Surrogacy around the world and across international boundaries

Here's a wide ranging survey of the literature on surrogacy practice around the world.

Brandão, Pedro, and Nicolás Garrido. "Commercial Surrogacy: An Overview." Revista Brasileira de Ginecologia e Obstetrícia/RBGO Gynecology and Obstetrics 44, no. 12 (2022): 1141-1158.

Abstract: "Objective Surrogacy is the process in which a woman carries and delivers a baby to other person or couple, known as intended parents. When carriers are paid for surrogacy, this is known as commercial surrogacy. The objective of the present work is to review the legal, ethical, social, and cultural aspects of commercial surrogacy, as well as the current panorama worldwide.

"Methods This is a review of the literature published in the 21st century on commercial surrogacy.

"Results A total of 248 articles were included as the core of the present review. The demand for surrogate treatments by women without uterus or with important uterine disorders, single men and same-sex male couples is constantly increasing worldwide. This reproductive treatment has important ethical dilemmas. In addition, legislation defers widely worldwide and is in constant change. Therefore, patients look more and more for treatments abroad, which can lead to important legal problems between countries with different laws. Commercial surrogacy is practiced in several countries, in most of which there is no specific legislation. Some countries have taken restrictive measures against this technique because of reports of exploitation of carriers.

"Conclusion Commercial surrogacy is a common practice, despite important ethical and legal dilemmas. As a consequence of diverse national legislations, patients frequently resort to international commercial surrogacy programs. As of today, there is no standard international legal context, and this practice remains largely unregulated."

Here's the beginning of the section on "transnational" surrogacy:

"The denial of surrogacy in most countries, for all or for some (such as single people or same-sex couples), its cost or the lack of available carriers led to an important transnational search for these (and other) reproductive treatments.[155] [156] This phenomena has been called reproductive, procreative or fertility tourism, transnational reproduction or cross border reproductive care.[157] [158] [159] [160] [161] [162] In European countries alone and concerning any kind of ART, in 2010, a total of 24,000 to 30,000 cycles of cross border fertility treatment within the continent were estimated each year, involving 11,000 to 14,000 patients.[163] Transnational surrogacy is one of the fastest-growing cross-border reproductive treatments.[164] Choosing where to perform the surrogacy treatment usually entails finding the right equilibrium between legal guarantees and costs.[165] Due to the variety of legislations, costs and availability of donors and carriers between countries, patients may search for other countries to do the entire process of surrogacy, or different phases of the surrogate treatment in more than one country.[158] As an example, a male couple may get their donated oocytes from South Africa, where there are many donors available, do the IVF, recruit the surrogate and embryo transfer in Georgia (Sakartvelo), due to attractive prices, and fly the gestational carrier to the USA to deliver the baby, where children may be registered by both parents.[166] [167]" 

Kidney Transplantation Across International Boundaries

 When global kidney exchange was first proposed it met with some hysterical reactions, equating it to organ trafficking.  It is good to see that being replaced by more sober, well informed discussion. Here's a recent paper on how data might be collected and shared.

The Role of Registries in Kidney Transplantation Across International Boundaries  by G. V. Ramesh Prasad, Manisha Sahay, and Jack Kit-Chung, Seminars in Nephrology, Available online 27 December  2022, https://doi.org/10.1016/j.semnephrol.2022.07.001 

Summary: Transplant professionals strive to improve domestic kidney transplantation rates safely, cost efficiently, and ethically, but to increase rates further may wish to allow their recipients and donors to traverse international boundaries. Travel for transplantation presents significant challenges to the practice of transplantation medicine and donor medicine, but can be enhanced if sustainable international registries develop to include low- and low-middle income countries. Robust data collection and sharing across registries, linking pretransplant information to post-transplant information, linking donor to recipient information, increasing living donor transplant activity through paired exchange, and ongoing reporting of results to permit flexibility and adaptability to changing clinical environments, will all serve to enhance kidney transplantation across international boundaries.

"Most KT activity occurs within a country's confines, but the increasing ease of worldwide travel and communication, and the ongoing organ shortage both motivate KT efforts across international boundaries.

...

"This review explores the specific role of patient-based registries in activating and viably maintaining KT activity across official international borders.

...

"Fewer than two thirds of countries have some form of a KT registry. With KT, however, unlike for many other therapies for which registries exist, there are two parties to consider; the donor and the recipient, and their two distinct phases of pre- and post-KT health.

...

"Transplant tourism remains a peril when promoting international transplantation. By contrast, an increasing number of international LDs now travel abroad to the home country of recipients for undergoing their donor nephrectomy.75 This travel for transplantation differs from transplant tourism by referring to the movement of organs, donors, recipients, or transplant professionals across jurisdictional borders in the absence of organ trafficking. Travel for transplantation may be increased through registries.

...

