Indian lower house of Parliament (Lok Sabha) passes bill banning commercial surrogacy

A bill banning commercial surrogacy (and restricting who can take part in altruistic surrogacy) has passed through the Lok Sabha, the lower house of Parliament:

LS Passes The Surrogacy (Regulation) Bill, 2019: Read The Salient Features [Read Bill] BY: AKSHITA SAXENA 6 Aug 2019

 "The Lok Sabha on Monday passed the Surrogacy (Regulation) Bill, 2019, introduced by Union Health Minister Harsh Vardhan. The bill essentially seeks to regulate surrogacy in India while imposing an absolute prohibition on commercial surrogacy."

Under the terms of the proposed law, a surrogate mother would have to be a married close relative of the intended parents, with at least one child of her own.  The intended parents would have to be a childless married couple, Indian citizens married for at least 5 years, with medically certified infertility.

The bill has yet to be passed by the upper house and signed by the president, so at this stage it's not yet the law.
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Here's a news story from the Times of India:
Commercial surrogacy banned in India; government passes tough laws

By - TNN Created: Aug 6, 2019

And from the Hindustan Times, indicating that this bill has some prior history, and so isn't a sure thing to become law:

 Lok Sabha passes bill that bans commercial surrogacy

"The Bill was passed by Lok Sabha in December, 2018 but lapsed as it could not get nod from Parliament.

"Earlier, the Bill was introduced in the Lok Sabha on November 21, 2016 and was then referred to a parliamentary standing committee on January 12, 2017."

Large strategy sets: college financial aid, and automatic weapons

One of the big lessons of market design is that participants have big strategy sets, so that many kinds of rules can be bent without being broken. That is, there are lots of unanticipated behaviors that may be undesirable, but it's hard to write rules that cover all of them. (It's not only contracts that are incomplete...)

Two examples in the recent news:

First, from ProPublica Illinois:
Parents Are Giving Up Custody of Their Kids to Get Need-Based College Financial Aid
First, parents turn over guardianship of their teenagers to a friend or relative. Then the student declares financial independence to qualify for tuition aid and scholarships.
by Jodi S. Cohen and Melissa Sanchez July 29

and
U.S. Department of Education Wants to Stop “Student Aid Fraud Scheme” Where Parents Give Up Custody Through Dubious Guardianships
One day after our reporting, the department’s inspector general said it wants to close financial aid loopholes.
by Jodi S. Cohen, Duaa Eldeib and Melissa Sanchez July 30
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Second (with pictures), pointed out to me by Jacob Leshno:

When Lawmakers Try to Ban Assault Weapons, Gunmakers Adapt
By Jeremy White

Diversity of methodology in science, interview with E.O. Wilson

The Chronicle of Higher Ed interviews E.O. Wilson on, among other things, diversity in scientific approaches:

A Legendary Scientist Sounds Off on the Trouble With STEM
E.O. Wilson on the next big thing, the gladiatorial nature of academe, and the world beyond the human senses

"There’s no question that we need all the ablest people that can be recruited to go into science and technology to keep this country strong. But STEM is an unnecessarily forbidding set of stairs.

"Consider a young person who’s thrilled by seeing a natural system, a remarkable geological formation that stirs the imagination, or a group of animals or plants. This youngster says, Boy, when I get to college, I would like to move on to a career in science, and biology especially. Now, the STEM-oriented teacher — if we are following the STEM ideology as we hear it — says: "I think that’s a good ambition. But remember that biology is based substantially upon chemistry. So, I advise you to start getting a good background in chemistry. Oh, and while you’re at it, you should keep in mind that chemistry is based upon, to a major degree, principles of physics. So consider starting to get a background in physics, too. And, oh, I almost forgot: To get into physics, and a lot of the best parts of chemistry, you’re going to need ‘M,’ mathematics. So I want you to get started on math courses right now."
...
"Those universities that have large collections of organisms have not come close to providing educational tools for students at the undergraduate and graduate level. Harvard is particularly short. I came there as a graduate student in 1951, and I’m now honorary curator of insects, now that I’ve retired. Harvard has some of the best collections in the world — plants and animals — and we have a great arboretum. And yet the collections are not being used effectively to train people in biodiversity. They’re being neglected.

"We should be putting much more emphasis in both undergraduate and graduate biology courses on biodiversity. Right now we have given formal names to a little more than two million species. How many species remain unknown? The answer: an estimated eight million. We’re not talking about bacteria; we’re talking about eukaryotic animals.

