Here's a collection of events in which people interested in kidney transplantation can participate. I'll give a short talk on kidney exchange in the May 7 event. There are also events tomorrow, April 23, and June 12, as well as ways to help particular transplant candidates who you know.
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Here's the story in the WSJ:
‘No Father Wants to Sell His Son’s Kidney.’ Afghans Pushed to Desperate Measures to Survive. Afghanistan’s deepening humanitarian crisis fuels booming organ trade By Sune Engel Rasmussen
"For those willing, an illegal but barely hidden business in the western city of Herat offers a reprieve from the downward spiral. Two hospitals in town offer kidney transplants that attract Afghans from across the country, performing 15-20 surgeries a month. Officials turn a blind eye. Buying and selling organs is illegal, as in most other countries. But scores of Afghans have come here to make the trade.
...
"Finding a seller of a kidney isn’t hard. Notes advertising private organ sales are plastered on walls and lampposts in Herat and other cities. Kidney brokers distribute business cards offering to put buyers in touch with sellers.
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"Mr. Mohammad and his wife decided that unless they sold a child, they would have to sell an organ. Both of them were unsuited, as Mr. Mohammad had kidney stones and his wife had diabetes. Their oldest son made up to three dollars a day collecting plastic for recycling, so was spared. The choice fell on Khalil Ahmad, their second son.
...
"Ghulam Hossein came to Herat from the eastern Nangarhar province after a doctor told him his kidneys were failing. It took him 25 days to find a seller.
“I have no words to thank this man,” Mr. Hossein said about the donor, who needed money after being forced to sell his small grocery store, and who visited Mr. Hossein after the operation.
“I know he was poor but it takes huge courage and sacrifice to sell your kidney,” Mr. Hossein said. “I am more concerned now about his health than my own.”
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Here's an earlier story from the Guardian:
I’ve already sold my daughters; now, my kidney’: winter in Afghanistan’s slums. Crushing poverty is forcing starving displaced people to make desperate choices by M Mursal and Zahra Nader, 23 Jan 2022
“I was forced to sell two of my daughters, an eight-by and six-year-old,” she says. Rahmati says she sold her daughters a few months ago for 100,000 afghani each (roughly £700), to families she doesn’t know. Her daughters will stay with her until they reach puberty and then be handed over to strangers.
"It is not uncommon in Afghanistan to arrange the sale of a daughter into a future marriage but raise her at home until it is time for her to leave. However, as the country’s economic crisis deepens, families are reporting that they are handing children over at an increasingly young age because they cannot afford to feed them.
"Yet, selling her daughters’ future was not the only agonising decision Rahmati was forced to make. “Because of debt and hunger I was forced to sell my kidney,” she tells Rukhshana Media from outside her home in the Herat slum."
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And from the BMJ:
Afghans driven to sell kidneys on black market in the face of extreme poverty BMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o587 (Published 04 March 2022) by Gareth Iacobucci
"People in Afghanistan are resorting to selling their kidneys on the black market to feed their families as the country faces extreme poverty.
"The United Nations estimates that 24 million people in Afghanistan—more than half of the population—are in need of lifesaving humanitarian aid. This is 30% higher than in 2021 when the Taliban seized control of the country.
"Illegal organ trading already existed in Afghanistan before the Taliban’s takeover, but a combination of economic sanctions, severe drought, and covid-19 have led to the black market surging as many more people experience extreme poverty.
"A lot of the trade is focused in the western city of Herat, close to the border with Iran."
Here's a nice article about Guido Imbens in the Stanford GSB magazine:
An Unexpected Result: How Nobelist Guido Imbens Helped Kick-Start the “Credibility Revolution” Years of patient collaboration generated insights that have narrowed the gap between economics and the real world. April 15, 2022 | by Julia Kane
"Imbens had been sitting in his office in Harvard’s economics department, thinking about the problem for so long that his head hurt. When the seed of an idea popped into his mind, he jotted down some notes, paused, and realized, “This is pretty much the best thought I’ve had.”
...
“Nobody had really started off on that journey thinking that this is where it would go,” Imbens says, “but this does feel like an end to a journey — a very unexpected end."
