"Scraping poison off the bone": Transplants in China without organs from executed prisoners

 Following a long period in which the bulk of China's organ transplants used organs from executed prisoners, there have been steady efforts to create a system of voluntary deceased donation comparable to that in most of the world where transplants are done.

Global Times has the latest bit of that evolving story:

China’s organ donation to be more transparent under newly issued rules By Zhao Yusha and Zhang Yuying   Dec 15, 2023

"Chinese Premier Li Qiang has signed a decree of the State Council to unveil rules on human organ donation and transplantation, media reported on Thursday, with Chinese experts noting that the country’s organ donations will be more transparent under the regulation, which reflects great determination in China's organ donation reform. 

The newly issued rules, which will take effect on May 1, 2024, have been refined from the ones on human organ transplantation issued in 2007 to meet the demands of changing situations and ensure the healthy development of the cause, according to the Xinhua News Agency.

The rules strengthen the publicity and guidance of organ donation. Besides, the regulations stipulate that organ donation must adhere to the principles of voluntary and unpaid participation, and the conditions and procedures of donation should be improved based on the Civil Code. 

...

"China’s organ donations will be more transparent under the newly issued rules, Huang Jiefu, chairman of China Human Organ Donation and Transplantation Committee and chair of the China Organ Transplant Development Foundation Advisory Board, told the Global Times on Thursday.

"Huang noted that the revision of the rules shows the great determination in China's organ donation reform, which he described as scraping poison off the bone. “The regulations reflect the importance the Party and country attach to organ donation, which provides a strong legal guarantee for the high-quality development of organ donation cause.” 

"According to the rules, the application management of organ transplantation technologies should be improved to ensure medical quality. Specifically speaking, the rules define the conditions that medical institutions and practicing physicians must possess when engaging in organ transplantation, and require regular evaluation of the clinical application capabilities of relevant technologies in medical institutions. 

...

"In addition, the rules improve related provisions on legal liabilities and strengthen the punishment of malpractice in the field, Xinhua reported.

"Experts said the new rules call for more people to get involved in organ donations and transplants, and it is hoped that China's organ transplantation technology will spread to more countries in the future."

********

Here (in Chinese, but with Google Translate) is the announcement from Xinhua News Agency

李强签署国务院令 公布《人体器官捐献和移植条例》"Li Qiang signed a State Council order announcing the "Regulations on Human Organ Donation and Transplantation"

[The new regulations] "stipulate that patients whose spouses, direct blood relatives and other relatives have donated deceased organs can apply for organ transplantation , priority is given to them under the same conditions. 

...

"Ethical review requirements before organ harvesting will be refined, and the witnessing procedures for harvesting organs from deceased persons will be stipulated. Improve the cadaver organ distribution system, stipulate that the distribution of cadaver organs should meet medical needs, follow the principles of fairness, impartiality, and openness, and distribute uniformly through the distribution system established by the health department of the State Council. It is required to regularly announce the donation and distribution of cadaver organs and accept social supervision.

...

"In addition, relevant provisions on legal liability have been improved, penalties have been increased, and illegal activities in the field of organ donation and transplantation have been severely cracked down on.

　　"(Authorized release) Order No. 767 of the State Council of the People's Republic of China

　　"(Authorized release) Regulations on Human Organ Donation and Transplantation"

HT: Michelle Miao

Black market monkeys for medical research

 Monkeys used in medical research are supposed to come from carefully bred laboratory colonies, but the rising price has led to black markets, which is bad for both monkeys and for medical researchers. (And monkeys are useful for medical research because of their relatively close relation to humans, which makes for difficult conversations regardless of their source...)

The Guardian has the story:

$20,000 monkeys: inside the booming illicit trade for lab animals  by Phoebe Weston

"An international shortage of lab monkeys has driven up prices, incentivising a booming illicit trade. The problem risks undermining research, creating new pandemics, and fuelling wildlife trafficking. As the trade expands, a once-thriving species is now on the edge: in 2022, it was added to the IUCN list of endangered species. Some animal rights activists are calling to end the trade altogether.

"Long-tailed macaques are the most heavily traded primate species in the world, according to a paper published in September, and much of this is for laboratory research. The US National Association for Biological Research says non-human primates remain a critical resource for research, with about 70,000 monkeys imported a year to study infectious diseases, the brain and the creation of new drugs. Difficulty getting monkeys is compromising important research, Sacha says. Before the pandemic he was paying between $2,000 (£1,600) and $5,000 for an animal. Now, it’s about $20,000. “For a couple of years during lockdown it was near impossible to get them,” he says.

"He is not alone. Almost two-thirds of researchers struggled to find monkeys in 2021, according to a report from the US National Academies of Sciences, Engineering, and Medicine, which found that the supply of monkeys for research is at crisis point. According to an article in Science, the report is the “strongest government statement yet on the precarious state of monkey research”. A similar picture is coming from Europe, where a shortage of monkeys has resulted in some research being abandoned.

"Long-tailed macaques (the monkey most commonly used in medical research) are protected under international trade law and special permits are required to import the animals into the US.

"Laboratories need pathogen-free primates that are in good condition and so do not want monkeys that have been wild-caught. With prices so high, however, traffickers are incentivised to catch them in the wild and launder them in via established breeding colonies.

"For decades, China was the largest supplier, but it banned the wild animal trade in 2020 in light of the Covid pandemic. Demand for monkeys increased significantly in the following years, but supply did not. Cambodia has since significantly increased exports to plug the gap and tap into this increasingly lucrative market.

...

"Animal rights campaigners want the US government to end the “cruel trade”, saying it poses a significant threat to public health. The National Academies report says investing in non-animal “organ on a chip” technology could reduce overall demand.

"It also recommended that the US expand its domestic breeding facilities – which it can then regulate. Sacha says: “We shouldn’t be reliant on external countries for these animals that are really critical to our ability to test new therapeutics and vaccines and medicines.”

Organ transplantation in China: in transition--and controversy about paying funeral costs

 I recently spoke at the CAST transplant conference in Hong Kong (see picture), and the underlying theme of my talk, and of many talks there, was the transition of transplantation in China, and what its future might hold.

Jie-Fu HUANG is the other speaker on Zoom (to my right and your left), and Haibo Wang is on the far left on stage.

Here are two of my opening slides (using 2021 data from the Global Observatory on Donation and Transplantation)

On the left, you see that, today, China and India already perform more kidney transplants than any country in the world except the U.S.  On the right, you see that, by virtue of their large populations, they accomplish this despite their quite low rates of transplants per million population, compared to the U.S. and countries in Europe.  So if China and India can raise their transplant rates to rates comparable to the U.S. and Europe, most of the transplants in the world will be done in Asia, and many many additional lives will be saved.

