Kim Krawiec on repugnance, and global kidney exchange

Kim Krawiec talks about podcasts, and then about repugnance with some of her old podcast pals at Oral Argument.  They talk about global kidney exchange (the short title they propose to her is "more kidneys, more better," around minute 5:30 when the substantive discussion starts).

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


Kim blogs about this herself over at the Faculty Lounge:
Repugnance, Global Kidney Exchange, and Drinking Our Own Spit: An Oral Argument Reunion

Medically assisted death

The Guardian and the BBC bring us up to date on death with dignity in the Netherlands.

Here are some excerpts from the Guardian's long read:

Death on demand: has euthanasia gone too far?
Countries around the world are making it easier to choose the time and manner of your death. But doctors in the world’s euthanasia capital are starting to worry about the consequences
By Christopher de Bellaigue

"Keizer is one of around 60 physicians on the books of the Levenseindekliniek, or End of Life Clinic, which matches doctors willing to perform euthanasia with patients seeking an end to their lives, and which was responsible for the euthanasia of some 750 people in 2017. For Keizer, who was a philosopher before studying medicine, the advent of widespread access to euthanasia represents a new era. “For the first time in history,” he told me, “we have developed a space where people move towards death while we are touching them and they are in our midst. That’s completely different from killing yourself when your wife’s out shopping and the kids are at school and you hang yourself in the library – which is the most horrible way of doing it, because the wound never heals.
...
"Euthanasia has been legal in the Netherlands for long enough to show what can happen after the practice beds in.
...
"In 2002, the parliament in the Hague legalised euthanasia for patients experiencing “unbearable suffering with no prospect of improvement”. Since then, euthanasia and its close relation, assisted dying, in which one person facilitates the suicide of another, have been embraced by Belgium and Canada, while public opinion in many countries where it isn’t on the national statute, such as Britain, the US and New Zealand, has swung heavily in favour.

"The momentum of euthanasia appears unstoppable; after Colombia, in 2015, and the Australian state of Victoria, in 2017, Spain may be the next big jurisdiction to legalise physician-assisted death, while one in six Americans (the majority of them in California) live in states where it is legal. In Switzerland, which has the world’s oldest assisted dying laws, foreigners are also able to obtain euthanasia.
...
"Euthanasia is counted as a basic health service, covered by the monthly premium that every citizen pays to his or her insurance company. But doctors are within their rights not to carry it out. Unique among medical procedures, a successful euthanasia isn’t something you can assess with your patient after the event. A small minority of doctors refuse to perform it for this reason, and others because of religious qualms. Some simply cannot get their heads around the idea that they must kill people they came into medicine in order to save.
...
"At any meeting organised by the NVVE [Dutch Voluntary Euthanasia Society], you will look in vain for poor people, pious Christians or members of the Netherlands’ sizeable Muslim minority. Borne along by the ultra-rational spirit of Dutch libertarianism (the spirit that made the Netherlands a pioneer in reforming laws on drugs, sex and pornography), the Dutch euthanasia scene also exudes a strong whiff of upper-middle class entitlement.

"Over coffee I was introduced to Steven Pleiter, the director of the Levenseindekliniek. We went outside and basked in the early October sun as he described the “shift in mindset” he is trying to achieve. Choosing his words with care, Pleiter said he hoped that in future doctors will feel more confident accommodating demands for “the most complex varieties of euthanasia, like psychiatric illnesses and dementia” – not through a change in the law, he added, but through a kind of “acceptance … that grows and grows over the years”. When I asked him if he understood the scruples of those doctors who refuse to perform euthanasia because they entered their profession in order to save lives, he replied: “If the situation is unbearable and there is no prospect of improvement, and euthanasia is an option, it would be almost unethical [of a doctor] not to help that person.”
...
"Even those who have grave worries about the slippery slope concede that consensual euthanasia for terminal illness can be a beautiful thing, and that the principle of death at a time of one’s choosing can fit into a framework of care. The question for any country contemplating euthanasia legislation is whether the practice must inevitably expand – in which case, as Agnes van der Heide recognises, death will eventually “get a different meaning, be appreciated differently”. In the Netherlands many people would argue that – for all the current wobbles – that process is now irreversible."
*******

And here's a link and a figure from the BBC story, which concentrates on the difficult case of dementia--difficult because even the clearest directive from a patient with early stage dementia who wants to end his or her life as the disease progresses can often not be confirmed by the patient once dementia is fully established.

