Alex Chan draws my attention to this paper on airline transport of kidneys for transplant:
38 Pages Posted: 6 May 2020
Nearly 5,000 patients die every year while waiting for kidney transplants, and an estimated 18% of procured kidneys are discarded. Such a polarized co-existence of dire scarcity and massive wastefulness has been mainly driven by insufficient pooling of cadaveric kidneys across geographic regions. Although numerous policy initiatives are aimed at broadening organ pooling, they rarely account for a key friction — efficient airline transportation, ideally direct flights, is necessary for long-distance sharing due to the time-sensitive nature of kidney transplantation. Conceivably, transplant centers may be reluctant to accept kidney offers from far-off locations without direct flights. In this paper, we estimate the effect of the introduction of new airline routes on broader kidney sharing. By merging the U.S. airline transportation and kidney transplantation datasets, we create a unique sample tracking (1) the evolution of airline routes connecting all the U.S. airports and (2) kidney transplants between donors and recipients connected by these airports. We estimate the introduction of a new airline route increases the number of shared kidneys by 7.3%. We also find a net increase in the total number of kidney transplants with the introduction of new routes. Notably, the post-transplant survival rate remains largely unchanged, though average travel distance increases after the introduction of new airline routes. Our results are robust to alternative empirical specifications and have important implications for improving access to the U.S. organ transplantation system.
Who better to talk about forbidden markets than Kim Krawiec? Her new podcast is off to a great start.
Kimberly D Krawiec
"A podcast about things we aren’t supposed to trade . . . But do anyway"
The Alliance for Paired Kidney Donation has announced the details of its Donor Protection Program
Peter Cramton* is an astute observer of electricity markets. Here's his op-ed in the San Diego Union-Tribune:
Here's the first paragraph:
"Rolling outages may appear to be a symptom of climate change. Extreme heat and intermittent renewables certainly challenge electricity markets. But these challenges can be met with good market design. The California market has flaws that make California electricity more expensive and less reliable than it should be. Fixing these flaws should be a priority."
and here's the final paragraph:
"California illustrates that good intentions do not necessarily produce good policy. Good policy is designed from what we know about markets and human behavior. Good policy is the only way to provide reliable electricity at least cost"
*"Cramton is a professor of economics at the University of Cologne and the University of Maryland, is an independent board member of ERCOT, the electricity operator in Texas. The views here are his own and not those of ERCOT or ERCOT’s board."
Here's an essay from the WSJ, adapted from a forthcoming book with an evocative title, “Who Gets In and Why, by Jeffrey Selingo. The subtitle is A Year Inside College Admissions
The Secrets of Elite College Admissions: In the final ‘shaping’ of an incoming class, academic standards give way to other, more ambiguous factors by By Jeffrey Selingo, Aug. 28, 2020
"The year I was inside Emory University’s admissions office, the school received a record 30,000 applications for fewer than 1,400 spots in its incoming class. In early March, just weeks before official notices were scheduled to go out, the statistical models used by Emory to predict enrollment indicated that too many applicants had been chosen to receive acceptances. In the span of days, teams of admissions officers covering five geographical areas had to shift 1,000 applications from the thin “admit” stack to the much larger “deny” or “wait list” piles.
Here's a paper that analyses the immediate acceptance ("Boston") algorithm that was in use in China's college admissions system in many provinces, in 2003.
by BinzhenWu and Xiaohan Zhong
Games and Economic Behavior, Volume 123, September 2020, Pages 1-21, https://doi.org/10.1016/j.geb.2020.05.007
Abstract: We examine matching inequality in students' matching outcomes for the Boston Mechanism in a large matching system, by measuring the degree of mismatch for each student. We link a student's mismatch with her reporting behavior of the first choice on her preference list to explore the reasons for matching inequality. Using administrative data from college admissions in China, we find significant gender differences, rural-urban gaps, and ethnic gaps in mismatching and first-choice behavior. These demographic differences exhibit various patterns and may be explained by risk aversion, information disadvantage, and minority-preferential admissions policies, respectively.
Two papers have made me think about the power of econometric methods applied to studies of medical issues related to matching deceased donor kidneys to patients.