Note that China mostly transplants kidneys from deceased donors, while India mostly transplants kidneys from living donors. So they have different paths (and plenty of untapped potential) for raising donation and transplantation rates.  And their paths to their current positions have also been very different.

Here is a recent account reflecting China's recent progress:

Chen, Zhitao, Han, Ming, Dong, Yuqi, Zeng, Ping, Liao, Yuan, Wang, Tielong, et al. (2023). First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China: 5-year Experience at a High-volume Donor and Recipient Liver Transplant Center. Transplantation, 107, 1855-1859. https://doi.org/10.1097/TP.0000000000004561

" In 1972, our center performed the first living donor kidney transplantation in China. Since then, kidney and liver transplant programs have evolved. By the beginning of the 21st century, organ transplantation had advanced, and clinical liver transplants have been performed successfully at the First Affiliated Hospital of Sun Yat-sen University.1

"Organ shortage has been a prominent feature at our institution as it has been around the world. Starting in the early 1980s, many organs had been procured from inmates on death rows. This unethical approach has been rightfully criticized by the worldwide community. As a consequence, the source of organs for transplants has solely been replaced by voluntary donations from Chinese citizens since January 1, 2015.

...

"Moreover, policies and methods for humanitarian aid to donor families were established. Those policies follow WHO guidelines while recognizing specific aspects of the Chinese culture. The State Ministry of Health and the Red Cross Society of China launched a pilot project on organ donation after the death of citizens in 2010 and established the China Organ Donation Committee. The principle of this pilot project was to learn from the experiences and standards in developed countries while recognizing national conditions and the social reality in China aiming to build an ethical and effective scientific organ donation and transplantation system.2

**********

In the same issue of Transplantation as the above article is this invited commentary by Ascher and Delmonico, both former Presidents of The Transplanation Society (of which Transplantation is the official journal). They largely approve of the effort China has made in transplants, but they have a big reservation.

Ascher, Nancy, MD, PhD & Delmonico, Francis. (2023). Organ Donation and Transplantation in China. Transplantation, 107, 1880-1882. https://doi.org/10.1097/TP.0000000000004562

"The date of 2015 is important for the review of any organ transplantation report from China because of the public proclamation in the media in 2015 prohibiting the use of organs from executed prisoners. Clinical transplantation articles antecedent to 2015 have been consistently rejected by Transplantation and the international community because the source of the transplanted organs was most often an incarcerated prisoner. China took a major step to condemn this practice publicly in 2015. However, because there is no law or regulation that prohibits this unethical practice, there has been ongoing concern that this practice may be continuing. Notwithstanding such a reality, there have been regulations that are citable and may be reflective of the changing experience of organ donation and transplantation in China that are consistent with the World Health Organization (WHO) Guiding Principles.

...

"WHAT CONTINUES TO BE OBJECTIONABLE

"The Chinese Red Cross is prominent in the organ donation process and a center of support for deceased donor families designated by the Red Cross as humanitarian aid to donor families.7 However, such humanitarian aid, although not limited to China, should not be misinterpreted to be an effort because it includes payment to elicit consent for donation. The Sun Yat-sen publication suggests that the Red Cross policies follow WHO guidelines while recognizing specific aspects of Chinese culture without elaboration as to the cultural details. A payment to donor families for funeral expenses or other monetary incentives should be recognized as a form of commercialization and would not comply with WHO guidelines."

**********

Some background may help put this objection in perspective. Doctors Delmonico and Ascher are prominent signatories of a declaration that payments to families of organ donors are crimes against humanity (as are payments to living donors, and both are declared comparable to transplanting organs from executed prisoners, and to be organ trafficking. See my 2017 post.)

So, they raise the question of whether saving many lives by increasing deceased donation in China will be justified if it involves paying funeral expenses of donors.  

My guess is that Chinese health authorities, thinking of the many lives to be saved, will think that this act of generosity to families of deceased donors will indeed be justified, taking account of (see above) "national conditions and the social reality in China aiming to build an ethical and effective scientific organ donation and transplantation system." 

Many people in China and elsewhere might even think that little if any justification is needed for generosity, particularly generosity to families of deceased donors, that is to families who are themselves generous.

Kidney Paired Donation in Developing Countries: a Global Perspective

 Vivek Kute and his colleagues argue that one of the lessons from the developing world is that kidney exchange can save many lives, but may need to be organized differently in some ways than in the developed world.

Kidney Paired Donation in Developing Countries: a Global Perspective by Vivek B. Kute, Vidya A. Fleetwood, Sanshriti Chauhan, Hari Shankar Meshram, Yasar Caliskan, Chintalapati Varma, Halil Yazıcı, Özgür Akın Oto & Krista L. Lentine, Current Transplantation Reports (2023)  (here's a link that may provide better access]

Abstract

...

"Despite the advantages of KPD programs, they remain rare among developing nations, and the programs that exist have many differences with those of in developed countries. There is a paucity of literature and lack of published data on KPD from most of the developing nations. Expanding KPD programs may require the adoption of features and innovations of successful KPD programs. Cooperation with national and international societies should be encouraged to ensure endorsement and sharing of best practices.

Summary

KPD is in the initial stages or has not yet started in the majority of the emerging nations. But the logistics and strategies required to implement KPD in developing nations differ from other parts of the world. By learning from the KPD experience in developing countries and adapting to their unique needs, it should be possible to expand access to KPD to allow more transplants to happen for patients in need worldwide."

...

" Despite the advantages of KPD programs, they remain rare in the developing world, and the programs that exist have many differences with those of developed countries. Program structure is one of these differences: multi-center, regional, and national KPD programs (Swiss, Australia, Canada, Dutch, UK, USA) are more common in the developed than the developing world, whereas single center programs are more common

...

"kidney exchanges frequently take weeks to months to obtain legal permission in India despite the fact that only closely-related family members (i.e., parents, spouse, siblings, children, and grandparents) are allowed to donate a kidney [47].

...