Wanting to die at 'five to midnight' - before dementia takes over

Colleges harvest signals of interest in more ways

Congested markets--those in which there are more potential transactions than can be easily processed--promote signaling, and the search for signals, about which transactions to pursue.  College admissions is a famously congested market, particularly since it became easy for students to submit many applications. So all but the most elite colleges have long searched for signals of "demonstrated interest."  The WSJ has an update on how technology is changing that search.

The Data Colleges Collect on Applicants
To determine ‘demonstrated interest,’ some schools are tracking how quickly prospective students open email and whether they click links  By Douglas Belkin

"Enrollment officers at schools including Seton Hall University, Quinnipiac College and Dickinson College know down to the second when prospective students opened an email from the school, how long they spent reading it and whether they clicked through to any links. Boston University knows if prospective students RSVP’d online to an event—and then didn’t show.
...
"At Seton Hall University, in South Orange, N.J., students receive a score between 1 and 100 that reflects their demonstrated interest, said Alyssa McCloud, vice president of enrollment management. The score includes about 80 variables including how long they spent on the school’s website, whether they opened emails and at what point in high school they started looking on the website (the earlier the better).
...
"In 2017, 37% of 493 schools surveyed by the National Association of College Admission Counseling said they consider demonstrated interest to be of moderate importance—on par with teacher recommendations, class rank and extracurricular activities. It carried less weight than grades, class rigor or board scores.
...
"Colleges also have low-tech means to help determine demonstrated interest. Last year, one third of students who applied to American University either visited its Washington, D.C., campus or attended an information session about the school, said Andrea Felder, assistant vice provost for undergraduate admissions. Two thirds of those admitted took part in either the campus tour or offsite information session.
...
"Mary Hinton, a senior at Dickinson College, benefited from demonstrated interested without knowing it. After she toured Dickinson in high school, she sent a thank-you note to her tour guide, at her mother’s suggestion.

Now a tour-guide herself, Ms. Hinton has learned those notes are forwarded from tour guides to admissions officers. Her advice to prospective students about thank-you notes: “Write them. It just takes a minute and it can make a difference.”

Understanding and misunderstanding algorithmic bias

Adventures in Computation explains a recent political discussion:

Algorithmic Unfairness Without Any Bias Baked In
"Discussion of (un)fairness in machine learning hit mainstream political discourse this week, when Representative Alexandria Ocasio-Cortez discussed the possibility of algorithmic bias, and was clumsily "called out" by Ryan Saavedra on twitter.
...
"Bias in the data is certainly a problem, especially when labels are gathered by human beings. But its far from being the only problem. In this post, I want to walk through a very simple example in which the algorithm designer is being entirely reasonable, there are no human beings injecting bias into the labels, and yet the resulting outcome is "unfair".

Kidney exchange in Germany? It will need an amendment to the Transplantation Act

Axel Ockenfels points out that the Frankfurter Allgemeine Sonntagszeitung has a recent piece on "Tauschen wir die Nieren?" ("Do we exchange kidneys?"). I can't find it online, but here's a picture:

Google translate renders the opening paragraphs as follows:

"Patients wait a long time for donor organs. That can be changed - with a proposal that has received the Nobel Prize.
Organ donation is literally a matter of life and death. Anyone who receives the urgently needed organ in good time lives on. In Germany, however, many are waiting for the necessary transplantation - often for years. At the same time, the number of organ donations is falling. So how can the number of donated organs be increased so that affected people can live? That's a tricky question, because too many answers tend to limit the voluntary nature of the donation. On Wednesday, the topic is on the agenda of German politics, when the Health Committee of the Bundestag deals with the amendment of the Transplantation Act.
The economists Dorothea Kübler and Axel Ockenfels advise the politicians to take a look at living donations. Kidneys or parts of the liver can also be donated by living people - and this is much less common in Germany than in other countries. The proposal goes in the direction of the FDP parliamentary group around the chairman Christian Lindner, who are pushing for more living donations. In a motion for the health committee on Wednesday, the FDP is proposing to allow the cross-donation of two couples and an anonymous live donation to an organ pool. "

Repugnant markets and black markets -- interview

Here's a short interview on repugnant markets, in Stanford's engineering magazine:

Repugnant markets spur thinking about how to engineer complex systems
"​When some people want to engage in economic activity that others seek to ban, society faces tough choices in designing the right market incentives — or disincentives."
By ​Edmund L. Andrews

"when is it effective to outlaw an activity, and when does that simply foster a black market? At what point does it make more sense to focus on harm reduction than prevention?