"The third and arguably most important pillar of increasing international transplant activity is to increase LD transplant activity. International comparisons based on donor source readily illustrate the varied relative proportion of DD and LD transplants worldwide.4 Large developed countries such as Canada, the United States, and Australia have developed registries to share LD organs across vast distances,80 with the goal to benefit highly sensitized recipients who have a medically suitable but immunologically incompatible LD, but at the same time maximizing the total number of KT procedures performed. Paired exchange programs and domino transplant chains81 triggered by altruistic nondirected donors best illustrate these accomplishments. Complicated computer algorithms are used to accomplish these two goals. It is important to remember, however, that organs such as kidneys are not to be treated merely as physical objects external to the human body.82 Organ donors are being paired, not organs. International LD transplants are best implemented through a paired exchange,83 as long as strict oversight policies have already been developed to respect human dignity, minimize financial burden, and ensure adequate follow-up care. Involving LICs and LMICs in paired exchange can reduce international access inequities immediately by overcoming both biological and economic imperfections. Linked registries will also permit the expansion of clinical expertise and ensure that donors and recipients are selected appropriately. Linked registries will facilitate regular follow-up evaluation and data sharing. Challenges to international LD transplantation that are best addressed through paired exchange programs include sharing hospital and travel costs, providing health insurance, respecting social and cultural norms, and ensuring administrative oversight including a mechanism for dispute resolution. The close administrative oversight provided by a paired exchange registry serves to ensure LD safety, which becomes especially pertinent when the donor belongs to a less developed country. Travel for transplantation can be encouraged, while morally burdensome transplant tourism and incentivized donation84 can be defeated. For all this to occur, however, an international registry must be much more than simply a clearinghouse for organs."

Cross-border transplantation between China and Hong Kong

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

From the Global Times:

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

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

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

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

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

...

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

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

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

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

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

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

********

And from the South China Morning Post:

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

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

...

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

...

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

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

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

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

Non-compete clauses are anti-competitive: Lina Kahn (FTC chair) in the NYT

 An op-ed this morning by the chair of the FTC explains her opposition to non-compete clauses in labor contracts (which are already non-enforceable in California), following last week's proposed Non-Compete Clause Rulemaking

Lina Khan: Noncompetes Depress Wages and Kill Innovation,  by By Lina M. Khan (chair of the Federal Trade Commission) Jan. 9, 2023 

"Noncompetes were long assumed to apply mainly to high-level executives with access to sensitive corporate information. But their use has exploded in the past few decades, extending far beyond the boardroom. Today, experts estimate that one out of every five American workers, or about 30 million people, are bound by a noncompete. Studies and media reports have found noncompetes routinely invoked against fast-food workers, arborists and manual laborers, to name a few examples. Just this week, the Federal Trade Commission, where I am chair, settled allegations against a company in Michigan that prohibited its workers — security guards earning at or near the minimum wage — from going to work for a competitor within a 100-mile radius of their job location for two years. 

...

"over the past few decades, several states restricted the enforceability of noncompete clauses to various degrees, usually because of court decisions. This created natural experiments, allowing researchers to draw causal inferences about their impact.

"Their most staggering finding: Noncompete clauses systemically drive down wages, even for workers who aren’t bound by one. Every worker stuck in a job represents a position that isn’t opening up for someone else. And if employers know their workers can’t leave, they have less incentive to offer competitive pay and benefits, which puts downward pressure on wages for everyone.

...

"the evidence to date suggests that noncompetes suppress wages, reduce competition and keep innovative ideas from breaking into the market. One study even found that noncompetes lead to higher prices for consumers by reducing competition in the heavily concentrated health care sector.

"Noncompetes are the type of restriction that Section 5 of the F.T.C. Act, a federal law passed by Congress more than a century ago, is supposed to prevent. That’s why the F.T.C. last week proposed a rule forbidding companies to subject workers to noncompetes. Under the proposal, noncompetes would be designated an “unfair method of competition,” which the law prohibits. The rule would apply to professions across the board — janitors, nurses, engineers, journalists. Because employers often try to use noncompetes even when they’re unenforceable, the rule would require companies to proactively notify employees currently subject to noncompetes that those restrictions are now void.

"People might worry that eliminating noncompetes would make it impossible for companies to hold on to their secrets. But there is good reason to believe that more-targeted alternatives, such as nondisclosure agreements and trade secret law, would get the job done without imposing such a burden on the economy."

Moral certainties versus moral tradeoffs

 An article and a commentary in PNAS raise the possibility that  economists and psychologists and moral philosophers concerned with morally contested transactions may be able to engage in more useful discussions. A problem is that economists mostly think about tradeoffs while many moral philosophers (or at least those who write about medical ethics) often think of morality as involving absolutes. (This is clearly illustrated in discussions about repugnant transactions, such as those involving compensation of donors of blood plasma or kidneys, for example.)

The PNAS article is   

Guzmán, Ricardo Andrés, María Teresa Barbato, Daniel Sznycer, and Leda Cosmides. "A moral trade-off system produces intuitive judgments that are rational and coherent and strike a balance between conflicting moral values." Proceedings of the National Academy of Sciences 119, no. 42 (2022): e2214005119. https://doi.org/10.1073/pnas.2214005119

"Significance: Intuitions about right and wrong clash in moral dilemmas. We report evidence that dilemmas activate a moral trade-off system: a cognitive system that is well designed for making trade-offs between conflicting moral values. When asked which option for resolving a dilemma is morally right, many people made compromise judgments, which strike a balance between conflicting moral values by partially satisfying both. Furthermore, their moral judgments satisfied a demanding standard of rational choice: the Generalized Axiom of Revealed Preferences. Deliberative reasoning cannot explain these results, nor can a tug-of-war between emotion and reason. The results are the signature of a cognitive system that weighs competing moral considerations and chooses the solution that maximizes rightness.