I recently heard Chuck Manski give a seminar on this paper published last year in PNAS:
One thing I took away from it is that proportional hazard (Cox) models are very popular in the medical literature, but they assume that effects (e.g. rejection of a graft) are proportional to time, and there are immunological processes that don't in fact have a constant hazard rate, but build up over time, so that isn't a good model for those things.
Predicting kidney transplant outcomes with partial knowledge of HLA mismatch
Charles F. Manski, Anat R. Tambur, and Michael Gmeiner, PNAS October 8, 2019 116 (41) 20339-20345
"Abstract: We consider prediction of graft survival when a kidney from a deceased donor is transplanted into a recipient, with a focus on the variation of survival with degree of human leukocyte antigen (HLA) mismatch. Previous studies have used data from the Scientific Registry of Transplant Recipients (SRTR) to predict survival conditional on partial characterization of HLA mismatch. Whereas earlier studies assumed proportional hazards models, we used nonparametric regression methods. These do not make the unrealistic assumption that relative risks are invariant as a function of time since transplant, and hence should be more accurate. To refine the predictions possible with partial knowledge of HLA mismatch, it has been suggested that HaploStats statistics on the frequencies of haplotypes within specified ethnic/national populations be used to impute complete HLA types. We counsel against this, showing that it cannot improve predictions on average and sometimes yields suboptimal transplant decisions. We show that the HaploStats frequency statistics are nevertheless useful when combined appropriately with the SRTR data. Analysis of the ecological inference problem shows that informative bounds on graft survival probabilities conditional on refined HLA typing are achievable by combining SRTR and HaploStats data with immunological knowledge of the relative effects of mismatch at different HLA loci."
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And here's a recent working paper that says that if we want to maximize life years added by transplant, more organs should go more quickly to healthier patients:
Choices and Outcomes in Assignment Mechanisms: The Allocation of Deceased Donor Kidneys
Nikhil Agarwal, Charles Hodgson, Paulo Somaini, August 17, 2020
Profile of Amy N. Finkelstein by Jennifer Viegas
"“It is a very exciting time to be an economist,” says Amy Finkelstein, a professor of economics at the Massachusetts Institute of Technology (MIT) who was elected to the National Academy of Sciences in 2018. “Economics has become a rigorous science, combining theory and data to better understand how the world works and how to improve it.” Focusing on the healthcare sector in the United States, Finkelstein integrates economic models, empirical methods, and data to find solutions for problems facing health insurance markets and healthcare delivery systems. Her research carries implications for healthcare policy. Finkelstein’s Inaugural Article (1) reports that a nationwide Medicare reform influenced the treatment of patients who were covered by other kinds of health insurance. The findings suggest that such broad effects should be taken into account when formulating future healthcare policies.
"Three Generations of Women with Doctorates
"Finkelstein was born in New York City in 1973 to biologist parents, who both earned doctorates at The Rockefeller University. In 1940, her mother immigrated to the United States from Poland, where her maternal grandmother had received a doctorate in comparative literature at the University of Warsaw. Finkelstein says, “It is remarkable that a Jewish woman in the 1920s was able to earn a doctorate in Eastern Europe.” The Finkelstein family papers documenting their lives are archived at the US Holocaust Memorial Museum in Washington, DC."
Two days ago I received a note of encouragement by email from Övül Sezer, a former student in my Harvard class on experimental economics, which she spoke about while being celebrated by Poets and Quants.
BY: NATHAN ALLEN
Here's that Q&A from her interview:
"Professor I most admire and why:
"There have been so many professors who inspired me and influenced me in several ways and I am so grateful for all the things I learned from them. But one class that I took in college changed the course of my path. Back in college, I was studying math, spending a lot of time on equations and mathematical proofs. In a very serendipitous way, I ended up trying to take a graduate-level economics class, called “Experimental Economics” because I wanted to take a class where I didn’t have to do any weekly “problem set” but it still counted as credit. To be able to take the class as an undergrad, I needed the professor’s permission. The professor teaching the course happened to be Al Roth, who allowed me to the class and introduced me to the love of experiments. Through him, I started learning a lot about experiments, and how we can take our very own observations about life and test them. This was the first time I fell in love with experimental science, and this is where I am today. In addition to being a great professor, Al Roth is also a very thoughtful and a kind person. I feel tremendously grateful to have taken that class."
