How will the Army build AI and robotics expertise in uniform?

 The US armed services have an unusual labor market.  Most soldiers, sailers, airmen and now space forcers join the military pretty much right out of high school, either directly, or in college ROTC (Reserve Officer Training Corps), or in one of the military academies.  Two exceptions are lawyers and doctors, who can join as officers without prior military experience (i.e. they can become officers without ever having learned how to salute).

Now that computer science of various sorts is entering warfare, cyber warriors are also needed.  But there's only so much you can do with contractors and consultants.  

This month, the Army is introducing a new career path for officers:

Army establishes new AI, machine learning career path for officers 

"The U.S. Army has established a new career pathway for officers to specialize in artificial intelligence and machine learning (AI/ML), formally designating the 49B AI/ML Officer as an official area of concentration. It advances the Army's ongoing transformation into a data-centric and AI-enabled force.

Full implementation of the new career field will be phased. The first selection of officers will occur through the Army's Volunteer Transfer Incentive Program (VTIP) beginning January 2026. The officers will be reclassified by the end of fiscal year 2026."

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And here's another report that indicates that some CS experts have also been laterally recruited into the officer corps.

 Army creates AI career field, pathway for officers to join

"In June, the Army directly commissioned several tech executives with artificial intelligence backgrounds from companies such as Meta and Palantir as lieutenant colonels as part of its Executive Innovation Corps (EIC). Those executives serve in the reserves as “senior advisors,” the Army said. 

The job market for economists, 2026

 The WSJ has the story:

Economists Are Studying the Slowing Job Market—and Feeling It Themselves
Newly minted Ph.D.s tend to work for universities, government agencies and big white-collar companies. It’s not a great hiring time for any of them.  By  Justin Lahart 

"The economics job market is getting buffeted by a confluence of forces. Worries about federal funding have led many major universities to reduce, or even freeze, hiring. Jobs within the federal government have dried up. The private sector, where demand for economists has been intense in recent years, has pulled back. 

“It’s like a perfect storm,” said Syracuse University economist John Cawley, who heads the American Economic Association’s job market committee.

"The tough market for doctoral students finishing up their studies is hardly unique to economics. What’s different about economists is that they are intensely interested in measuring and understanding how labor markets work—and they have brought that to bear on their own profession. As a result, armed with data from the AEA and all the knowledge they gained in graduate school, doctoral students in economics have a much more precise grasp of what type of environment they are facing than their counterparts in political science, philosophy or biophysics.

...

"The economics job market has its own peculiar rhythms and hierarchies. In the fall, students who are finishing their Ph.D.s, as well as economists in postdoctoral programs, apply for jobs that typically start the following summer. But because students can apply to dozens, or even hundreds, of jobs, this creates a matching problem: How does a prospective employer know which candidates are serious?

"Economists, being economists, have tried to solve this. When a candidate applies for jobs via JOE, they are able to send up to two “signals” of interest for jobs they are particularly interested in—almost like a winking emoji on a dating app. That signaling system was put together with the help of Stanford economist Alvin Roth, who also developed systems for matching kidney donors with patients and New York City schoolchildren with schools." 

AEA Code of Conduct: (I can't answer "no" to all of the screening questions)

 When I was president of the American Economic Association, we began to think it would be prudent to have a formal code of conduct (see the link below for details).  But part of that effort resulted in a disclosure questionnaire required of all those who would serve on AEA committees. As I recall, I felt that one of the questions was too broadly posed. 

I've agreed to serve another term on the Committee on the Job Market, so I get to fill out the questionnaire, once again.  My responses are below. You should be able to guess the question I thought was phrased too broadly.

AEA Disclosure Questionnaire

Please review and respond to the disclosure questions below, with explanations as needed. It is important that you answer truthfully. Your answers to the questions will be reviewed by the President and Secretary-Treasurer and will be shared with other members of the Executive Committee only if necessary and on a need-to-know basis.

Affirmative answers to questions would not necessarily be disqualifying but will be considered during the review. To expedite this process, I ask that you please respond to these questions at your earliest convenience.