"Abstract: How does the mind make moral judgments when the only way to satisfy one moral value is to neglect another? Moral dilemmas posed a recurrent adaptive problem for ancestral hominins, whose cooperative social life created multiple responsibilities to others. For many dilemmas, striking a balance between two conflicting values (a compromise judgment) would have promoted fitness better than neglecting one value to fully satisfy the other (an extreme judgment). We propose that natural selection favored the evolution of a cognitive system designed for making trade-offs between conflicting moral values. Its nonconscious computations respond to dilemmas by constructing “rightness functions”: temporary representations specific to the situation at hand. A rightness function represents, in compact form, an ordering of all the solutions that the mind can conceive of (whether feasible or not) in terms of moral rightness. An optimizing algorithm selects, among the feasible solutions, one with the highest level of rightness. The moral trade-off system hypothesis makes various novel predictions: People make compromise judgments, judgments respond to incentives, judgments respect the axioms of rational choice, and judgments respond coherently to morally relevant variables (such as willingness, fairness, and reciprocity). We successfully tested these predictions using a new trolley-like dilemma. This dilemma has two original features: It admits both extreme and compromise judgments, and it allows incentives—in this case, the human cost of saving lives—to be varied systematically. No other existing model predicts the experimental results, which contradict an influential dual-process model."

Here is their first example:

"Two countries, A and B, have been at war for years (you are not a citizen of either country). The war was initiated by the rulers of B, against the will of the civilian population. Recently, the military equilibrium has broken, and it is certain that A will win. The question is how, when, and at what cost.

"Country A has two strategies available: attacking the opposing army with conventional weapons and bombing the civilian population. They could use one, the other, or a combination of both. Bombing would demoralize country B: The more civilians are killed, the sooner B will surrender, and the fewer soldiers will die—about half from both sides, all forcibly drafted. Conventional fighting will minimize civilian casualties but maximize lives lost (all soldiers).

"More precisely: If country A chooses not to bomb country B, then 6 million soldiers will die, but almost no civilians. If 4 million civilians are sacrificed in the bombings, B will surrender immediately, and almost no soldiers will die. And, if A chooses an intermediate solution, for every four civilians sacrificed, approximately six fewer soldiers will die.

"How should country A end the war? What do you feel is morally right?"

**********

Here is the followup commentary:

Lieberman, Debra, and Steven Shenouda. "The superior explanatory power of models that admit trade-offs in moral judgment and decision-making." Proceedings of the National Academy of Sciences 119, no. 51 (2022): e2216447119.

"We make “moral” decisions each day (should I stay and help my graduate student with her thesis thereby delaying dinner for my children? And if I do stay, how long is acceptable until the trade-off tips in favor of my children—30 min? An hour? Longer?). There are costs associated with every act, and part of the human condition is that we seek to balance our duties to everyone in our social network.

"Moral judgments, as the above example illustrates, lead to intermediate, compromise solutions. For this reason, the value of moral dilemmas like the trolley problem that yield only binary outcomes is limited to the superficial exploration of normative theories within philosophy—not the underlying mental software driving moral cognition

...

"As a philosophical tool, the trolley problem playfully probes certain (limited) contours of moral decision-making. But, as a methodology imported from philosophy into cognitive science to illuminate moral cognition, the translation is impoverished because it yields only binary, extreme solutions and prevents moral trade-offs or compromise judgments. "

It's hard to enforce the ban on cannabis in Kansas

 Just as markets need social support, bans on markets need social support.  Even in Kansas, apparently, where marijuana remains completely outlawed. (Kansas borders on Colorado and Missouri, where (even) recreational use of marijuana is legal, and on Arkansas, and Oklahoma, where medical use is legal.)

The Guardian has the story:

A dying cancer patient used cannabis to ease pain. His hospital called the police. ‘You’d think they would have shown compassion’: patient’s son decries Kansas police who issued citation as father suffered.  by Lois Beckett

"Hospital staff in Kansas called the police on a man dying of cancer who was using cannabis products to cope with his symptoms, in an incident that has since sparked outrage and renewed calls to rethink the state’s strict cannabis laws.

"The encounter took place in mid-December, when police in the city of Hays say two officers showed up at the cancer patient’s hospital room to issue him a citation for a drug violation. 

...

"Because of the Christmas holiday, the city prosecutor had not seen the email about dismissing the charge until after the police interaction with the cancer patient had already become a viral news story, the police chief said. He said he personally let the patient know on 27 December that the police department was not pursuing the citation and that he would not have to appear in court.

"More than a hundred people have called or emailed the Hays police department, upset about news reports of officers’ interactions with the cancer patient, the chief said. "

Nicotine will be with us for a long time--survey of middle school use

 Sales of tobacco products to minors are generally illegal in the U.S., but a survey shows that doesn't stop children from smoking and vaping.  Here's a report from the Centers for Disease Control and Prevention, in JAMA

Tobacco Use Remains High in Middle and High Schools by Bridget M. Kuehn, MSJ

JAMA. 2022;328(24):2389-2390. doi:10.1001/jama.2022.20058

"Nearly 1 in 9 US middle and high school students reported tobacco product use in the past 30 days—most commonly e-cigarettes—according to a CDC and US Food and Drug Administration analysis of data from the 2022 National Youth Tobacco Survey (NYTS). The researchers estimated that approximately 3.08 million students in 6th to 12th grade currently use tobacco products.

...

"The data show that 16.5% of high school students and 4.5% of middle school students reported using a tobacco product in the past 30 days. About 14% of high school students and about 3% of middle school students used electronic cigarettes. Nearly 4% of all those surveyed reported using any combustible tobacco product.

"Several subgroups of students reported even higher rates of tobacco product use. About 16% of students who identified as lesbian, gay, bisexual, or transgender reported current use of these products. The 2022 NYTS survey was the first to provide data on tobacco product use among American Indian or Alaska Native, Asian, multiracial, or Native Hawaiian or other Pacific Islander youths. It found that American Indian or Alaska Native youth reported the highest rate of a tobacco product use of any racial or ethnic group, at 13.5%.

