Pros and cons of paying for kidneys, in the Journal of Medical Ethics

Some pros and cons on paying for kidneys in the Journal of Medical Ethics, March 2014, Volume 40, Issue 3

From the editors' summary in the first article ("The concise argument")"

"For over half a century the subject of organ transplantation has attracted ethical debate. One such ongoing debate, provoked by the severe scarcity of organs for transplantation and a concern to increase their supply, has been about why willing live donors should continue to be prohibited from offering their own organs for sale. Against allowing this, it has often been argued that prohibition protects people in poverty from being driven to, and then harmed by, this desperate last resort. But is that how such people in poverty themselves see it? From their point of view, it has been suggested, wouldn't it be reasonable to see prohibition as depriving them of their best option, leaving them worse off than if they had been able to exercise it? Isn't the claim to protect people in poverty therefore ‘misplaced paternalism’, providing no ethical justification for prohibition?

"In this month's feature article, Simon Rippon (see page 145, Editor's choice) mounts a serious and sustained challenge to that conclusion. He argues that while it would be reasonable for people in poverty to sell their organs if given the option, it would be equally reasonable, given the ‘significant and unavoidable’ harms of a live organ donor market, for them to prefer not to have this option at all. In her commentary on Rippon's paper, Janet Radcliffe-Richards (see page 152) acknowledges that ‘a plausible case for prohibition would probably take this form’, but goes on to argue that ‘although in principle prohibition need not be paternalistic, in practice it is’, since it ‘has been imposed on everyone irrespective of any consultation’. To this, and two further commentaries, by Gerald Dworkin (see page 151) and by Adrian Walsh (see page 153), Rippon responds (see page 155) in a significant contribution to a debate that nevertheless seems likely to continue unabated as long as the need for whole organs continues so greatly to exceed their supply."

The concise argument

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  Responding to complexity

  • Kenneth Boyd

  J Med Ethics 2014;40:143-144 doi:10.1136/medethics-2014-102070

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Feature article

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  Imposing options on people in poverty: the harm of a live donor organ market

  • Simon Rippon

  J Med Ethics 2014;40:145-150 Published Online First: 28 June 2012doi:10.1136/medethics-2011-100318
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Commentaries

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  Organ sales and paternalism

  • Gerald Dworkin

  J Med Ethics 2014;40:151-152 Published Online First: 19 June 2012doi:10.1136/medethics-2012-100647
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  Commentary by Janet Radcliffe-Richards on Simon Rippon's ‘Imposing options on people in poverty: the harm of a live donor organ market’

  • Janet Radcliffe-Richards

  J Med Ethics 2014;40:152-153 Published Online First: 19 October 2012doi:10.1136/medethics-2012-100645
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  Commentary on Simon Rippon, ‘Imposing options on people in poverty: the harm of a live donor organ market’

  • Adrian Walsh

  J Med Ethics 2014;40:153-154 Published Online First: 29 June 2012doi:10.1136/medethics-2012-100646
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  Organ markets and harms: a reply to Dworkin, Radcliffe Richards and Walsh

  • Simon Rippon

  J Med Ethics 2014;40:155-156 Published Online First: 5 November 2012doi:10.1136/medethics-2012-101083
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Clinical ethics

Update on school choice in Britain

The Telegraph reports, unfavorably, on the rise of school choice (and demise of assignment to local schools) in Britain:
:
Surge in admissions lotteries threatens children's right to place at local school
One in 12 schools is shunning traditional catchment areas in favour of rules designed to engineer a more balanced student body

"Some one in 12 schools is shunning traditional catchment areas in favour of rules designed to engineer a more balanced student body and break the middle-class stranglehold on places.

"The shift is being driven by a rise in the number of academies and free schools whose admissions policies are independent of local council control.
...
"Research by The Sunday Telegraph found that the proportion of highly oversubscribed secondary schools using lotteries or “fair banding” systems rises close to 100 per cent in parts of London. Across England, half of councils confirmed that at least one school in their area now used them.
...
"The Department for Education said admissions were run by individual schools or councils but insisted places “should be allocated in a fair and transparent way”. Parents will find out which state secondary school their children have been allocated on March 3 as part of National Offer Day.
Most schools have traditionally allocated places based on the distance between a pupil’s home and the school gates. This has allowed wealthier parents to buy property close to the best schools to secure places, with research suggesting that living in the catchment area of a highly sought-after school can add an average £31,500 “premium” to house prices.
But admissions guidance introduced by Labour allows institutions to employ a series of measures designed to break the stranglehold.
Lotteries, or “random allocation”, involve some or all applicants having their names drawn from a ballot, giving pupils living several miles away the same chance of a place as those next door.
“Fair banding” sees all applicants sit an aptitude test, with a set number of bright, average and low ability pupils being admitted. Schools usually use distance or a lottery to decide who gets a place within each ability band. Mrs Wallis said many parents “find fair banding complicated”, but insisted it was preferable to straight lotteries because “its goals are clearer”.