The NY Times has the story:
Legal Marijuana Sales Will Start Next Thursday in New Jersey. All adults will be able to purchase cannabis at certain medical-marijuana dispensaries starting April 21. By Tracey Tully
"The first sales of recreational, adult-use cannabis in New Jersey will start next Thursday, marking the culmination of a yearslong effort to legalize marijuana and to curtail the racially unbalanced penalties for possessing the drug.
"At least a half-dozen medical-marijuana dispensaries are planning to open their doors to all adults on April 21 after winning final approval this week from New Jersey’s Cannabis Regulatory Commission.
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"“The end of prohibition is coming to New Jersey,” said Ben Kovler, chief executive of Green Thumb Industries, which operates both dispensaries. “We’re prepared for a tidal wave of demand.”
"He estimated that New Jersey, the second state on the East Coast to begin adult-use sales, could eventually become a $3 billion industry.
“The war on drugs was a failure for people of color,” he said. “This is going to create a lot of wealth, for a lot of people.”
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"New Jersey voters approved a referendum legalizing marijuana in November 2020, but it was not until this week that the commission established a pathway for the first legal sales of adult-use, recreational cannabis."
Some time ago, Esther Duflo likened market design to plumbing. I think she had in mind construction plumbing, making sure the pipes are all tight. But there's also maintenance (and home repair) plumbing, which involves plugging new leaks. Parag Pathak alerts me to such an issue in New York City's school choice system.
The NY Post has the story:
Parents uncover major glitch in NYC school lottery system By Susan Edelman
"A Manhattan mom discovered an embarrassing glitch in the city Department of Education lottery system used to match students with middle and high schools.
"When NYC students filled out their online applications for 2022-23, each kid automatically received a long string of random numbers from 0 to 9 mixed with lower-case letters from a to f.
"The random numbers are used to determine the order in which students are matched to programs.
"Lottery numbers starting with 0 are most likely to land students in a school at the top of their list – 8th graders can rank up to 12 preferred high schools.
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"But as one 8th-grader’s mom figured out, if students canceled and re-started their applications – as the DOE permitted – they received a different lottery number each time. The loophole allowed users to potentially game the system by simply re-applying until a favorable lottery number popped up.
"Parent leaders alerted the DOE’s Chief Enrollment Officer, Sarah Kleinhandler, who was unaware of the snafu and promised to look into it. She did.
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"The DOE said it was able to identify 163 students who received new lottery numbers – less than 1 percent of applicants. They included 121 students out of 71,000 high-school applicants, and 42 students out of 58,000 middle school applicants, a spokesman said.
"Students who received new lottery numbers after restarting their applications will get their first lottery numbers back, a spokeswoman told The Post."
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Speaking of home repairs, here's an earlier post about some self inflicted problems:
Elite public schools, which admit students by exam, are under attack in many places.
In San Francisco, that would be Lowell high school, whose principal has just resigned. SFGate has the story.
Principal at Lowell High School abruptly resigns, rebuking SFUSD in resignation email by Joshua Bote
"The principal of Lowell High School — the highly selective, highly controversial school at the center of this year’s San Francisco school board recalls — has resigned, rebuking the school district in a farewell email sent Wednesday.
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“While I deeply appreciate you all for the community and support I have received in the last three years, the decision to leave SFUSD is solely based on my desire to apply my passion for education in a district that values its students and staff through well organized systems, fiscal responsibility and sound instructional practices as the path towards equity,” Dominguez wrote in the email.
"Statewide budget cuts, due in large part to decreasing student attendance, have hit San Francisco Unified hard this year, with Lowell being affected by a pause of funding to its Advanced Placement program — perhaps where the allusion to “fiscal responsibility” in Dominguez’s email comes from.
"In the past year, Lowell made national headlines when the decision to replace its GPA- and test score-based admissions policy with a districtwide lottery was approved by the previous school board, receiving criticism from parents who said that they were “caught off guard” by the decision. The move, intended to increase racial equity and diversity on campus, was put on hold by a San Francisco court in November 2021."