"We need more courses about different groups of organisms — courses in ornithology, or invertebrate zoology, or entomology. That’s the way you get students hooked.
...
"We certainly need research that involves modeling and statistical techniques, but that should be ancillary. What we need much more is a study of those 10 million species.

"I’m going to rattle off the names of some groups of organisms that desperately need experts to work on them.

...

"A. Schizomids: a kind of arachnid found all over the world. Spidery-like creatures. We know almost nothing about them.

"Oribatid mites: Go out to any bit of leaf litter, start digging up decaying leaves, and start shaking out the little things. Among them you’ll find oribatid mites.

"A few years ago I studied a group of ants that were very good at collecting oribatid mites for food. So I thought I’d better figure out what species of oribatid mites I was seeing in my work. I looked around and found that the number of oribatid mite specialists who could do that in the United States was two. One of them, fortunately, was very generous.

"Q. Why isn’t there enough of this work being done?

"A. The dominance of molecular biology and biological medicine. Which is a good thing. But it’s become an overwhelming emphasis.

"That’s going to change. We’re moving into a new era. We’re entering the environmental-science era, where we want to take care of the environment around us, treat the earth the way we would a person and keep it healthy. And we need to know about these species for the purposes of synthetic biology."

Lovely short film about the resident match by Dr. Trisha Pasricha

Here's a charming and insightful 11 minute video by the remarkable physician-filmmaker Dr. Trisha Pasricha, about the experience of going through the residency match run each year by the National Residency Matching Program (NRMP). It includes some bits of an interview that Dr. Pasricha conducted with me.


: 

A PERFECT MATCH: The Selection Ritual to Become A Doctor from Trisha Pasricha on Vimeo.


Here's a link on the NRMP web page:
Documentary “A Perfect Match” Follows Student Through The Match Process
"Directed by Dr. Trisha Pasricha (Massachusetts General Hospital) and produced by Dr. Michael Pilla (Vanderbilt University School of Medicine), A Perfect Match: The Selection Ritual to Become a Doctor follows a Vanderbilt University School of Medicine student as he experiences the medical residency match process. The 12 minute film was a finalist at the Nashville Film Festival,

Dr. Pasricha graduated from Harvard University with a B.A. in film production and went on to study at Vanderbilt University School of Medicine. She completed an internal medicine residency at Johns Hopkins and is currently a first-year gastroenterology fellow at Massachusetts General Hospital.."

And here's the direct link on vimeo.
******
Even short films can take a long time to produce; here's my earlier post:

Friday, September 2, 2016

A perfect match--documentary on the medical match by Dr Trisha Pasricha

*********
Perhaps I'll get a chance to chat with Dr. Pasricha again after she goes through the gastroenterology match.

Reducing discards of deceased donor kidneys

Some changes that could lead to transplantation of more deceased donor kidneys:

KAPP Implements Recommendations from NKF Kidney Discards Conference

"New York, NY—July 17, 2019—Today the Organ Procurement and Transplantation Network (OPTN) announced the launch of the Kidney Accelerated Placement Project (KAPP) to assess whether accelerating the placement of extremely hard-to-place kidneys via the Organ Center can increase their utilization. This significant step is derived from recommendations outlined in a report by the National Kidney Foundation and published in the journal Clinical Transplantation, the Journal of Clinical and Translational Research, the “Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards” in October, 2018. The report focused on decreasing the number of kidneys discarded and provided the first systematic nationwide approach to reducing kidney discards.
...
"The 14 specific recommendations in the published in the Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards are:

• Strengthen local Organ Procurement Organization (OPO) and transplant center cooperative Quality Assurance and Performance Improvement (QAPI) efforts to reduce discard to identify the root causes of failure to place kidneys locally and implement solutions to increase allocation.
• Improve communication between OPO and Accepting Transplant Surgeon at time of organ placement to improve information used to make acceptance decisions.
• Routinely send prospective crossmatch to at least three transplant centers to speed up time to acceptance in case initial centers do not accept the kidney.
• Grant “local backup” to centers receiving exported kidneys to ensure shipped organs can be used at first destination.
• Identify “local backup” in local DSA for shared allocation of high Calculated Panel Reactive Antibodies (CPRA) or high KDPI kidneys to decrease the need for organ export.
• Expand use of virtual crossmatching to decrease the time to decision on acceptance by avoiding the need for testing of shipped specimen prior to transplant.
• Involve the nephrologist working cooperatively with the surgeon in decisions regarding organ acceptance to share responsibility and utilize the medical knowledge of the nephrologist in acceptance decisions that consider downstream risks of acceptance versus refusal of a given kidney for each specific patient.
• Improve practitioner and patient education on acceptance of higher risk for discard kidneys to prevent delays in acceptance and speed up decisions regarding kidney acceptance. 
• Disseminate best practices from OPOs and transplant centers that routinely accept high risk organs to increase the number of centers which utilize high risk organs.
• Create expedited placement pathways to directly offer organs at risk of discard to small subset of centers that opt-in to accepting these organs.  Center must sustain high rates of acceptance to receive offers.
• Identify organs that become a risk for discard during standard allocation and allocate them to patients in rescue centers that utilized high-risk organs when standard placement has been unsuccessful to place limit on time that the kidney is in standard allocation pathway to ensure it is transplanted.
• Standardize technical aspects of obtaining and interpreting renal (deceased donor) biopsies to utilize renal pathologists to improve decision making based on biopsy.
• Standardize provision of gross photos of procured kidneys and post on DonorNet to better inform the surgeon on condition of procured organ.
• Develop risk adjusted payment system to cover increased costs of high-risk kidneys to remove disincentive to accept the organ which may result in an increased risk of post-transplant morbidity with associated cost.

About Kidney Discards

There are many reasons why kidneys are discarded including poor organ quality, abnormal biopsy findings, prolonged cold ischemic time, anatomy, punitive regulatory and payer sanctions due to poor clinical outcomes, and the increased costs associated with the use of higher kidney donor profile index (KDPI) grafts, the report points out, yet experts believe and data supports that many of these kidneys can be used for transplant. Kidney discard rates also vary upon geography leading experts to believe that the variation may be based on a subjective view of organ viability by an individual transplant team.  Every year kidneys that could be used for transplant are discarded.  In 2016, more than 3,600 were deemed unfit for transplant and thrown away.  But a panel of transplant experts convened by NKF agree that as many as 50% of those kidneys could be transplanted to prolong the lives of Americans otherwise treated with dialysis. The recommendations chronicled in the published report emerged from NKF’s Consensus Conference to Reduce Kidney Discards, held in May 2017 with 75 multidisciplinary experts in the transplant field including kidney patients and families."

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

From the 2018 "Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards," by Matthew Cooper  Richard Formica  John Friedewald  Ryutaro Hirose  Kevin O’Connor  Sumit Mohan Jesse Schold  David Axelrod  Stephen Pastan

"4 EFFECT OF THE REGULATORY ENVIRONMENT ON KIDNEY DISCARD

The current regulatory environment may impact the kidney discard rate by increasing risk aversion on the part of transplant centers.26, 27 Transplant centers are held accountable for one‐year graft and patient survivals, and there are concerns regarding how the use of high KDPI kidneys, or those with long cold ischemic times, will impact center ratings. Empirical evidence indicates that poor center performance ratings are associated with a decline in transplant volume.28, 29 This effect persists despite analyses demonstrating that donor factors are adequately captured in the risk adjustment models.30 Overcoming the concern of the influence of donor risk on center outcomes will require both continued education and research. Additionally, because there are perceptions of the limitations of risk adjustment for recipient factors, testing the effect of exempting certain organs from inclusion in center outcomes may reduce risk aversion. In fact, in 2017, the Membership and Professional Standards Committee of the OPTN instituted a new operational rule to exempt transplants from a donor with a KDPI of 85 or higher transplanted into a recipient with an EPTS greater than the 80th percentile, that is,a high‐risk donor into a high‐risk recipient. Although CMS has not endorsed a similar policy, this “natural experiment” may help to inform the transplant community regarding the effect of the regulatory environment on decision making, and inform other prospective policies that impact organ utilization.

New criteria for rating transplant centers should incorporate the potentially reduced graft survival of higher risk donor kidneys; this would remove the current disincentives that exist to use these kidneys.31 The development of more comprehensive metrics may improve alignment of transplant center and patient incentives and increase organ utilization. This approach would benefit older patients who through accepting higher risk kidneys could experience shorter waiting times, or avoid dialysis through preemptive transplantation. Additionally, society would benefit through an overall reduction in health care costs."

Sharing good health: a nice turn of phrase about kidney exchange

This struck me as a nice turn of phrase:

On Paired Kidney Donation: ‘Good Health is Never Something I Thought I Could Share’
By REBECCA SMITH • JUL 25, 2019

"One of the things I've learned is being blessed with good health is never something I thought I could share. I mean, your good health is yours. There's… I guess there are ways to share it in the sense that you can lift up other people by being healthy, but I never thought it was something I can actually literally give away in a way.