For more information, see the AEA Professional Code of Conduct and the policy on harassment, discrimination, and retaliation.

Here are the questions, and my answers. 

  

######## 

 I would have had more reason(s) to answer "yes" if I had played on any  gender-segregated athletic teams.

Religion and gender turn out to be complicated (and therefore well worth studying). 

Copyright transfer clause: blacklisted countries

Here's something I hadn't encountered before, in the copyright transfer form of a prominent international transplant journal:

"6. TRADE COMPLIANCE: Each author warrants that if the author, any of the author’s coauthors or any other individual whose content is included in the Work resides in Iran, Cuba, Syria, North Korea, Crimea, the Donetsk People’s Republic (DNR) or the Luhansk People’s Republic (LNR) regions of the Ukraine, the Work has been prepared in a personal, academic, or research capacity and not as an official representative or otherwise on behalf of the relevant government" 

The post-Nobel career of Adam Riess, and controversies in cosmology

The Atlantic has a story about a controversy in cosmology about the expansion of the universe, and whether its explanation requires the hypothesis of dark energy.  But what caught my eye is the author's apparent surprise that a Nobel laureate at the center of the controversy continued his research career, post-Nobel.

Here's the link, and the paragraphs that caught my eye: 

The Nobel Prize Winner Who Thinks We Have the Universe All Wrong  Cosmologists are fighting over everything.  By Ross Andersen 

  "Adam Riess was 27 years old when he began the work that earned him the Nobel Prize in Physics, and just 41 when he received it.

...

"When he returned from Stockholm with his prize in 2011, he found that his academic life had changed. People around him started to behave oddly, he told me. Some clammed up. Others argued with him about trivial things, he said, perhaps so they could boast of having dunked on a Nobel laureate. Riess was besieged with invitations to sit on panels, give talks, and judge science fairs. He was asked to comment on political issues that he knew nothing about. He told me he was even recruited to run major scientific institutions. 

"Riess wondered about that path—being the big boss of a NASA mission or gliding around a leafy university as its chancellor. He could see the appeal, but he hated fundraising, and unlike other, older Nobel laureates, he said, Riess still felt that he had scientific contributions to make, not as an administrator, but as a frontline investigator of capital-n Nature. “Scientists sometimes tell themselves this myth: I’ll go lead this thing, and then I’ll come back and do research,” he told me. But then, by the time they’ve finished up with their administrative roles, they’ve lost touch with the data. They become clumsy with the latest software languages. “The science passes them by,” Riess said.

"Riess decided to stick with research. "

Offering deceased donor transplants out of sequence when there is a chance the organ will (otherwise) be unutilized (Ashlagi and Roth in AJOB)

 Itai Ashlagi and I weigh in on recent controversy about "out of sequence" offers of organs for transplant, with some ideas about how the current system might be redesigned and maintained so as to reduce organ discards while maintaining transparency about how and to whom organs are offered.

 Itai Ashlagi and Alvin E. Roth (2026). Out of Sequence Offers: Towards Efficient, Equitable Organ Allocation. The American Journal of Bioethics, 26(1), 5–8. https://doi.org/10.1080/15265161.2026.2594937  

"Organs for transplant are very scarce compared to the need, and so the allocation of organs from deceased donors raises questions about both efficiency and fairness. Because offers of organs take time to consider, and because the viability of organs from deceased donors decreases over time, efficiency sometimes requires increasing the chance of reaching a patient who will accept the organ while it remains viable. So fairness and efficiency, concerning who gets to consider the next offer, and the probability that the organ on offer will be accepted in time for it to be transplanted, may sometimes be in conflict, or at least appear to be. And even the appearance of unfairness may undercut trust in the system of organ donation and transplantation. 

"This conflict between fairness and efficiency has resulted in controversy about offers made “out of sequence” (Covered in a lead article in the NYT article (Times 2025)) 

...

"Collecting data is essential for both efficiency and transparency. It is unfair to future patients not to have transparent allocation systems that can be studied with precision (with causal inference from experimentation), so that it can be improved over time. It is also unfair to future patients who will join increasingly congested waiting lists as a result of the failure to utilize a large number of transplantable organs.