"Roth expanded on these ideas in a recent interview..."

Another link is here.

School choice in New Haven: studied by Kapor, Neilson and Zimmerman and switching from immediate to deferred acceptance

The New Haven Independent reports on efforts to change school choice there:
Profs Tapped To Fix School-Choice Lottery

"Would knowing the exact odds make any difference in the parents’s choices? If they’d been warned about their slim chances, would they be more likely to swap in a backup? If they still went ahead with a big gamble, should the lottery administrators take that as a signal of how deeply they care about their picks?

"The school district has tapped three academics to study those very questions in an effort to make the lottery process more transparent, simple and equitable this year.

"At its Monday night meeting on Meadow Street, the Board of Education’s Finance & Operations Committee recommended approving a non-financial agreement with three assistant professors —  Princeton’s Adam Kapor and Christopher Neilson and University of Chicago’s Seth Zimmerman —  to recommend how the district could do a better job marketing and communicating about a revamped enrollment process.

"As part of the agreement, New Haven will change the algorithm that it uses to assign students in 2019-20. Modeled on applications in New York, Chicago and Boston, the new model will ideally reward students for listing the schools that they’d like to attend rather than for gaming the system."

The project started with a study of the system's current, immediate acceptance algorithm

"In the paper, which was published in the American Economic Review in 2016, Kapor, Neilson and Zimmerman said that there’s currently more uninformed parents making mistakes than sophisticated gamblers making savvy bets. They concluded that “offering some means to learn about admissions probabilities for different portfolios” would likely be “welfare-improving.”

"Figuring out exactly what that will look like is the subject of Kapor, Neilson and Zimmerman’s next experiment.

As part of the memorandum of understanding that the Finance & Operations Committee reviewed on Monday, the academics agreed to provide a data analyst who will assist the Choice & Enrollment Office in-house at no charge for the next two years. With additional surveys and data analysis, they’ll review how the revamped lottery changes placement outcomes, family satisfaction and student achievement."

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

For more on the investigators, see https://sites.google.com/site/adamkapor/research
http://wws.princeton.edu/sites/default/files/person/cvfiles/CNeilson_vita_extended_Princeton_2018_08_01.pdf
https://sites.google.com/site/sethdavidzimmerman/research

Black market kidney transplants to UK patients? An inflammatory article in the Daily Mail

There seems to be good evidence that kidneys for transplantation are bought and sold in some parts of the world. However I'm not aware of any good data on how much of this trade involves people from wealthy countries, as opposed to internal commerce in less well resourced countries.

 Here's a scare headline from the British tabloid newspaper the Daily Mail:
REVEALED: Hundreds of Britons who buy KIDNEYS on the black market from overseas traffickers charging £30,000 in a bid to avoid NHS waiting lists are coming back with deadly diseases such as HIV and hepatitis

It turns out that the "hundreds"  in the National Health Service data are 400, over a period of 16 years, which averages out to 25 Britons a year.

"Around three million Britons have chronic kidney disease, with the biggest causes uncontrolled diabetes and high blood pressure. It contributes to 45,000 early deaths every year.

NHS figures show almost 400 UK residents have received follow-up support after a transplant abroad over the past 16 years. But medics say the true number is likely to be higher because most are advised by brokers not to tell the NHS what they have done."

I don't know what kinds of health data the NHS collect, but in principle it would be easy to track all patients who return to the UK with a transplant from overseas, because such patients immediately need to get prescriptions for daily immunosuppressive drugs. (However I don't think we track these data in a centralized way in the U.S.)


HT Frank McCormick
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Here some of what I've gleaned in the past:

Monday, December 17, 2018 

Australia's parliament reports on organ trafficking

Australia's parliament has published a report on organ trafficking in Australia. They didn't find much trafficking there, but recommend that data be more vigorously collected. They report that only one case of (attempted) paid organ donation has come to the attention of the authorities, but that it was successfully prevented, and the intended recipient died. The report ends with a case study of an anatomical exhibit using human cadavers.

Wednesday, October 4, 2017 

Kidney black markets are persistent

Black markets in kidneys--like those for narcotic drugs--have resisted attempts to abolish them.

