Friday, July 31, 2009

Assisted suicide, Right to Die in England: new development

The long discussion in England about the circumstances in which assisted suicide will be prosecuted has moved a step forward with a ruling from the House of Lords:

'Right to die' campaigner Debbie Purdy wins House of Lords ruling

"Families who help terminally ill relatives to end their lives will be free from the risk of prosecution after a landmark ruling yesterday.
The Director of Public Prosecutions is to rush out urgent guidance to clarify the law after Debbie Purdy, a multiple sclerosis sufferer, won an historic judgment from the House of Lords.
The guidance will not remove the offence of assisted suicide under the Suicide Act 1961 but make the situation clearer for people who help relatives to die in circumstances of “compassionate” assisted suicide.
In their unanimous ruling, five law lords said that the DPP must issue a “custom-built” policy stating the circumstances that would lead him to prosecute in such cases, and those where he would not. It is the first time that the DPP has been asked by the courts to detail the circumstances under which he would prosecute. "
"To date, 115 people have travelled from Britain to a Swiss clinic to be helped to die. Eight cases have been referred to the DPP but no relatives have been prosecuted. However, the uncertainty has led some people to make their last journey alone, without family members, so as not to risk their being prosecuted, Lord Hope of Craighead, giving judgment yesterday, said. Others, he added, had given up the idea of assisted suicide and “been left to die what has been described as a distressing and undignified death”.
Sarah Wootton, chief executive of Dignity in Dying, said that the ruling would clear up “the current legal muddle”. She said: “A law which is not understood, enforced or supported by the majority of the public is not fit for purpose. The ruling distinguishes between maliciously encouraging someone to commit suicide and compassionately supporting someone’s decision to die, in order that these acts are treated differently. More and more people want choice about how they end their life. Yet, until now, the law has refused to say whether people would face prosecution for accompanying someone abroad to exercise this choice.”
This month, an amendment tabled by Lord Falconer of Thoroton to remove the threat of prosecution from those who go abroad to help the terminally ill to die was defeated by peers in the Lords sitting not as a court but as the second chamber of Parliament. "

Thursday, July 30, 2009

Medieval market design

The International Congress on Medieval Studies has issued a call for papers (posted by Dan Ernst on the Legal History Blog):
"We welcome proposals for papers that explicitly link legal history with economic history in explaining the dynamics of medieval life and culture.
Here are some examples of possible topics:

"The canon law generated regulations concerning Usury, the Just price etc. during the "long" Twelfth Century. Meanwhile, secular laws sought to regulate markets (through laws on forestalling, regrating, engrossing, Assize of Bread and Ale etc.) and boosted those on coining offenses. This sustained attempt to restrain economic activity through law must be largely explicable from the context of economic change against which it was made. How might the Legal Revolution (the whole or any part) and the rising "Profit Economy" (Lester Little) be causally linked?"

My one attempt to study Medieval market design, in a paper on unravelling (with Xiaolin Xing), concerned forestalling (forestalling was the medieval crime of transacting before the official opening of a market). Our discussion can be found here. (The selection is short, and on rereading it I recall that I particularly enjoyed footnote 72, partly because of the name of one of the plaintiffs in the case it describes).

Wednesday, July 29, 2009

Kidney exchange: moving towards a national program

Kidney exchange, which works best with a thick market (lots of patient-donor pairs), is now moving towards experimenting with a national matching program: UNOS Currently Accepting Proposals for Kidney Paired Donation Pilot Program

"United Network for Organ Sharing (UNOS) is developing a national kidney paired donation (KPD) system. UNOS, as the OPTN contractor, will administer this system and it will be open to all OPTN/UNOS-approved transplant programs that perform living donor kidney transplants.
To help prepare for the final implementation, UNOS will begin an interim implementation of the KPD Pilot Program in September 2009. The interim implementation will allow UNOS staff to gain experience with KPD and refine its business processes before rolling out the full system in 2010. We will limit the interim implementation to two to four groups initially.
Any living kidney programs who would like to participate in the interim implementation must submit a proposal... by August 5, 2009.
A complete copy of the Request for Proposal (RFP), including details about who can participate, is available on the UNOS Web site. Learn more now "

Tuesday, July 28, 2009

Assisted suicide in England and Switzerland, continued

The British press continues to follow British citizens who choose to end their lives in Switzerland, where assisted suicide is legal. (In Britain, as in many if not most places, it remains a repugnant transaction: it's not a crime to attempt suicide, but it is a crime to assist.) In this case, one of the members of the couple who ended their lives was not terminally ill (although it sounds like his quality of life had been severely compromised): With Help, Conductor and Wife Ended Lives

"The controversy over the ethical and legal issues surrounding assisted suicide for the terminally ill was thrown into stark relief on Tuesday with the announcement that one of Britain’s most distinguished orchestra conductors, Sir Edward Downes, had flown to Switzerland last week with his wife and joined her in drinking a lethal cocktail of barbiturates provided by an assisted-suicide clinic."
"“After 54 happy years together, they decided to end their own lives rather than continue to struggle with serious health problems,” the Downes children said in their statement."
"“Even if they arrest us and send us to prison, it would have made no difference because it is what our parents wanted,” he said.
Attempting suicide has not been a criminal offense in Britain since 1961, but assisting others to kill themselves is. But since the Zurich clinic run by Dignitas was established in 1998 under Swiss laws that allow clinics to provide lethal drugs, British authorities have effectively turned a blind eye to Britons who go there to die.
None of the family members and friends who have accompanied the 117 people living in Britain who have traveled to the Zurich clinic for help in ending their lives have been charged with an offense. Legal experts said it was unlikely that that would change in the Downes case.
But British news reports about the Downes’ suicides noted one factor that appeared to set the case apart from most others involving the Dignitas clinic: Sir Edward appeared not to have been terminally ill. There have been at least three other cases similar to the Downes’, in which a spouse who was not terminally ill chose to die with the other. "

A subsequent story in the Times reveals changing sentiments: Huge public support emerges for the right to die

"Overwhelming public support for a change in the law to allow medically assisted suicide is revealed in a poll for The Times.
Almost three quarters (74 per cent) of people want doctors to be allowed to help terminally ill patients to end their lives. Support is particularly strong among those aged 55 to 64.
Six out of ten people also want friends and relatives to be able to help their dying loved ones to commit suicide without fear of prosecution.
Changing the law has always been opposed strongly by doctors, with two out of three against legalisation. But yesterday saw the first sign of change in the medical establishment. "

Monday, July 27, 2009

Corruption and kidneys in New Jersey and Brooklyn

The NY Times reports on a corruption investigation resulting in 44 arrests in New Jersey and Brooklyn: In New Jersey Case, Nervous Jokes and a Cereal Box of Cash

Almost as an aside, the story reports that a broker for transplant kidneys was caught in the net:

"Another man in Brooklyn, Levy-Izhak Rosenbaum, was accused of enticing vulnerable people to give up a kidney for $10,000 and then selling the organ for $160,000. Mr. Dwek pretended to be soliciting a kidney on behalf of someone and Mr. Rosenbaum said that he had been in business of buying organs for years, according to the complaint."