Public data about transplant centers’ performance and patients’ waiting times would further allow patients to choose, based on their own preferences, a transplant center that fits their need. 

...

"Policies to expedite the placement of marginal quality organs that can be tested over time and studied with experiments include when to determine an organ is hard-to-place and when and how to adapt the priority list.

"In summary, it is sometimes desirable to expedite an organ that risks being unused, by offering it to a patient or transplant center that is likely to accept it if the offer is received in a timely way. But it is important to make sure that this flexibility does not promote unfairness to patients or transplant centers. Increasing the transparency and efficiency of the system for expediting organs can address both these issues."

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The same issue of the journal contains a number of articles discussing organ allocation out of sequence  

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Earlier:

Friday, May 23, 2025  Deceased organ allocation: deciding early when to move fast

Transplant problems and public support for organ donation

 The Kidney Transplant Collaborative is worried about the status of kidney transplants in the US.  Here's the statement they published this month, which expresses concern about a drop in deceased donations.

LOSING TRANSPLANTS FOR ALL THE WRONG REASONS: A STATISTICAL ANALYSIS OF THE REDUCTION IN KIDNEY TRANSPLANTS IN RESPONSE TO REPORTS OF OPO FAILURES

"The kidney transplant waitlist has long exceeded the supply of available kidney organs. The waitlist today includes more than 94,000 Americans, with more than 28,000 deceased and living kidney transplants occurring in 2025. Even more troubling, recent events seem to have led to a decline in overall kidney transplants from 2024 to 2025, driven by a decline in deceased donor transplants. This represents the first time in the 21st century that we see an annual isolated decline in deceased donations and deceased donor kidney transplants, even while living donor kidney transplants increase and the kidney discard rate declines, the latter reflecting increased use of available deceased donor kidneys.

...

"What has caused this unprecedented and isolated decline in deceased kidney donations? While policymakers have been appropriately focused on maintaining the integrity of the
deceased donor process, an unanticipated effect of recent oversight efforts of the kidney transplant system and accompanying negative media reports has shaken the deceased donor
landscape and may have possibly caused the reduction in deceased donor rates. Given this emerging trend, the importance of increasing living donation has come into even sharper focus. Policymakers and all stakeholders in the kidney transplant process will need to focus on the impact of the recent oversight efforts and take clear measures to responsibly increase kidney transplant rates, most likely via a focus on living kidney donor supportive policy.

...

"Unreported until now, however, is the negative impact that this recent Congressional focus may be having on kidney transplant levels themselves. The impact is measurable – from 2024 to 2025, there were 116 fewer kidney transplants. This is due to 218 fewer deceased donor kidney transplants and an increase of 102 living donor kidney transplants for 2025 as compared to 2024 – the first time this century that there appears to be an isolated decline of deceased kidney donations driving the decrease in overall kidney transplants.

...

"Recent, highly publicized revelations involving OPOs have had a serious and harmful effect on public trust in organ donation. As a result, fewer individuals and families appear willing to consent to organ donation after death. Data from the OPTN Transplant Metrics National Dashboard shows that the number of kidneys recovered from deceased donors remained steady during the first half of 2025. However, beginning in June 2025, the number of deceased donors began to decline, and that decline has continued to accelerate. In 2025, a total of 15,274 deceased donors underwent kidney recovery, compared to 15,937 during 2024 for a net percentage change of negative 4.2%."

HT: Martha Gershun
 

 

Mike Luca reviews Judd Kessler's "Lucky by design" in the WSJ

 In the WSJ, Mike Luca has a good book review of Judd Kessler's "Lucky by Design".  

‘Lucky by Design’ Review: The Game of Getting More
Costly signals can help with college admissions and hiring. Visiting a campus or attending a meeting in person demonstrate commitment.  By Michael Luca 

"In “Lucky by Design,” Judd Kessler turns over the cards in often-hidden markets, offering advice on topics from standing out in a job hunt to getting a dinner reservation at an in-demand restaurant. Mr. Kessler, a professor of business economics and public policy at Wharton, notes that these systems frequently “allocate valuable, scarce resources without relying on prices” and that the criteria “are not always obvious or visible the way that prices are.”