The day I went to the hospital, I remember a doctor saying that living donors are the only people that walk into a hospital and don't need to be there. Who undergo surgery and absolutely don't need surgery that day. So, being able to give away a little bit of my good health, which was really a profound lesson for me.

I will say giving an organ, the benefits far, far far outweigh the risks. The surgery was incredibly uneventful for me, the recovery was really uneventful, and in fact, it made me a lot more mindful about my own health.

On the downside, I will say, as I've said before, the system is very complex, it's very difficult to navigate. For, particularly for someone who has a chronic disease, we're often left to self-navigate the emotional, financial and social barriers related to transplant, while struggling to try to maintain some quality of life.

And so, between the two of us, we were trying to climb this huge mountain of how to figure out how to get them a functioning kidney.

The unintended consequences that I never saw coming, that are have really been a blessing are, I learned the value of being a fierce advocate in the healthcare system and I will never stop being a fierce advocate for my family, for myself and for my loved ones.

I also found my voice when it comes to talking about health care, and I'm deeply respectful of healthcare systems and of healthcare providers, but I also know that without a loud and informed and passionate voice, often, nothing good can happen to you in this system. "

How Market Design Emerged from Game Theory, by Roth and Wilson in the JEP

This paper was quite fun to collaborate on, with my dissertation advisor Bob Wilson...

How Market Design Emerged from Game Theory: A Mutual Interview
Alvin E. Roth and Robert B. Wilson
Journal of Economic Perspectives—Volume 33, Number 3—Summer 2019—Pages 118–143

Abstract
"We interview each other about how game theory and mechanism design evolved into practical market design. When we learned game theory, games were modeled either in terms of the strategies available to the players ("noncooperative games") or the outcomes attainable by coalitions ("cooperative games"), and these were viewed as models for different kinds of games. The model itself was viewed as a mathematical object that could be examined in its entirety. Market design, however, has come to view these models as complementary approaches for examining different ways marketplaces operate within their economic environment. Because that environment can be complex, there will be unobservable aspects of the game. Mathematical models themselves play a less heroic, stand-alone role in market design than in the theoretical mechanism design literature. Other kinds of investigation, communication, and persuasion are important in crafting a workable design and helping it to be adopted, implemented, maintained, and adapted."

**********
It turns out that some people read footnotes .  I got the following welcome email from Charlie Nathanson at Northwestern, expanding on one of mine (in which I reflected on writing a paper with Bob):

"I was delighted to see your reference to the Talmud in your JEP article that came out today (footnote 22). There is a verse from Pirkei Avot about the student/teacher relationship that I did not see in your footnote or in your linked blog post. In case you haven't come across it, I wanted to share it with you. It's chapter 4, verse 12 (https://www.sefaria.org/Pirkei_Avot.4.12):
רַבִּי אֶלְעָזָר בֶּן שַׁמּוּעַ אוֹמֵר, יְהִי כְבוֹד תַּלְמִידְךָ חָבִיב עָלֶיךָ כְּשֶׁלְּךָ, וּכְבוֹד חֲבֵרְךָ כְּמוֹרָא רַבְּךָ, וּמוֹרָא רַבְּךָ כְּמוֹרָא שָׁמָיִם:
Rabbi Elazar ben Shammua said: let the honor of your student be as dear to you as your own, and the honor of your colleague as the reverence for your teacher, and the reverence for your teacher as the reverence of heaven. 

Best wishes,
Charlie"

*********
And here's the footnote that prompted that email:

22 A brief account of our subsequent teacher–student interactions, along with some other remembrances related  to  the  present  essay,  is  included  in  my  intellectual  autobiography  at  the  Nobel  Prize  website:  https://www.nobelprize.org/prizes/economics/2012/roth/auto-biography/.   The   rabbinic   literature   does  not  overlook  teacher–student  relations.  In  the  Talmud,  for  example,  one  is  enjoined:  “Provide  for yourself a teacher and get yourself a friend ...” See my related blog post for more on this: https://marketdesigner.blogspot.com/2013/06/notes-on-teachers-and-students-from.html. The martial arts also value teacher–student relations, and I benefited from that too, as I describe at https://marketdesigner.blogspot.com/2013/06/honorary-7th-dan-black-belt-in-jka.html. 