"Protecting the privacy of a donor, including maintaining anonymity when requested, is common practice among developed countries but uncommon in developing nations. Anonymous allocation during KPD is a standard practice in the Netherlands, Sweden, and other parts of Europe, but this is not the case in countries such as India, Korea, and Romania [14, 48, 49]. In areas where anonymity is not maintained, the intended donor/recipient pair must meet and share medical information once a potential exchange is identified, but before formal allocation of pairs occurs. The original donor/ recipient pair may refuse the proposed exchange option for any reason and continue to be on the waitlist. In India, nonanonymous KPD allocation is standard practice and has the goal of increasing trust and transparency between the transplant team and the administrative team [14, 49]. Countries differ in philosophical approaches to optimizing trust and transparency, and objective data on most effective practices would benefit the global community."

********

Tomorrow I hope to have a few words to say about the equally unique situation in China.

######

Update:

Tuesday, September 19, 2023

Organ transplantation in China: in transition--and controversy about paying funeral costs

THE 18TH CONGRESS OF ASIAN SOCIETY OF TRANSPLANTATION (CAST) 25 -28 August 2023 • Hong Kong

Tonight, Sunday, at 5:30pm California time, I'll be opening the Monday morning session in Hong Kong of the THE 18TH CONGRESS OF ASIAN SOCIETY OF TRANSPLANTATION 25 -28 August 2023.

Keynote Lecture

28 Aug 0815-0915 Theatre 1 Keynote Lecture III

Chairs : Albert CY CHAN, Hong Kong, China

Hai-Bo WANG, Mainland China

Topic 1. Transplant economics Alvin ROTH USA

Topic 2. Organ transplantation reform in China: The synergy of Chinese cultural traditions and WHO guiding principle  Jie-Fu HUANG Mainland China

Organ transplants between Hong Kong and mainland China: the promise and the politics

 This is a followup post to an earlier post# about the first cross border transplant in China between the mainland and Hong Kong. That's been followed by some political tensions, as reported in this forthcoming article in the American Journal of Transplantation.

A plan to save lives: Hong Kong–mainland China second-tier mutual assistance allocation. The new program between the transplant communities plays out on a backdrop of controversy and historical tension  by Lara C. Pullen, PhD, Published:July 28, 2023DOI:https://doi.org/10.1016/j.ajt.2023.07.015

"Key points:

"The transplant communities of Hong Kong and mainland China have proposed a second-tier mutual assistance allocation program that some find controversial.

• Tensions between Hong Kong and mainland China have a long and deep history.

• In 2014, the Chinese government announced a stop to obtaining organs from executed prisoners.

• Transplantation in mainland China has rapidly evolved, and people monitoring the change report that data from 10 to 15 years ago does not reflect the country’s current system."

**********

The background:

In December, the South China Morning Post carried this story about a transplant involving an organ recovered on the mainland and transplanted into a baby in Hong Kong, which was apparently the first such  transplant to cross that border:

4-month-old Hong Kong girl suffering from heart failure receives successful transplant with donated organ from mainland China, in city’s first such arrangement by Cannix Yau

One of the subheadlines is "Health Bureau notes importation of organ met relevant regulations, and hospital officials say arrangement involving mainland might be repeated in future"

***

And here's the story in the China Daily:

Securing a new lease of life By Li Bingcun | HK EDITION | Updated: 2023-03-31 15:10

"Hong Kong and the Chinese mainland have successfully carried out the first-ever cross-boundary organ-sharing operation, saving the life of an infant. The feat caps the city’s strenuous efforts to create a standing mechanism in organ sharing with the mainland to save more lives. Li Bingcun reports from Hong Kong."

***

Apparently the discussion of closer cooperation between transplant authorities in Hong Kong and the mainland is politically fraught. 

Here's a story from the Global Times that refers to some pushback from the mainland:

First organ donation between mainland and HK saves 4-month old baby By Wan Hengyi

"the acceptable heart donation for Cleo requires a donor weighing between 4.5 kilograms and 13 kilograms, and the chances of a suitable donor appearing in Hong Kong are slim to none. 

...

"COTRS initiated the allocation of a donated heart of a child with brain death due to brain trauma in the mainland on December 15. As a very low-weight donor, no suitable recipients were found after multiple rounds of automatic matching with 1,153 patients on a national waiting list for heart transplants in the COTRS system. In the end, the medical assistance human organ-sharing plan between the Chinese mainland and Hong Kong was launched.

"Some netizens from the Chinese mainland asked why a baby from Hong Kong who has not lined up in the COTRS system can get a donated heart when there is a huge shortage of donated organs in the mainland.

"In response, the organ coordinator told the Global Times that the requirements for organ donation are extremely high, noting that all the prerequisites including the conditions of the donor and recipient, the time for the organ to be transported on the road and the preparation for surgery must reach the standards before the donation can be completed.

"The COTRS system has already gone through several rounds of matching, which is done automatically by computer without human intervention, said the organ coordinator. "

...

"As of the end of October 2022, a total of 42,500 donors had donated more than 126,300 large organs in China, according to Guo Yanhong, director of the medical emergency department of the NHC."

******

Here's a story from the Guardian, about political concerns on the Hong Kong side:

Hongkongers opt out of organ registry ‘amid fear of Chinese donations’      by Amy Hawkins

"Thousands of Hongkongers have opted out of the city’s organ donor registry, seemingly as a form of subtle protest against proposals to establish deeper medical ties with mainland China.

...

"The trigger appears to have been a life-saving operation carried out in December on a four-month-old baby girl in Hong Kong, who was in need of a heart transplant. When a local match could not be found, a heart was transferred from a child who had suffered brainstem death in mainland China.

...

"Since the baby’s heart transplant, authorities have discussed the idea of establishing a mutual assistance registry with mainland China to facilitate future donations. That would be yet another erosion of the boundary between China and Hong Kong, which was supposed to remain largely autonomous from Beijing until 2047.

"Earlier this month, local news outlet Ming Pao reported that there had been discussion on social media among Hongkongers who did not want their organs donated to patients in mainland China."

********

China has a population approaching 1.5 Billion people, and Hong Kong is a city of about 7.5 Million people, so my guess is that HK is too small to have an efficient self-contained transplant system, and could benefit from being integrated into the mainland's system.

********

#Here's my earlier (contemporaneous) post:

Tuesday, January 10, 2023

Cross-border transplantation between China and Hong Kong

Kidney Exchange in Hong Kong

While liver exchanges have been done for some time in Hong Kong, possibly the first kidney exchange  has recently been reported by China Daily:

Exchanging the hope of life By Li Bingcun | HK EDITION |  2023-06-16 

"It was the first time that paired kidney transplants had been carried out in the city. Following a pilot program launched in 2018, if a patient's family member is willing to donate a kidney to the patient but their conditions do not match, the family is allowed to make a cross-donation with another family in the same situation. Previously, organ donations from living donors could be made only by close blood relatives and spouses.