Part of the repugnance to the transaction seems to be the buying and selling prices. (Would we/should we feel differently if the kidneys were bought for $100,000 and sold for $115,000?)

Steve Leider points me to an Indiana Jones connection: Anthropologist's 'Dick Tracy moment' plays role in arrest of suspected kidney trafficker. (The anthropologist in question, Nancy Scheper-Hughes, writes frequently about black markets for kidneys, and apparently indentified Mr Rosenbaum some years ago, although the story doesn't suggest to me an immediate connection to the recent arrest.)

Parag Pathak points me towards Benyamin Cohen's story in Slate, following up on the Jewish connection: The arrests of rabbis who trafficked body parts uncover more complicated issues, that suggests some of the nuances of Jewish religious jurisprudence about organ donation and sales.

Trying to figure out Jewish law directly from the Bible skips a couple of centuries of subsequent interpretation. Here's what I wrote about kidney sales in a footnote of my paper Repugnance as a constraint on markets:

3 While there is no central authority on the application of Jewish law to modern concerns such as transplantation, the most authoritative opinions are contained in various “responsa” or answers to particular questions by rabbis acting as legal “deciders” (poskim), whose authority arises from the respect of their peers. The consensus on the matter of live kidney donation, for example, seems to be that live donation is allowed (since it saves lives), but it is not required (since the donor becomes wounded and takes some risk to his own life), and hence it falls into the category of things for which compensation could be offered and accepted (unlike actions that are either forbidden or required). See, for example, Eisenberg (2006), Grazi and Wolowelsky (2004), Kunin (2005), and Israeli (1997) who cite eminent modern poskim such as Rabbi Shlomo Zalman Auerbach and Rabbi Moshe Feinstein."

"For example, Avraham (2004, p. 271–2) reports the opinion of the eminent Rabbi Shlomo Zalman Auerbach that someone who sells a kidney with the intention of saving a life does a good deed “even if he would not have donated his kidney only to save life.” But he goes on to note, “[I ]n spite of all that has been said above, it seems to me that it is the community that needs soul-searching for allowing a person to reach such a depth of despair that he must sell a kidney, either because of poverty, debts, or the inability to pay for a relative’s medical expenses.”

Although mainstream Jewish authorities support organ donation, some streams of ultra-orthodox Judaism do not: here's a disturbing article brought to my attention by Miran Epstein, from Yediot: Heart recipient's father: We'll never donate organs
It goes on to note
"The father's words angered Prof. Yaacov Lavee, director of the Heart Transplantation Unit at the Sheba Medical Center. "This is outrageous," he said. "I've heard such statements from many of my candidates (for a transplant), who weren't ashamed to admit they wouldn't donate organs.
"Such statements led me to initiate the bill that prioritizes transplants for people who have signed an organ donor card. This is clearly immoral behavior," he added.
The new transplant law, which will go into effect in May, states that any person in need of a transplant and who has had an organ donor card for at least three years will be given priority on the organ transplant waiting list. "

This makes some aspects of Israeli transplant law resemble parts of Singapore's transplant law, which also gives priority for organs to those who are registered as donors. (I wrote about this near the end of an earlier post.)

Update: Sally Satel's take is in the WSJ: About That New Jersey Organ Scandal It’s not surprising when 80,000 Americans are waiting for kidneys, and a background piece from Time magazine: How Does Kidney-Trafficking Work?

Sunday, July 26, 2009

House flipping fraud in Florida

I received the following email from Eric Budish, the Chicago market designer:

"I came across a neat investigative journalism feature on a form of mortgage fraud called “house flipping” .

The newspaper reviewed 19mm Florida real-estate transactions, and found that 50,000 involved appreciation of 30%+ in less than 90 days. They investigate one fraud circle in depth, and have features on the local police, lenders, etc.

What makes the fraud tick is that the buyer can finance at the new price. So if A legitimately buys a house for 100, then immediately sells it to his buddy B for say 150, B can get a mortgage against the 150 (especially if his buddy C is a real-estate appraiser). Even if B makes a small down payment on the 150, together A and B have extracted 50 minus downpayment minus fees in cash from the transaction. B never intends to repay the 150, and B’s mortgage lender is severely under collateralized.

The reason I think this is all so interesting is that the fraud is only possible because houses are idiosyncratic, but not too idiosyncratic. If houses were perfect substitutes, then A, B and C couldn’t trick the mortgage lender about house values (50,000 flips is a lot, and likely an underestimate, but still less than 1% of transactions). If houses were substantially more idiosyncratic, then banks would never have gotten in the habit of financing 90%+ of the purchase price in the first place: in the event of foreclosure they’d have to worry about whether the right types of buyers would be in the market. Put differently, the housing market is not too thick, but not too thin."

Saturday, July 25, 2009

Is fish-tossing repugnant?

Fishmongers in Seattle throw dead fish around the market, and it has apparently become not just a way of handling fish for sale, but a form of entertainment.

"Jeremy Ridgway, one of the managers at the market, said that he has done fish shows for the ministry of manpower in Singapore, for schoolchildren in Oklahoma and at countless other venues."

One of those other venues was a meeting in Seattle of the American Veterinary Medical Association, which decided to go ahead with "a plan to host a team-building program offered by the famous fish-throwers of Seattle's Pike Place Fish Market."

The organization People for the Ethical Treatment of Animals (PETA) finds this repugnant, and thinks such events should not be conducted.

Judge for yourself: Seattle's Pike Place fishmongers under fire .

Friday, July 24, 2009

Fly fishing

I spent last weekend in Jackson Hole Wyoming at a transplant conference. My friend Owen Phillips, the U. of Wyoming experimental economist who I first met when he visited Harvard in 2005, invited me to go fly fishing with him the next day. He hired a well recommended fishing guide, Mickey Brockman.

Fishing guides are licensed by the state, and work as subcontractors for businesses that hold outfitters' licenses (in Mickey's case, Westbank Anglers). So the arrangement is a bit like taxi drivers in cities where legal cabs require taxi medallions, except that fishing guides use their own equipment. Mickey's equipment includes a dory, which he rows facing forward, and a variety of fishing gear, including the barbless hooks that allow you to release the fish quickly after catching it. (He also packed lunch, which we ate looking up at the Grand Tetons, which sounds even better in French.)

Owen and I presented Mickey with a complicated task, since Owen is an expert angler with a lifetime of experience, and I was holding a fly reel for the first time. So, Mickey had to teach me the mechanics of casting, while keeping up a running list of likely targets for Owen to aim at.
It was an experience, and if you're in Jackson Hole and can't get Owen to take you, I certainly recommend Mickey.
(Thanks, Owen.)
To make the story long, we finished the day eating elk at Stiegler's (also recommended), which got us thinking about the market for elk: it turns out they are farm raised.
From Jackson Hole I flew to Stony Brook, Long Island, for a game theory conference. That tells you something about medicine and economics...