How much do Kidney Exchanges Improve Patient Outcomes? Keith Teltser in AEJ-Policy

Do Kidney Exchanges Improve Patient Outcomes?
By Keith F. Teltser
American Economic Journal: Economic Policy 2019, 11(3): 427–453
https://doi.org/10.1257/pol.20170678

Abstract: "In this paper, I estimate the number of additional transplants generated by kidney exchanges. To do this, I analyze substitution patterns between exchange transplants and other transplant outcomes. Exploiting variation in patients exposure to exchange activity across time and place, I find that 64 percent of exchange transplants represent new living donor transplants. Using the same approach, I find that an increase in the probability of receiving an exchange transplant reduces the probability of graft failure and reduces time spent waiting for a kidney. Back-of-the-envelope calculations suggest that each exchange transplant increases social welfare by $300,000 to $700,000"

Mark Kleiman (1951-2019)

From the NY Times:
Mark Kleiman, Who Fought to Lift Ban on Marijuana, Dies at 68
"Kelly Kleiman, his sister and only immediate survivor, said the cause was lymphoma and complications of a kidney transplant he received from her in April.
...
"Beginning in the mid-1980s, Professor Kleiman was best known for what was then a cry in the wilderness: a thesis that wars on drugs waged on the basis of enforcement had failed; that alcohol does more harm than cannabis; and that the cost of banning marijuana altogether outweighed any of the benefits of prohibition. At the same time, he warned that complete legalization remained a high-risk gamble."

From Reason magazine

RIP Mark Kleiman, Who Brought Rigor, Dispassion, and Candor to a Frequently Overheated Drug Policy Debate
The widely quoted and consulted academic died yesterday at the age of 68.
JACOB SULLUM | 7.22.2019 12:50 PM

"Back in 1989, Mark Kleiman published a book, Marijuana: Costs of Abuse, Costs of Control, that exemplified his calm, methodical, just-the-facts approach to drug policy. Kleiman argued that federal efforts to curtail cannabis consumption were ineffective and diverted resources from programs that had a better public safety payoff. Three years later, in Against Excess: Drug Policy for Results, he came out in favor of legalizing marijuana, arguing that the costs of prohibition outweighed its benefits. At a time when three-quarters of Americans still supported marijuana prohibition, Kleiman's position was striking, especially coming from a widely quoted and consulted academic who had the ear of policy makers."
*********

From The Intercept:
Remembering Mark Kleiman, a Relentlessly Thoughtful Scholar of Drug Policy, by Maia Szalavitz

"As an opponent of drug war dogma, he was willing to explore alternative approaches to punishment, rather than argue for it to be abolished entirely. That’s a sharp departure from much of the left, which has often been content to firmly oppose the moral stain that is mass incarceration without seriously grappling with what alternative policies might look like. At its best, Kleiman’s work and teachings made people on all sides think much more deeply about their positions, regardless of where they ultimately came down.

"Kleiman supported going after drug dealers, but selectively targeting only the most violent and disruptive, to avoid, essentially, creating evolutionary pressure in markets that would favor the most ruthless and cause the most harm."
**********

From the National Review:

Mark Kleiman Was the Nation’s Greatest Thinker on Drug Policy

By GABRIEL ROSSMAN

"As expressed in its most programmatic form in Against Excess, Kleiman applied rigorous economic logic, but with the curious inversion that the markets he studied have severe externalities and ruin the lives of their most devoted consumers. Market failure and high transaction costs are policy successes when the commodity is poison, and so good policy means encouraging bad market design. For instance, Kleiman favored a noncommercial approach to marijuana decriminalization precisely because he expected nonprofit or state-operated dispensaries to be less efficient than for-profit firms, and in particular less likely to grow the user base through advertising and make intense use more convenient. The billboards advertising dispensaries, and even marijuana delivery, that saturate Los Angeles are exactly what Kleiman thought sensible decriminalization should avoid.

"But just as good market design has to be careful, so does deliberately bad market design. A major argument in Against Excess is that if you make selling drugs risky by locking up drug dealers (or encouraging them to shoot each other over territory), you build in a risk premium to the price, which draws in suppliers who don’t mind risk. The better approach is to create a deadweight loss so you don’t encourage more supply. For illegal drugs, make it a time-consuming hassle to score. For legal drugs like tobacco and alcohol, impose stiff excise taxes. In both cases the consumer faces costs that do not benefit, and therefore encourage, sellers. These costs might not discourage addicts in the short run, but long-run demand is relatively “elastic”: Increased costs from hassle or taxes can discourage potential users from starting and encourage existing addicts to quit.