The NY Times has the story:
Mothers, Babies Stranded in Ukraine Surrogacy Industry--Virus travel bans are wreaking havoc on surrogacy agencies that help same-sex couples build families By Maria Varenikova
"In one of the more bizarre consequences of coronavirus travel restrictions, biological parents, babies and surrogate mothers have become scattered and sometimes stranded in multiple countries for months this year.
"Ukraine, with its relatively permissive reproductive health laws and an abundance of willing mothers among a poor population, is a hub of the international business, executives in the industry and women’s rights advocates say.
"But Ukrainian law bans surrogacy for same-sex couples or for clients who wish to select the sex of the child. In response, a branch of the Ukrainian industry began moving women to other jurisdictions for impregnation and birth, often to legal gray zones like the largely unrecognized, Turkish-backed, splinter state of Northern Cyprus.
...
"The women travel to have an embryo implanted, return to Ukraine for seven months of pregnancy, then travel again to give birth.
"Virus travel restrictions drew attention earlier this year for blocking heterosexual parents from retrieving their babies inside Ukraine. At one point, 79 babies were stacked up in Kyiv, cared for by nurses, in cribs at a hotel.
...
"It is a very common illegal business in such countries as Northern Cyprus, Transnistria, Abkhazia and other unrecognized statelets, said Sergii Antonov, a lawyer and authority on reproductive law in Ukraine.
"In Northern Cyprus, the Ukrainian mothers give birth without a legal surrogacy contract. Instead, they renounce custody after birth, which allows the genetic parents to adopt the children. It is a legal process that can stretch for several weeks.
"In February and March, 14 Ukrainian mothers, fearful of being stranded by virus travel bans, left Northern Cyprus after giving birth but before completing the transfer to the genetic parents, leaving behind a crop of babies in legal limbo.
Suppose that schools have an intrinsic quality that would affect the preferences of all students if they knew it, but some students are better informed than others. Then, for uninformed students, there can be a kind of winner's curse associated with being accepted to a school: the fact that it had seats available suggests that it might not be high quality. Kloosterman and Troyan propose mitigating this by giving each student a secure school for which he/she has high enough priority to be admitted regardless of others' preferences: " a secure school is one with enough seats for j and every student who has higher priority than j. " When all students have the same ordinal preferences at every state of the world, then the deferred acceptance algorithm with students proposing continues to make it a dominant strategy for informed students to state their true preferences, and there is an equilibrium that avoids the winners curse in which each uninformed student lists their secure school as their first choice.
School choice with asymmetric information: Priority design and the curse of acceptance
by Andrew Kloosterman and Peter Troyan|
Webinar on the new
Ph.D. Job Market, hosted by the AEA ad hoc Committee on the Job Market |
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August 25, 2020 *********** The communications page includes the following:
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Some rules seem clear: anyone born in the U.S. is an American citizen, as is any child of an American parent. But in these partisan times, even clear rules are subject to argument, and questionable distinctions can be brought up to litigate old repugnances.
ABC has the story:
State Dept. fighting to deny US citizenship to gay couple's child: A federal judge ruled in June that the agency had to grant citizenship. By Conor Finnegan
"The State Department is appealing a federal judge's decision that it must recognize the U.S. citizenship of a young girl born via surrogate to a gay couple -- prolonging one of many legal fights over its controversial policy that was deemed unconstitutional in June.
"Roee Kiviti and Adiel Kiviti of Chevy Chase, Maryland, are legally married and both U.S. citizens. Their daughter Kessem was born in Canada via a surrogate, so the State Department has argued in federal court that she is "born out of wedlock" and not entitled to birthright citizenship.
...
"The Kiviti's are not the only family in a legal battle with the department on this issue.
"According to Immigration Equality, Derek Mize and Jonathan Gregg, a gay couple in Atlanta, are also awaiting a ruling by a federal judge over their daughter Simone's citizenship.
"The group also represents Allison Stefania and Lucas Zaccari -- a lesbian couple fighting for their daughter's citizenship. She was born to Lucas, an Italian citizen, via in vitro fertilization, so the State Department ruled she was born out of wedlock to a non-U.S. citizen, disregarding Allison's U.S. citizenship and their marriage. The couple is also awaiting a decision."
