wako)

Related recent post: Children can't get organ donations in Japan, because they can't be deceased donors

New Key Opinion Leaders in Transplantation

I'll be spending this weekend in Jackson Hole, Wyoming, participating in an unfamiliar ritual. The Transplantation Society introduces what they call "New Key Opinion Leaders," surgeons and others with notable accomplishments. The ritual is that each new KOL is supposed to be introduced by an old KOL. Typically a young surgeon is introduced by an old one, etc.

Here is the program. There's something a little unusual about Section 6, devoted to developments in Living Donor Exchange: Like the actor who isn't a doctor but plays one on TV, I have been asked to introduce Mike Rees, the kidney exchange innovator who is the founder of the Alliance for Paired Donation.

He and I will talk about Market Design and Kidney Exchange.

Here's the program for the session we are a part of: I'm looking forward to learning the latest.

Session 6: Living Donor Exchange

Chairs: Alan Leichtman, MI, USA and Miran Epstein, UK

Presentation 6.1
KOL: Robert A. Montgomery, Johns Hopkins Hospital, MD, USA
New KOL: Dr. Dorry L. Segev, MD, USA
Title: Living Donor Exchange: Optimization and Application

Presentation 6.2
KOL: Gabriel Danovitch, University of California in Los Angeles, CA, USA
New KOL: Dr. Jeffrey Veale, CA, USA
Title: Challenges in the Development of Living Donor Exchange Programs

Presentation 6.3
KOL: Alvin E. Roth, Harvard Business School, MA, USA
New KOL: Dr. Michael Rees, University of Toledo Medical Center, OH, USA
Title: Market Design and Kidney Exchange

Presentation 6.4
KOL: Laura A. Siminoff, Virginia Commonwealth University, VA, USA
New KOL: Dr. Heather Marshall Traino, VA, USA
Title: Improving Rates of Living Donation among Minority Population

China outlaws shock treatment for uncontrollable urge to blog

Those of you reading this will be glad to know
China bans electric shock therapy for internet addicts

"China has outlawed the use of electric shock therapy to treat internet addiction, after a scandal at a hospital in the Northern province of Shandong."

"Internet addiction has become a growing problem in China, where officials believe as many as four million people spend more than six hours a day online.
Several clinics have sprung up, offering parents the chance to "cure" their children of the uncontrollable urge to blog..."

Surrogate motherhood continued: where did I come from?

As the market for surrogate wombs becomes more usual, and as the kids grow up, some new twists are added to the question "where did I come from?"

Here's a story that makes clear that surrogacy has been around for a while. It's one of the first articles I've seen that takes for granted that surrogacy is not a repugnant transaction, a point underlined by its placement on the front page of the NY Times:
No Stork Involved, but Mom and Dad Had Help .

The secondary ticket industry (scalping, to you)

The "secondary ticket industry" has a trade show, meeting tomorrow in Las Vegas, about which they say: "Ticket Summit is the leading trade show and conference in the secondary ticket industry."

These are the folks who sell tickets on the aftermarket (often after buying them on the primary market before others can), and who are often called by the more familiar, less charitable name of scalpers.

Grownup economists recognize that there's a place for secondary markets, but I wonder if a convention of ticket re-sellers doesn't have something of the flavor of a sex-workers' conference, in the sense that the participants are engaged in an industry that is often viewed as repugnant, and which is hemmed in by legal constraints that are sometimes ignored.

My attention was drawn to the conference by one of the speakers, Christian Hassold, who I met when he did an undergrad thesis on secondary ticket sales. The most interesting undergraduate theses are written by students with a real passion for what they are studying, and Christian, who is now off in the entrepreneurial world, has continued to write about ticket sales on his blog The Ticket Economist.

He always seemed like the kind of guy you would like to take in a game with, and it turned out that he's good at getting tickets too: his blog mixes reviews of news and scholarship with some practical advice: see e.g. Buying from a Scalper? Five Do’s and Don’ts, and Bargaining for Tickets on the Street.

TTE points to two thoughtful essays on scalping. One is by Trent Reznor of the band Nine Inch Nails: TR thoughts on ticket re-sellers / scalping (which also includes some interesting links).
Another is this Slate article by Mark Gimein:
Is Ticket Scalping All That Bad? Miley Cyrus' new crackdown on concert gouging just shows how complex the problem is.

Virginia Postrel on Kidney Exchange, and other (less distinguished) news coverage

Virginia Postrel's latest article in the Atlantic is about kidney exchange: ...With Functioning Kidneys for All.