Sunday, September 17, 2017

Yemenis selling kidneys in Egypt: Al Jazeera

Al Jazeera has the (nuanced) story:
Desperate Yemenis sell organs to survive

Sunday, January 15, 2017

Egypt arrests 'organ trafficking ring'

The BBC has the story: Egypt arrests 'organ trafficking ring'
Egyptian authorities have arrested doctors, nurses and professors suspected of being involved in an international organ trafficking ring.

Black markets for kidney transplants--arrests in Israel

A late December story of black markets and law enforcement from the Times of Israel:
2 charged with running international organ traffic ring. Patients allegedly paid $180,000 for a kidney; illegal transplants carried out in Turkey, Bulgaria, Thailand, Philippines

"In the last two years, the ring reportedly arranged for 14 transplants in four countries; Turkey, Bulgaria, Thailand and Philippines"

Saturday, October 8, 2016

More on kidney black markets in India

Top Indian Hospital Complicit In Lucrative Black Market for Human Organs

Friday, August 19, 2016

Interview with a kidney buyer and seller in Syria

Here's an interview with a displaced person in Syria (an internal refugee) and the Syrian woman to whom he sold his kidney:
The woman in need of a kidney and the man willing to sell one to her: ‘I’m at the end of the line’

Tuesday, June 21, 2016

Kidney black market arrests at Apollo hospital in Delhi

Wednesday, June 8, 2016

On Patients Who Purchase Organ Transplants Abroad--Many or few?

An article in the American Journal of Transplantation:
On Patients Who Purchase Organ Transplants Abroad
by F. Ambagtsheer,*, J. de Jong,W. M. Bramer and W. Weimar

"We conclude that the scientific literature does not reflect a large number of patients buying organs. Organ purchases were more often assumed than determined. A reporting code for transplant professionals to report organ trafficking networks is a potential strategy to collect and quantify cases."

Universal health coverage under siege from both the right and the left, in the U.S. and Mexico

Here's a commentary in The Lancet, comparing attacks on the Affordable Care Act in the U.S. and on Seguro Popular in Mexico.

A dark day for universal health coverage, by Julio Frenk, Octavio Gómez-Dantés, and Felicia Marie Knaul

"Dec 14, 2018, was a dark day for universal health coverage (UHC). To begin with, a federal judge in Texas, USA, ruled that the Affordable Care Act (ACA) is unconstitutional.1 That same day, the new President of Mexico, Andrés Manuel López Obrador, announced his intention to abolish the country's largest public insurance programme, known as Seguro Popular (People's Health Insurance).2 The ACA and Seguro Popular have extended health coverage to millions of previously uninsured families, most of them among the poorest in their respective countries. Signed into law in 2010, the ACA roughly halved the number of uninsured, from 46·5 million then to 26·7 million in 2016, towards the end of the Obama administration.3,  4 Following legislative approval, Seguro Popular began full-scale implementation in Mexico in 2004. Public expenditure increased to finance coverage for non-salaried workers and their families, approximately half of Mexico's total population, who were excluded from employment-based social insurance. By 2018, 53 million beneficiaries had access to 290 essential and 65 high-cost interventions.
...
"The challenge to the ACA has been headed by the right wing of the US Republican Party, whereas the attack to Seguro Popular comes mostly from the far left factions of the President's Morena party. This is an example of the way in which opposing political extremes can converge in their attack against centrist positions.
...
"Seguro Popular is one of the most thoroughly evaluated programmes in the world. A 2006 Lancet Series set out the evidence base for the design of this innovative initiative.7,  8 A comprehensive review9 published 8 years into implementation identified a large body of peer-reviewed articles, including one of the few randomised assessments of a large-scale social intervention.10 The evidence strongly points to major benefits of Seguro Popular in terms of financial protection and effective coverage,11 without labour market distortion.12 In a recent cover article on UHC, The Economist featured Seguro Popular among the most successful efforts in low-income and middle-income countries, noting how “studies suggest that Seguro Popular has drastically reduced the number of Mexicans facing catastrophic health costs and reduced infant mortality”

Kidney transport: a Tesla and a flat tire

Transporting kidneys can be surprisingly informal.  Here's an account of a Tesla, a flat tire, and hitching a ride.

Good Samaritan drives stranded surgeon, donor kidney to Pa. hospital

"Dr. Martin Wijkstrom had two jobs to perform Wednesday evening: Drive a donor kidney from Pittsburgh to Erie, Pa., then implant the organ in a patient at UPMC Hamot.
...
“I had already picked up the kidney at a Pittsburgh hospital and had just charged my Tesla in Cranberry Township,” said Wijkstrom, a UPMC transplant surgeon. “I was driving to get back on (Interstate 79) to go to Erie when I struck a pothole.”