Mr. Kessler’s premise is that we can make our own luck by understanding the rules of a system and navigating the process accordingly. Take sign-ups for popular children’s activities such as summer camps or after-school programs, which are often offered on a first-come, first-served basis. Mr. Kessler advises that the key in these situations is to “recognize that you are in a race” and “be there, ready to sprint, when the starting gun goes off.” He suggests reading between the lines: If an email offers a starting time for sign-ups, but no end time, it may be because organizers expect things to go quickly, suggesting it’s time to lace up. 

... 

"What’s good for individuals need not be good for the system overall. Mr. Kessler recounts how, when traveling by plane, he and his wife used to book the aisle and window seats in the same row, hoping the middle seat would remain empty but offering to trade for the aisle seat if someone showed up: a clever hack for one group, but one that would get complicated quickly if everyone did that.

"An overemphasis on winning risks rewarding the vigilant while exhausting everyone. Constant sprinting also risks crowding out time for quiet reflection. Mr. Kessler offers a helpful release valve he calls “settling for silver,” a strategy for stepping away from the fiercest competition. Sometimes the race is unavoidable, and it helps to know the quickest route. But the deeper question isn’t whether to sprint harder or settle sooner; it’s defining for ourselves what the prize is and what will actually bring us joy and fulfillment in life. After all, as Mr. Kessler writes, “the fact that we have different preferences is what makes markets—and life—more exciting.” 

The administration takes its eye off medical journals (TACOs can be good)

The war against science hasn't just focused on research universities, but also on scientific journals. (The concern with journals is that they privilege evidence, which is seen as discriminating against some viewpoints.)  And the war on science has a particular focus on medicine, and hence on medical journals. But policing journals takes patience, and (in this case, fortunately) the eye of Sauron doesn't have a lot of patience. (Sort of like pediatricians, who are always in a hurry because they have little patients...) 

Medpage Today has the story:

DOJ Sent Letters to Medical Journals. Then What Happened?
— Worrying probe into publications' partisanship may have lost steam  by Rachael Robertson, 

"A few months into the second Trump administration, major medical journals received letters from Edward R. Martin Jr., who was the U.S. attorney for the District of Columbia at the time. (He has since been replaced by Jeanine Pirro.) 

"The first letter to come to light was addressed to CHEST Editor-in-Chief Peter Mazzone, MD, MPH, of the Cleveland Clinic, and dated April 14. Martin's letter contained five questions, including how the journal assessed its "responsibilities to protect the public from misinformation" and how it handled competing viewpoints. Martin requested a response by May 2.

"Other major journals received similar letters, including the New England Journal of Medicine and Obstetrics & Gynecology, the official journal of the American College of Obstetricians and Gynecologists, as well as two other journals that did not want to be named.

"But since receiving those letters in April, the publications haven't heard a peep on the matter from DOJ, several of the journals confirmed to MedPage Today. Most of the journals also declined to comment on the details of their responses to DOJ's letter. "

History of the U.S. National Science Foundation (NSF)

 The NSF has played a key role in American science, and risks being collateral damage in the war against science.

Here is a their history web page:

History of the U.S. National Science Foundation 

Like many scientists, I'm deeply grateful for their support, particularly their early support. 

 The section "NSF's history and impacts: A brief timeline" mentions some accomplishments decade by decade, including this for the 2010's

    2010

"NSF-supported researchers use economic matching theory to develop a kidney exchange program that dramatically improves efficiency and doctors' ability to match organs. For his work in this area, Alvin Roth shares the 2012 Nobel Memorial Prize in Economic Sciences."

#####

All my posts on NSF.  