She writes well (check out her Dynamist blog). In addition, as someone who gave one of her kidneys to a friend, she writes with a personal as well as a professional interest and authority. Her article mostly talks about kidney exchange as it is developing in the U.S., but also discusses possible donor compensation, and the international black market.

The article is well worth reading, and contains interesting links (including to this paper, in the New England Journal of Medicine, about a ten-transplant kidney chain, of which I'm happy to be among the coauthors).

It's a great thing to have kidney exchange covered in the press, because that allows more potential kidney exchange candidates to hear about the possibility, and it allows potential donors to know just how big an impact they could have. On this latter point, Postrel's article points out that
"Since the current transplant system extols altruism, one way to end the [long deceased donor waiting] list would be to find more altruists. With, say, 50,000 new living donors, deceased donation could easily pick up the slack. Again, the numbers aren’t that big. The Southern Baptist Convention includes 42,000 member churches; the United Methodist Church, whose Web site earlier this year featured the quote, “As United Methodists, we’re life savers,” counts more than 34,000 U.S. congregations. If each congregation produced just one new living donor, the waiting list would disappear. "

But press coverage is a bit puzzling. Not all of it is as careful and accurate and well reported as the Postrel article. (Which is not to say that even inaccurate coverage still isn't a good thing, for the way it spreads the news.) But I've been a little bemused at the way coverage sometimes simply follows press releases. Here's a story for those of you who find media an interesting subject.

Remember that NEJM article I mentioned above? It got a lot of press when it came out in March, maybe because the NEJM embargoes its articles until a day before publication, and that creates some buzz. That journal article reported a novel, non-simultaneous chain of transplants which begain in July 2007, in which 10 donors gave kidneys to 10 recipients, involving 6 transplant centers in 5 states. The innovative surgeon who was responsible for organizing that, Mike Rees, was the lead author of that article, and is the founder of the Alliance for Paired Donation. I thought the coverage was pretty accurate, perhaps because it was a news story that was about an article in a medical journal that the reporters could refer to.

But not all press releases are about peer-reviewed journal articles. This past week there have been a lot of stories about another remarkable accomplishment, another such chain, which accomplished 8 transplants, almost as many. It was organized out of Johns Hopkins, one of the leading hospitals doing kidney exchange in the U.S. It's not surprising that Hopkins surgeons should be among those pushing this kind of innovation forward; two of them who were involved in this new chain were among the coauthors of the NEJM article. And, while the accomplishment, so soon after the NEJM article, is noteworthy, the news coverage is in some ways as remarkable.

Here's the lead paragraph of the first of two stories about it in the Washington Post: "A Maryland transplant surgeon says he and doctors at four hospitals in four states have transplanted eight kidneys and he considers that the largest series of multi-kidney donations ever. "

The second Post story, the next day, repeats that claim (under the headline Successful Eight-Way Chain of Surgeries Involving Johns Hopkins Is a First:
"The first-of-its-kind surgery -- believed to be the largest chain of donations in history -- involved hospitals in four cities..."

The Post isn't alone. A few days later, after a chance to do some more in depth reporting and fact checking, the (July 11) CBS evening news reports on how one of the patients experienced "...a surprise rescue - the chance to be a part of the biggest multi-city, multi-patient domino kidney exchange ever."

There are three surprises for those interested in news reporting. First, the surgeon quoted above in the first Post story is one of the coauthors of the NEJM article about the earlier, larger chain, so that quote was an odd slip of the tongue (or, maybe he was misquoted, or maybe that's what's required to get kidney exchange the press coverage it deserves). Second, the AP and Post and CBS evening news reporters weren't aware of the earlier chain despite all the press coverage it received, including this (March 12) story (also) on the CBS Evening News about the earlier chain: A Transplant Surgeon Matches 10 Donors With Recipients In The Longest Chain In History .

But the third surprise is that there's a really great human interest story about this latest, Hopkins led chain. It's not just about the surgeons, it's also about the donors. One of the donors was a Hopkins hospital administrator, who had seen first hand the good that kidney donors can do, and wanted to help a friend, but turned out to be incompatible with that friend. That is just the kind of situation that kidney exchange was invented to help. (How do I know this? I read the Hopkins press release, which was headlined
Johns Hopkins leads first 16-patient, multicenter 'domino donor' kidney transplant.

The subheadline was "Johns Hopkins vice president 1 of the donors".