"A curious consequence of Kleiman’s logic is that he consistently preferred an emphasis on retail markets rather than high-level distributors or source-country trafficking. His reasoning was that street prices substantially reflect retail markup. In the United States and most European countries, retail markup is about half of the purity-adjusted street price for cocaine and heroin, and the domestic wholesale price itself is about five to ten times higher than the wholesale price in source countries. Source-country interdiction efforts do increase wholesale prices, but this has little effect on retail prices and destabilizes countries. For instance, if you have read Killing Pablo or seen Narcos, you know about the escalation of the dirty war against the Medellin cartel by American intelligence and the Colombian National Police in the early 1990s, but this bloodbath had only a trivial and short-lived impact on retail cocaine prices in the United States, which is still cheaper than it was in the crack era."

Speed bumps for high frequency trading

From the WSJ:

More Exchanges Add ‘Speed Bumps,’ Defying High-Frequency Traders
Over a dozen financial markets plan mechanisms that impose a split-second delay before executing trades  by By Alexander Osipovich.

"By 2020, more than a dozen markets in stocks, futures and currencies from Toronto to New York to Moscow will slow down trading via speed bumps or similar features, if all the current planned launches are carried out. Five years ago, only a few markets had speed bumps.
...
"Among the exchanges set to debut their first speed bumps are the London Metal Exchange, which plans to add an eight-millisecond delay to gold and silver futures later this year. Chicago-based Cboe Global Markets hopes to add a speed bump on its EDGA stock exchange in 2020, if it wins regulatory approval.

"LME, Cboe and other markets adopting speed bumps say they want to neutralize “latency arbitrage,” a strategy in which a fast trader takes advantage of a moving price before other players can react.
...
"Cboe’s proposal would force the HFT firm to wait four milliseconds before buying the Ford shares. But the same delay wouldn’t apply if the investor sent Cboe an electronic message canceling his or her $10.00 sell order. That gives the investor a brief window of time to avoid being picked off by the faster trade.

"Most of the latest speed-bump plans have a similar, “asymmetrical” design, meaning they don’t apply equally to all trades. Such speed bumps are typically meant to favor players who publicly quote prices on an exchange, rather than those who attempt to buy or sell using those prices."

Operational experience of kidney exchange with the Alliance for Paired Donation (APD)

Like having children, the hard work of market design doesn't end at conception, or even at birth, it's an ongoing process, particularly when it has to interact with the day to day operating procedures (excuse the double entendre) of the participants.

Here's a paper that reports results of some of that experience with the innovative kidney exchange network that began life as the Alliance for Paired Donation (APD), and is now called the Alliance for Paired Kidney Donation (APKD):

The 6‐year clinical outcomes for patients registered in a multiregional United States Kidney Paired Donation program ‐ a retrospective study
Stanislaw M. Stepkowski  Beata Mierzejewska  David Fumo  Dulat Bekbolsynov Sadik Khuder  Caitlin E. Baum  Robert J. Brunner  Jonathan E. Kopke  Susan E. Rees Connie Smith  Itai Ashlagi  Alvin E. Roth  Michael A. Rees
Transplant International, 2019, Volume 32, Issue 8, 839-853.

"Summary

We examined what happened during a 6‐year period to 1121 end‐stage renal disease patients who registered with their willing/incompatible living donors for kidney exchanges with the Alliance for Paired Donation (APD). Of all patients, 65% were transplanted: 37% in kidney paired donation (APD‐KPD, APD‐other‐KPD); 10% with compatible live donors (APD‐LD); and 18% with deceased donors (APD‐DD). The remaining patients were withdrawn (sick/died/others; 15%), or were still waiting (20%). For those patients with a cPRA 0–94%, 72% received a transplant. In contrast, only 49% of very highly sensitized (VHS; cPRA 95–100%) were transplanted. Of the VHS patients, 50% were transplanted by KPD/APD‐LD while 50% benefited through prioritization of deceased donors in the modified kidney allocation system (KAS introduced in 2014). All APD transplanted groups had similar death‐censored 4‐year graft survivals as their relevant Organ Procurement and Transplantation Network (OPTN) groups. It is noteworthy that VHS graft and patient survival results were comparable to less sensitized and nonsensitized patients. All patients should be encouraged to search for compatible donors through different options. Expanding the donor pool through KPD and the new KAS of the OPTN increases the likelihood of transplantation for VHS patients.

Sperm selection

I've blogged before about selection of sperm donors, but here's a story from the NY Times about the selection of sperm itself:

Tinder for Sperm: Even in the Petri Dish, Looks and Athleticism Are Prized
What makes one sperm cell — a blob of DNA with a tail — stand out? The selection process is like a microscopic Mr. America contest.
By Randi Hutter Epstein

“Not that one with the droopy head,” Lo said, pointing to a sperm that looked like a deflated balloon sagging over its string. He rejected a sperm with a thickened midpiece that he described as a “turtleneck,” and said he also avoids sperm with curlicue tails or an extra tail. Slow pokes and non-swimmers are spurned as well.