"Last week, The Sunday Telegraph obtained data on the admissions policies of more than 1,400 schools – 43 per cent of those nationally. Half of local authorities surveyed said at least one school in their area used lotteries, fair banding or both.
In total, one in 12 of the schools identified employed these admissions policies. Twice as many used fair banding as lotteries"

Gale and Shapley '62, a long-standing appreciation

While preparing for a talk I gave in England, I recently reread my 1990 paper: Roth, A.E., "New Physicians: A Natural Experiment in Market Organization," Science, 250, 1990, 1524-1528.

I hadn't recalled it, but this was the last paragraph of that paper:

"It is noteworthy that the simple idea of pairwise stability formulated by Gale and Shapley (5) has turned out to have so much empirical power. I think their paper has thus proved to be the kind of theoretical work that merits the highest scientific recognition."

Some industrial farming practices become cause for popular concern

Kristof in his NY Times column: Is that sausage worth this?

"While forcing hogs to be solitary and immobile in gestation crates for their entire adult lives is soul-crushing, popular disgust is leading to a revolution in industrial farming practices. Whole Foods and Chipotle and Burger King were among the first companies to avoid pigs raised in gestation crates, and, in the last few years, McDonalds, Safeway, Costco, Oscar Mayer and dozens of other companies have announced similar moves, often after a transition. It doesn’t seem as though costs will rise significantly.

"Carl Icahn, the investor, warned Tyson Foods that it had to drop gestation crates if it wanted to find buyers for its pork. Tyson got the message: Just last month, it wrote to all its suppliers and told them to treat pigs more humanely and to give them space to turn around. Smithfield Foods, which is the world’s largest pork producer and was acquired last year by a Chinese company, last month reaffirmed its commitment to transition away from gestation crates."

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Here's an interview on such matters I gave not long ago: Alvin Roth On Future Of Food

Should museums sell art only to buy more art?

Another university has contemplated--and then gone ahead with--selling art to raise money.
Inside Higher Ed has the story:

Art vs. Endowment

February 10, 2014

By

Scott Jaschik

"More than six years after announcing plans to sell a masterpiece of American painting -- the 1912 work "Men of the Docks," by George Bellows -- Randolph College has done so, gaining $25.5 million for its endowment.

In selling the painting, the college disregarded the policies of several art and museum groups, which state that museums (including those run by colleges) should sell art only to buy more art, not to improve their finances. The significance of "Men of the Docks" is evident not only by the price, but by the purchaser, the National Gallery of Britain, for which the painting is the first major work by an American ever bought for the permanent collection.

Randolph officials portray the sale as a success for the college, giving its endowment a significant boost, and point as well to internship opportunities the National Gallery has agreed to create for Randolph students.

But arts associations fear that such sales only encourage others, and undermine the role of college museums in preserving art, and educating students about art. In some cases, as at Randolph, college administrators have proposed to sell art. Brandeis University administrators in 2009 proposed to sell off its noted collection of modern art -- and the university backed away from the plan after a huge uproar.

Sometimes the idea is pushed from outside (especially at public universities). In 2011, some legislators urged the University of Iowa to sell Jackson Pollock's "Mural," an 8-by-20-foot painting that is considered one of the masterpieces of abstract art and of modern American art. (The university resisted the push.)

At Randolph, the board approved plans in 2007 to sell four paintings from the college's art museum, fought off a lawsuit seeking to block the sale, and sold one prior to "Men of the Docks," which is by far the most valuable and artistically significant in the collection."

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Recall the earlier imbroglio that ensued when Brandeis university considered selling some of its art, which I wrote about here.

Commercial surrogacy: legal in California, illegal in NY

I woke up in England this morning preparing to give the second of two Marshall Lectures, in which I'll talk about kidney exchange, and repugnant transactions. What better to see in the NY Times then the story about a same sex married couple in NY that had a child via gestational surrogacy in California, because it's illegal in NY. But one of the husbands is a NY State Senator who is introducing legislation in the hope of changing that.

And Surrogacy Makes 3: In New York, a Push for Compensated Surrogacy
By ANEMONA HARTOCOLLIS FEB. 19, 2014

"They had their baby in California because if they had had her in New York, they would have been breaking a 1992 New York law that bars commercial surrogacy contracts and equates them with baby-selling — a legacy of the notorious Baby M case of the 1980s.*

"Now Mr. Hoylman, as a novice state senator, is in a position to do something about it. He is the co-sponsor of a proposed law that would overturn the current law and make compensated surrogacy legal in New York State.