So, hats off to the Hopkins surgeons and their talented colleagues at Barnes-Jewish Hospital in St. Louis, INTEGRIS Baptist Medical Center in Oklahoma City and Henry Ford Hospital in Detroit. And a deep bow to the donors. As for the reporters, yours is a noble craft too; kidney exchange is complicated, keep trying.

(And thank you, Virginia, for your thoughtful story in the Atlantic.)

Dynasties in college legacy admissions

Along with other kinds of affirmative action, colleges are likely to give preferential status to applicants whose parents and other close relatives have attended. The idea seems to be that having a relationship with a family increases donations. (For example, imagine that one of your descendents will become a billionaire and look for a big philanthropic outlet. If everyone in the family has gone to Family U., maybe this urge will turn into a new campus building, whereas if everyone in your family went to a different college, maybe this philanthropy would go to the poor...)

This intuition receives some support in a recent paper, by authors at Stanford and Princeton, who study an anonymous but selective university.

Family Bonding with Universities by Jonathan Meer, Stanford University, and Harvey S. Rosen, Princeton University
From the abstract:
"One justification offered for legacy admissions policies at universities is that that they bind entire families to the university. Proponents maintain that these policies have a number of benefits, including increased donations from members of these families. We use a rich set of data from an anonymous selective research institution to investigate which types of family members have the most important effect upon donative behavior. We find that the effects of attendance by members of the younger generation (children, children-in-law, nieces and nephews) are greater than the effects of attendance by older generations (parents, parents-in-law, aunts and uncles). "

Indirect affirmative action in Texas college admissions

When the state of Texas ruled out race as an explicit criterion in college admissions, it adopted a rule that any Texas students in the top 10% of their high school class would be given automatic admission to the state university of their choice. Because Texas high schools are collectively diverse, that guaranteed a diverse freshman class. But it proved to be a very rigid way of matching students to schools, and the policy is about to end: Texas Vote Curbs a College Admission Guarantee Meant to Bolster Diversity.

"The University of Texas, Austin, a top-ranked institution, had sought changes to the program for years because it allowed admissions officials almost no latitude in putting together a class and endangered some important but less popular departments, like music. Last fall, 81 percent of the members of the incoming class were admitted under the 10 percent rule.
Suburban parents with students at schools with rigorous standards also complained that the law discriminated against their children, since it was harder to make the cut at such schools than at smaller, rural and some urban schools. "
...
"The law given final approval by the Senate on Saturday caps the number of students let in under the rule at three-quarters of the class, giving university officials discretion over the makeup of the last quarter. Sponsors of the bill had wanted a lower cap — 50 percent — but their colleagues in the House would go no lower.
Supporters said it was not a moment too soon. The state has only three top-rated universities — the University of Texas at Austin, Texas A&M University and Rice University — and it had been projected that the entire incoming class at the Austin campus would be made up of top-10-percent students by 2013."
...
"Bill Powers, the president of the University of Texas, Austin, said that, left untouched, the previous law would have forced the university, in the long run, to accept more students than it had the capacity to teach. What is more, the automatically admitted students tended to opt for popular majors, and it had become a struggle to find talented students for programs like architecture, engineering, music, art and geosciences, he said.
While still restrictive, Mr. Powers said, the new law would give admissions officers more flexibility to reach down into high school classes for students who may be brilliant in some regards, like in music, but not in the top 10 percent.
“Judging people on one criterion is not the way to do admissions policy,” he said. “No one else in the country does it.” "

Market for doctors: work rules for surgical residents

Surgical residents are young doctors in training, and there is an ongoing conflict playing out between perceptions of their training needs and patient well being and safety. The Boston Globe reports: MGH cited on surgeons' overload, Trainees' hours exceed safety rule; Hospital says it has fixed problem.

"Junior surgeons at Massachusetts General Hospital have been working too many hours, in violation of patient safety rules, according to a national accrediting organization that is threatening to put the hospital’s surgery training program on probation.
The Accreditation Council for Graduate Medical Education cited the hospital because a significant number of its surgeons in training, known as residents, were exceeding hour limits and working seven days straight. The organization believes these workloads contribute to fatigue-related mistakes, and has given the hospital until Aug. 15 to fix the problem."
...
" But five years after the hour restrictions were adopted, Warshaw and other surgeons said frustration is building at the nation’s teaching hospitals, because residents believe the rules interfere with their work and ultimately may harm, rather than help, patients.
The council acknowledged the tension in its April 13 letter to Mass. General, in which reviewers wrote: “The greatest challenge . . . has been getting the culture of the residents to change.’’