The Economic Experience: An Introduction through Experiments by Charles A. Holt and Erica Sprott

 Princeton University Press has a new economics textbook centered on experiments:

 The Economic Experience: An Introduction through Experiments by Charles A. Holt and Erica Sprott  

"An innovative introduction to economic behavior that uses interactive experiments to promote experience-based discovery"

Here's my blurb:

“Experiments have had a huge impact on behavioral economics, and Holt and Sprott’s book aims to make teaching economics, through experiments, easy on instructors and fun for students.”—Alvin Roth, Stanford University

 

What to read in 2026: FT recommends Moral Economics (plus blurbs by Milgrom, Wilson and Goldin:)

 The Financial Times looks into its crystal ball to suggest what books to read in the coming year, organized by the month in which they are scheduled to appear.  I'm happy to see my book among them. (And the first two blurbs are now online as well:)

What to read in 2026 

May 

    Moral Economics: What Controversial Transactions Reveal About How Markets Work by Alvin Roth (Basic Books)
Today’s fiercest moral battles are reframed as questions of market design, rather than absolute rights and wrongs. From reproductive medicine to drug policy and organ donation, Nobel Prize winner Roth shows how societies can calibrate what is permitted, restricted or banned without abandoning ethical concern.
 

The subtitle (subtly different from the U.S. version) reveals that they are thinking of the U.K. Version of my book. 

 

 

"Review
"From the right to sell a kidney to the cost of a surrogate birth, our sense of "right and wrong" shapes the economy more than we realize. Nobel laureate Alvin Roth - the world's leading "philosopher-economist" -unpacks the hidden moral codes that govern our most intimate transactions. This is a clear-eyed guide to understanding where the market ends, where morality begins, and how we can design a world that honors both -- Paul Milgrom and Robert Wilson, Nobel laureates, Stanford University

"With clarity and compassion, Al Roth explores the transactions society cannot escape - surrogacy, the purchase of body parts, the sale of sex, and a host of "repugnant" relationships. What should be regulated? What should be banned? What are the limits of using price in the marketplace? Be prepared to think in new ways and gain from the insights of a great market designer -- Claudia Goldin, Nobel laureate and author of CAREER AND FAMILY  "

WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood by Krawiec and Roth (now open source)

The published version of our paper is now widely available:

Kimberly D. Krawiec and Alvin E. Roth, “WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood,” in James Stacey Taylor and Mark J. Cherry, eds., Markets in Human Organs for Transplantation: Controversy and Contention., Routledge, November 2025 (open source) https://www.taylorfrancis.com/reader/download/5885e1ba-c9af-4547-941c-821a2afaa7ee/chapter/pdf?context=ubx  

From the introduction:

[The nonremuneration principle] is only half of a WHO policy, broadly accepted around the world, that mandates both national (or sometimes only regional) self-sufficiency and an absence of remuneration for both blood products and transplantable organs (hereafter, the “twin principles”) (WHO 2009, 2023). This self-
sufficiency mandate, though less examined than the ban on  remuneration, presents a real hurdle to progress in transplantation, especially for smaller and low and middle income (LMIC) countries. 

"WHO’s insistence on self-sufficiency inhibits cooperative kidney
exchange efforts (as well as other innovations) among countries that
would benefit all concerned, especially the LMIC that the policy is purportedly designed to help. As will be discussed, the policy’s effect on blood products, especially when combined with the no remuneration rule, is even more stark – no country that fails to compensate donors is self-sufficient in plasma collection and few LMIC collect sufficient supplies of whole blood.
 

"This chapter critiques these twin principles, making several central points. In Section 2.2, we discuss the twin principles as applied to blood products, noting the particularly pernicious effects on plasma supply and availability, especially in poorer nations. In Section 2.3, we turn to transplantation, emphasizing the numerous benefits of international cooperation and cross-border transplantation – benefits that would be undermined by self-sufficiency, especially in smaller countries and those without well-developed domestic exchange programs. We illustrate this point with examples drawn from several noteworthy instances of cross-border kidney exchange.
 

"In Section 2.4, we argue that the current discourse around remuneration and organ donation is frequently overdramatic and unhelpful. Although nearly every effort to increase organ donation and transplantation presents ethical challenges, not every such effort amounts to “trafficking” or “a crime against humanity.” These labels stifle helpful deliberation, progress, and consensus. Section 2.5 concludes with recommendations for a saner approach to the scarce resources of blood products and transplantable organs – one that is focused on international cooperation, rather than self-sufficiency; evidence-based policies, rather than a reliance on decades-old
assumptions and understandings; and the use of pilot studies and trials to test the ethics, safety, and efficacy of incentives in various settings."