"In addition to kidney transfers, Hong Kong has accomplished several cross-family liver transplants since 2009 with special approvals made by the Human Organ Transplant Board on a case-by-case basis. Facing a severe shortage of organ donations, Hong Kong is drawing on overseas experiences to widen the scope of donations from living donors by trying to overcome restrictions concerning blood type and marriage, seeking greater matching possibilities to achieve more life-saving miracles.

"These attempts involve considerable efforts to update traditional mindsets, address the accompanying ethical and legal issues, and protect the safety and interests of donors and recipients to the fullest extent.

However, because of risks to donors, medical experts suggest that organ donations from living people should never be the first choice, and that the priority should be boosting people's willingness to register as organ donors, allowing organs to be reused after registered people die.

"Globally, such kidney exchange programs have been introduced in South Korea, the United States, the United Kingdom, Australia and Canada, with surgeries performed two decades ago.

"Besides paired donations, the US also allows "nondirected donations", which means a donor can donate his or her kidney to any compatible patient. The largest kidney swaps were completed in 2014, involving 70 participants. Some global exchange programs have also carried out transnational kidney donations.

"With Hong Kong's relatively low organ-donation rate, more than 2,000 local residents are awaiting kidney transplants each year, with an average waiting time of about five years, and the longest 29 years. The number of kidney donations from living family members is less than 20 annually, while the number of cadaveric donations declined from 84 in 2012 to 45 in 2022.

"Although renal-failure patients can receive dialysis to sustain their lives, organ transplantation is still the best option. Moreover, the quality of organs of living donors is considered better than that of cadaveric organs.

"To offer patients another option, Hong Kong had been preparing to introduce the paired kidney donation (PKD) program since 2012, according to Chau Ka-foon, former co-chairperson of the Hospital Authority's Paired Kidney Donation Working Group. After extensive discussions, the city revised the law in 2018 and officially launched the program.

...

"two families that were successfully matched in 2020 canceled their planned surgeries due to personal concerns. Chau explains that the families might have worried that the organ received was of lower quality than the one they donated. It would also be a heavy blow if a family donating a kidney were unable to receive one if an operation were to fail.

...

"Attempts to swap organs among strangers have also encountered complex legal and technical problems.

"In Hong Kong's first-ever cross-family transplant in 2009, the medical team made a lot of efforts explaining to the Human Organ Transplant Board that the operation wasn't a transaction. "We repeatedly emphasized that the two families did not intend to exchange organs. It was simply the medical workers' proposal to raise the success rate of organ transplants," says Lo Chung-mau, chief surgeon of the operation and also director of the liver transplantation center at Queen Mary Hospital at that time.

...

"The 2019 social unrest and the following COVID-19 pandemic presented even greater challenges for Hong Kong's PKD program. In 2021, there were 26 eligible families in the city's organ matching pool.

"The Hospital Authority expects the number of participating families to climb to 50 to 100 in a few years. It will consider expanding the program to liver donations and collaborating with overseas matching pools. Chau hopes that kidney swaps will not be limited to just two families, and that multiple swaps among several families will be allowed to increase the chances of matching.

...

"Wang Haibo, a member of China's National Organ Donation and Transplantation Committee, says the pair-donation program is worth looking into and being discussed. The mainland is also conducting clinical research on paired-kidney donations. Alvin Roth, who won the 2012 Nobel Memorial Prize in Economic Sciences and developed a global kidney-exchange program, visited China before the COVID-19 pandemic to seek collaboration in this area, he recalls.

"Wang says both Hong Kong's and the mainland's organ donation rates still lag far behind those of developed economies. "They have reached a plateau and have made relatively adequate utilization of organ donations from the deceased. We have much room to develop in this regard."

"He says that while officials explore innovative approaches concerning living-organ donations, the priority should still focus on how to boost people's willingness to register as organ donors and better utilize the organs. "These are the so-called 'low hanging fruit'. It would be wise to concentrate our limited resources on the most rewarded option."

**********

Statement of Policy Principles and Solutions: Living Organ Donation, from the American Association of Kidney Patients (AAKP), the American Society of Transplant Surgeons (ASTS), and the American Society of Transplantation (AST)

 Here's a joint statement about living-donor kidney transplantation from the American Association of Kidney Patients (AAKP), the American Society of Transplant Surgeons (ASTS), and the American Society of Transplantation (AST). The statement opposes rethinking the ban on compensation for donors, suggests that other policies should be evidence-based, and opposes increased bureaucratization and cumbersome regulation of the transplant process.

Statement of Policy Principles and Solutions:  Living Organ Donation

"We stand together in our conviction that any policy changes impacting living organ donation, including those aimed at improving access to living donor transplantation and increasing the survival of already transplanted patients, must begin with principled and transparent dialogue with patients and the expert transplant teams who care for them.  

...

"The United States ranks in the top tier of nations in terms of living donor transplant rates,[1] meaning the current system for living donation works. However, disparities in access to living donor transplantation remain, and we must continue to improve and expand living donor transplantation for those in need.  As such, we support policy changes that are patient-centric, fiscally realistic, and ethically and legally sound. 

"Over the past decade some well-intended organizations and advocates have advanced ideas to increase access to living donor transplantation, including direct payments for or large financial incentives for organ transplants, that may appear expedient but can result in serious adverse consequences for transplantation and for patients. Many of these proposals pose serious unintended negative consequences to both donors and to public trust in organ donation. We fundamentally reject efforts to model changes to the current US system based on research or organ transplant practices in nations such as China and Iran whose governments fail to meet or ignore high international and US standards for ethical medical research and basic human rights.

...

"AAKP, ASTS, and AST strongly support the elimination of disincentives to transplantation and adamantly oppose coercive financial incentives to donate.

...

"AAKP, ASTS, and AST believe that improvements to the transplant system can best be made through ethically and legally sound, evidence-based, data driven policies informed and guided by patients and transplant professionals rather than by overhauling the entire transplant system.

"The transplantation system is a public-private partnership between the federal government and the transplant community and is designed, in part, to prevent overt political influence or other governmental interference in shared patient-physician decision making and clinical judgement. The relationship between patients, including living organ donors, and the doctors and medical institutions they choose to care for them must be protected and respected, as should the ability of individual transplant professionals to make clinical decisions in the best interest of those patients.