"The pothole caused one of Wijkstrom’s tires to go flat. He was stuck in the Cranberry Mall parking lot with a donor kidney, 108 miles from the hospital where a patient waited to receive it.

"His Tesla didn’t carry a spare tire. Though the kidney was secured in a refrigerated container in Wijkstrom’s trunk, the surgeon had about 12 hours to implant the organ for the best chances of success.

“It wasn’t an emergency situation but we needed to put the kidney into the patient as soon as possible,” said Wijkstrom, who said he had transported kidneys in his car three or four previous times.
...
"Brad Dostlik was driving his Nissan Sentra near the mall, listening to his portable police scanner.
He heard a dispatcher send police to the surgeon’s car and notify them about the kidney. Dostlik, who was headed to the nearby Field & Stream store, decided to see if he could help.
...
“He asked if I could take him to Erie,” Dostlik said. “I had a full tank of gas, so why not?”
...
“I learned a lot of stuff during the trip,” Dostlik said. “I don’t think I could do what he does.”
...
"The two men shook hands and the surgeon walked into the hospital with the donor organ, just 40 minutes later than expected.

“The surgery was uneventful,” Wijkstrom said. “The patient is doing well, his kidney is making some urine already.”

Kosher and halal slaughtering banned in Belgium

The coalition of liberal animal rights activists and European anti-Semites and Islamophobes doesn't make the new laws easy to parse:

Belgium Bans Religious Slaughtering Practices, Drawing Praise and Protest

"BRUSSELS — A Belgian ban on the Muslim and Jewish ways of ritually slaughtering animals went into effect on New Year’s Day, part of a clash across Europe over the balance between animal welfare and religious freedom.

"With both animal rights advocates and right-wing nationalists pushing to ban ritual slaughter, religious minorities in Belgium and other countries fear that they are the targets of bigotry under the guise of animal protection.
...
"Laws across Europe and European Union regulations require that animals be rendered insensible to pain before slaughter, to make the process more humane. For larger animals, stunning before slaughter usually means using a “captive bolt” device that fires a metal rod into the brain; for poultry it usually means an electric shock.
...
"But slaughter by Muslim halal and Jewish kosher rules requires that an animal be in perfect health — which religious authorities say rules out stunning it first — and be killed with a single cut to the neck that severs critical blood vessels. The animal loses consciousness in seconds, and advocates say it may cause less suffering than other methods, not more.

"Most countries and the European Union allow religious exceptions to the stunning requirement, though in some places — like the Netherlands, where a new law took effect last year, and Germany — the exceptions are very narrow. Belgium is joining Sweden, Norway, Iceland, Denmark and Slovenia among the nations that do not provide for any exceptions.
...
"The idea for the ban was first proposed by Ben Weyts, a right-wing Flemish nationalist and the minister in the Flanders government who is responsible for animal welfare. Mr. Weyts was heavily criticized in 2014 for attending the 90th birthday of Bob Maes, who had collaborated with the Nazi occupation of Belgium in World War II and later became a far-right politician."

Bounty hunters, licensing, and cellphone location data

The Seattle Times has a disturbing article about a little-regulated private enterprise part of the criminal justice system in many American states--the bounty hunters who work with bail bondsmen:

Lax Washington oversight of bounty hunters sets stage for mayhem, tragedy
(The url gives an alternative headline: https://www.seattletimes.com/seattle-news/times-watchdog/high-adrenaline-bounty-hunter-industry-operates-with-little-oversight-despite-concerns-over-training-tactics/ .)

"Formally known as bail-bond recovery agents, bounty hunters frequently carry firearms and have the right to forcibly enter homes and apprehend people who jump bail.

"Yet getting a license is relatively easy, and hardly anyone is turned away — even if they have a history of violence, a Seattle Times investigation has found.
...
"The lax requirements for bounty hunters are at odds with the weapons and tactics the agents are allowed to use. To get a license, an applicant must take 32 hours of training, which can include self-study, and must pass a 50-question, multiple-choice exam. The state has no formalized curriculum or certification process for instructors. Only the person teaching the firearms portion of the training is required to be certified through the state.