"The report also found a link between social determinants of health and tobacco product use. For example, students who had experienced severe psychological distress or were from less affluent households were more likely to report current tobacco product use. More than a quarter of students with low academic achievement reported current use. "

Sell a kidney to save a life? by Dylan Walsh, in WIRED.

 Martha Gershun alerts me to this story which appeared this morning in WIRED, in which the author, a kidney transplant recipient (24 years ago), considers the history of the long debate about whether kidney donors might be compensated, to end the shortage of life-saving kidney transplants.  It's very well written, and contains some details (e.g. dialog between Al Gore and Barry Jacobs) that I hadn't seen before.  It's well worth reading the whole thing.

Would You Sell One of Your Kidneys? Each year thousands die because there aren’t enough organs for transplants, and I may be one of them. It’s time to start compensating donors. by Dylan Walsh

Here's the first sentence:

"WHEN WE WERE teenagers, my brother and I received kidney transplants six days apart. "

Here's some history of transplantation itself:

"In 1963, the world’s preeminent kidney transplant surgeons met in DC to discuss the state of the field. They were few in number and dispirited. Roughly 300 operations had been performed by then, with only 10 percent of patients surviving more than six months, according to one account. The procedure remained no more than “highly experimental,” in the words of even its fiercest proponents. But the prevailing gloom lifted when two little-known surgeons from Denver, Thomas Starzl and Thomas Marchioro, presented results from a series of transplants they’d performed. They had managed to flip the outcomes: 10 percent failure, 90 percent success. A euphoric shock spread through the crowd, which quickly gave way to skepticism. The results were studied, confirmed, and eventually replicated. "

Here's a bit about the origins of the legal ban on compensating donors (the 1984 National Organ Transplant Act, or NOTA):

"In 1967, one study found that roughly 8,000 people were eligible for a kidney transplant; only 300 received one.

"IT TOOK ABOUT a decade for someone of enterprising disposition to step into this gap. H. Barry Jacobs was a Virginia doctor who lost his license to practice medicine in 1977 for attempting to defraud Medicare. He spent 10 months in jail and shortly after his release turned his energies to the unregulated business of organ brokering. His company, International Kidney Exchange Ltd., was built around the fact that most of us are born with two kidneys but can function with one. If one kidney is removed, the other grows larger and works harder, filtering more blood to cover as best it can for its emigrant twin. This redundancy supported Jacobs’ straightforward business model. He would connect people who wanted to sell one of their kidneys, for a price of their choosing, with people who needed one. As a mi"ddleman, Jacobs would charge a brokerage fee to the recipients.

"At the time, Al Gore, then a member of the US House of Representatives, was developing the National Organ Transplant Act, which centered on establishing a repository to match organ donors with those in need of a transplant. Upon hearing of Jacobs’ plan, Gore also took up the question of compensation. Jacobs appeared before the Subcommittee on Health and the Environment on October 17, 1983, and spoke with truculence. He talked about one doctor who had testified before him “sitting on his butt” and failing to seriously address the problem of organ shortages. He interrupted and challenged his questioners. His testimony, above all, highlighted the likely abuses in an unregulated organ market.

“I have heard you talk about going to South America and Africa, to third-world countries, and paying poor people overseas to take trips to the United States to undergo surgery and have a kidney removed for use in this country,” Gore said. “That is part of your plan, isn't it?”

“Well, it is one of the proposals,” Jacobs said.

...

"This exchange gave public force to a debate that had been unfolding in the dimmer theater of academia ever since transplantation first became possible. ...Proponents of an organ market had historically invoked the crisp—some say cold—logic of utilitarianism. A properly designed market, they suggested, would provide economic surplus to both the organ donor, in the form of money, and to the recipient, in the form of a longer, healthier life. Opponents of a market typically crafted their dissents from the gossamer realm of ethics."

There's more, both personal and policy.  

Good luck to all who need a kidney and to those who donate them. Maybe we'll make some more progress in 2023.

"It Is Time for Interventional Cardiology Fellowship to Join the National Resident Matching Program," say its leaders

 The current appointment process for interventional cardiology fellows is early and congested, and programs feel obliged to make exploding offers, often to internal candidates, without much opportunity for external candidates and programs to become acquainted. In short, they are facing the problems with decentralized hiring that have led many medical specialties to use a centralized match to organize the labor market for residencies and fellowships.  Here's a proposal that this fellowship program should join the Match in order to have a more orderly, better informed process.

Vallabhajosyula, Saraschandra, Sabeeda Kadavath, Alexander G. Truesdell, Michael N. Young, Wayne B. Batchelor, Frederick G. Welt, Ajay J. Kirtane, Anna E. Bortnick, and ACC Interventional Section Leadership Council. "It Is Time for Interventional Cardiology Fellowship to Join the National Resident Matching Program." Cardiovascular Interventions 15, no. 17 (2022): 1762-1767.

"In this perspective article, which is a summation of the deliberations of the American College of Cardiology Interventional Section Leadership Council, we describe the current process of interventional cardiology fellowship candidate selection and opportunities for improvement by joining the Match.

...

"Current Application Process

...