"Transplantation is heavily regulated by multiple federal agencies, including the Centers for Medicare and Medicaid Services (CMS), the Health Resources Services Administration (HRSA), and two HRSA contractors (the Organ Procurement and Transplantation Network (OPTN) and the Scientific Registry of Transplant Recipients (SRTR)).  Transplant centers are subject to duplicative (and often conflicting) requirements and surveys imposed by CMS and the OPTN. Living donor transplant programs are subject to additional scrutiny to ensure that donors are not pressured, coerced, or intimidated into donating an organ.  All living donor transplant programs are required to have independent living donor advocates that ensure that donors’ full and informed consent is given with a full understanding of the procedure and its potential risks and consequences.

"Into this existing and complex regulatory framework, some organizations are proposing policy and legislative changes that would either expand federal control over transplant by inserting yet another federal agency into the process or overhauling the entire transplant system to give federal agencies, as well as political appointees and politicians, greater authority to regulate living donor transplantation. Exposing the living organ donation system to such political influence and putting decision-making in the hands of non-transplant experts is a mistake with dangerous consequences for patient health, public trust, and donor and patient confidence.

"These proposals raise the possibility that the federal government would mandate a “one-size fits all approach” to an incredibly complex set of clinical problems. Such an approach would likely result in fewer innovations and fewer opportunities to reduce barriers to transplantation, especially for historically underserved communities. There are many potential reforms to the transplant system that can be effective, have been suggested by the wider transplant community over the past decade, and should be adopted by Congress and federal agencies. However, any policy or legislative proposal that seeks to amend or replace the existing system with an even larger federal bureaucratic reach with the potential for federal interference in decisions made among organ donors and patients and the doctors and medical institutions they choose to receive care from should be viewed with skepticism.

"We oppose policy efforts that seek to place any governmental entity in the position of determining clinical criteria for living donor transplantation or otherwise interfering with the relationship between and among potential recipients, potential donors, and their caregivers.

*******

As a reader of many such joint statements, I wonder if the phrase  "coercive financial incentives" resulted from a compromise between those who believe that all financial incentives are coercive, and those who wish to leave the door open in the future to ordinary, non-coercive financial incentives, of the kinds that attach to so many human activities, and have done so much to relieve other kinds of shortages.

HT: Laurie Lee via Frank McCormick

Incentives for deceased organ donation, in Asia

 Here's a discussion, in an Asian context, of providing incentives to families to consent to deceased donation.

Introducing Incentives and Reducing Disincentives in Enhancing Deceased Organ Donation and Transplantation by Kai Ming ChowMBChB⁎ Curie AhnMD† Ian DittmerMBChB‡ Derrick Kit-SingAuLMCHK§ IanCheungMBBS║ Yuk LunChengMBChB¶ Chak SingLau MBChB Deacons Tai-KongYeungMBBS║ Philip Kam-TaoLi MD Seminars in Nephrology,  Available online 27 December 2022

*Department of Medicine and Therapeutics, Carol and Richard Yu PD Research Centre, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong

† Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea

‡Department of Renal Medicine, Auckland City Hospital, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand

§Centre for Bioethics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong

║Cluster Services Division, Hospital Authority, Kowloon, Hong Kong

¶Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong

#Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pok Fu Lam, Hong Kong, China

Summary: Despite the effectiveness of solid organ transplantation, progress to close the gap between donor organs and demand remains slow. An organ shortage increases the waiting time for transplant and involves significant costs including patient morbidity and mortality. Against the background of a low deceased organ donation rate, this article discusses the option of introducing incentives and removing disincentives to deceased organ donation. Perspectives from ethics, general public opinion, and the health care profession are examined to ensure a comprehensive appraisal and illustrate different facets of opinion on this complex area. Special cultural and psychosocial considerations in Asia, including the family based consent model, are discussed.

This sentence caught my eye:

"After suggestion by Economics Nobel Laureate Alvin Roth for the community to unite to remove disincentives to kidney donation, the transplant community and academia have been having more discussion and analysis. That, in part, hinges on the estimates of the economic welfare gain for the society as a whole."

...

"PERSPECTIVES OF ASIAN SOCIETY

"It is widely recognized that deceased organ donation rates in Asian countries have been significantly lower than that in Western countries.

...

"No one disputes the social and cultural beliefs in the decision to donate organs. 

...

"An example of honoring the principles of reciprocity in incentivizing organ donor registrations is the organ allocation priority policy. Israel became the first country in 2008 to enact legislation incorporating such incentives based on individuals’ willingness to donate into their organ procurement system.26,42,43 The policy provides an incentive or motivation by the reciprocal altruistic dictum that “each partner helping the other while he helps himself,”42 granting priority on organ donor waiting lists to those individuals who registered as organ donors by signing a donor card for at least 3 years. Subsequent observations in Israel, as analyzed 5 years after introduction of the new policy, included an increase in the authorization rate of next of kin of unregistered donors, as well as a two-fold higher likelihood of next-of-kin authorization for donation when the deceased relative was a registered donor.44

"How does the concept of reciprocity apply for Asian societies? Will the results from Israel be replicated in Asia? Although social exchange theory should be a universal normal applicable to all human relationships, cultural influence or patterns might differ. Previous research on reciprocity across different cultural contexts, indeed, has shown that East Asians tend to reciprocate in kind and emphasize more on equity-based theory than Americans.45 Viewed through such a lens of “to give is to take,” it is relevant to quote another similar example in Taiwan, where incentives were provided to deceased organ donors’ families. In brief, after a person has become a deceased organ donor in Taiwan, up to three of his or her blood relatives will be granted priority to receive a deceased donor organ should they be on the waiting list for transplantation.46

"At the heart of the issue is the family based consent that is unique and vital, albeit not exclusive, in Confucian tradition within Chinese societies. It is important to note that organ donation is more often a family based consent process in Chinese culture than those “from a Western cultures”. As such, family priority right provided in the Israel or Chinese model would be more likely to motivate organ donation within a family based ethical culture.47 As in any discussion of culture's influence on organ donation decision, we must be mindful that East Asians tend to favor family centered decision making.

...

"If the concept of reimbursing funeral expenses for deceased organ donors is explored further then these four tenets are suggested as a guide: Tenet 1: the overarching principle is to appreciate and recognize the altruistic behavior of organ donors, and not the next of kin. Tenet 2: the second priority of reimbursing funeral expenses is to motivate the passive-positive public to sign up for organ donation. Tenet 3: the ultimate beneficiary from an incentive system is society, with an improved deceased organ donation rate. Government and charitable organizations, but not organ recipients, should be the source of payment. Tenet 4: as a token of expressing gratitude to the deceased organ donors, funeral expenses reimbursement preferably should be offered to those who have expressed the wish to donate (donor registration); they should have been provided the option to decline the offer."