"By comparison, to get a license to perform manicures and style hair, a cosmetologist must receive 1,600 hours of training from a state-approved and licensed instructor."
***********

Furthermore:
I Gave a Bounty Hunter $300. Then He Located Our Phone
T-Mobile, Sprint, and AT&T are selling access to their customers’ location data, and that data is ending up in the hands of bounty hunters and others not authorized to possess it, letting them track most phones in the country.

and
Ajit Pai Refuses to Brief Congress About Why Bounty Hunters Can Buy Cell Phone Location Data
The Chairman's staff said the selling of location data is not a 'threat to the safety of human life or property that the FCC will address during the Trump shutdown.'

National Kidney Foundation (NKF) statement

A January press release from the NKF :

NKF Statement: A Path Forward for Increasing Kidney Transplantation

"Nearly 680,000 Americans have irreversible kidney failure, or end-stage renal disease (ESRD), and need dialysis or a kidney transplant. More than 475,000 ESRD patients receive dialysis at least three times per week to replace kidney function.  Nearly 100,000 Americans are on the waitlist for a kidney transplant right now.  Depending on where a patient lives, the average wait time for a kidney transplant can be upwards of three to seven years.  

The National Kidney Foundation is calling on Congress and the Administration to make organ transplantation a top priority and has identified several critical areas to be addressed from a legislative and regulatory standpoint. These priorities will create a strategic and effective path forward towards increasing the number of kidney transplants and decreasing the number of patients who die waiting.

1. Living Donation

a. Expand financial assistance offered to living organ donors to cover all expenses related to organ donation including lost wages; travel expenses including transportation, lodging and food; child care or dependent care expenses incurred during the donor’s recovery; living donor medical care and follow-up care for donation; paperwork or legal costs related to the donation; and other expenses related to the donation.

..."

More at the link...

HT: Frank McCormick

Pharma pricing, and the secondary market for diabetes test strips

The NY Times has the story on the gray market for diabetes test strips:

The Strange Marketplace for Diabetes Test Strips

"Test strips are a multi-billion-dollar industry. A 2012 study found that among insulin-dependent patients who monitor their blood sugar, strips accounted for nearly one-quarter of pharmacy costs. Today, four manufacturers account for half of global sales.

"In a retail pharmacy, name-brand strips command high prices. But like most goods and services in American health care, that number doesn’t reflect what most people pay.

"The sticker price is the result of behind-the-scenes negotiations between the strips’ manufacturer and insurers. Manufacturers set a high list price and then negotiate to become an insurer’s preferred supplier by offering a hefty rebate.
...
"For a patient testing their blood many times a day, paying for strips out-of-pocket could add up to thousands of dollars a year. Small wonder, then, that a gray market thrives. The middlemen buy extras from people who obtained strips through insurance, at little cost to themselves, and then resell to the less fortunate.

"That was the opportunity that caught Chad Langley’s eye. He and his twin brother launched the website Teststripz.com to solicit test strips from the public for resale. Today they buy strips from roughly 8,000 people; their third-floor office in Reading, Mass., receives around 100 deliveries a day.

"The amount the Langleys pay depends on the brand, expiration date and condition, but the profit margins are reliably high. For example, the brothers will pay $35 plus shipping for a 100-count box of the popular brand Freestyle Lite in mint condition.

"The Langleys sell the box for $60. CVS, by contrast, retails the strips for $164.
...
"While some resellers use websites like Amazon or eBay to market strips directly to consumers, the biggest profits are in returning them to retail pharmacies, which sell them as new and bill the customer’s insurance the full price.
...
“Test strips are basically printed, like in a printing press,” said David Kliff, who publishes a newsletter on diabetes. “It’s not brain surgery.”

"He estimated the typical test strip costs less than a dime to make."

Surrogacy as viewed from Spain (where it is illegal)

Not late-breaking news, but here are some El Pais reports that reflect the ongoing situation in Spain:

Spain struggles with surrogate pregnancy issue
Practice is illegal here but debate rages over whether surrogacy is a right or a form of exploitation

"The Swiss-based International Social Security Association estimates that every year, surrogate mothers give birth to around 20,000 children worldwide. Agencies and parents estimate that between 800 and 1,000 go on to live with Spanish parents, but there are no official figures. There are numbers, however, for international adoptions undertaken by Spaniards, and these have fallen from 5,541 in 2004 to 799 in 2015.