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Here are some earlier related stories about the troubles at Lowell and in SF:
More School Board Drama Looming, as Lowell High Sticks to Lottery-Based Admissions Another Year 2 DECEMBER 2021
"The SFUSD superintendent says there’s not enough time to implement a court order to re-vote on admissions changes at Lowell. That’s likely to further infuriate the alumni groups that sued the district to win that court order."
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The SF Chronicle covered the first act of this play in three acts:
S.F.'s elite Lowell High School would permanently switch to lottery admission under fast-track proposal by Jill Tucker Jan. 30, 2021
"San Francisco’s elite academic public high school would no longer admit students based on top grades and test scores, and instead use a random lottery system for admission, if the school board approves a measure fast-tracked for a vote."
^^^^^^^^^^^^^^^
And here's an earlier post that touches on similar developments in Boston and NYC:
In 1990, when I was on the faculty of the University of Pittsburgh (where I happily taught from 1982-1998), my colleague Jan Svenjar was instrumental in founding a graduate program in Economics at Charles University, which soon after became CERGE-EI, which is now about to celebrate it's 30th anniversary. It is an appropriate time once again to be thinking about post-communist Europe.
Tuesday, April 26, 2022 ● 4:00 p.m. Bohemian National Hall, 321 East 73rd Street, New York City
CERGE-EI has reached a pivotal moment of change in its history. The 30th Anniversary Celebration of CERGE-EI, hosted by the CERGE-EI U.S. Foundation in conjunction with the Consulate General of the Czech Republic in New York, will be both a reflection of CERGE-EI’s impact over the last thirty years and an opportunity to lay out our vision for the future.
The war in Ukraine and its impact on the surrounding region have established that the Cold War whose ending we celebrated more than 30 years ago has revived and is heating up. Now more than ever, initiatives to raise the standards of economics education and leadership have a critical role to play in supporting national and regional stability.
For the 30th Anniversary, we are honored to be supported by a Host Committee of Nobel Memorial Prize in Economic Sciences Laureates.
The future treatments of kidney failure are just around the corner, where it seems they have been for a long time. So it's perhaps appropriate that this optimistic look at emerging technologies was published on April 1, but I think that's just an accident.
Beyond kidney dialysis and transplantation: what’s on the horizon? by Hamid Rabb, Kyungho Lee, and Chirag R. Parikh, J Clin Invest. 2022 Apr 1; 132(7): e159308., Published online 2022 Apr 1. doi: 10.1172/JCI159308
"There are currently over 750,000 patients with end-stage renal disease (ESRD) in the United States. Globally, 2.6 million patients receive renal replacement therapy with either dialysis or a kidney transplant, which is estimated to double in number by 2030 (1). Kidney care was revolutionized by the invention of the dialysis machine in 1943 by Willem Kolff and the subsequent development of the arteriovenous fistula in 1960 by Belding Scribner. The first successful human kidney transplantation was performed in 1954 by Joseph Murray, teaming with John Merrill, and has since become the treatment of choice for patients with ESRD. Although there have been only incremental innovations since that time, recent exciting developments in kidney research have the potential to transform treatment beyond dialysis and transplantation. Here, we highlight five emerging approaches for ESRD."
They go on to briefly discuss:
Here's a recent NBER working paper that sheds some further light on how assortative mating leads to divergence in family wealth. (Apparently the spouse who managed pre-marital wealth better has more weight in managing the family finances...). Among other things we learn that Norwegian data on income and wealth is really good.
Assortative Mating and Wealth Inequality by Andreas Fagereng, Luigi Guiso & Luigi Pistaferri, NBER WORKING PAPER 29903 DOI 10.3386/w29903, April 2022
We use population data on capital income and wealth holdings for Norway to measure asset positions and wealth returns before individuals marry and after the household is formed. These data allow us to establish a number of novel facts. First, individuals sort on personal wealth rather than parents' wealth. Assortative mating on own wealth dominates, and in fact renders assortative mating on parental wealth statistically insignificant. Second, people match also on their personal returns to wealth and assortative mating on returns is as strong as that on wealth. Third, post-marriage returns on family wealth are largely explained by the return of the spouse with the highest pre-marriage return. This suggests that family wealth is largely managed by the spouse with the highest potential to grow it. This is particularly true for households at the top of the wealth distribution at marriage. We use a simple analytical example to illustrate how assortative mating on wealth and returns and wealth management task allocation between spouses affect wealth inequality.