Cross-border transplantation between China and Hong Kong

 Here are two recent reports of the first cross-border transplant between China proper and Hong Kong.

From the Global Times:

First organ donation between mainland and HK saves 4-month old baby By Wan Hengyi

"A medical team of the Hong Kong Children's Hospital successfully transplanted a heart donated from the mainland to a 4-month-old baby in Hong Kong Special Administrative Region on Saturday, achieving a historic breakthrough in the sharing of human organs for emergency medical assistance between the two places for the first time.

"The donated heart, which had been matched by China's Organ Transplant Response System (COTRS) through several rounds and had no suitable recipient, was successfully matched in Hong Kong through the joint efforts between 24 departments and 65 medical experts in the mainland and Hong Kong.

"Cleo Lai Tsz-hei, the recipient of the transplant from Hong Kong, was diagnosed with heart failure 41 days after birth and was in critical condition. Receiving a heart transplant was the only way to keep her alive, according to media reports.

"Moreover, the acceptable heart donation for Cleo requires a donor weighing between 4.5 kilograms and 13 kilograms, and the chances of a suitable donor appearing in Hong Kong are slim to none.

...

"COTRS initiated the allocation of a donated heart of a child with brain death due to brain trauma in the mainland on December 15. As a very low-weight donor, no suitable recipients were found after multiple rounds of automatic matching with 1,153 patients on a national waiting list for heart transplants in the COTRS system. In the end, the medical assistance human organ-sharing plan between the Chinese mainland and Hong Kong was launched.

"Some netizens from the Chinese mainland asked why a baby from Hong Kong who has not lined up in the COTRS system can get a donated heart when there is a huge shortage of donated organs in the mainland.

"In response, the organ coordinator told the Global Times that the requirements for organ donation are extremely high, noting that all the prerequisites including the conditions of the donor and recipient, the time for the organ to be transported on the road and the preparation for surgery must reach the standards before the donation can be completed.

"The COTRS system has already gone through several rounds of matching, which is done automatically by computer without human intervention, said the organ coordinator. 

"Medical teams from both jurisdictions, as well as customs officers in Shenzhen and Hong Kong, carried out emergency drills to reduce the customs clearance time to eight minutes, racing against the four-hour limit for preserving donated hearts, said Wang Haibo, head of the COTRS for medical assistance contact between the mainland and Hong Kong.

"The collection of donated hearts began at 17:00 pm on Friday, and the hearts were delivered to the Hong Kong Children's Hospital at 20:00 pm under the escort of Hong Kong police on the same day. At 1:00 am on Saturday, Cleo's heart transplant operation in Hong Kong was successfully completed, and she has not required extracorporeal circulation support at present."

********

And from the South China Morning Post:

Hong Kong could greatly benefit from cross-border organ imports mechanism, doctors say after local baby receives heart from mainland China  by Jess Ma

"Hong Kong could greatly benefit from cross-border organ donations given the city’s persistently low rate of residents willing to sign up to become donors, doctors have said after a local baby girl received a heart from mainland China in the first arrangement of its kind.

...

"Hong Kong’s organ donation rate is currently among the lowest in the world, at 3.9 donors per a million people in 2019, down from 5.8 in 2015, according to research conducted by the Legislative Council.

...

"Medical lawmaker David Lam Tzit-yuen and election committee legislators Elizabeth Quat Pei-fan and Rebecca Chan Hoi-yan urged the government to begin discussions on legal frameworks and procedures for cross-border transplants, saying that the mainland had a robust donation system and that organ sharing between the city and the mainland was not unusual.

"Human rights groups and lawyers have accused the mainland of forcibly harvesting organs from executed prisoners, a practice that then health minister Huang Jiefu publicly acknowledged in 2005. The government announced in 2015 that organ donations would only come from “voluntary civilian organ donors,” but critics argued prisoners were not excluded under the system.

But Chan argued that the mainland’s efforts to improve the transparency and ethics of its organ donation system over the past decade should be acknowledged.

“I disagree that this would be the beginning of a slippery slope. The transparency of the mainland’s organ donation system has been a lot clearer and stricter,” Chan said, adding that a lot of work had been done across the border to prohibit organ harvesting and trading."

Organ transplants and capital punishment don't go well together

 I recently blogged about a paper by Robertson and Lavee in the American Journal of Transplantation, looking at surgeries conducted in China before 2015, a period in which China acknowledged that most transplants there were conducted with organs from executed prisoners.  Now they summarize their report in a column in the WSJ.

In China, New Evidence That Surgeons Became Executioners. Clinical reports recount scores of cases in which organ donors were alive when operations began.  By Jacob Lavee and Matthew P. Robertson

"The Wuhan doctors write: “When the chest of the donor was opened, the chest wall incision was pale and bloodless, and the heart was purple and beating weakly. But the heartbeat became strong immediately after tracheal intubation and oxygenation. The donor heart was extracted with an incision from the 4th intercostal sternum into the chest. . . . This incision is a good choice for field operation where the sternum cannot be sawed open without power.”

"By casually noting that the donor was connected to a ventilator (“tracheal intubation”) only at midsurgery, the physicians inadvertently reveal that the donor was alive when the operation began.

...

"Our findings end in 2015, but we think the abuse likely continues. Medical papers like those we studied were first unearthed by Chinese grass-roots investigators in late 2014, and it would have been simple to command journals to stop publishing the incriminating details after that. While China claims to have stopped using prisoners in 2015, our previous research raises doubts. In a 2019 paper in the journal BMC Medical Ethics, we used statistical forensics to show that the official voluntary-organ donation numbers were falsified, inflating the success of a modest voluntary organ-donation reform program used to buttress the reform narrative.

"Global medical leaders have largely dismissed such concerns. The World Health Organization took advice from Chinese transplant surgeons in the establishment of its anti-organ-trafficking task force—and then installed them on the membership committee. In 2020, WHO officials joined long-time apologists for China’s transplant system, attacking our previous research showing falsified numbers."

...

"Dr. Lavee is the director of the Heart Transplantation Unit at Tel Aviv’s Sheba Medical Center and a professor of surgery at Tel Aviv University. Mr. Robertson is a research fellow with the Victims of Communism Memorial Foundation and a doctoral candidate in political science at the Australian National University."

"Execution by organ procurement: Breaching the dead donor rule in China," by Matthew P. Robertson, and Jacob Lavee in the AJT

 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.