Thursday, July 23, 2009

Regulatory capture in French electricity market

David Jolly reports in the NY Times: France Resists a Power-Monitoring Business

"Two weeks ago, the French Energy Regulatory Commission, the C.R.E., decided that Voltalis, a company that installs electricity management devices in homes and businesses and then manages their use, would have to, in effect, pay power producers for the power that it saves. "

Wednesday, July 22, 2009

Taxing a repugnant transaction, medical marijuana version

Steve Levitt's post When Taxpayers Welcome Taxes, is about a medical marijuana provider who lobbied to have his business taxed. Levitt speculates why:
"The real answer, I suspect, is that he is generating $19 million a year in revenues selling in a market (medical marijuana) that is barely legal. And DeAngelo probably suspects that taxation will increase the likelihood that his business remains legal, for two reasons. "

I'm inclined to agree. This reminds me of the similar case of legal brothels in Nevada.

Universities and price discrimination

According to Yale's president Richard Levin (interviewed in the WSJ), elite universities are more than ever able to charge different prices to different students:

"Four years of college at $200,000 strikes lots of people as indecent. "You're talking about sticker prices," Mr. Levin says. "The actual net price people pay, tuition minus financial aid, is basically not changed at all. If you look at the average net price for all of our students, it's actually declined over the last decade." That makes for an average cost of $18,000 per student per year now, compared to $19,000 a decade ago. Mr. Levin says the boom provoked "something of an arms race to give more financial aid," and opened private schools up to a larger -- and as a result stronger -- pool of students "that used to think that elite private schools were inaccessible to them." Yale may be "more affordable than ever," he says. But then Yale's president admits "this logic only applies to five schools" who offer "need blind" admissions."

The article ends by noting (in this time of recession and falling endowments) that universities are among our oldest self perpetuating institutions:
"For all the anxiety about the future for universities, it's hard to think of American institutions that have been as durable, surviving revolution, war and depression. At Yale, they like the refrain, "Older than the Republic." "

Tuesday, July 21, 2009

Gambling, in Russia

Gambling is sometimes regarded as a repugnant transaction, and sometimes as a tax on the willing. In Russia the pendulum has swung both ways. With the fall of communism, casinos became legal. Now they are becoming illegal, in all but some distant parts of Russia: Exiled by Russia: Casinos and Jobs

"The government is shutting down every last legal casino and slot-machine parlor across the land, under an antivice plan promoted by Vladimir V. Putin that just a few months ago was widely perceived as far-fetched. But the result will be hundreds of thousands of people thrown out of work.
And in a move that at times seems to have taken on almost farcical overtones, the Kremlin has offered the gambling industry only one option for survival: relocate to four regions in remote areas of Russia, as many as 4,000 miles from the capital. The potential marketing slogans — Come to the Las Vegas of Siberia! Have a Ball near the North Korean Border! — may not sound inviting, but that is in part what the government envisions. "

Monday, July 20, 2009

Credit markets, old and new: The Receivables Exchange

The WSJ reports CIT's Woes Prompt Surge In Activity At Receivables Exchange.

"The turmoil surrounding finance giant CIT Group Inc. (CIT) is driving a surge in new business for a New Orleans-based company that runs a market in receivables.
The Receivables Exchange, which lets small- and mid-sized companies auction their accounts receivable to buyers that include hedge funds and commercial banks, on Wednesday recorded its busiest day ever and is fielding a flood of calls from businesses searching for financing alternatives."

The Receivables Exchange is a new firm built a round the idea of disintermediating accounts receivable. Here's my earlier post.

Sunday, July 19, 2009

Same sex marriage divides the Anglican Communion

Among American Episcopalians, and in the Anglican Communion worldwide, the issue of gay marriage has involved a contentious debate on what some regard as a repugnant transaction. That appears to be coming to a head.

Gay marriage approval sounds death knell for Anglican unity

"Bishops in the US dealt a death blow to hopes for unity in the worldwide Anglican Church when they approved in principle services for same-sex partnerships. The decision will finally split the Communion between Bible-based conservative evangelicals and liberal modernisers.
The bishops at the Episcopal General Convention voted by 104 to 30 to “collect and develop theological resources and liturgies” for blessing same-sex relationships, to be considered at the next convention in 2012.
The resolution notes the growing number of states that allow gay marriage, civil unions and domestic partnerships, and gives bishops in those regions discretion to provide a “generous pastoral response” to couples in local parishes. It was passed on Wednesday, hours after the Episcopal Church voted on Tuesday to allow the consecration of gay bishops. The motion passed by 99 to 45 among the bishops and by 72 per cent to 28 per cent among church deputies, made up of clergy and laity.
The decisions on gay consecrations and same-sex blessings end the uneasy truce agreed after the consecration of the openly gay Gene Robinson as Bishop of New Hampshire in 2003. "

Saturday, July 18, 2009

Eugene Volokh on kidney transplantation and the law

Volokh writes:
"Should a Parent Be Required To Donate a Kidney to a Child Who Needs a Life-Saving Transplant?"
"A commenter asked this as a rhetorical question, suggesting, I think, that the answer must obviously be "no." But I don't see why, assuming that we're talking about a minor child of the parent. Parents are rightly seen as having duties to their children. These include the duties to work to support the child for 18 years (more controversially, that's extended even beyond 18 years in many child support decisions, but for now I set that aside); to care for the child; to bear a post-viability fetus, at least absent some substantial threat to the mother's life or health; and more.
Why wouldn't this also extend to the obligation to provide a life-saving transplant, at least when the risk is as low (not zero, but very low) as it is for kidney transplants? You bring a child into the world, and you incur major obligations to it; why shouldn't this be one of them?"

Volokh has earlier written, in the Harvard Law Review, an article titled

He argues there that there may be a right to self defense (similar the right to use lethal force against an attacker) that would invalidate bans on experimental medical treatments, and bans on the sale of kidneys for transplant. That is, he argues that a person at risk of dying from kidney failure is being denied her right of self defense--medical self defense--when she is legally prevented from trying to buy a kidney.

Here's a relevant paragraph, which follows some other analogies:
"Olivia is dying of kidney failure. A kidney transplant would likely save her life, just as an abortion would save Alice’s, lethal self-defense might save Katherine’s, and an experimental treatment might save Ellen’s. But the federal ban on payment for organs sharply limits the availability of kidneys, so Olivia must wait years for a donated kidney; she faces a 20% chance of dying before she can get one. Barring compensation for goods or services makes them scarce. Alice and Ellen would be in extra danger if doctors were only allowed to perform abortions or experimental treatments for free. Katherine likely wouldn’t be able to defend herself with a gun or knife if weapons could only be donated. Likewise, Olivia’s ability to protect her life is undermined by the organ payment ban."

HT: Steve Leider

Friday, July 17, 2009

Organ tranplants and law in Japan

Japanese transplant law and practice are in flux. Recent news stories convey different parts of the story.

