I post market design related news and items about repugnant markets. See my Stanford profile. I have a 2026 book : Moral Economics The subtitle is "From Prostitution to Organ Sales, What Controversial Transactions Reveal About How Markets Work."
Showing posts with label global kidney exchange. Show all posts
Showing posts with label global kidney exchange. Show all posts
I'm on my way to the Brocher Foundation, near Geneva, for a conference organized by Swisstransplant (SWT) and the Declaration of Istanbul Custodian Group (DICG), on
"The shortage of organs available for transplantation poses a major challenge to healthcare systems. Some proposals aim to introduce incentives to encourage organ donation. This workshop examines the ethical implications of these strategies and discusses acceptable limits for promoting donation while respecting human dignity."
Protections intended to thwart organ trafficking may inadvertently also "protect" legitimate patients and donors from receiving life-saving medical care.
"Globally, unrelated and nondirected living kidney donations have become important mechanisms for expanding transplant access.1 Structured programs in the United States and Spain support unrelated donation through rigorous psychological evaluation, independent donor advocacy, and transparent oversight systems.3,4 For example, nondirected donors serve as critical initiators of kidney paired donation chains, substantially amplifying transplant opportunities beyond a single donor-recipient pair.3-5 However, a recent regulatory shift in Mexico threatens to effectively preclude these pathways in practice, leaving living kidney donors (including living liver donors) with genuine altruistic intent declined and vulnerable patients losing critical access to life-saving transplants.
"WHEN ALTRUISM REQUIRES PROOF "On August 4, 2023, the National Transplant Center and the Federal Commission for Protection against Health Risks issued a High Health Directive (Alta Directiva Sanitaria), establishing mandatory standardized protocols for Mexican transplant centers.6 This directive emerged in response to well-documented regional concerns regarding organ trafficking, transplant tourism, regulatory gaps, and the “legal simulation” of donor-recipient relationships. These concerns are entirely legitimate and align with the principles articulated by the Declaration of Istanbul on Organ Trafficking and Transplant Tourism.7
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"Although the directive does not explicitly outlaw nondirected donation, its evidentiary requirements effectively preclude it at the committee level. As a result, viable donor candidates may be categorically declined for regulatory rather than medical reasons.
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"Although data isolating the exact proportion of donor evaluations declined solely for documentation rather than medical or psychosocial factors are currently unavailable, Mexican National Registry data highlight a concerning sign.9 During the 12 mo preceding the directive’s publication, 438 unrelated living donor kidney transplants were performed nationally, compared with 354 during the subsequent 12 mo—a 19% decline. "
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"This directive severely limits Mexico’s potential to establish domestic paired-exchange networks or participate in cross-border paired kidney exchanges. The Global Kidney Exchange model, for instance, incorporates pairs from middle-income countries into US-initiated chains to overcome financial and immunological barriers.10 This approach has been accompanied by ethical discussion in the transplant literature, particularly regarding concerns about potential inducements and unintended exploitation.10"
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"Ultimately, the critical question is not whether expanding living kidney donation should be permitted, but whether a transplant system can be considered ethically complete if a viable living kidney donor candidate is categorically declined for regulatory rather than medical reasons."
"Editor’s note: Entertainer Pat Boone, Pro Football Hall of Fame quarterback Steve Young and actor Robert Hays of “Airplane” fame signed on as authors of a guest essay provided by US Blood Donors.org for Mississippi Today on “Kidney Chains.”
"This guest essay, though, written from a national perspective is of special importance to MT Ideas since Mississippi is among the states with the highest number of kidney disease-related deaths per 100,000 adjusted for age, according to the National Center for Health Statistics.*
"Hundreds of thousands of dialysis patients in the United States could receive lifesaving kidney transplants sooner if one simple idea became widely known: “kidney chains”— sequences of living-donor transplants that allow one donor to save multiple lives.
The goal is simple: Make “kidney chains” a household phrase.