"the date for program review of applications starts on December 1st (1½ years before the start of the interventional cardiology training program to which applicants are applying), although programs are free to offer spots earlier. At the time applications are submitted, cardiovascular medicine fellows in traditional 3-year programs have variable exposure to the cardiac catheterization laboratory. In our experience, for many applicants, the timing of the application process precludes an adequate diagnostic catheterization laboratory experience in order to inform decision-making. ... program leadership is heavily reliant on candidate performance in the interview and on subjective evaluation through letters of recommendation from faculty mentors who have typically had a single year of exposure to applicants.

Residency interviews, in person vs by zoom, at Stanford

 

Residency interviews in the digital era by Isabel Beshar1, William J Tate2, Dan Bernstein3  Postgraduate Medical Journal 98, no. 1166 (2022): 892-894.

Abstract: "In the midst of the SARS-CoV-2 pandemic, the US Association of American Medical Colleges (AAMC) required residency programme transition from in-person to virtual interviews for all applicants. The new virtual format upended a system that has relied on programmes and applicants balancing the likelihood of acceptance with the financial and time demands of cross-country travel.

"In this commentary, we address the history of residency interviewing in the USA and the emerging changes that are taking place in light of virtual interviews. We discuss the advantages of the new online format, including the reduced cost for applicants and programmes, as well as the decreased carbon footprint.

"We also discuss the inequities of virtual interviewing, involving a national maldistribution of interviews to only the top-tier candidates. We share previously unpublished data on the number of virtual interviews accepted by Stanford’s 2020 residency applicants, compared with those conducted in person in 2019. We find Stanford applicants in all fields accepted more interviews: from a mean of 8 in 2019 to 14 in 2020, a change of 160% on average. Despite this, only half of Stanford 2020 applicants interviewing in the virtual format thought they had accepted more interviews than they would have in person.

"We comment on how transitions to online interviewing may be affecting medical schools and applicants disproportionately. Ultimately, we highlight the need and offer ideas for additional regulation on behalf of the AAMC to ensure a more equitable distribution of interview opportunities."

...

"At our institution—Stanford School of Medicine—and as applicants of the 2020–2021 cycle ourselves—we saw the effect of this firsthand. We administered a survey to all students participating in the match process in both the 2019 (in-person) and 2020 (virtual) years. In the survey, respondents identified the residency programme or programmes to which they applied as well as the number of interviews they attended.

Synthetic biology and the ethics of eating (Virgina Postrel in the WSJ)

 Remarkable changes will keep coming.  Here's Virginia Postrel in the WSJ on how changes in the food supply might influence both repugnance towards meat eating and towards technology:

Synthetic Meat Will Change the Ethics of Eating. Consumers will soon be able to dine on chicken and other animal proteins grown in a factory, upending the way we think about nature and technology  By Virginia Postrel

"Most Americans aren’t about to give up chicken, but we’d rather not dwell on where it comes from. In the not-too-distant future, however, the trade-off between conscience—or ick factors—and appetite may no longer be relevant. Instead of slaughtering animals, we’ll get our meat from cells grown in brewery-like vats, with no blood and guts. In November, that science-fiction vision came a crucial step closer to reality when the Food and Drug Administration gave its OK to the slaughter-free chicken from Upside Foods, a San Francisco-based startup originally known as Memphis Meats. The company must still work with the Agriculture Department to establish inspection procedures and win labeling approval. It plans to first offer the meat to high-end restaurants.

...

"Synbio executives talk like animal lovers and environmental activists. But synbio is still a form of engineering, a science of the artificial. As such, its ethical appeal represents a significant cultural shift. Since the first Earth Day in 1970, businesses large and small have emerged from the conviction that “natural” foods, fibers, cosmetics, and other products are better for people and the planet. It’s an attitude that harks back to the 18th- and 19th-century Romantics: The natural is safe and pure, authentic and virtuous. The artificial is tainted and deceptive, a dangerous fake. Gory details aside, the “factory” in factory farming makes it sound inherently bad.

"Synthetic biology upends those assumptions, raising environmental and ethical standards by making them easier and more enjoyable to achieve."

*******

Some commentators on her WSJ article criticized it as "woke propaganda."

*******

Earlier:

Tuesday, November 22, 2022

Lab grown meat: taking slaughter out of the food chain

Monday, May 30, 2022

Eliminating cruelty (and methane) from the food chain: lab-grown ("no-kill") meat

New York State's Living Donor Support Act (LDSA, S. 1594) was signed by Governor Hochul on Dec. 29

 Frank McCormick forwards this email:

From: Elaine Perlman

Sent: Thursday, December 29, 2022 5:44 PM

Subject: Governor Hochul Has Signed the Living Donor Support Act!

 "Hello!

I am delighted to inform you all that the New York State's Living Donor Support Act (LDSA, S. 1594) was signed by Governor Hochul today.

 New York is becoming the best state for organ donation!

 Thank you for your advocacy in support of this legislation. The LDSA will save more New Yorkers' lives.

 Waitlist Zero's Executive Director Josh Morrison wrote the legislation. State Senator Rivera from The Bronx and Assembly Member Gottfried from Manhattan sponsored the bill.

 This spring, a team from the NKDO, NKF, DOVE, LiveOn New York, and Waitlist Zero lobbied for the bill's passage in Albany. Soon after, the LDSA was unanimously passed by both houses.

 This new law creates the opportunity for New York's living donors to avoid going into debt to donate. Living donors will be reimbursed for their lost wages and out-of-pocket expenses. New York will be the first state in the country to offer this opportunity for donation to be cost neutral for donors.

 Currently the Federal Government only reimburses when both the recipient and donor make less than 350% of the poverty line (around $47,000). The LDSA will reimburse the lost wages of donors who make up to $125,000 as well as the costs of donation (travel, childcare, etc).