In the U.S., foster care isn't regarded as a profession (it's repugnant to pay foster parents, so they just get a stipend for childcare expenses). So we don't have a high quality foster care system. But we're learning more about it from careful studies, and there's some interstate variation that might yield further evidence about best practices. Here's a recent survey.
Economics of Foster Care by Anthony Bald, Joseph J. Doyle Jr., Max Gross & Brian Jacob NBER WORKING PAPER 29906 DOI 10.3386/w29906, April 2022
Abstract: Foster care provides substitute living arrangements to protect maltreated children. The practice is remarkably common: it is estimated that 5 percent of children in the United States are placed in foster care at some point during childhood. These children exhibit poor outcomes as children and adults, and economists have begun to estimate the causal relationship between foster care and life outcomes. This paper describes tradeoffs in child welfare policy and provides background on the latest trends in foster care practice to highlight areas most in need of rigorous evidence. These trends include efforts to prevent foster care on the demand side and to improve foster home recruitment on the supply side. With increasing data availability and a growing interest in evidence-based practices, there are opportunities for economic research to inform policies that protect vulnerable children.
One approach that is being adopted in applications for medical residencies is to allow signals of interest.
Here's an announcement from ERAS, the Electronic Residency Application Service® :
Supplemental ERAS® application for the ERAS 2023 cycle
"With the support of their specialty leadership organizations, programs from the following specialties may participate in the supplemental ERAS application for the 2023 ERAS season. "
Here's a 2010 paper that includes some of the experience of signaling in the Economics Ph.D. market. We used (and still use) only 2 signals, and we definitely rejected the idea of gold and silver signals...
The Job Market for New Economists: A Market Design Perspective, by Peter Coles, John Cawley, Phillip B. Levine, Muriel Niederle, Alvin E. Roth, and John J. Siegfried (Journal of Economic Perspectives—Volume 24, Number 4—Fall 2010—Pages 187–206)
Liver transplants from living donors are on the increase in the U.S., so liver transplants are coming to more closely resemble kidney transplants. Apparently that comes with some of the politics that I've witnessed involving kidney transplants. At least that's what the article below, by a very large and distinguished set of American authors, seems to be dealing with, in this critique of a paper published in a European journal. (It's unusual to see a question about scientific integrity highlighted in the title of an academic paper...). Apparently the title of the paper being criticized received news coverage unfavorable to transplantation, and not justified by the data being reported.
Emamaullee, J., Heimbach, J.K., Olthoff, K.M., Pomfret, E.A., Roberts, J.P., Selzner, N. and NALLDIG Consortium, 2022. Assessment of long‐term outcomes post living liver donation highlights the importance of scientific integrity when presenting transplant registry data. American Journal of Transplantation, online early, First published: 30 March 2022 https://doi.org/10.1111/ajt.17045
"Abstract: Living donor liver transplantation has expanded in recent years, particularly in North America. As experience with this procedure has matured over the last 25 years, centers are increasingly faced with potential living donors who are more medically complex. As donors move through the evaluation process, completing the informed consent process continues to be challenged by a paucity of granular data demonstrating long-term outcomes and overall safety specifically in the otherwise ‘healthy’ living liver donor population. Two recently published studies examined long-term outcomes post-living liver donation using Korean registry data and reported similar results, with excellent overall survival when compared to appropriately matched controls. However, the authors of these studies were presented differently, with one reporting an alarmist view based on one aspect of a suboptimal analysis approach using an inappropriate comparator group. Herein, the North American Living Liver Donor Innovation Group (NALLDIG) consortium discusses these two studies and their potential impact on living liver donation in North America, ultimately highlighting the importance of scientific integrity in data presentation and dissemination when using transplant registry data."
"Recently, in the Journal of Hepatology, Choi and colleagues published a noteworthy study of long-term outcomes of Korean living liver donors, titled “Outcomes of living liver donors are worse than those of matched healthy controls.”