"Yet if the estimates are correct, international surrogacy has overtaken international adoption in popularity. Instead of the international adoption process, which can take up to eight years, it seems that those wanting to be parents are more frequently opting for the quicker route, and paying between €45,000 and € 60,000 in the Ukraine or Russia or up to €120,000 in California – one of 14 American states where the practice is legal.

"Every country has different legislation. Ukraine, for example, only allows heterosexual couples to use surrogates. In Canada, the United Kingdom and Portugal, surrogacy is only allowed in the altruistic sense, meaning the surrogate mother receives no direct economic benefit. And the latter two countries only let nationals use surrogacy. India, a former worldwide power in surrogacy, has vetoed it for foreign couples, and is on the verge of making it illegal for economic profit. Mexico too, particularly the State of Tabasco, has recently restricted surrogacy laws.
...
"“The best solution to avoid abuses is to legislate it. It’s like organ transplants – regulating the legal practice gets rid of organ trafficking,” says Pedro Fuentes, president of a pro-surrogacy parental association that brings together around 400 families, Son Nuestros Hijos. Fuentes is a gynecologist and alongside his husband, he is also the father of a six-year-old boy who was born in California to a surrogate mother. He gets emotional when he tells the story of how he met the surrogate mother and the warm relationship they developed. He said that her own ethics also guided the process, as she had decided to use her body as a surrogate to help a gay couple.

"The association itself has a code of ethics and recommends not trusting “agencies that don’t let you meet the mother, which guarantee results, and which offer package deals saying you won’t have to worry about anything.” Also, they suggest that parents work with a woman who has already given birth. The association certainly makes the case for altruism but it is also open to economic compensation.
...
"The association asks: “When is a women being exploited? When you pay her or when you don’t?”
**********

Also,
The dark side of Ukraine’s surrogacy boom
Lack of oversight, lax regulations and a failing economy have made the eastern European country one of the most popular destinations to find a surrogate mother
*******

And here's a story from 2014 with background on the Spanish supreme court's decision not to recognize the child of Spanish parents borne by a California surrogate:
Are you my mother? The Spanish Supreme Court and surrogacy tourism

"The majority of the judges, however, contend that the “best interests” criterion is not the sole factor to be taken into account. Judges should also ponder the State’s interest in preventing the commodification of children and motherhood. But more strikingly, the Supreme Court argues that it is not obvious that it goes in the best interests of the twins to be legally declared as the sons of Ramón and César and not of the surrogate mother. It is striking, in my view, to argue along those lines when the surrogate mother is a woman who has relinquished her motherhood and the intending parents are not only willing to be the parents, but, most importantly, are the “social” fathers."



HT: Stephanie Wang

The Urology Residency Match

Yesterday was Match Day for urologists, a medical specialty that runs its own residency match, in advance of the NRMP.

They write: "This year's Match once again proved urology is a competitive specialty for aspiring young physicians. More than 430 applicants registered for the 2019 SAU/AUA Urology Residency Match. Of those who registered, 90 percent submitted preference lists, competing for a record 339 available positions across the country. When the matching algorithm was processed, 85 percent matched to a vacancy within 136 registered and accredited U.S. training programs, leaving only nine vacancies unmatched."

Here are the statistics from the AUA's web page:

Urology Residency Match Statistics

There are 137 non-military accredited urology residency programs in the United States. (Military programs cannot participate due to government regulations regarding eligibility.) For 2019, 135 non-military accredited urology residency programs in the United States listed 339 positions with 330 vacancies being matched. 389 applicants submitted preference lists netting 59 unmatched applicants. Of the senior medical students in the U.S. applying, 91% percent were matched.

View additional 2019 Urology Residency Match Statistics [pdf]

	Jan 2019	Jan 2018	Jan 2017	Jan 2016	Jan 2015	Jan 2014	Jan 2013
Programs
Positions Offered	339	325	319	295	296	285	279
Positions Filled	330	314	317	294	295	285	279
Positions Open	9	11	2	1	1	0	0
Applicants
Registrations	434	436	477	468	493	534	537
Lists Submitted	389	402	422	417	433	446	434
Ranked by Programs	368	369	385	373	388	420	400
Matched	330	314	317	294	295	285	279
Not Matched	59	88	105	123	138	161	155
Averages and Match Results
Average Applications	71.0	70.0	68.0	65.0	63.0	59.0	53.0
Average Interviews	37.0	11.0	11.0	10.0	10.0	10.0	9.0
Average Offers	14.85	13.78	11.77	11.35	12.23	9.35	8.87
US Seniors Matched	91%	86%	82%	77%	77%	68%	69%
US Graduates Matched	78%	43%	47%	47%	43%	15%	33%
Int'l Graduates Matched	58%	24%	33%	17%	31%	24%	23%
Women Matched	83%	75%	75%	68%	68%	65%	68%