...

"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

...

"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.

...

"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.

...

"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. 

...

"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

...

"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. 

...

"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.

...

"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."

Market design course for health policy and medical students, at Stanford, taught by Alex Chan and Kurt Sweat

 Starting tomorrow, a short course in market design:

BIOS 203, Fall 2021: Market Design and Field Experiments for Health Policy and Medicine 

Primary Instructor: Alex Chan chanalex@stanford.edu | Office Hours: By appointment

Secondary Instructor: Kurt Sweat kurtsw@stanford.edu | Office Hours: By appointment

Description. Market design is an emerging field in economics, engineering and computer science about how to organize systems to allocate scarce resources. In this course, we study (1) the theory and practice of market design in healthcare and medicine, and (2) methods to evaluate the impact of such designs. Students will be provided with the necessary tools to diagnose the problems in markets and allocation mechanisms that render them inefficient, and subsequently develop a working toolbox to remedy failed markets and finetune new market and policy designs.

With a practical orientation in mind, we will learn how to construct rules for allocating resources or to structure successful marketplaces through successive examples in healthcare and medicine: medical residency matching, kidney exchange, allocation of scarce medical resources like COVID vaccine and tests, medical equipment procurement, online marketplace for doctors, and, if time permits, reward system for biopharmaceutical innovation. Guest lectures by practicing market designers and C-suite healthcare executives (CEO, CFO) would feature in the course as well.

An important goal of the class is to introduce you to the critical ingredients to a successful design: a solid understanding of institutions, grasps of economic theory, and well-designed experiments and implementation. In the final sessions, students will also learn how to design and deploy one of the most powerful tools in practical market design: A/B testing or randomized field experiments. These techniques are widely used by tech companies like UBER, Amazon, eBay, and others to improve their marketplaces.

At the end of the course, students should have acquired the necessary knowledge to become an avid consumer and user, and potentially a producer, of the market design and field experimental literature (recognized by 4 recent Nobel Prizes in Economics: 2007/2012/2019/2020).

Time & Location.

● Tue, Thu 6:30 PM - 8:00 PM (beginning November 16, 2021) at Encina Commons Room 119

Course Webpage. ● https://canvas.stanford.edu/courses/145148

Schedule and Readings

(* required readings, others are optional)

Session 1. Market design and Marketplaces – November 16

1. * Roth, A. E. (2007). The art of designing markets. harvard business review, 85(10), 118.

2. Kominers, S. D., Teytelboym, A., & Crawford, V. P. (2017). An invitation to market design. Oxford Review of Economic Policy, 33(4), 541-571.

3. Roth, A. E. (2002). The economist as engineer: Game theory, experimentation, and computation as tools for design economics. Econometrica, 70(4), 1341-1378

Session 2. Matching Markets: Medical Residents and the NRMP – November 18

1. * Chapter 1 in Gura, E. Y., & Maschler, M. (2008). Insights into game theory: an alternative mathematical experience. Cambridge University Press.

2. * Fisher, C. E. (2009). Manipulation and the Match. JAMA, 302(12), 1266-1267.

3. * National Resident Matching Program. (2021). Feasibility of an Early Match NRMP Position Statement

4. Roth, A. E., & Peranson, E. (1997). The effects of the change in the NRMP matching algorithm. JAMA, 278(9), 729-732.

5. Gale, D., & Shapley, L. S. (1962). College admissions and the stability of marriage. The American Mathematical Monthly, 69(1), 9-15.

Session 3. Kidney Exchange and Organ Allocation – November 30

1. * Wallis, C. B., Samy, K. P., Roth, A. E., & Rees, M. A. (2011). Kidney paired donation. Nephrology Dialysis Transplantation, 26(7), 2091-2099.

2. * Chapter 3 in Roth, A. E. (2015). Who gets what—and why: The new economics of matchmaking and market design. Houghton Mifflin Harcourt.

3. Gentry, S. E., Montgomery, R. A., & Segev, D. L. (2011). Kidney paired donation: fundamentals, limitations, and expansions. American journal of kidney diseases, 57(1), 144-151.

4. Salman, S., Gurev, S., Arsalan, M., Dar, F., & Chan, A. Liver  Exchange: A Pathway to Increase Access to Transplantation.

5. Sweat, K. R. Redesigning waitlists with manipulable priority: improving the heart transplant waitlist.

6. Agarwal, N., Ashlagi, I., Somaini, P., & Waldinger, D. (2018). Dynamic incentives in waitlist mechanisms. AEA Papers & Proceedings, 108, 341-347.

Session 4. 1 st Half: Repugnance as a Constraint on Markets – December 2

1. * Roth, A. E. (2007). Repugnance as a Constraint on Markets. Journal of Economic perspectives, 21(3), 37-58.

2. * Minerva, F., Savulescu, J., & Singer, P. (2019). The ethics of the Global Kidney Exchange programme. The Lancet, 394(10210), 1775-1778.

3. Chapter 11 in Roth, A. E. (2015). Who gets what—and why: The new economics of matchmaking and market design. Houghton Mifflin Harcourt.

2 nd Half: Market Design and Allocation during COVID-19 – December 2

1. * Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M., Glickman, A., ... & Phillips, J. P. (2020). New England Journal of Medicine. Fair allocation of scarce medical resources in the time of Covid-19.

2. Piscitello, G. M., Kapania, E. M., Miller, W. D., Rojas, J. C., Siegler, M., & Parker, W. F. (2020). Variation in ventilator allocation guidelines by US state during the coronavirus disease 2019 pandemic: a systematic review. JAMA network open, 3(6), e201

3. Schmidt, H., Pathak, P., Sönmez, T., & Ünver, M. U. (2020). Covid-19: how to prioritize worse-off populations in allocating safe and effective vaccines. British Medical Journal, 371.

4. Schmidt, H., Pathak, P. A., Williams, M. A., Sonmez, T., Ünver, M. U., & Gostin, L. O. (2020). Rationing safe and effective COVID-19 vaccines: allocating to states proportionate to population may undermine commitments to mitigating health disparities. Ava

5. Neimark, J. (2020). What is the best strategy to deploy a COVID-19 vaccine. Smithsonian Magazine.

Session 5. 1 st Half: Auction Design and Procurement in Medicine – December 7

1. * The Committee for the Prize in Economic Sciences in Memory of Alfred Nobel. (2020). Improvements to auction theory and inventions of new auction formats. Scientific Background on the Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel 20

2. * Song, Z., Cutler, D. M., & Chernew, M. E. (2012). Potential consequences of reforming Medicare into a competitive bidding system. Jama, 308(5), 459-460.