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"Although careful examination of long-term outcomes for living liver donors is essential, and the South Korean population is an excellent population in which to conduct these analyses given the relative frequency of living donor liver transplantation, the current study suffers from a serious design flaw which makes interpretation of the data very challenging, as highlighted in detail in the letter to the editor from the Toronto group.4 Indeed, the Control Group I “heathy population” is actually healthier than the living liver donors given that “the proportion of individuals with Charlson Comorbidity Index ≥1, diabetes, hypertension, or depression in the living liver donor group was higher than that in the matched healthy group (Control Group I).” They then use this heavily weighted (10:1 match) heathier group to demonstrate, unsurprisingly, a subtle but statistically worse outcome in the living liver donor group, hence the title of the paper.
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"Unfortunately, both the manuscript title, “Outcomes of living liver donors are worse than those of matched healthy controls” and the lay summary, which is intended for the public at large are highly misleading, given this lack of a matched control group. This leads to confusion and uncertainty not only for those within the medical community but also for prior donors as well as for future potential living donors and their recipients. One may wonder whether these choices were made to drive the sensationalism of the media on this topic particularly in some European countries where practice of LDLT is no longer pursued for a variety of reasons including overall skepticism that the procedure is truly safe for living donors.
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"Journal editorial boards bear the responsibility of arranging high-quality, expert peer review. The dramatic increase in the volume of manuscripts submissions during COVID-19 pandemic has strained many editorial board members and reviewers, likely resulting in publication of studies of variable rigor.16 In parallel, careful assessment of statistical techniques and interpretation of analyses has become an integral part of the review process. Many journals now employ full-time statistical editors, which has enabled identification of serious flaws in experimental design including insufficient study power, missing data, or inappropriate use of statistical tests or models.17 Editors must also critically assess the power of a provocative manuscript title, as initially it may grab the reader's attention and can bias the reader's interpretation and impression. Journals also must be willing to publish studies even when results are disappointing and/or controversial. The transplant community should continue to carefully assess and respond to any work that may dampen enthusiasm for living donation or living donor liver transplantation."
Prior to 2015, it was legal in China to transplant organs recovered from executed prisoners. When I visited China in those days to talk about kidney transplantation from living donors, it was sometimes pointed out to me that, as an American, I shouldn't object to the Chinese use of executed prisoner organs, because we also had capital punishment in the US, but we "wasted the organs." I replied that in the US we had both capital punishment and transplantation, but were trying to limit one and increase the other, and that I didn’t think that either would be improved by linking it to the other.
So here's a just-published retrospective paper looking at Chinese language transplant reports prior to 2015, which identifies at least some instances that it regards as "execution completed by organ procurement."
Execution by organ procurement: Breaching the dead donor rule in China, by Matthew P. Robertson1, and Jacob Lavee2, American Journal of Transplantation, Early View, First published: 04 April 2022 https://doi.org/10.1111/ajt.16969
1 Australian National University | Victims of Communism Memorial Foundation, Washington, D.C., USA
2 Heart Transplantation Unit, Leviev Cardiothoracic Center, Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel
Abstract: The dead donor rule is fundamental to transplant ethics. The rule states that organ procurement must not commence until the donor is both dead and formally pronounced so, and by the same token, that procurement of organs must not cause the death of the donor. In a separate area of medical practice, there has been intense controversy around the participation of physicians in the execution of capital prisoners. These two apparently disparate topics converge in a unique case: the intimate involvement of transplant surgeons in China in the execution of prisoners via the procurement of organs. We use computational text analysis to conduct a forensic review of 2838 papers drawn from a dataset of 124 770 Chinese-language transplant publications. Our algorithm searched for evidence of problematic declarations of brain death during organ procurement. We find evidence in 71 of these reports, spread nationwide, that brain death could not have properly been declared. In these cases, the removal of the heart during organ procurement must have been the proximate cause of the donor's death. Because these organ donors could only have been prisoners, our findings strongly suggest that physicians in the People's Republic of China have participated in executions by organ removal.