Japan’s Parliament Eases Rules on Organ Transplants, Death Law
July 13 (Bloomberg) -- Japan’s parliament approved legislation to ease restrictions on organ transplants in a move that backers say will save thousands of lives.
The upper house today approved a bill passed in the lower chamber last month that eliminates the need for a written will for organ donations. The new rules also accept a lack of brain function as a legal definition of death.
Doctors performed 11 heart transplants in Japan last year, according to the Japanese Circulation Society, compared with more than 2,000 in the U.S. The 12-year-old limitations lawmakers voted to end today had forced Japanese to travel overseas for transplants “as a last resort to survive,” according to a joint statement from medical groups including the Japan Society for Transplantation.
Each year, about 400 Japanese die because they aren’t able to get a heart transplant, while 2,000 pass away without a new liver, according to statistics presented to lawmakers last year by the society.

Travelling overseas--to the U.S.--for a heart transplant isn't an easy thing to arrange:An organ in U.S. won't be cheap

" Japanese who traveled to the United States to get new hearts were charged as much as about $1.63 million for the operation in 2008, or five times higher than in previous years, medical sources well-versed in organ transplants said Thursday.
...The average fee charged to 42 Japanese who went to the U.S. for heart transplants between 1998 and 2008 rose to about ¥80 million last year, compared with between ¥30 million and ¥70 million in the past, they said.
One child patient was charged as much as ¥160 million for the operation last year, while another was required to put down a deposit of ¥400 million in March, the sources said.
In the U.S., the only country that accepts Japanese for heart transplants, nationals are charged $300,000 on average in hospital and physician fees for the operation, they said, adding that the figure does not include pre- and posttreatment fees."

Japan lifts ban on children donating organs
"Japan lifted a ban Monday on organ donations from children, reversing a restriction that created such a dearth of small organs in the country that young patients were forced to seek transplants abroad.
The law will allow children, defined as those under 15, who are brain dead to donate their organs — a sea change in this country, where organ donating is sensitive because of Buddhist beliefs consider the body sacred and reject its desecration."

Kids under 15 can give organs
"The bill, known as Plan A, which won Lower House approval last month, allows brain-dead children under age 15 to be an organ donor with the family's consent and recognizes brain death as legal death.
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...The current transplant law, enacted 12 years ago, forbids brain-dead people under age 15 from becoming an organ donor. Supporters of Plan A had aimed to revise the law to increase the self-sufficiency of domestic organ availability, but some lawmakers argued brain death is too sensitive an issue and thus should not be universally recognized as actual death. " (HT: Jun Wako)

Related recent post: Children can't get organ donations in Japan, because they can't be deceased donors

Thursday, July 16, 2009

New Key Opinion Leaders in Transplantation

I'll be spending this weekend in Jackson Hole, Wyoming, participating in an unfamiliar ritual. The Transplantation Society introduces what they call "New Key Opinion Leaders," surgeons and others with notable accomplishments. The ritual is that each new KOL is supposed to be introduced by an old KOL. Typically a young surgeon is introduced by an old one, etc.

Here is the program. There's something a little unusual about Section 6, devoted to developments in Living Donor Exchange: Like the actor who isn't a doctor but plays one on TV, I have been asked to introduce Mike Rees, the kidney exchange innovator who is the founder of the Alliance for Paired Donation.

He and I will talk about Market Design and Kidney Exchange.

Here's the program for the session we are a part of: I'm looking forward to learning the latest.

Session 6: Living Donor Exchange

Chairs: Alan Leichtman, MI, USA and Miran Epstein, UK

Presentation 6.1
KOL: Robert A. Montgomery, Johns Hopkins Hospital, MD, USA
New KOL: Dr. Dorry L. Segev, MD, USA
Title: Living Donor Exchange: Optimization and Application

Presentation 6.2
KOL: Gabriel Danovitch, University of California in Los Angeles, CA, USA
New KOL: Dr. Jeffrey Veale, CA, USA
Title: Challenges in the Development of Living Donor Exchange Programs

Presentation 6.3
KOL: Alvin E. Roth, Harvard Business School, MA, USA
New KOL: Dr. Michael Rees, University of Toledo Medical Center, OH, USA
Title: Market Design and Kidney Exchange

Presentation 6.4
KOL: Laura A. Siminoff, Virginia Commonwealth University, VA, USA
New KOL: Dr. Heather Marshall Traino, VA, USA
Title: Improving Rates of Living Donation among Minority Population

Wednesday, July 15, 2009

China outlaws shock treatment for uncontrollable urge to blog

Those of you reading this will be glad to know
China bans electric shock therapy for internet addicts

"China has outlawed the use of electric shock therapy to treat internet addiction, after a scandal at a hospital in the Northern province of Shandong."

"Internet addiction has become a growing problem in China, where officials believe as many as four million people spend more than six hours a day online.
Several clinics have sprung up, offering parents the chance to "cure" their children of the uncontrollable urge to blog..."

Surrogate motherhood continued: where did I come from?

As the market for surrogate wombs becomes more usual, and as the kids grow up, some new twists are added to the question "where did I come from?"

Here's a story that makes clear that surrogacy has been around for a while. It's one of the first articles I've seen that takes for granted that surrogacy is not a repugnant transaction, a point underlined by its placement on the front page of the NY Times:
No Stork Involved, but Mom and Dad Had Help .

Tuesday, July 14, 2009

The secondary ticket industry (scalping, to you)

The "secondary ticket industry" has a trade show, meeting tomorrow in Las Vegas, about which they say: "Ticket Summit is the leading trade show and conference in the secondary ticket industry."

These are the folks who sell tickets on the aftermarket (often after buying them on the primary market before others can), and who are often called by the more familiar, less charitable name of scalpers.

Grownup economists recognize that there's a place for secondary markets, but I wonder if a convention of ticket re-sellers doesn't have something of the flavor of a sex-workers' conference, in the sense that the participants are engaged in an industry that is often viewed as repugnant, and which is hemmed in by legal constraints that are sometimes ignored.

My attention was drawn to the conference by one of the speakers, Christian Hassold, who I met when he did an undergrad thesis on secondary ticket sales. The most interesting undergraduate theses are written by students with a real passion for what they are studying, and Christian, who is now off in the entrepreneurial world, has continued to write about ticket sales on his blog The Ticket Economist.

He always seemed like the kind of guy you would like to take in a game with, and it turned out that he's good at getting tickets too: his blog mixes reviews of news and scholarship with some practical advice: see e.g. Buying from a Scalper? Five Do’s and Don’ts, and Bargaining for Tickets on the Street.

TTE points to two thoughtful essays on scalping. One is by Trent Reznor of the band Nine Inch Nails: TR thoughts on ticket re-sellers / scalping (which also includes some interesting links).
Another is this Slate article by Mark Gimein:
Is Ticket Scalping All That Bad? Miley Cyrus' new crackdown on concert gouging just shows how complex the problem is.

Monday, July 13, 2009

Virginia Postrel on Kidney Exchange, and other (less distinguished) news coverage

Virginia Postrel's latest article in the Atlantic is about kidney exchange: ...With Functioning Kidneys for All.