"Surrogate baby-making has long been a path taken by the affluent and celebrities, partly because it takes good legal advice and money to accomplish. But in recent years, it has been growing among gay men, who in a fundamentally conservative embrace of family values, see having children and building a family as the logical next step after getting married.

“Not to be cliché, but you know how the phrase goes — first comes love, then comes marriage, then comes the baby and the baby carriage,” said Allison Steinberg, a spokeswoman for the Empire State Pride Agenda, which has endorsed the bill.

The bill’s supporters argue that it makes no sense for New York, which has a large number of fertility clinics, not to mention a flourishing gay community, not to be able to offer commercial surrogacy to those who want it. And they say that making surrogacy more widely available could reduce the exorbitant costs, easily as much as $100,000 per baby."
...
*"The Baby M case, in which Mary Beth Whitehead, left with her husband, Richard, refused to give up custody of a baby girl she agreed to bear for a New Jersey couple, led to a New York law prohibiting paid surrogacy."
...
"Surrogate births are a small but growing part of the in vitro fertilization industry. Conservatively, about 1,600 babies a year in the United States are born through gestational surrogacy (which now accounts for almost all surrogacies), more than double the number in 2004, according to the American Society for Reproductive Medicine.
...
"But driven by the law of supply and demand, a first-time egg donor could be paid $8,000 to $10,000, and a first-time surrogate $30,000 and up, bringing the cost of a no-frills contract to $75,000 to $120,000 with medical, legal and agency fees.

“You basically have to take out a loan to have a child,” Mr. Hoylman said.

"Agencies prefer to contract with surrogates who are married with children, because they have a proven ability to have a healthy baby and are less likely to have second thoughts about giving up the child.

"Conversely, gay couples are popular among surrogates. “Most of my surrogates want same-sex couples,” said Darlene Pinkerton, the owner of A Perfect Match, the agency in San Diego that Mr. Hoylman used. Women unable to become pregnant often go through feelings of jealousy and loss, she said. But with gay men, that is not part of the dynamic, so “the experience is really positive for the surrogate.”

"Or as her husband, Tom, a third-party reproductive lawyer, put it, “Imagine instead of just having one husband doting on you, you have three guys now sending you flowers.”

"New York has one of the harshest surrogacy laws in the country, along with Arizona, Indiana, Michigan, Nebraska and the District of Columbia.
...
"It is legal in New York for a volunteer to carry a baby without pay, known as altruistic or compassionate surrogacy. And New Yorkers find ways around the law by shipping frozen embryos to clinics in nearby surrogacy-friendly states — Connecticut, Maryland, Pennsylvania, Massachusetts — for implantation. In New Jersey, paid surrogacy is still considered risky because of case law going back to Baby M. In 2012, Gov. Chris Christie vetoed a law that would have permitted some types of payment, saying he wanted more discussion of such “profound change in the traditional beginnings of a family.”

"Historically, the legal aversion to surrogacy stems from a sort of Margaret Atwood, “Handmaid’s Tale” fear that it lends itself to unnatural social engineering and the subjugation of women. This led to an unusual alliance of feminists, civil libertarians and the Catholic church in the early 1990s, when the New York Catholic Conference joined with the New York Civil Liberties Union and the National Organization for Women to oppose surrogacy.

"The Baby M case led to a pioneering court ruling on the validity of a surrogate-mother contract, and its outcome had a strong impact on New York because it played out across the river in New Jersey. Mary Beth Whitehead was a young homemaker with two children, in a rocky marriage to a sanitation worker, when she agreed in 1985 to have another man’s baby for $10,000.

"Soon after giving birth, she took the baby to Florida and renounced her fee, saying she wanted to keep the child.

"On appeal, the New Jersey Supreme Court restored her parental rights while leaving custody of Baby M with her biological father and his wife. “This is the sale of a child, or at the very least, the sale of a mother’s right to her child, the only mitigating factor being that one of the purchasers is the father,” the high court said.

"“So much has changed since Baby M,” said Sonia Ossorio, president of the New York City chapter of the National Organization for Women.

For one thing, Ms. Whitehead was artificially inseminated using her own egg and the prospective father’s sperm, a process now disdained as “traditional” surrogacy. Today, the pregnancy would involve a third-party egg, so the surrogate would not be genetically related to the baby.

The new technology has given rise to a whole new language — gestational carrier, instead of surrogate mother, “intended parents,” “collaborative reproduction.”