..." Dr. Thomas Nasca, head of the accreditation council, lamented in a letter to training programs earlier this year that residents are placed in an “ethical quandary’’ because “we compel them to lie [about their hours] if they do the right thing for their patients.’’
Still, the council is stepping up enforcement, and 5 percent to 10 percent of surgery programs were cited last year, including many of the country’s most prestigious training programs. Beth Israel Deaconess Medical Center was threatened with probation last year, but has since reined in residents’ workloads."
...
"Surgeons are adamantly opposed to tougher limits, saying there is little evidence that sending residents home after a prescribed work shift has improved patient care and that the rules actually may be hurting residents’ education. General surgery residents need to complete at least 750 cases during their five-year training so they are ready to operate on their own once they finish.
Any change would also have financial implications for teaching hospitals, where the nation’s 107,000 residents provide the majority of care."

I haven't done any work related to residents' work rules, but I've done a lot of work related to how residents get hired....

Contraception: reversal of the direction of repugnance?

What is viewed as a repugnant transaction can change over time, and even reverse direction entirely. An example is that laws in the US have gone from prohibiting contraception to prohibiting pharmacists from declining to provide contraception.

Repugnance to contraception is far older than effective contraception, with roots sometimes attributed to the Bible*. In the United States, the Comstock Law of 1873 made it a Federal crime to sell or distribute contraceptives or information about them, and many states followed with bans of their own. These were not finally overturned until the Supreme Court, in Griswold v. Connecticut (1965), overturned Connecticut's ban on contraception, and found that the Connecticut law violated a fundamental right of privacy. (Here's a summary of the case.)

More recently, a number of states have passed laws requiring hospitals and health care providers to inform rape victims of the availability of "morning after" contraception, and sometimes requiring pharmacies to stock it and dispense it: 50 State Summary of Emergency Contraception Laws.

This in turn has raised the question of whether health care providers and pharmacists who find contraception repugnant can or should be compelled to provide information about it. One of the final acts of the Bush administration was to issue regulations allowing pharmacists and doctors to decline to provide contraception or information about it if they found it morally repugnant:

Bush's Last-Minute 'Conscience' Rules Cause Furor
"Health care workers, hospitals and even entire insurance companies could decline to perform, refer or pay for abortion or any other health care practice that violates a "religious belief or moral conviction" under new rules issued by the outgoing Bush administration.
"This rule protects the right of medical providers to care for their patients in accord with their conscience," said Health and Human Services Secretary Michael Leavitt.
But opponents of the rule, now set to take effect Jan. 19, say it could threaten patients' health. "This is a very wide, broadly written regulation that upsets what has been a carefully established balance between respecting the religious views of providers, while also making sure that we're guaranteeing patients access to health care," said Cecile Richards, president of the Planned Parenthood Federation of America. "
(See the rule here, called (confusingly) Ensuring That Department of Health and Human Services Funds Do Not Support Coercive or Discriminatory Policies or Practices in Violation of Federal Law)

Subsequently, these conscience clauses have come under attack:
Obama administration may rescind 'conscience rule'

"February 27, 2009
WASHINGTON — Taking another step into the abortion debate, the Obama administration Friday will move to rescind a controversial rule that allows health-care workers to deny abortion counseling or other family-planning services if doing so would violate their moral beliefs, according to administration officials.The rollback of the "conscience rule" comes just two months after the Bush administration announced it last year in one of its final policy initiatives.The new administration's action seems certain to stoke ideological battles between supporters and opponents of abortion rights over the responsibilities of doctors, nurses and other medical workers to their patients.Seven states, including California, Illinois and Connecticut, as well as two family planning groups, have filed suits challenging the Bush rule, arguing it sacrifices the health of patients to religious beliefs of medical providers."

(See the proposed rule here: Rescission of the Regulation Entitled ``Ensuring That Department of Health and Human Services Funds Do Not Support Coercive or Discriminatory Policies or Practices in Violation of Federal Law''; Proposal)

So it appears that we have come full circle in a certain sense, and now have laws that prohibit the withholding of information about contraception (and contraception itself), where once we had laws forbidding the dissemination of contraception and information about it.

(No wonder the study of repugnant transactions doesn't lend itself to simple theories about what is and is not repugnant...)

*The biblical story that is sometimes interpreted as indicating repugnance to contraception is the story of Onan in Genesis 38. However that story is complex, and it is far from clear to me that contraception is the issue.