She writes well (check out her Dynamist blog). In addition, as someone who gave one of her kidneys to a friend, she writes with a personal as well as a professional interest and authority. Her article mostly talks about kidney exchange as it is developing in the U.S., but also discusses possible donor compensation, and the international black market.

The article is well worth reading, and contains interesting links (including to this paper, in the New England Journal of Medicine, about a ten-transplant kidney chain, of which I'm happy to be among the coauthors).

It's a great thing to have kidney exchange covered in the press, because that allows more potential kidney exchange candidates to hear about the possibility, and it allows potential donors to know just how big an impact they could have. On this latter point, Postrel's article points out that
"Since the current transplant system extols altruism, one way to end the [long deceased donor waiting] list would be to find more altruists. With, say, 50,000 new living donors, deceased donation could easily pick up the slack. Again, the numbers aren’t that big. The Southern Baptist Convention includes 42,000 member churches; the United Methodist Church, whose Web site earlier this year featured the quote, “As United Methodists, we’re life savers,” counts more than 34,000 U.S. congregations. If each congregation produced just one new living donor, the waiting list would disappear. "

But press coverage is a bit puzzling. Not all of it is as careful and accurate and well reported as the Postrel article. (Which is not to say that even inaccurate coverage still isn't a good thing, for the way it spreads the news.) But I've been a little bemused at the way coverage sometimes simply follows press releases. Here's a story for those of you who find media an interesting subject.

Remember that NEJM article I mentioned above? It got a lot of press when it came out in March, maybe because the NEJM embargoes its articles until a day before publication, and that creates some buzz. That journal article reported a novel, non-simultaneous chain of transplants which begain in July 2007, in which 10 donors gave kidneys to 10 recipients, involving 6 transplant centers in 5 states. The innovative surgeon who was responsible for organizing that, Mike Rees, was the lead author of that article, and is the founder of the Alliance for Paired Donation. I thought the coverage was pretty accurate, perhaps because it was a news story that was about an article in a medical journal that the reporters could refer to.

But not all press releases are about peer-reviewed journal articles. This past week there have been a lot of stories about another remarkable accomplishment, another such chain, which accomplished 8 transplants, almost as many. It was organized out of Johns Hopkins, one of the leading hospitals doing kidney exchange in the U.S. It's not surprising that Hopkins surgeons should be among those pushing this kind of innovation forward; two of them who were involved in this new chain were among the coauthors of the NEJM article. And, while the accomplishment, so soon after the NEJM article, is noteworthy, the news coverage is in some ways as remarkable.

Here's the lead paragraph of the first of two stories about it in the Washington Post: "A Maryland transplant surgeon says he and doctors at four hospitals in four states have transplanted eight kidneys and he considers that the largest series of multi-kidney donations ever. "

The second Post story, the next day, repeats that claim (under the headline Successful Eight-Way Chain of Surgeries Involving Johns Hopkins Is a First:
"The first-of-its-kind surgery -- believed to be the largest chain of donations in history -- involved hospitals in four cities..."

The Post isn't alone. A few days later, after a chance to do some more in depth reporting and fact checking, the (July 11) CBS evening news reports on how one of the patients experienced "...a surprise rescue - the chance to be a part of the biggest multi-city, multi-patient domino kidney exchange ever."

There are three surprises for those interested in news reporting. First, the surgeon quoted above in the first Post story is one of the coauthors of the NEJM article about the earlier, larger chain, so that quote was an odd slip of the tongue (or, maybe he was misquoted, or maybe that's what's required to get kidney exchange the press coverage it deserves). Second, the AP and Post and CBS evening news reporters weren't aware of the earlier chain despite all the press coverage it received, including this (March 12) story (also) on the CBS Evening News about the earlier chain: A Transplant Surgeon Matches 10 Donors With Recipients In The Longest Chain In History .

But the third surprise is that there's a really great human interest story about this latest, Hopkins led chain. It's not just about the surgeons, it's also about the donors. One of the donors was a Hopkins hospital administrator, who had seen first hand the good that kidney donors can do, and wanted to help a friend, but turned out to be incompatible with that friend. That is just the kind of situation that kidney exchange was invented to help. (How do I know this? I read the Hopkins press release, which was headlined
Johns Hopkins leads first 16-patient, multicenter 'domino donor' kidney transplant.

The subheadline was "Johns Hopkins vice president 1 of the donors".

So, hats off to the Hopkins surgeons and their talented colleagues at Barnes-Jewish Hospital in St. Louis, INTEGRIS Baptist Medical Center in Oklahoma City and Henry Ford Hospital in Detroit. And a deep bow to the donors. As for the reporters, yours is a noble craft too; kidney exchange is complicated, keep trying.

(And thank you, Virginia, for your thoughtful story in the Atlantic.)

Sunday, July 12, 2009

Dynasties in college legacy admissions

Along with other kinds of affirmative action, colleges are likely to give preferential status to applicants whose parents and other close relatives have attended. The idea seems to be that having a relationship with a family increases donations. (For example, imagine that one of your descendents will become a billionaire and look for a big philanthropic outlet. If everyone in the family has gone to Family U., maybe this urge will turn into a new campus building, whereas if everyone in your family went to a different college, maybe this philanthropy would go to the poor...)

This intuition receives some support in a recent paper, by authors at Stanford and Princeton, who study an anonymous but selective university.

Family Bonding with Universities by Jonathan Meer, Stanford University, and Harvey S. Rosen, Princeton University
From the abstract:
"One justification offered for legacy admissions policies at universities is that that they bind entire families to the university. Proponents maintain that these policies have a number of benefits, including increased donations from members of these families. We use a rich set of data from an anonymous selective research institution to investigate which types of family members have the most important effect upon donative behavior. We find that the effects of attendance by members of the younger generation (children, children-in-law, nieces and nephews) are greater than the effects of attendance by older generations (parents, parents-in-law, aunts and uncles). "

Saturday, July 11, 2009

Indirect affirmative action in Texas college admissions

When the state of Texas ruled out race as an explicit criterion in college admissions, it adopted a rule that any Texas students in the top 10% of their high school class would be given automatic admission to the state university of their choice. Because Texas high schools are collectively diverse, that guaranteed a diverse freshman class. But it proved to be a very rigid way of matching students to schools, and the policy is about to end: Texas Vote Curbs a College Admission Guarantee Meant to Bolster Diversity.