Unraveling of college athletic recruiting

At Stanford, when I meet student athletes I sometimes ask them when they first met a Stanford coach, and the earliest answer I've gotten so far is 8th grade. Here's a great NY Times story by Nathaniel Popper that confirms this isn't an extreme outlier.

Committing to Play for a College, Then Starting 9th Grade

"In today’s sports world, students are offered full scholarships before they have taken their first College Boards, or even the Preliminary SAT exams. Coaches at colleges large and small flock to watch 13- and 14-year-old girls who they hope will fill out their future rosters. This is happening despite N.C.A.A. rules that appear to explicitly prohibit it.

"The heated race to recruit ever younger players has drastically accelerated over the last five years, according to the coaches involved. It is generally traced back to the professionalization of college and youth sports, a shift that has transformed soccer and other recreational sports from after-school activities into regimens requiring strength coaches and managers.

...

"Early scouting has also become more prevalent in women’s sports than men’s, in part because girls mature sooner than boys. But coaches say it is also an unintended consequence of Title IX, the federal law that requires equal spending on men’s and women’s sports. Colleges have sharply increased the number of women’s sports scholarships they offer, leading to a growing number of coaches chasing talent pools that have not expanded as quickly. In soccer, for instance, there are 322 women’s soccer teams in the highest division, up from 82 in 1990. There are now 204 men’s soccer teams.

“In women’s soccer, there are more scholarships than there are good players,” said Peter Albright, the coach at Richmond and a regular critic of early recruiting. “In men’s sports, it’s the opposite.”

"While women’s soccer is generally viewed as having led the way in early recruiting, lacrosse, volleyball and field hockey have been following and occasionally surpassing it, and other women’s and men’s sports are becoming involved each year when coaches realize a possibility of getting an edge.

"Precise numbers are difficult to come by, but an analysis done for The New York Times by the National Collegiate Scouting Association, a company that consults with families on the recruiting process, shows that while only 5 percent of men’s basketball players and 4 percent of football players who use the company commit to colleges early — before the official recruiting process begins — the numbers are 36 percent in women’s lacrosse and 24 percent in women’s soccer.

At universities with elite teams like North Carolina and Texas, the rosters are almost entirely filled by the time official recruiting begins.
...
For girls and boys, the trend is gaining steam despite the unhappiness of many of the coaches and parents who are most heavily involved, many of whom worry about the psychological and physical toll it is taking on youngsters.

“It’s detrimental to the whole development of the sport, and to the girls,” Haley’s future coach at Texas, Angela Kelly, said at the Florida tournament.

:The difficulty, according to Ms. Kelly and many other coaches, is that if they do not do it, other coaches will, and will snap up all of the best players. Many parents and girls say that committing early ensures they do not miss out on scholarship money.
...
"The N.C.A.A. rules designed to prevent all of this indicate that coaches cannot call players until July after their junior year of high school. Players are not supposed to commit to a college until signing a letter of intent in the spring of their senior year.

"But these rules have enormous and widely understood loopholes. The easiest way for coaches to circumvent the rules is by contacting the students through their high school or club coaches. Once the students are alerted, they can reach out to the college coaches themselves with few limits on what they can talk about or how often they can call.

"Haley said she was having phone conversations with college coaches nearly every night during the eighth grade.
...
"Mr. Dorrance, who has won 22 national championships as a coach, said he was spending his entire weekend focusing on the youngest girls at the tournament, those in the eighth and ninth grades. Mr. Dorrance is credited with being one of the first coaches to look at younger players, but he says he is not happy about the way the practice has evolved.

“It’s killing all of us,” he said.

"Mr. Dorrance’s biggest complaint is that he is increasingly making early offers to players who do not pan out years later.

“If you can’t make a decision on one or two looks, they go to your competitor, and they make an offer,” he said. “You are under this huge pressure to make a scholarship offer on their first visit.”

"The result has been a growing number of girls who come to play for him at North Carolina and end up sitting on the bench.
...
"Once the colleges manage to connect with a player, they have to deal with the prohibition on making a formal scholarship offer before a player’s final year of high school. But there is now a well-evolved process that is informal but considered essentially binding by all sides. Most sports have popular websites where commitments are tallied, and coaches can keep up with who is on and off the market.

"Either side can make a different decision after an informal commitment, but this happens infrequently because players are expected to stop talking with coaches from other programs and can lose offers if they are spotted shopping around. For their part, coaches usually stop recruiting other players."
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The article makes reference to a 2011 paper by Boston College Law professor Alfred Yen: Early Scholarship Offers and the NCAA

HT: Stephanie Hurder