HT: Kim Krawiec
Here's a brief history of the Canadian medical residency match:
Gallinger J, Ouellette M, Peters E, Turriff L. CaRMS at 50: Making the match for medical education [Les 50 ans du CaRMS: jumelage pour l’éducation médicale]. Can Med Educ J. 2020;11(3):e133-e140. Published 2020 Jul 15. doi:10.36834/cmej.69786
Abstract: "Entry into postgraduate medical training in Canada is facilitated through a national application and matching system which establishes matches between applicants and training programs based on each party’s stated preferences.
"Health human resource planning in Canada involves many factors, influences, and decisions. The complexity of the system is due, in part, to the fact that much of the decision making is dispersed among provincial, territorial, regional, and federal jurisdictions, making a collaborative national approach a challenge. The national postgraduate application and matching system is one of the few aspects of the health human resources continuum that is truly pan-Canadian.
"This article examines the evolution of the application and matching system over the past half century, the values that underpin it, and CaRMS' role in the process."
I anticipate that we will be reading more in the future about kidney exchange chains started by a deceased donor kidney. In the meantime, here are two recent papers:
From the American Journal of Transplantation:
Deceased donors as non‐directed donors in kidney paired donation
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi:10.1111/ajt.16268
As proof of concept, we simulate a revised kidney allocation system that includes deceased donor (DD) kidneys as chain‐initiating kidneys (DD‐CIK) in a kidney paired donation pool (KPDP), and estimate potential increases in number of transplants. We consider chains of length 2 in which the DD‐CIK gives to a candidate in the KPDP, and that candidate’s incompatible donor donates to the deceased donor (DD) waitlist. In simulations, we vary initial pool size, arrival rates of candidate/donor pairs and (living) non‐directed donors (NDDs), and delay time from entry to the KPDP until a candidate is eligible to receive a DD‐CIK. Using data on candidate/donor pairs and NDDs from the Alliance for Paired Kidney Donation, and the actual DDs from the Scientific Registry of Transplant Recipients (SRTR) data, simulations extend over two years. With an initial pool of 400, respective candidate and NDD arrival rates of two per day and 3 per month, and delay times for access to DD‐CIK of 6 months or less, including DD‐CIKs increases the number of transplants by at least 447 over two years, and greatly reduces waiting times of KPDP candidates. Potential effects on waitlist candidates are discussed as are policy and ethical issues.
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And from Transplant International:
Lucrezia Furian Antonio Nicolò Caterina Di Bella Massimo Cardillo Emanuele Cozzi Paolo Rigotti
First published: 09 August 2020 https://doi.org/10.1111/tri.13712
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi:10.1111/tri.13712
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Abstract: "Kidney paired donation (KPD) is a valuable way to overcome immunological incompatibility in the context of living donation, and several strategies have been implemented to boost its development. In this article, we reviewed the current state of the art in this field, with a particular focus on advanced KPD strategies, including the most recent idea of initiating living donor (LD) transplantation chains with a deceased‐donor (DD) kidney, first applied successfully in 2018. Since then, Italy has been running a national program in which a chain‐initiating kidney is selected from a DD pool and allocated to a recipient with an incompatible LD, and the LD’s kidney is transplanted into a patient on the waiting list (WL).
"At this stage, since the ethical and logistic issues have been managed appropriately, KPD starting with a DD has proved to be a feasible strategy. It enables transplants in recipients of incompatible pairs without the need for desensitizing and also benefits patients on the WL who are allocated chain‐ending kidneys from LDs (prioritizing sensitized patients and those on the WL for longer)."
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Previous posts:
Given the heated discussions and intense repugnance that often accompany questions concerning compensation for organs, you might be surprised to find an American Organ Clearing House that has a section devoted to Organs for Sale.
The site appears to get a lot of support from religious institutions
Needless to say, although money plays an important role, this kind of commerce still involves a good deal of matching.
"There is more to placing a pipe organ than checking physical dimensions. We will work with you to choose an instrument appropriate for the acoustics, liturgy, and other activities of your church."
Defining human life is hard, but defining death used to be easy: no heartbeat or respiration. That changed with modern technology--e.g. a patient in the midst of a heart transplant may have no heart, but may have a long life ahead.