Kidney chains allow living donors who are incompatible with their intended recipient to help initiate a sequence of transplants that can save multiple lives. The concept builds on Nobel Prize-recognized work** in market design and has already enabled thousands of lifesaving kidney transplants.
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*Figure from the NCHS
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** The video link is to the last three minutes of this 15 minute talk from 2014
One feature of giving talks to unfamiliar audiences is that you only get noisy feedback on how your talk was received. This past June, I gave the Starzl Lecture at the American Transplant Congress in Boston. (The ATC is jointly organized by the two big American transplant societies, the AST and the ASTS,*) I spoke to an audience of about 1500 people (just a guess, but I could see some empty seats in an auditorium set up for 2,000). My talk included topics, including global kidney exchange, that have raised controversies.
Afterwards, what seemed like a lot of people came to speak to me, and were enthusiastic about my talk. But "a lot of people" was fewer than 100. So what about everyone else? (It probably wouldn't be statistically kosher to assume that those who came to congratulate me were a representative sample:)
Since global kidney exchange has led to some people calling me an organ trafficker, I didn't have any measure of the general sentiment of the meeting.
I got some reassuring news recently when the ATC sent out an email soliciting ideas for talks for next year's meeting, in Seattle. The email came with a picture from this oat meeting:
So I'm guessing this means that my talk was well received by people responsible for organizing the next meeting.
And, indeed, I'm getting multiple signals that there's an appetite for productive change in the transplant community. I hope to have more to say about that in the coming year.
India, which performs the third most kidney transplants in the world (after only the U.S. and China) is a natural location for international kidney exchange on a global scale. Here's a brief outline of the legal, administrative and procedural obstacles that need to be overcome on the way.
The moral philosophers Peter Singer & Kasia de Lazari Radek interviewed me about Moral Economics on their podcast Lives Well Lived. At the end, they ask their guests to think about their own life, and to what extent their own life has been well lived. That's a bit like being asked what you would like to have inscribed on your tombstone. So I hedged a bit. But the conversation that followed was interesting, so if you scroll down you'll see the transcript of that last bit, which starts about minute 1:09 in the recording.
Jun 25, 2026 "Nobel Prize-winning economist Alvin Roth explains how innovative market designs can reduce exploitation and save lives. Drawing on his pioneering work in kidney exchanges, Roth explores some of society’s most contentious moral dilemmas involving organ markets, surrogacy, and unpacks the ethical tensions surrounding what he calls “repugnant transactions.”
"Lives Well Lived is hosted by Peter Singer & Kasia de Lazari Radek. Episodes consist of interviews with remarkable guests who have lived well, both in the sense of living an ethical life, but also in that they are fulfilled and happy with what they have achieved in their lives. Some of these guests will be well-known figures, but others who are doing extraordinary things will be unfamiliar to almost all of our listeners. The conversations will often cover ground that involves ethics, how to live well, and how to make a positive difference in the world. It will inspire and empower its audience to change their own lives for the better. "
Here's the transcript of the last few minutes of the conversation (starting around minute 1:09 of the recording).
PETER: We always asked our guests to think about their own life, and to what extent their own life has been well lived, and by what criteria they make that judgment? Would you like to comment on that, Al?
Al: Sure. Has my life been well lived so far? Well, first, I've had a very fortunate life so far. I am lucky in my family, and my children, and my grandchildren, and my friends. And when you talk about friends, one thing that's often not talked about are the relations that professors have with students. So I've made lifelong friendships with many students who are productively engaged around the world, and that's very gratifying, and I hope it helps make my life worthwhile.
But also, I'm a market designer, and market design is very outward facing part of, economics. And, one of its goals is, a phrase even older than effective altruism, which is tikkun olam (תִּיקּוּן עוֹלָם) mending the world. And one of the things that market designers try to do is fix markets when they're broken or create them when they're absent. When you think of something like kidney exchange, you know, in a different podcast, on a different subject, I could tell you about victory after victory, where thousands, many thousands of transplants have been done, and lives have been saved through kidney exchange, even though it's in a war that we're losing: the shortage of kidneys is growing faster than the increase in transplants as diabetes grows, and high blood pressure, things like that. So, I would hope that some of my life has looked well lived, not just from the inside, but perhaps also from the outside.