"how should we understand the physician's role in a context where executed prisoners are the primary source of transplant organs? Might the transplant surgeon become the de facto executioner? Evidence suggestive of such behavior has emerged over many years from the People's Republic of China (PRC).8-14 To investigate these reports, this paper uses computational methods to examine 2838 Chinese transplant-related medical papers published in scientific journals, systematically collecting data and testing hypotheses about this practice. By scrutinizing the clinical procedures around intubation and ventilation of donors, declaration of brain death, and commencement of organ procurement surgery, we contribute substantial new evidence to questions about the role of PRC physicians in state executions.
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"The data we rely on in this paper involves transplant surgeries from 1980 to 2015. During this period, there was no voluntary donation system and very few voluntary donors. According to three official sources, including the current leader of the transplant sector, the number of voluntary (i.e., non-prisoner) organ donors in China cumulatively as of 2009 was either 120 or 130,30-32 representing only about 0.3% of the 120 000 organs officially reported to be transplanted during the same period (on the assumption that each voluntary donor gave three organs).18, 33, 34 The leader of China's transplant sector wrote in 2007 that effectively 95% of all organ transplants were from prisoners.35 According to official statements, it was only in 2014 that a national organ allocation system could be used by citizens.36
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"Procuring vital organs from prisoners demands close cooperation between the executioner and the transplant team. The state's role is to administer death, while the physician's role is to procure a viable organ. If the execution is carried out without heed to the clinical demands of the transplant, the organs may be spoiled. Yet if the transplant team becomes too involved, they risk becoming the executioners.
"Our concern is whether the transplant surgeons establish first that the prisoners are dead before procuring their hearts and lungs. This translates into two empirical questions: (1) Is the donor intubated only after they are pronounced brain dead? And (2) Is the donor intubated by the procurement team as part of the procurement operation? If either were affirmative the declaration of brain death could not have met internationally accepted standards because brain death can only be determined on a fully ventilated patient. Rather, the cause of death would have been organ procurement.
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"We define as problematic any BDD in which the report states that the donor was intubated after the declaration of brain death, and/or the donor was intubated immediately before organ procurement, as part of the procurement operation, or the donor was ventilated by face mask only.
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"The number of studies with descriptions of problematic BDD was 71, published between 1980 and 2015. Problematic BDD occurred at 56 hospitals (of which 12 were military) in 33 cities across 15 provinces.
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"We have documented 71 descriptions of problematic brain death declaration prior to heart and lung procurement. From these reports, we infer that violations of the DDR took place: given that the donors could not have been brain dead before organ procurement, the declaration of brain death could not have been medically sound. It follows that in these cases death must have been caused by the surgeons procuring the organ.
"The 71 papers we identify almost certainly involved breaches of the DDR because in each case the surgery, as described, precluded a legitimate determination of brain death, an essential part of which is the performance of the apnea test, which in turn necessitates an intubated and ventilated patient. In the cases where a face mask was used instead of intubation48, 49—or a rapid tracheotomy was followed immediately by intubation,50 or where intubation took place after sternal incision as surgeons examined the beating heart44—the lack of prior determination of brain death is even more apparent.
"If indeed these papers document breaches of the DDR during organ procurement from prisoners as we argue, how were these donors prepared for organ procurement? The textual data in the cases we examine is silent on the matter. Taiwan is the only other country we are aware of where death penalty prisoners’ vital organs have been used following execution. This reportedly took place both during the 1990s and then once more in March 2011.51, 52
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"The PRC papers we have identified do not describe how the donor was incapacitated before procurement, and the data is consistent with multiple plausible scenarios. These range from a bullet to the prisoner's head at an execution site before they are rushed to the hospital, like Tsai's description, or a general anesthetic delivered in the operating room directly before procurement. Paul et al. have previously proposed a hybrid of these scenarios to explain PRC transplant activity: a lethal injection, with execution completed by organ procurement.
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"We think that our failure to identify more DDR violations relates to the difficulty of detecting them in the first instance, not to the absence of actual DDR violations in either the literature or practice. Our choice to tightly focus only on papers that made explicit reports of apparent DDR violations likely limited the number of problematic papers we ultimately identified.
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"As of 2021, China's organ transplant professionals have improved their reputation with their international peers. This is principally based on their claims to have ceased the use of prisoners as organ donors in 2015."
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