"The University of Texas, Austin, a top-ranked institution, had sought changes to the program for years because it allowed admissions officials almost no latitude in putting together a class and endangered some important but less popular departments, like music. Last fall, 81 percent of the members of the incoming class were admitted under the 10 percent rule.
Suburban parents with students at schools with rigorous standards also complained that the law discriminated against their children, since it was harder to make the cut at such schools than at smaller, rural and some urban schools. "
"The law given final approval by the Senate on Saturday caps the number of students let in under the rule at three-quarters of the class, giving university officials discretion over the makeup of the last quarter. Sponsors of the bill had wanted a lower cap — 50 percent — but their colleagues in the House would go no lower.
Supporters said it was not a moment too soon. The state has only three top-rated universities — the University of Texas at Austin, Texas A&M University and Rice University — and it had been projected that the entire incoming class at the Austin campus would be made up of top-10-percent students by 2013."
"Bill Powers, the president of the University of Texas, Austin, said that, left untouched, the previous law would have forced the university, in the long run, to accept more students than it had the capacity to teach. What is more, the automatically admitted students tended to opt for popular majors, and it had become a struggle to find talented students for programs like architecture, engineering, music, art and geosciences, he said.
While still restrictive, Mr. Powers said, the new law would give admissions officers more flexibility to reach down into high school classes for students who may be brilliant in some regards, like in music, but not in the top 10 percent.
“Judging people on one criterion is not the way to do admissions policy,” he said. “No one else in the country does it.” "

Friday, July 10, 2009

Market for doctors: work rules for surgical residents

Surgical residents are young doctors in training, and there is an ongoing conflict playing out between perceptions of their training needs and patient well being and safety. The Boston Globe reports: MGH cited on surgeons' overload, Trainees' hours exceed safety rule; Hospital says it has fixed problem.

"Junior surgeons at Massachusetts General Hospital have been working too many hours, in violation of patient safety rules, according to a national accrediting organization that is threatening to put the hospital’s surgery training program on probation.
The Accreditation Council for Graduate Medical Education cited the hospital because a significant number of its surgeons in training, known as residents, were exceeding hour limits and working seven days straight. The organization believes these workloads contribute to fatigue-related mistakes, and has given the hospital until Aug. 15 to fix the problem."
" But five years after the hour restrictions were adopted, Warshaw and other surgeons said frustration is building at the nation’s teaching hospitals, because residents believe the rules interfere with their work and ultimately may harm, rather than help, patients.
The council acknowledged the tension in its April 13 letter to Mass. General, in which reviewers wrote: “The greatest challenge . . . has been getting the culture of the residents to change.’’

..." Dr. Thomas Nasca, head of the accreditation council, lamented in a letter to training programs earlier this year that residents are placed in an “ethical quandary’’ because “we compel them to lie [about their hours] if they do the right thing for their patients.’’
Still, the council is stepping up enforcement, and 5 percent to 10 percent of surgery programs were cited last year, including many of the country’s most prestigious training programs. Beth Israel Deaconess Medical Center was threatened with probation last year, but has since reined in residents’ workloads."
"Surgeons are adamantly opposed to tougher limits, saying there is little evidence that sending residents home after a prescribed work shift has improved patient care and that the rules actually may be hurting residents’ education. General surgery residents need to complete at least 750 cases during their five-year training so they are ready to operate on their own once they finish.
Any change would also have financial implications for teaching hospitals, where the nation’s 107,000 residents provide the majority of care."

I haven't done any work related to residents' work rules, but I've done a lot of work related to how residents get hired....

Thursday, July 9, 2009

Contraception: reversal of the direction of repugnance?

What is viewed as a repugnant transaction can change over time, and even reverse direction entirely. An example is that laws in the US have gone from prohibiting contraception to prohibiting pharmacists from declining to provide contraception.

Repugnance to contraception is far older than effective contraception, with roots sometimes attributed to the Bible*. In the United States, the Comstock Law of 1873 made it a Federal crime to sell or distribute contraceptives or information about them, and many states followed with bans of their own. These were not finally overturned until the Supreme Court, in Griswold v. Connecticut (1965), overturned Connecticut's ban on contraception, and found that the Connecticut law violated a fundamental right of privacy. (Here's a summary of the case.)

More recently, a number of states have passed laws requiring hospitals and health care providers to inform rape victims of the availability of "morning after" contraception, and sometimes requiring pharmacies to stock it and dispense it: 50 State Summary of Emergency Contraception Laws.

This in turn has raised the question of whether health care providers and pharmacists who find contraception repugnant can or should be compelled to provide information about it. One of the final acts of the Bush administration was to issue regulations allowing pharmacists and doctors to decline to provide contraception or information about it if they found it morally repugnant:

Bush's Last-Minute 'Conscience' Rules Cause Furor
"Health care workers, hospitals and even entire insurance companies could decline to perform, refer or pay for abortion or any other health care practice that violates a "religious belief or moral conviction" under new rules issued by the outgoing Bush administration.
"This rule protects the right of medical providers to care for their patients in accord with their conscience," said Health and Human Services Secretary Michael Leavitt.
But opponents of the rule, now set to take effect Jan. 19, say it could threaten patients' health. "This is a very wide, broadly written regulation that upsets what has been a carefully established balance between respecting the religious views of providers, while also making sure that we're guaranteeing patients access to health care," said Cecile Richards, president of the Planned Parenthood Federation of America. "
(See the rule here, called (confusingly) Ensuring That Department of Health and Human Services Funds Do Not Support Coercive or Discriminatory Policies or Practices in Violation of Federal Law)

Subsequently, these conscience clauses have come under attack:
Obama administration may rescind 'conscience rule'

"February 27, 2009
WASHINGTON — Taking another step into the abortion debate, the Obama administration Friday will move to rescind a controversial rule that allows health-care workers to deny abortion counseling or other family-planning services if doing so would violate their moral beliefs, according to administration officials.The rollback of the "conscience rule" comes just two months after the Bush administration announced it last year in one of its final policy initiatives.The new administration's action seems certain to stoke ideological battles between supporters and opponents of abortion rights over the responsibilities of doctors, nurses and other medical workers to their patients.Seven states, including California, Illinois and Connecticut, as well as two family planning groups, have filed suits challenging the Bush rule, arguing it sacrifices the health of patients to religious beliefs of medical providers."

(See the proposed rule here: Rescission of the Regulation Entitled ``Ensuring That Department of Health and Human Services Funds Do Not Support Coercive or Discriminatory Policies or Practices in Violation of Federal Law''; Proposal)

So it appears that we have come full circle in a certain sense, and now have laws that prohibit the withholding of information about contraception (and contraception itself), where once we had laws forbidding the dissemination of contraception and information about it.

(No wonder the study of repugnant transactions doesn't lend itself to simple theories about what is and is not repugnant...)

*The biblical story that is sometimes interpreted as indicating repugnance to contraception is the story of Onan in Genesis 38. However that story is complex, and it is far from clear to me that contraception is the issue.

Wednesday, July 8, 2009

Jury design

How to design a committee to determine when a probability is "beyond a reasonable doubt?" That's the task facing juries in criminal cases. (Juries are like prediction markets for the past: they are charged with determining probabilities ex post.)

In all but two States, the rule is that unanimous agreement is required. But the States aren't unanimous. A current challenge to a non-unanimous Oregon conviction raises the question: Guilty by a 10-2 Vote: Efficient or Unconstitutional?