And of course, if we are who we think we are, it is brain death that matters most: loss of heartbeat and respiration kills our brains, our selves. But defining brain death is not so easy, especially for a patient on a ventilator who may have a pulse and be visibly breathing.
A recent discussion in JAMA seeks to standardize definitions of brain death, which are of more than academic interest, because deceased donor organ transplantation mostly goes on after brain death but while the organs are still receiving oxygen from (artificially maintained) heartbeat and respiration.
Greer DM, Shemie SD, Lewis A, et al. Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project. JAMA. Published online August 03, 2020. doi:10.1001/jama.2020.11586
"The concepts of life and death have always been complicated, but ever more so as medical and technological advances continue to extend the limits to saving life and prolonging physiological function. For previous generations, cardiorespiratory death was the sole clinical definition of death, often without any standard criteria, leading to the risk of misdiagnosis. As resuscitation techniques and mechanical ventilation developed, a new definition of death was needed.
"The idea of brain death/death by neurologic criteria (BD/DNC) was first recognized in 1959 as “coma depassé”1 and subsequently described as “brain death” with the first published clinical definition in 1968, commonly known as the Harvard Brain Death Criteria.2 Since then, many other guidelines and protocols have been published, adopted, and revised throughout the world with general acceptance of the concept of BD/DNC among medical groups, major religions, and governments.3
'However, there continues to be confusion and dilemmas that arise regarding BD/DNC. The wide variance in practice reflects this confusion and numerous other challenges. Inconsistencies in concept, criteria, practice, and documentation exist internationally and within countries.3,4 Difficulties in conducting randomized clinical trials and large-scale studies on BD/DNC have resulted in a lack of robust data from which to develop evidence-based recommendations. Challenges to the validity of BD/DNC continue to promote controversy. These factors initiated this project to harmonize practice and improve the rigor of BD/DNC determination."
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Here's an earlier take, with a more philosophical slant:
Sarbey, Ben. “Definitions of death: brain death and what matters in a person.” Journal of law and the biosciences vol. 3,3 743-752. 20 Nov. 2016, doi:10.1093/jlb/lsw054
Here are the concluding sentences:
"The neurological criteria for death represent a remarkable advance in our ways of responding to changes in death and dying. However, as medical technology and life extension techniques develop, we must also develop increasingly precise notions of what aspects of our neurological lives are the most important. While the current total brain death standard currently suffices in the vast majority of cases, the standard does not fully line up with what we value in persons. Should we retain the current brain death standard despite its mismatch with our values and despite negative consequences in determining death and in organ donation? Technological advances seem as if they will inevitably make this question inescapable."
Canada has a different political culture than the U.S., and attitudes towards drug abuse are one place in which that shows through clearly.
The Washington Post has the story--drug overdoses have risen during the pandemic:
By Amanda Coletta
"a growing chorus, including top public health officials, the premier of British Columbia and the nation’s police chiefs, is calling on Prime Minister Justin Trudeau to decriminalize the possession of illicit drugs for personal use.
...
"British Columbia, the epicenter of the crisis, recorded its deadliest month in May — and then surpassed it in June. Nearly four times as many people in the province have died of a suspected overdose this year as have died of the coronavirus.
...
"Border closures have disrupted drug markets, making the street supply more unpredictable and toxic. Authorities have urged people to stay at home, pushing some to use drugs alone, without anyone nearby to help when dosages go wrong. Some supervised consumption sites and treatment centers have reduced operations, cutting people off from support networks.
...
"For the pandemic, officials have marshaled extraordinary financial resources and provided daily updates. Lawmakers have stood side-by-side with public health officials, largely deferring to their advice.
"But they’ve not always backed the remedies those same officials have offered to fight overdoses.
...
"“The most important thing we can do is make it okay for people to talk about their drug use and to seek assistance for it,” Henry said. “Labeling somebody a criminal is one of those major barriers that keeps people hiding and afraid and ashamed.”
...
"That followed an extraordinary endorsement from the Canadian Association of Chiefs of Police, which said police resources would be better spent on cracking down on drug trafficking, illegal production and importation than on pursuing users.
"The chiefs said that arresting people for simple possession has been “ineffective” and that police should instead direct users to social services and health care, which could reduce recidivism and ancillary crimes."
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