Peter: Absolutely sure that it has. You're right. And what you've done for kidney markets is just one example, where you've saved many lives, and I think that obviously would be an important part of living well. despite the fact that the problem, as you say, has not been solved as a whole.
Kasia: It must be very satisfying.
Al: People often say that to me, and it will be satisfying when I'm retired. Right now, it's still frustrating, right? There's so much left to do, and it's not so easy to do it. But the times are changing. In two weeks, I'm gonna be opening up the American Transplant Conference in Boston, and, you know, there are people who invite me to these things. I sometimes joke with my young colleagues that as the old people who feel a lot of repugnance die off, it'll be left to just us young people. And we'll see.
I was in a transplant conference in Cairo in November. in which we tried to reach consensus on the question of, should countries have to be self sufficient in transplantation, which is the traditional position of the World Health Organization and some other organizations. And, of course, it works against countries that don't have much kidney exchange, because you need a big pool of patient-donor pairs to find lots of exchanges. And in that spirit, incidentally, during COVID, I was in the United Arab Emirates for the first kidney exchange between the UAE and Israel. And, that had to overcome a lot of obstacles, but it makes a lot of sense, because the UAE and Israel each have only a population of about 10 million. And that's not enough to find kidneys in your domestic pool for the hard to match patients, for patients who have a lot of antibodies to human proteins. So, we would like to see much more cooperation and not just between rich countries, but also inviting patients from poor countries, patient-donor pairs, to take part in American kidney exchange. And that's something that remains very controversial, but I think that we might be on the verge of making some progress with that. That's something that Peter has written about also.
Peter: Yes, I certainly hope so, and because I'm now working as a regular visiting professor in Singapore, which is another small country, the population of about 6 million, there's a very good case for saying that Singapore should also get into international kidney exchanges, and perhaps assist some of the poorer countries in its region. So we're trying to make that argument, and let's hope we succeed. One thing I've tell you, there might be bad news. I don't believe that when you retire from Stanford, you're going to stop working on these issues and be able to relax and feel satisfied, because I know I retired from Princeton 2 years ago, but the issues that I'm concerned about, whether it's the factory farming or global poverty, or all these kidney issues as well, I'm still concerned about, I can't let them go just because I'm no longer paid to be a professor at Princeton.
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In terms of lives lived well and deeply, here's an earlier post of mine about teachers and students.
I'll be speaking Sunday at the American Transplant Congress, on kidney exchange. It will be hard to squeeze in all the recent developments in my half hour, including current controversies.
"Roth gave a talk in 2017 at the Organ Donation Congress in Geneva about one such chain that started in 2015. A woman from the Philippines, known in the literature as FW, was willing to give up one of her kidneys to save the life of her husband, FM. The two flew to the US, where FM received a kidney from an altruistic donor in Georgia, and FW’s kidney was transplanted into a man in Minnesota. A friend of the Minnesota man, who had been willing to give up one of her kidneys to save his life, instead gave one to a man in Washington, whose father-in-law gave a kidney to a woman in Georgia, and so on. By the end of the year there had been 11 successful transplants, and the chain was still continuing.
" After his talk, Roth was confronted by a Spanish doctor who was deeply concerned about the potentially problematic implications of the economic inequality between the Philippines and the US. Roth pointed out that without the transplant, the patient would surely have died. Replied the Spanish nephrologist: “He should be dead!” Spain’s National Transplant Organization later denounced Roth as an organ trafficker.
"Roth tells this story in his most recent book, Moral Economics (Basic Venture, May 12), which, at least in part, is an attempt to apply the empiricism of economics to domains that are often resistant to such analysis. The opposition to the 2015 kidney chain, for instance, comes from nephrologists who have no problem with chains but who draw the line at international chains, or at least chains linking poor and rich countries."