...
"When a sperm cell reaches the egg, it releases hyaluronidase, an enzyme that dissolves the cumulus, a layer of cells surrounding the egg. Next, the acrosome, a vesicle inside the sperm cell’s head, fuses with the outer layer of the egg, igniting the release of enzymes that ease the route inside. The sperm’s vigorously waving tail provides an extra push to help it through. Once inside, proteins within the sperm cell’s head prompt the oocyte to finish maturing and to release chemicals that harden the outer shell of the egg, preventing other sperm from barging in.

"These days, many leading fertility centers use techniques that allow them to bypass all these steps. Instead, they pick a single sperm and inject it into the egg, a technique called intracytoplasmic sperm injection or ICSI (pronounced ICK-see). ICSI was designed to help men with few or defective sperm, but has become so common that it’s used in more than half* of all I.V.F. procedures.
...
"In addition to having a keen eye for promising sperm, an embryologist must have excellent hand-eye coordination. Even then, learning to identify and successfully catch a single sperm before it swims away can take months of practice, said Lo. “I told my parents those years of video game playing, they’ve really paid off.”

* From The Lancet: "Globally, between 2008 and 2010, more than 4·7 million treatment cycles of assisted reproduction techniques were performed, of which around half involved intracytoplasmic sperm injection (ICSI), leading to the birth of 1·14 million babies.

Compensation of kidney donors in Chile: an estimate of benefits

A look into a possible future, from the December 2019 issue of the Latin American Economic Review:

An analysis of economic incentives to encourage organ donation: evidence from Chile
Parada-Contzen, M. & Vásquez-Lavín, F. Lat Am Econ Rev (2019) 28: 6. https://doi.org/10.1186/s40503-019-0068-2

Abstract
We perform a cost–benefit analysis on the introduction of monetary incentives for living kidney donations by estimating the compensation that would make an individual indifferent between donating and not donating a kidney while alive using Chilean data. We find that monetary incentives of US$12,000 save US$38,000 to health care system per donor and up to US$169,871 when we consider the gains in quality of life of receiving an organ. As one allows the incentives to vary depending on the individual position on the wage distribution, the compensation ranges from US$4214 to US$83,953. Importantly, introducing payments to living donors payable by a third party helps patients who currently may not have access to necessary medical treatment. Therefore, exclusions in access for organs due to the monetary constraints can be prevented.

Removing disincentives to kidney donation, by McCormick et al. in J.Am.Soc.Nephrology

Here's the latest paper in an illuminating series on the costs and consequences of kidney donation and transplantation:

McCormick F, Held PJ, Chertow G, Peters T, and Roberts J.  Removing Disincentives to Kidney Donation: A Quantitative Analysis.  J Am Soc Nephrol 30: ccc–ccc, 2019. doi: https://doi.org/10.1681/ASN.2019030242 is:

https://jasn.asnjournals.org/content/jnephrol/early/2019/07/23/ASN.2019030242.full.pdf

I'm fortunate to be on McCormick's distribution list for email updates on matters related to kidney transplantation, and here's how he introduced and summarized this paper (the table of cost estimates is at the very bottom):

"Friends,

About two years ago, Economics Nobel Laureate Alvin Roth observed that since no-one in the transplant community seemed to be opposed to removing disincentives to kidney donation, the community should unite behind accomplishing that goal.  Our just-published article -- “Removing Disincentives to Kidney Donation: A Quantitative Analysis” -- lays out the consequences of pursuing that consensus objective.  It identifies seven disincentives facing living kidney donors and a single disincentive facing the families of deceased donors. 

The seven disincentives to living donors are listed in column 1 of the table below.  Columns 2 - 5 show estimates of the magnitudes of some of these disincentives made by earlier researchers.  Column 6 indicates our own best estimates of all of the disincentives, and Column 7 specifies the government actions needed to remove these disincentives without violating the National Organ Transplant Act.

Note that the disincentives to living donors total almost $38,000, which is much larger than generally assumed.  This is a substantial deterrent to kidney donation by living donors and goes a long way toward explaining why, even though about 125,400 patients were diagnosed with kidney failure in the U.S. in 2017, most of whom could have benefited from a kidney transplant, only 5,811 patients (4.6%) received a kidney from a living donor.