######

Here's the book:

 

Commercial plasma collection in the US: the Jaworski report for 2025

 Peter Jaworski, a tireless student of blood donation around the world, has published a report on the plasma industry.  It's full of interesting facts, a few of which are highlighted below.

America’s Plasma Contribution to the World: 2025
Launching the Georgetown Blood and Plasma Research Group and the annual state of the U.S. plasma industry report  by Peter Jaworski 

"I am proud to announce the official launch of the Georgetown Blood and Plasma Research Group. Housed at Georgetown University, this initiative will serve as a dedicated academic hub for research on the ethics and economics of global supply chains for not only blood plasma, but blood, bone marrow, and other medically-useful substances of human origin. Our goal is to provide data-driven insights, foster serious philosophical discussion, and be a home for interdisciplinary research.
 

"This 2025 Annual Report is the first contribution to that mission. 

...

"As of December 31, there are 1,247 plasma collection centers in the United States (including four centers in Puerto Rico).

"To put this into perspective: The U.S. is now home to more plasma centers than community colleges (just over 1,000) or Kohl’s department stores (around 1,175). There are almost as many plasma collection centers as Denny’s restaurants (around 1,300). 

...

"we can look at the economics of independent plasma companies. Their business is to sell plasma to fractionators, not to make medicine from the plasma.

"The current selling price of a liter of plasma is around $190, give or take $10.

• Donors receive between 30-40% of that revenue, or around $70 (an average donation is 850 - 880 mL, requiring more than one donation to equal a liter).
• The center spends a majority of the remaining revenue on costs like employees, supplies (“softgoods”), testing, and facility overhead.
• The plasma center will pocket around 8-12%, or around $15 in profit. 

...

"The U.S. plasma industry does more than save American lives, it provides the material for life-saving therapies for patients around the world.

"The 62.5 million liters collected in the U.S. in 2025 represents around 68% of global plasma collections for the manufacture of medicines. About 52% of those collections will end up in medicines to treat American patients, while the remaining 48% will end up treating patients in the rest of the world."

John Henry Kagel (1942-2026), an incomparable experimental economist

 John Kagel will be buried this morning,  January 7, at  New Tifereth Israel Cemetery in Columbus, Ohio. He passed away yesterday.  I don't know the details, but my sense is that he hadn't been well for a while. He was 83.

In his prime, John was the best experimental economist in the world.

He was also my friend, colleague, coauthor, co-editor, and all-around mensch and role model. He was full of life.  

Words fail. 

Here's his Google scholar page. 

In 2023 the journal Experimental Economics had a special issue in John's honor: here's the Introduction. 

May his memory be a blessing. 

Surrogacy stories (state regulators, take note)

 Surrogacy in the U.S. has become well established, with commercial surrogacy legal in almost all US states.  But problems sometimes occur, often of a financial nature, which suggest that in many places the regulatory oversight is still insufficient. (It's natural new regulations should be applied to newish markets as they experience fixable problems...)

Here are three recent stories that I recommend to the attention of regulators. 

WSJ:

Surrogacy Is a Multibillion-Dollar Business—but Surrogates Can Be Left With Big Debts
Booming fertility industry, a new target of private-equity and other investors, is largely unregulated, leaving the women giving birth with few financial or legal protections  By  Katherine Long

 

NBC

 How a top-tier surrogacy agency became an FBI target
Dozens of clients and surrogates were left panicked and in the dark after the agency’s owner seemingly disappeared. One intended parent, Mariana Klaveno, is missing $66,000. By Kenzi Abou-Sabe, Alexandra Chaidez, Liz Kreutz and Andrew Blankstein

 

NYT:

A Surrogacy Firm Told Parents-to-Be Their Money Was Safe. Suddenly, It Vanished.
Surro Connections held itself out as a reliable business. Now, clients have lost as much as tens of thousands of dollars meant to compensate women carrying their pregnancies.  
By Sarah Kliff

Prenups: formerly repugnant, now online

 The New Yorker writes about prenuptial agreements that can be written online, and not just for the wealthy.