 In addition, the LDSA will ensure that all potential recipients will be educated about transplantation.

 There are currently 8,569 people on New York's transplant wait lists, 7,234 of whom are awaiting a kidney. With the LDSA, we anticipate that far more New Yorkers will benefit from a living organ donation.

Here is the press release.

On Tuesday, January 3rd from 4-5pm ET, we will have a virtual celebration and toast the passage of the LDSA! Here is our zoom link.

Please share this good news far & wide!

Best,

 Elaine

Director, Waitlist Zero "

***********

Because the National Living Donor Assistance Center (NLDAC) is a payer of last resort, the NY law will replace NLDAC for NY donors who do meet the means test, and so it will also allow the NLDAC budget to go further.

********

Update: Frank McCormick writes to alert me that, like the authorization for NLDAC,  the NY State law (https://www.nysenate.gov/legislation/bills/2021/S1594) "requires that the Program shall be payer of last resort..." I hope that this doesn't turn into a competition to be the payer of last resort in a way that might cause some NY donors to fall between the cracks, and not be reimbursed either by NLDAC or the State of New York.

The year in passings

 We come to the end of another long year.

Saturday, December 10, 2022

Amnon Rapoport (1936-2022)

Monday, October 17, 2022

Jacques Drèze (1929-2022)

Thursday, September 1, 2022

Elizabeth "Betsy" E. Bailey (1939-2022)

Monday, August 29, 2022

ANTHONY PETER "TONY" MONACO M.D. 1932 - 2022--performed first kidney exchange in the U.S.

Thursday, June 30, 2022

Same sex marriage in Colorado: then and now   Clela Rorex, Clerk Who Broke a Gay-Marriage Barrier, Dies at 78.

Friday, March 18, 2022

David Schmeidler (1939-2022)

Thursday, March 10, 2022

David Bennet Sr., who lived for two months with a transplanted pig heart, RIP

Friday, February 18, 2022

The Economic Theory Conference in Memory and Honor of Hugo Sonnenschein, April 29-30, U. Chicago     (Thursday, July 15, 2021  Hugo Sonnenschein (1940-2021))

IN MEMORIAM : Roy RADNER (1927-2002) by Jean-Michel Grandmont

Dale Jorgenson (1933-2022) by Bob Hall

Remembering Professor Emeritus Stuart Mestelman. Members of the McMaster community have shared their memories of Stuart Mestelman who died on June 25, 2022.

"In 1994, Stuart and his colleagues helped found the McMaster Experimental Economics Laboratory (McEEL). Stuart served as the lab’s co-director between 1994 and 2017, long past his official retirement from McMaster in 2008."

Remembering Robert Andrew “Andy” Muller (1943 – 2021)

"Professor Emeritus of Economics and Co-Director Emeritus, McMaster Decision Science Laboratory, Robert Andrew “Andy” Muller, passed away on October 14, 2021. He was 77 years old. "

The market for battlefield intelligence

Here's a column from the Washington Post, which (although it reads partly like an ad from Palantir) emphasizes that real time battlefield data can be acquired from a variety of commercial sources:

How the algorithm tipped the balance in Ukraine, By David Ignatius

"The “kill chain” that I saw demonstrated in Kyiv is replicated on a vast scale by Ukraine’s NATO partners from a command post outside the country. The system is built around the same software platform developed by Palantir that I saw in Kyiv, which can allow the United States and its allies to share information from diverse sources — ranging from commercial satellite imagery to the West’s most secret intelligence tools.

...

"What makes this system truly revolutionary is that it aggregates data from commercial vendors. Using a Palantir tool called MetaConstellation, Ukraine and its allies can see what commercial data is currently available about a given battle space. The available data includes a surprisingly wide array, from traditional optical pictures to synthetic aperture radar that can see through clouds, to thermal images that can detect artillery or missile fire.

"To check out the range of available data, just visit the internet. Companies selling optical and synthetic aperture radar imagery include Maxar, Airbus, ICEYE and Capella. The National Oceanic and Atmospheric Administration sells simple thermal imaging meant to detect fires but that can also register artillery explosions.

"In our Kherson example, Palantir assesses that roughly 40 commercial satellites will pass over the area in a 24-hour period. Palantir normally uses fewer than a dozen commercial satellite vendors, but it can expand that range to draw imagery from a total of 306 commercial satellites that can focus to 3.3 meters. Soldiers in battle can use handheld tablets to request more coverage if they need it. According to a British official, Western military and intelligence services work closely with Ukrainians on the ground to facilitate this sharing of information.

"A final essential link in this system is the mesh of broadband connectivity provided from overhead by Starlink’s array of roughly 2,500 satellites in low-earth orbit. The system, owned by Elon Musk’s SpaceX company, allows Ukrainian soldiers who want to upload intelligence or download targeting information to do so quickly."

Towards greater gun safety in San Jose

 The mayor of San Jose, CA, has some thoughts on making guns and gun ownership less dangerous, in a  NY Times opinion column:

400 Million Guns Aren’t Going to Just Go Away. In San Jose, We’re Trying Something New. By Sam Liccardo (Mr. Liccardo, a Democrat, has been the mayor of San Jose, Calif., since 2015. He is a former federal and local prosecutor.)

"Amid the rising tide of firearms, reducing gun deaths and injuries requires new solutions. In San Jose, Calif., where I am mayor, we’ve embarked on two approaches untried in any other city or state: We’re imposing an annual fee on gun-owning residents and investing the revenues in violence prevention efforts. And on Jan. 1, the city will begin requiring gun owners to carry liability insurance to compensate victims harmed by the negligent or reckless use of a firearm.