"...Oregon is one of only two states that does not require juries to reach unanimous verdicts in criminal cases. Like Louisiana, it allows convictions by a vote of 10 to 2.
In a pair of decisions in 1972, the Supreme Court said that was all right, that the Constitution does not require states to insist on unanimity.
But the decisions, one each from Oregon and Louisiana, were badly fractured and internally inconsistent. They concededly ignored the historical record and made assumptions about jury behavior that have been called into question by more recent research."
"According to the Oregon Criminal Defense Lawyers Association, most felony convictions in the state are the products of nonunanimous juries. Oddly, misdemeanor convictions still require a unanimous vote, though from a six-member jury. That means, the association said in a brief supporting Mr. Bowen, that prosecutors face a lighter burden in more serious cases.
Oregon does require a unanimous vote in first-degree murder cases, and Louisiana requires it in capital cases.
A unanimity rule would seem to reinforce the requirement that prosecutors prove their cases beyond a reasonable doubt. Two jurors out of 12, if you do the math, represent about 17 percent of the panel. That’s a fair amount of doubt."

Tuesday, July 7, 2009

Market Design, Experimental Economics, and Game Theory

I've recently agreed to become a director of Market Design Group, Inc., primarily for the pleasure of being associated with the stellar group of auction designers and game theorists who are the other principals of the firm.

I've also become the president elect of the Economic Science Association, the professional association that was founded to promote experimental economics.

There was a time when relatively few people saw a connection between market design and experimental economics (or were interested in either). But the connection of market design and experimental economics to each other, both directly, and through the connection of each to game theory, is becoming clearer. It helps that market design has moved from the theoretical to the practical, with economists increasingly becoming involved in design projects that go through to the establishment of successful markets.

Here are half a dozen experiments I've collaborated on related to market design (with links to my collaborators):

Kagel, John H. and A.E. Roth, "The dynamics of reorganization in matching markets: A laboratory experiment motivated by a natural experiment," Quarterly Journal of Economics, February, 2000, 201-235.

McKinney, C. Nicholas, Niederle, Muriel and Alvin E. Roth, "The collapse of a medical labor clearinghouse (and why such failures are rare)," American Economic Review, 95, 3, June, 2005, 878-889.

Niederle, Muriel, and Alvin E. Roth, "Market Culture: How Rules Governing Exploding Offers Affect Market Performance," American Economic Journal: Microeconomics, 1, 2, 2009, forthcoming.

Haruvy, Ernan, Alvin E. Roth, and M. Utku Unver,, “The Dynamics of Law Clerk Matching: An Experimental and Computational Investigation of Proposals for Reform of the Market,” Journal of Economic Dynamics and Control, 30, 3 , March 2006, Pages 457-486.

Ariely, Dan, Axel Ockenfels, and Alvin E. Roth, "An Experimental Analysis of Ending Rules in Internet Auctions," Rand Journal of Economics, 36, 4, Winter 2005, 891-908.

Katok, Elena, and Alvin E. Roth, "Auctions of Homogeneous Goods with Increasing Returns: Experimental Comparison of Alternative 'Dutch' Auctions," Management Science, 50, 8, August 2004, 1044-1063.

Monday, July 6, 2009

Rental market for textbooks

Here's a story about, which rents textbooks: We Rent Movies, So Why Not Textbooks?

"Yet the Craigslist model didn’t work. When classes ended in the spring, sellers couldn’t find many buyers online and sold their used books to the college store, often for pennies on the dollar. By the time students migrated back to campus in the fall, willing online sellers were few and far between. "
"With demand for good deals on textbooks running high, Chegg’s success comes in large part from being able to address those inefficiencies. While Chegg primarily rents books, it is also essentially acting as a kind of “market maker,” gathering books from sellers at the end of a semester and renting — or sometimes selling — them to other students at the start of a new one. "

See also,,

Sunday, July 5, 2009

"It's like fishing..." Indoor prostitution in Taiwan and Rhode Island

Taiwan has begun a process of legalizing prostitution : "Taiwan's cabinet will issue regulations within six months, when new regulations take effect, covering locations in Taiwan approved for prostitution."

"It's like fishing," Su said. "The activity may be legal, but in some places you can't do it."

"Taiwan outlawed prostitution 11 years ago, but older sections of the capital Taipei still teem with underground sex workers in bars and night clubs on the upper floors of high-rise buildings."

"Taiwan is the latest place to legalise prostitution. New Zealand allowed brothels to operate freely in 2003, when parliament narrowly voted to overturn 100-year-old sex laws. A court in Bangladesh decriminalized the trade in 2000, but for women only."

And in Rhode Island, things may be moving in the opposite direction.
The Providence Journal has a story about how indoor prostitution was decriminalized in Rhode Island (perhaps inadvertently, the story suggests) as part of legislation aimed at strengthening laws against public solicitation: Behind closed doors: How R.I. decriminalized prostitution. (HT: MR). The story goes on to describe ongoing attempts to reverse that:

"This year, as they have for the last three years, several state lawmakers are pushing to rewrite the 1980 law. A bill that passed the House earlier this month clearly states that anyone who engages in sex for money is guilty of a misdemeanor, punishable by up to six months in jail and a $1,000 fine. The bill is awaiting a hearing in the Senate Judiciary Committee. " (emphasis added)

Money is at the root of a lot of repugnance.

Saturday, July 4, 2009

Getting what you measure: college rankings version

As the rankings of universities conducted by the magazine US News and World Reports have become more influential, there are a growing number of reports of the ways, fair and not so fair, that universities respond to what USNWR tries to measure.

Clemson University has been in the news in connection with their stated efforts to rise higher in the US News and World Report rankings of colleges.
They and their critics agree that they want to do this; the question is are they doing it in the right way for the right reasons.

Here's a critic who says no:Researcher Offers Unusually Candid Description of University's Effort to Rise in Rankings:
"Clemson University is run in an almost single-minded direction, with nearly all policies driven by how they will help the land-grant institution rise in U.S. News & World Report’s rankings, according to a university official whose candid comments stirred debate among conference-goers here on Tuesday."

and the reply:
Clemson Assails Allegations That It Manipulates 'U.S. News' Rankings
"Clemson University, stung by charges by one of its own researchers that it willfully manipulates the U.S. News & World Report rankings, fired back on Wednesday, saying the accusations are “outrageous” examples of “urban legends” that have surrounded the university’s campaign to reach the top 20 of public research universities.“The accusation that Clemson, its staff, and administrators have engaged in unethical conduct to achieve a higher ranking is untrue and unfairly disparages the sincere, unwavering, and effective efforts of faculty and staff to improve academic quality over the past 10 years,” reads a statement issued by the university’s chief spokeswoman, Catherine T. Sams. “While we have publicly stated our goal of a top-20 ranking, we have repeatedly stressed that we use the criteria as indicators of quality improvement and view a ranking as the byproduct, not the objective.” "

Here's a summary: Clemson Explains Its Approach to U.S. News Rankings

And here's a story about alleged simple mis-counting at USC's School of Engineering: More Rankings Rigging , and a summary reflecting the relation between what is measured and what is reported: Gaming the Rankings. Here's an illuminating paragraph:

"Any performance measure is ripe to be gamed. The percentage of alumni giving is a measure worth 5 percent of a ranking in U.S. News. A few years ago, Albion College made its own stir in the higher education rankings world when it increased its percentage of alumni making donations with the stroke of a pen. As The Wall Street Journal reported, the college recorded a $30 donation from a graduating senior as a $6 alumnus gift for the next five years. Clemson, in its systematic approach to raising its rank — “no indicator, no method, no process off limits to create improvement,” as Watt stated — solicited alumni donations in such a way as to increase their giving rate: Alumni were encouraged to give as little as $5 annually."