Why Millennials Love Prenups
Long the province of the ultra-wealthy, prenuptial agreements are being embraced by young people—including many who don’t have all that much to divvy up.
By Jennifer Wilson

"The past few years have seen the rise of new apps such as HelloPrenup, Wenup, and Neptune that fast-track the process; the latter has couples discuss their finances with an A.I. chatbot before being matched, by algorithm, with a lawyer.

...

"There had been limited cases since the eighteenth century in which prenuptial contracts were recognized in the U.S., but these typically pertained to the handling of a spouse’s assets after death. The idea of a contract made in anticipation of divorce was considered morally repugnant. In an oft-cited case from 1940, a Michigan judge refused to uphold a prenup, emphasizing that marriage was “not merely a private contract between the parties.” You could not personalize it any more than you could traffic laws."
 

Four international kidney exchange programs: 3 achieve substantial success

 Here's a paper reporting on the experience of four cross-border kidney exchange programs, whose experience teaches an important lesson.  In particular (see the figure below), one of  the programs is run by Spain, Italy and Portugal, whose  total population of approximately 118 million people is far larger than the combined population of the other three*, but manages to do less than 5% of the total cross-border exchanges, far fewer than any of the others.  Despite its size, the Spain-Italy-Portugal program only tries to match hard-to-match patient-donor pairs with other hard-to-match pairs, unlike the other three programs.

 International Kidney Paired Donation Programs: Evolution and Practices of 4 Large Collaborations
Klimentova, Xenia PhD1; Domínguez-Gil, Beatriz MD, PhD2; Viana, Ana PhD1,3; Manlove, David PhD4; Andersson, Tommy PhD5; Ashkenazi, Tamar RN, PhD6; Berlakovich, Gabriela MD7; Böhmig, Georg A. MD8; Burton, Jo RN, PGDip9; Coll, Elisabeth MD, PhD2; Dittmer, Ian FRACP9; Fiaschetti, Pamela MD10; Fronek, Jiri MD, PhD11; Hughes, Peter D. MBBS, PhD12,13; Ivo da Silva, Margarida MD14; Mor, Eytan MD15; Viklický, Ondřej MD, PhD16; Weinreich, Ilse Duus BMLS17; Ferrari, Paolo MD, FRACP18,19
Transplantation ():10.1097/TP.0000000000005602, December 24, 2025. | DOI: 10.1097/TP.0000000000005602

"Plain Language Summary: Kidney paired donation (KPD) programs are organized in various countries to facilitate the donation of kidneys from willing but incompatible donors by matching them with pairs in similar situations. These programs often struggle with an accumulation of difficult-to-match recipients and small pools of incompatible pairs. To address this, several international collaborations have emerged to expand the pool sizes and increase the number of transplants by “exchanging” donors’ kidneys across countries. We identified 4 established international KPD programs, each supported by protocols and agreements signed by the participating parties. Each program is presented separately, detailing its historical establishment, operational aspects, and statistics on pool characteristics and performance. Following this, we provide a comparative analysis of key aspects across the 4 programs. Each program has its unique context and specificities. Even though 3 of 4 collaborations started just before the COVID-19 pandemic, they have collectively facilitated >450 transplants. This underscores the importance of further developing these collaborations to share practices and experiences, and to facilitate more transplants, particularly for difficult-to-match recipients. Three of the 4 presented collaborations are either fully operated or led by European countries. This highlights the crucial role of ongoing international cooperation in the development of KPDs, in particular in Europe. By further promoting collaboration among countries, we can facilitate pan-European exchanges and improve access to live kidney transplants for patients in need.

 ...

"A fundamental difference between the programs is their collaboration model. STEP, ANZKX, and the Czech-Austrian-Israeli collaboration operate as “merged pool” model, where all participating pairs are combined for joint matching runs. For STEP and ANZKX, no other matching runs are conducted by partners at any level (hospital or national), whereas in the Czech-Austrian-Israeli collaboration, the Austrian and Israeli partners report performing local exchanges whenever compatible pairs are identified.
 