...

"Most gun-owning residents can comply with the insurance mandate with little or no additional cost under standard homeowners’ and renters’ policies. As more jurisdictions adopt an insurance requirement — legislators in New Jersey and California have recently proposed them — we expect that the insurance industry will become increasingly invested in reducing gun-related harm. Premiums will reflect the risks of gun ownership and will adjust accordingly, in the same way that auto insurers offer “good driver” discounts or how they incentivized the installation of anti-lock brakes and airbags in the past.

"Of course, in the realm of gun regulation, no good deed goes unlitigated. Three groups sued San Jose after the ordinance imposing the fee and insurance requirement passed. A Federal District Court declined their pleas for an injunction to stop the ordinance from taking effect, finding no unconstitutional burden on Second Amendment rights where “there are no means by which a San Jose gun owner may be deprived of his or her firearm.”

Designing queues for overloaded waiting lists, by Jacob Leshno

 Here's a paper by Jacob Leshno, with a really creative new contribution to the (venerable) queuing literature. 

Leshno, Jacob D. 2022. "Dynamic Matching in Overloaded Waiting Lists." American Economic Review, December, 112 (12): 3876-3910. DOI: 10.1257/aer.20201111 (ungated working paper link here)

"Abstract: This paper introduces a stylized model to capture distinctive features of waiting list allocation mechanisms. First, agents choose among items with associated expected wait times. Waiting times serve a similar role to that of monetary prices in directing agents' choices and rationing items. Second, the expected wait for an item is endogenously determined and randomly fluctuates over time. We evaluate welfare under these endogenously determined waiting times and find that waiting time fluctuations lead to misallocation and welfare loss. A simple randomized assignment policy can reduce misallocation and increase welfare."

"A practical recommendation is the simple service-in-random order (SIRO) queuing policy. A SIRO buffer-queue mechanism has a simple description: agents who decline an item are allowed to join a priority pool for their preferred item, and agents in each priority pool have an equal probability of receiving an arriving item. We characterize the SIRO buffer-queue mechanism as the robustly optimal mechanism. This simple randomization does not fully equalize the expected wait across states, but it lessens the expected wait fluctuations and therefore reduces the misallocation probability and achieves higher welfare in equilibrium than FCFS." [FCFS= first come first served.]

"In summary, this paper offers two messages for the practical design of allocation through waiting lists. First, although many public-housing authorities have waiting list policies that discourage applicants from declining items, the analysis suggests agents should be encouraged to decline mismatched items. When the system is overloaded, an agent who declines a mismatched item allows the system to search further and assign the item to a matching agent. Furthermore, such an agent reduces the waiting costs of others by allowing them to be assigned before him. Second, equalizing the expected wait agents face when making their choice can improve welfare. This can be achieved by the SIRO buffer-queue mechanism or by partial information mechanisms. Both are practical mechanisms that offer agents more equal options at the time they make their choice, and thus reduce misallocation and improve welfare."

Suppressing vaping is hard

 The WSJ has the story:

Major effort needed to remove illegal vaping products, review finds. Group says FDA regulators are overwhelmed and reactive  By Laurie McGinley

"An independent review of the Food and Drug Administration’s tobacco regulators described them as overwhelmed, reactive and fatigued by an oppressive workload involving e-cigarettes and called for a major effort, by several parts of the Biden administration, to remove millions of illegal vaping products from the market.

"The report, by the Reagan-Udall Foundation for the FDA, also said the agency’s Center for Tobacco Products, created by federal law in 2009, has fallen short in laying out clear priorities and has been besieged by lawsuits brought by tobacco and vaping companies, on the one hand, and public health groups on the other.

"The review said there are millions of illegal vaping products on the market — involving companies that should have applied for FDA authorization and never did, or others that had their applications rejected — and that a major effort is needed to remove them."

The once and future Pasteur Act to incentivize antibiotic discovery and development

It doesn't look like Congress is going to act this year to pass the Pasteur Act.

Here's the NY Times:

Can a Federally Funded ‘Netflix Model’ Fix the Broken Market for Antibiotics? Shortages and drug-resistant germs have renewed attention on a $6 billion proposal in Congress that would reconfigure the way antimicrobial drugs are developed and sold. By Andrew Jacobs

"The broken marketplace for new antimicrobial drugs has stirred debate over a bill, languishing in Congress, that would dramatically reconfigure the way antibiotics are discovered and sold in the United States.

"The $6 billion measure, the Pasteur Act, would upend the conventional model that ties antibiotic profits to sales volume by creating a subscription-like system that would provide pharmaceutical companies an upfront payment in exchange for unlimited access to a drug once it is approved by the Food and Drug Administration.

...

The measure attempts to address the vexing economics of antibiotics: Promising new drugs often gather dust on pharmacy shelves because health providers would rather save them for patients whose infections don’t respond to existing ones. That’s because the more frequently an antibiotic is used, the more quickly it will lose its curative punch as the targeted bacteria develop the ability to survive.

...

"The bill, a decade in the making, has bipartisan support and is widely backed by researchers, health care policy experts and drug company executives. But as momentum for the bill has gained steam, opposition has emerged from a small group of doctors and health care advocates, many of them critics of Big Pharma. They say the bill is a drug-industry giveaway — and unlikely to address the problem of antibiotic resistance.

...