It follows that if the government could remove all of these disincentives by compensating donors, it could substantially boost kidney donations.  We estimate total donations from both living and deceased donors would increase by about 12,500 per year (63%).  That would cut the waiting list for transplant kidneys (currently numbering about 93,000 patients) in half in about four years.

We estimate removing all the disincentives would require an initial government outlay of only about $0.5 billion per year.  But this investment would quickly be recovered because (a) the long-run cost of transplantation is much less than for dialysis and (b) the government pays most of the costs of both.  So taxpayers would wind up saving a net $1.3 billion each year.  Much more importantly, society would enjoy a net welfare gain of about $14 billion per year, reflecting the great value of the additional donated kidneys to recipients and the savings from these recipients no longer needing expensive dialysis therapy. 

The timing of this article is fortuitous because there is currently great interest in Washington in proposals to remove disincentives to organ donation.  Indeed, on July 10, President Trump issued an executive order stating: “Within 90 days of the date of this order, the Secretary [of the Department of Health and Human Services] shall propose a regulation to remove financial barriers to living organ donation.”

               

Frank

The URL for the just published article: McCormick F, Held PJ, Chertow G, Peters T, and Roberts J.  Removing Disincentives to Kidney Donation: A Quantitative Analysis.  J Am Soc Nephrol 30: ccc–ccc, 2019. doi: https://doi.org/10.1681/ASN.2019030242 is:

https://jasn.asnjournals.org/content/jnephrol/early/2019/07/23/ASN.2019030242.full.pdf

This is the fourth in a series of articles aimed at reducing the kidney shortage and thereby saving tens of thousands of lives each year.  The previous three were:

1.             Held PJ, McCormick F, Ojo A, Roberts JP.  A cost-benefit analysis of government compensation of kidney donors.  Am J Transplant 16: 877–885, 2016.         

This article laid out in great detail (13 Supplements) all of the costs and benefits of compensating kidney donors, showing it would confer a net benefit on society of about $46 billion per year and would save taxpayers about $12 billion per year.

https://onlinelibrary.wiley.com/doi/full/10.1111/ajt.13490

2.       Held PJ, McCormick F, Chertow GM, Peters TG, Roberts JP.  Would government compensation of living kidney donors exploit the poor? An empirical analysis.  PLOS ONE, November 28, 2018. 

This article presented evidence that the poor would not be exploited by government compensation of kidney donors.  Indeed, the aggregate net benefit to the poor would increase to $12 billion per year from only $1 billion per year currently.

https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0205655&type=printable

 

 

3.       McCormick F, Held PJ, Chertow GM.  The Terrible Toll of the Kidney Shortage.   J Am Soc Nephrol 29: 2775–2776, 2018.

This editorial argued that the shortage of transplant kidneys is causing the needless premature deaths of about 43,000 Americans each year (118 per day), the same death toll as from 85 fully loaded 747s crashing each year.  This is a much larger number than had previously been assumed. 

 https://jasn.asnjournals.org/content/jnephrol/29/12/2775.full.pdf

Table 1 Disincentives to Kidney Donation Facing Living Donors
(1) Disincentive		Estimated Magnitudes of Disincentives (Adjusted to U.S. prices and standard of living in 2017)					(7) Proposed Government Action To Remove  the Disincentive
		(2) Gaston          et al.      (2006)	(3) Becker – Elías  (2007)	(4) Rodrigue  et al.    (2016)	(5) Przech  et al.    (2018)	(6) McCormick – Held  et al.  (this study)
1	Travel to, and lodging near, a transplant center	$4,313	--	$1,945	$1,653	$3,122	Expand current NLDAC program to include donors of all income levels
2	Loss of income while recovering from surgery		$3,631	$5,118	$4,368	$5,118	Expand current NLDAC pilot program to include donors of all income levels, providing donors with a tax credit of $5,000
3	Cost of home/ dependent care	--	--	--	$5,592	$5,592	Include cost of home/ dependent care in NLDAC program, providing donors with a tax credit of $6,000
4	Risk of dying during kidney removal	$2,951	$6,723	--	--	$1,860	Provide donors with a $5 million short-term life insurance policy
5	Pain and discomfort of kidney removal	$6,414	--	--	--	$6,414	Provide donors with a tax credit of $6,500
6	Decrease in the long-term quality of life	$23,250	$10,085	--	--	$7,910	Provide donors with an insurance policy covering death, disability, and long-term health problems due to donation
7	Concern that a relative or close friend may need a kidney in the future	--	--	--	--	$7,728	Promise to provide a kidney in the future for a specific person in exchange for a donation now
Total		$36,928	$20,439	--	--	$37,745