3. Newman, D., Barrette, E., & McGraves-Lloyd, K. (2017). Medicare competitive bidding program realized price savings for durable medical equipment purchases. Health Affairs, 36(8), 1367-1375.

4. Cramton, P., Ellermeyer, S., & Katzman, B. (2015). Designed to fail: The Medicare auction for durable medical equipment. Economic Inquiry, 53(1), 469-485.

5. Ji, Y. (2019). The Impact of Competitive Bidding in Health Care: The Case of Medicare Durable Medical Equipment.

6. Thaler, R. H. (1988). Anomalies: The winner's curse. Journal of economic perspectives, 2(1), 191-202.

7. Chapter 2 in Haeringer, G. (2018). Market design: auctions and matching. MIT Press.

2 nd Half: (GUEST LECTURE) Ralph Weber, CEO, MediBid Inc. on “The Online Marketplace for Medicine” – December 7

Session 6. A/B Testing and Field Experiments to Test Designs – December 9

1. * Chapters 1, 4 in List, John. (2021). A Course in Experimental Economics (unpublished textbook, access on course website)

2. * Gallo, A. (2017). A refresher on A/B testing. Harvard Business Review, 2-6.

3. Chan, A. (2021). Customer Discrimination and Quality Signals – A Field Experiment with Healthcare Shoppers.

4. Kessler, J. B., Low, C., & Sullivan, C. D. (2019). Incentivized resume rating: Eliciting employer preferences without deception. American Economic Review, 109(11), 3713-44.

5. Chapters 3, 5, 6, 7, 8 in List, John. (2021). A Course in Experimental Economics (unpublished textbook, access on course website)

6. The Committee for the Prize in Economic Sciences in Memory of Alfred Nobel. (2019). Understanding development and poverty alleviation. Scientific Background on the Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel 2019.

Bonus Session (optional). (GUEST LECTURE) Donald Lung, CFO, Antengene on “Designing Markets to Access Biopharmaceutical Intellectual Property Across Regulatory Regimes – the Case of China” – Date TBD

Bonus Session (optional). (GUEST LECTURE) TBD – Date TBD

Transplantation in China: update

I returned Sunday from a busy and potentially productive trip to China.

Since 2015 it has been illegal in China to use organs from executed prisoners for transplants. The passage of that law was the result of a long struggle between an opaque, often black market system of transplantation, and an emerging transparent system based on voluntary donation.  The transparent system has made, and is continuing to make, enormous strides.

In Shenzhen I visited the China Organ and Transplant Response System (COTRS), run by Dr. Haibo Wang, which organizes and records the data of transplant patients and donors. 

It also collects large amounts of data on all hospital stays at China’s largest hospitals. Together with the National Institute of Health Data Science at Peking University, run by Dr. Luxian Zhang, they are assembling a vast data resource that will have many uses.

In Beijing I also visited the China Organ Transplant Development Foundation, run by Dr. Jeifu Huang, which plays a role in guiding the emerging body of legislation through which transplants are being organized in China with increased transparency.

I also spoke at the Beijing Summit on Health Data Science.

It was a busy week that left me optimistic that we'll see continued big progress in healthcare delivery in China, including but not limited to transplantation.

Some photos were taken...

President Trump's Executive Order on kidney care

On July 10, while I was in China, President Trump issued an executive order touching on all aspects of care for kidney patients, including dialysis and transplantation from both deceased and living donors.

Here's the text of that executive order:
Executive Order on Advancing American Kidney Health
 Issued on: July 10, 2019

Because I anticipated being potentially incommunicado when the executive order was announced, I had filed an op-ed article (giving my proxy to my coauthor Greg Segal for any necessary last-minute edits) to be published on CNN's web site, applauding the order:
The Trump administration's organ donation efforts will save lives
By Alvin E. Roth and Greg Segal
Updated 1:20 PM ET, Wed July 10, 2019

As it happens, a reporter for PBS news hour reached me by phone in China, and so I got to chime in in person:
Trump’s plan to combat kidney disease aims to save money and lives. Can it?
Health Jul 10, 2019 4:39 PM EDT


The part of the executive order that touches most closely on my work on kidney exchange is Section 8:

"Sec. 8.  Supporting Living Organ Donors.  Within 90 days of the date of this order, the Secretary shall propose a regulation to remove financial barriers to living organ donation.  The regulation should expand the definition of allowable costs that can be reimbursed under the Reimbursement of Travel and Subsistence Expenses Incurred Toward Living Organ Donation program, raise the limit on the income of donors eligible for reimbursement under the program, allow reimbursement for lost-wage expenses, and provide for reimbursement of child-care and elder-care expenses."

Regarding deceased donor transplants, Section 7 says

"Sec. 7.  Increasing Utilization of Available Organs.  (a)  Within 90 days of the date of this order, the Secretary shall propose a regulation to enhance the procurement and utilization of organs available through deceased donation by revising Organ Procurement Organization (OPO) rules and evaluation metrics to establish more transparent, reliable, and enforceable objective metrics for evaluating an OPO’s performance.

(b)  Within 180 days of the date of this order, the Secretary shall streamline and expedite the process of kidney matching and delivery to reduce the discard rate.  Removing process inefficiencies in matching and delivery that result in delayed acceptance by transplant centers will reduce the detrimental effects on organ quality of prolonged time with reduced or cut-off blood supply."

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

Here is some of the news coverage:

Trump signs executive order revamping kidney care, organ transplantation By Lenny Bernstein July 10 (Washington Post);
Trump signs executive order to transform kidney care, increase transplants 
By Jen Christensen and Betsy Klein, CNN Updated 4:21 PM ET, Wed July 10, 2019

This executive order is well worth supporting, and it will need support to achieve the goals it outlines.  The Secretary of Health and Human Services has been directed to do things in fairly broad terms, and we'll have to watch carefully to see the results, which will be interpreted, contested, and implemented through multiple political/regulatory processess

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

Regarding removing financial disincentives for kidney (and liver) donors, I'm on the advisory board of the federally funded National Living Donor Assistance Center (NLDAC), which has been able, under very tight constraints, to reimburse some donors for some travel expenses (see related posts here).  A minimalist interpretation/implementation of the Executive Order would be to relax some of the constraints on whose expenses and which expenses can be reimbursed, and to increase NLDAC's budget accordingly.  A more expansive interpretation would be to remove some of those constraints so that no donor would have to pay to rescue someone with kidney failure by donating a kidney.