"It can cost a $1 billion or more to bring a new drug to market, but earning back that investment has proved increasingly elusive. Unlike blockbuster medications for chronic conditions like diabetes or high blood pressure, most antibiotics are prescribed for just days or weeks. Many hospitals, unwilling to pay the high prices that accompany new therapies, prefer to rely on cheaper but less effective options, experts say.

A number of antibiotic start-ups have gone bankrupt in recent years, sending a chill through the industry."

*****

Here's some more background from U. Minnesota:

For PASTEUR Act advocates, the finish line is in sight for antibiotic development aid by Chris Dall,   December 6, 2022

"With the clock ticking on Congress to finish its business before the end of the year, groups representing infectious disease and public health professionals and the pharmaceutical industry are trying to push a bill across the finish line that could change the antibiotic development landscape.

"The bill, known as the PASTEUR (Pioneering Antimicrobial Subscriptions to End Upsurging Resistance) Act, would create a subscription-style payment model in which the federal government would pay up front for access to Food and Drug Administration (FDA)-approved antibiotics that target drug-resistant pathogens and meet critical, unmet health needs.

"The aim of the bill, which would delink companies' profits from the volume of antibiotics sold, is to help solve the market challenges that have led many pharmaceutical companies to abandon antibiotic development and contributed to the weak pipeline for new, innovative antibiotics.

"Originally introduced in 2020 and re-introduced in June 2021, the PASTEUR Act, according to advocates, is closer than ever to becoming a reality in the wake of the COVID-19 pandemic and amid growing concern about rising antimicrobial resistance (AMR) rates and the lack of new antibiotics. But time is running out, and the how the bill might fare in the next Congress is unclear."

Epicures and Duck Farms Get a Reprieve From New York’s Foie Gras Ban

The WSJ has the latest turn of events in this long running story:

Epicures and Duck Farms Get a Reprieve From New York’s Foie Gras Ban. The city ordinance fails to pass muster with the state’s Agriculture Department. by  Megan Keller

"Good news for New York City epicures and upstate farmers: Foie gras will remain on menus in the city. They can thank the state’s Department of Agriculture and Markets, which last Wednesday found that the city’s ban on the avian delicacy violated the farmers’ rights under state law.

Foie gras is made from duck or goose livers fattened through a force-feeding process called gavage—administering gradually larger amounts of feed through a small tube in the bird’s throat. The farmers who produce foie gras say the ducks remain healthy and content throughout their lives, but some animal-rights activists consider the practice cruel. In 2019 the New York City Council enacted an ordinance banning the sale of foie gras, which was scheduled to take effect last month."

**********

Earlier: https://marketdesigner.blogspot.com/search?q=foie

 

Fifty Years of a National Program for the Treatment of Kidney Failure

 This JAMA viewpoint tells the story:

Fifty Years of a National Program for the Treatment of Kidney Failure, by Kevin F. Erickson,  Melandrea Worsley, andWolfgang C. Winkelmayer, JAMA. Published online December 19, 2022. doi:10.1001/jama.2022.23873

"Fifty years ago, on October 30, then-President Richard Nixon signed the Social Security Amendments of 1972, which created the End-Stage Renal Disease (ESRD) program. In extending Medicare benefits to people with kidney failure regardless of their age, this landmark legislation availed universal health care coverage for most persons with kidney failure.

...

"In the 1950s kidney transplant had emerged as a treatment option. By the early 1960s, innovations in dialysis machines and vascular access made it possible to treat chronic uremia with dialysis. These technological breakthroughs transformed kidney failure from a terminal illness into a treatable chronic condition. Although the first long-term dialysis center opened in 1962, most patients with kidney failure could not afford dialysis.

...

"For individuals with kidney failure, the ESRD program was transformative. By 1980, there were 58 000 patients receiving lifesaving treatment through the program, with enrollment growth averaging 22% per year. Enrollment growth spanned wide ranges of age, sex, and race, reflecting benefits across broad segments of the US population.4 Currently, more than 700 000 patients with kidney failure have Medicare coverage.

...

" In 2019, Medicare’s fee-for-service program spent $37 billion on the care of patients with kidney failure, accounting for more than 7% of overall Medicare expenditures.

...

"Despite past efforts to maintain quality and limit cost growth, major care gaps remain. Since the ESRD program’s inception, proponents of home dialysis have deplored the underuse of these modalities. Meanwhile, near-universal dialysis coverage may incentivize overtreatment with dialysis. Increasing evidence suggests that some of the sickest patients who start dialysis could instead benefit from active conservative management. A growing body of evidence also suggests that some patients who are new to dialysis may be able to safely undergo a hemodialysis regimen that includes fewer than the standard 3 treatments per week. Near-universal access to kidney failure treatment contrasts sharply with widespread limitations in access to preventive chronic kidney disease (CKD) care. This contrast is particularly poignant as it relates to racial disparities. Black patients face faster rates of CKD progression due, in part, to limited access to CKD care.9 In 2019, 33% of all patients receiving dialysis were Black individuals.

...

"the 2019 Advancing American Kidney Health initiative built on prior efforts to create a dialysis–focused alternative payment model (APM) through 6 new kidney care APMs that encourage home dialysis, kidney transplant, and advanced CKD care. It remains unclear whether dialysis-focused value-based payment initiatives will address outstanding cost and quality gaps. To date, substantial improvements in quality have not been observed.

...

"In summary, during its first 50 years the US ESRD program has provided critical access to lifesaving care for many patients with kidney failure while it has undergone a series of reforms as policy makers aim to control costs and maintain quality. Challenges in balancing cost and quality will persist as the program enters the second half-century of its existence."