Note incidentally that there are different ways to try to rise in the rankings, and some may be strictly gaming (e.g. soliciting and/or reporting the same $30 contribution in a different way), while others (lowering the number of classes with more than 20 students) may have a positive effect by themselves. But whenever the goal is one thing, but what is or can be measured is another, there of course will be incentives to respond to what is being measured.

Friday, July 3, 2009

Medical tourism and medical data

An Op-Ed in the NY Times reports on the difficulty of evaluating how well foreign hospitals do compared to American hospitals: Overseas, Under the Knife . A big difficulty is that appropriate data aren't collected on medical outcomes:

"There is reason to think the quality of care at some foreign hospitals may be comparable to quality in the United States. More than 200 offshore hospitals have been accredited by the Joint Commission International, an arm of the organization that accredits American hospitals. Many employ English-speaking surgeons who trained at Western medical schools and teaching hospitals.
So should offshore surgery be welcomed as a modest way to make American health care more affordable? We can’t know until we can directly compare the outcomes with those of American surgery. To begin, we must adopt a uniform way for American hospitals and surgeons to report on the frequency of short-term surgical complications.
Medicare could do this by requiring that all participating hospitals and surgeons count pre-surgical risk factors and post-surgical complications during hospitalization and for 30 days afterward, when most short-term problems become evident. The system used for many years by Veterans Affairs hospitals to reduce surgical complications is the best option for this, since it is available to all American doctors through the American College of Surgeons. So far, however, only a small minority of surgeons participate in this or any other valid national system of reporting surgical outcomes.
Patients and their surgeons also need comparable measurements of long-term success. Medicare should lead by adopting Sweden’s method of monitoring hip joint replacement outcomes. It tracks, for example, a patient’s ability to walk without pain six years after surgery.
Finally, Medicare should invite accredited offshore hospitals and their affiliated doctors to participate in all of its comparative performance reporting systems. Beyond informing Americans contemplating treatment abroad, such comparisons would allow us to learn if our care is the world’s best — and to accelerate our improvement efforts if it is not. "

Agreeing on what data to collect, and collecting it, isn't easy. (And of course what data you collect can influence what outcomes you get in ways that aren't all desirable.) But the lack of outcome data is a weak link in American medicine, which makes it difficult to evaluate alternative practices and procedures. I see this in discussions about kidney exchange, and my guess is that this is a big problem in improving medicine and the medical marketplace generally.

Thursday, July 2, 2009

Senate Judiciary Committee and College Football Playoffs

The United States Senate Committee on the Judiciary had the following item on its home page yesterday:
"Did You Know? The Senate Judiciary Committee conducted 104 hearings and business meetings in the 110th Congress, more than any other Senate Committee"

There is only one meeting so far on next week's calendar:
Tuesday 7/7/2009
Subcommittee on Antitrust, Competition Policy and Consumer Rights
"The Bowl Championship Series: Is it Fair and In Compliance with Antitrust Law? "

Here's the AP story: Senate to Hold Hearing on College Football's BCS
"The Senate plans to hold a hearing next week looking into antitrust issues surrounding the Bowl Championship Series. It's the second time this year that Congress is shining a light on the polarizing system college football uses to crown its national champion."
"Sen. Orrin Hatch of Utah, the subcommittee's top Republican and the lawmaker who sought the hearing, did not return telephone and e-mail messages left at his office Tuesday.
In an essay for Sports Illustrated being released Wednesday, Hatch wrote that the Sherman Antitrust Act prohibits contracts, combinations or conspiracies designed to reduce competition.
''I don't think a more accurate description of what the BCS does exists,'' Hatch wrote. He noted that six conferences get automatic bids to participate in series, while others do not. The system, he argued, ''intentionally and explicitly favors certain participants.''
Football fans in Hatch's state were furious that Utah was bypassed for the national championship despite going undefeated in the regular season. Hatch noted that President Barack Obama and others have called for the BCS to be replaced with a playoff system."
"David Frohnmayer, president of the University of Oregon and chairman of the BCS Presidential Oversight Committee, expressed a preference Tuesday for the current system, saying the proposals for a playoff system ''disrespect our academic calendars, and they utterly lack a business plan.'' "

College football bowls used to be an unravelled market, and, whatever its other flaws, the BCS system has largely eliminated that problem. While I'm rooting for the Judiciary Committee in their own competition to hold the most hearings, I hope that their efforts will not do too much harm to one of the main reasons we have colleges.

Wednesday, July 1, 2009

Chinese college admissions exams

Americans have the SATs, Chinese have the gao kao:
All-Nighter? For This Test, Some Chinese Cram All Year

"China may be changing at head-twirling speed, but the ritual of the gao kao (pronounced gow kow) remains as immutable as chopsticks. One Chinese saying compares the exam to a stampede of “a thousand soldiers and 10 horses across a single log bridge.”
The Chinese test is in some ways like the American SAT, except that it lasts more than twice as long. The nine-hour test is offered just once a year and is the sole determinant for admission to virtually all Chinese colleges and universities. About three in five students make the cut."

Many students who don't do well in one year study for an additional year and take the exam again:

"Mr. Liu calculated that his score leaped by more than 100 points over last year’s dismal performance. But he was still downcast, uncertain whether he would make the cutoff to apply to top-tier universities. The cutoff mark can vary by an applicant’s place of residence and ethnicity."

That last point is actually a very interesting feature of college admissions in China. As I understand it, the exam for the elite universities is the same exam everywhere, but it is administered and evaluated differently in different regions. Thus Peking University (whose name in English survived the change in the English spelling of the city to Beijing) sets a different admissions threshhold for different regions. I believe it also has a different quota of students from different regions, so that students from a given region compete only with each other for admission to PU (or Beida, as it is known in Mandarin).

Furthermore, different regions have different rules about how the exam is used in the application process. In some regions, students take the exam and learn their scores before deciding how to fill out a rank order list of applications (in which the first choice is a critical one). These students know how well they did on the exam compared to others in their region, so the only uncertainty is how many other students will apply to each top university, and hence where the exam cutoffs will be that will be needed to get in under quota.

In other regions, students make their applications after taking the exam, but before the results are announced, so they only have an estimate of how well they did compared to others. And in still other regions, students must decide on their applications before even taking the exam, so they only have information about how well they have performed on other measures compared to other students.

Thus, along with the ordinary difficulties of applying to university, different strategic decisions about how to deal with the application process face students in different regions.