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And here's some process data from the pdf:

HT: Mike Rees

Fifty years of "brain death"

There was a time when death came in threes: neurological, respiratory, and circulatory processes all shut down more or less together, because when a body lost one of these the others inevitably followed very quickly.  But what makes most deceased organ transplantation possible is that respiration and circulation can be maintained on a ventilator after the end of neurological activity, so that organs can remain oxygenated after the brain has died.

The Uniform Determination of Death Act (UDDA) states that an individual who has sustained either:
"an irreversible cessation of circulatory and respiratory functions, or
an irreversible cessation of all functions of the entire brain, including the brain stem, is dead."


A recent Hastings Center Report discusses brain death on the 50th anniversary of its 'birth'.


Brain Death at Fifty: Exploring Consensus, Controversy, and Contexts
Robert D. Truog  Nancy Berlinger  Rachel L. Zacharias  Mildred Z. Solomon

Abstract: This special report is published in commemoration of the fiftieth anniversary of the “Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death,” a landmark document that proposed a new way to define death, with implications that advanced the field of organ transplantation. This remarkable success notwithstanding, the concept has raised lasting questions about what it means to be dead. Is death defined in terms of the biological failure of the organism to maintain integrated functioning? Can death be declared on the basis of severe neurological injury even when biological functions remain intact? Is death essentially a social construct that can be defined in different ways, based on human judgment? These issues, and more, are discussed and debated in this report by leading experts in the field, many of whom have been engaged with this topic for decades.
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And here's an article about the report in Forbes (it seems to be in their section on "retirement":-)
What Does "Dead" Mean? The Debate Continues Some 50 Years After Harvard Defined Death.  Robin Seaton Jefferson

“Capron, one of the architects of the UDDA, summarized the situation well in 2001 when he described efforts to determine when death has occurred as both ‘well settled, yet still unresolved.’
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The article suggests that we won't have to worry about precise definitions of death once we don't need deceased donors for transplantation any more, but I'm not so sure.  Ventilators help keep people alive while their bodies are struggling, and some will recover.  But if not, there is still often a decision to be made about when to disconnect the ventilator, and make it available for someone who still has a chance of recovery.

Carbon tax with revenue returned through equal lump-sum rebates: open letter

An open letter from many economists, published today as an op-ed in the Wall Street Journal, proposes a carbon tax with the revenue to be returned to taxpayers, as a way to put incentives in place to deal with climate change.
 Here it is in the WSJ: 
Economists’ Statement on Carbon Dividends--Bipartisan agreement on how to combat climate change.

And you can click through to the oped (ungated) and related articles at https://www.clcouncil.org/?mod=article_inline

ECONOMISTS’ STATEMENT ON CARBON DIVIDENDS

27 Nobel laureates, all 4 former Fed Chairs, and 15 former Chairs of the Council of Economic Advisers unite behind carbon dividends as the bipartisan climate solution.

• Wall Street Journal op-ed
• Washington Post
• Axios
• Wall Street Journal article

Organ donation in Germany

Spiegel.de has the story:
Nach langem Abwärtstrend, Zahl der Organspender deutlich gestiegen
(GT: After a long downward trend, the number of organ donors has increased significantly)

"Last year, 955 people left organs for other critically ill patients after their death, as the German Foundation for Organ Transplantation (DSO) announced. That was an increase of nearly 20 percent compared to 2017 with 797 donors and the first major increase since 2010.
...
"a discussion on new organ donation rules has started in parliament across parliamentary boundaries. So far, withdrawals are only allowed with expressly agreed consent, but many postpone the occupation with this topic again and again.

"Spahn is therefore campaigning for a "double contradiction solution" ["doppelte Widerspruchslösung"]. Accordingly, everyone is automatically considered a donor. One should be able to say no to this, otherwise - as a double barrier - relatives would have to be asked. In an open debate in the Bundestag at the end of November broad reservations against such a new regulation became clear.

"Instead, a group led by Greens leader Annalena Baerbock and left-leaning boss Katja Kipping suggests a mandatory recurring query, such as collecting new passports or identity cards - with the option of not yet deciding."
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HT: Rosemarie Nagel