"In contrast, KEPSAT uses a “sequential pool” model, where national matches are attempted first, and only unmatched pairs are entered into the international pool. It is recognized that the last 2 strategy strategies may lead to a fragmented market, potentially limiting matches for highly sensitized patients, as easier-to-match pairs are removed beforehand."

 It's ironic that a program that appears to be intended primarily to help hard-to-match pairs is organized in a way that limits them in this way.

The paper concludes on an optimistic note (with which I fully agree):

"In conclusion, ongoing international cooperation is essential for advancing KPD programs globally. Expanding cross-border exchanges and improving access to kidney transplants can greatly benefit patients worldwide. Additional strategies, such as NDADs, desensitization protocols, and the inclusion of compatible pairs, can further enhance the effectiveness of both national and international programs. Oversight of these initiatives is crucial to safeguarding the welfare of both donors and recipients, as well as to maximizing the success rates of kidney transplants.
 

"Looking ahead, new initiatives, and projects, funded by international health organizations, such as the European Kidney Paired Exchange Programme project (https://www.hnbts.hu/euro-kep/project), funded by EU4Health and starting in November 2024, aim to expand global collaboration among KPD programs, building on and strengthening existing partnerships. This increased international cooperation is expected to create additional opportunities for patients in need of kidney transplants worldwide, making life-saving transplants accessible to more individuals regardless of their geographic location."

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Earlier: Portuguese transplant docs noted the problem and argued for more global kidney exchange:

Tuesday, March 12, 2024 Kidney exchange between Portugal and Spain, and prospects for global kidney exchange

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*Notes on population:

Spain: 49 million; Italy 59 million; Portugal 10 million ; KEPSAT total pop =  approx 118 million

 Australia 28 million; NZ 5 million: ANZKX total pop approx 33 million

Austria: 9 million, Czech Republic  11 million, Israel 10 million: AT-CZ-IL total 30 million

Sweden: 11 million; Norway:  6 million; Denmark 6 million; Finland  6 million: STEP total approx 29 mil

Should more professional societies condemn some of their members?

 Robert Reich posed the question on his substack:

Ethics Shmethics
Why are America’s most powerful professional associations silent in the face of professional disgraces in the Trump regime?
Robert Reich 

"Hell, if the American Economic Association can permanently ban Harvard economist (and former treasury secretary) Larry Summers for conduct “fundamentally inconsistent with its standards of professional integrity” (Summers had repeatedly asked Jeffrey Epstein for advice on Summers’s pursuit of a younger economist), surely the American Bar Association should ban Lindsey Halligan, and the American Medical Association, Vinay Prasad.

"Where are the American Bar Association and the American Medical Association during Trump’s unscrupulous reign? " 

UNOS continues to run the deceased-donor organ allocation system

 The U.S. Health Resources & Services Administration (HRSA) has published a document outlining its progress in modernizing the Organ Procurement and Transplant Network (OPTN) as required by recent legislation.  The idea was to make the system less dependent on the United Network for Organ Sharing (UNOS), which had been the single federal contractor running the OPTN since its inception.  For the time being, at least, it appears that UNOS will continue to run the organ allocation system.

 Modernizing the Nation’s Organ Donation, Procurement, and Transplantation System

"For more than 35 years, the OPTN was operated through a single national contract.  

"While this structure supported growth in organ donation, procurement and transplantation, the increasing complexity of modern medicine and the demands of real-time technology, safety, data, and public accountability required a new approach.  

"The bipartisan 2023 Securing the U.S. Organ Procurement and Transplant Network Act gave a clear mandate: bring the OPTN into the modern era of governance, technology, and healthcare delivery". 

 

 

Happier new year!

 Things I'm looking forward to in 2026 (not in chronological order)

U.S. midterm elections (forthcoming Nov 3, but you can start contributing/worrying now).

Publication of my new book, Moral Economics (forthcoming May 12, but you can preorder now:)

Grandchildren growing exuberantly older.

Their grandparents growing gently older (while their parents remain unchanged amidst the storm).