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Much of the objection to cross-border kidney exchange appears to be fading, some of it was based on the idea that countries should be self-sufficient in transplants.
This morning I zoomed in to the tail end of a quiet celebration in India of a decade of collaboration between the Alliance for Paired Kidney Donation (APKD) and our Indian medical colleagues..
Mike Rees and I both had sent messages of support, and during the call I spoke about my hope that India, which already does the third most kidney transplants in the world, will in the coming decade come to be the country that does the most kidney exchange transplants. That in turn could lead to India eventually becoming a global attractor for patient-donor pairs from countries that don't have lots of transplants or exchanges, to come to India to participate in kidney exchange there.
There remain many obstacles to be overcome before that can happen, but there's been so much progress in India already that those are real possibilities.
Here's the message I emailed to the founding team yesterday:
"Dear Vivek, Pranjal, Mike, Atul and Colleagues: It’s amazing that the collaboration between the Institute of Kidney Diseases and Research Center at the Dr. H L Trivedi Institute of Transplantation Sciences, and the Alliance for Paired Donation is entering its second decade. It’s been thrilling for me to observe the progress that you have made. I recall vividly meeting Dr. Trivedi in 2019 in his hospital room, and I was later deeply honored to deliver The Dr H.L. Trivedi Oration at the ISOT Meeting in 2022. I’ve learned so much from Vivek, and I will never forget watching Pranjal perform a robotic surgery. And it was memorable that you both were able to visit us at Stanford for the kidney summit organized by APKD and Stanford Impact Labs.
"Seeing what you have accomplished has been one of the highlights of my career in market design. It’s good that we’re all still young, since I’m looking forward to the next decade of accomplishment in India." #########
Here's Mike's message:
"Mike Rees on the 10-year anniversary of IKDRC and APKD working together
"I remember the first time I met Vivek in 2016 at the TTS meeting in Hong Kong. Vivek received the “International Transplantation Science Mentee-Mentor” Award at the TTS 2016 Congress in Hong Kong. The award recognized his work on "Impact of Single Center Kidney Paired Donation Transplantation to Increase Donor Pool in India," completed under the mentorship of Prof. H.L. Trivedi and Prof. P.R. Shah. I remember meeting Vivek, Dr. PR Shah and Pranjal at the award ceremony and thinking about how wonderful it would be if we could work together. I imagined harnessing their great passion of helping patients through kidney transplantation and paired exchange and combining that with the APKD’s powerful software employing Al Roth’s Nobel Prize winning algorithm. While in Hong Kong, Vivek and I went to dinner at my first vegetarian restaurant and there we agreed to work together to try to help expand kidney exchange in India.
"Three years later I travelled to Ahmedabad in May of 2019 with Alvin Roth for the ISOT Mid-term meeting. During that trip, Al and I watched Pranjal do a retroperitoneal donor nephrectomy and a robotic kidney transplantation. It was my first time seeing a robotic kidney transplant and it was so amazing. I met Dr. Himanshu Patel on that trip and I also had the honor of visiting Dr. HL Trivedi and his wife with Vivek. What a legacy Dr. Trivedi has left and I am so proud that APKD has been able to work together with Vivek, Himanshu, Pranjal and all the members of the IKDRC team to extend his wonderful vision.
"Since that meeting in Hong Kong, I have now made 12 trips to India and have become a big fan of Indian food and diversity of Indian culture. I have been so impressed with the passion and commitment of doctors across India, but none more so than at IKDRC. Along the way I have been fortunate to have been joined by Atul Agnihotri, Shridhar Hanchinal, and Trilly Mathew to expand our work in India. We are so grateful for the amazing example the IKDRC team has demonstrated in terms of what is possible when hard work and technology come together to saves the lives of patients with kidney disease. It is truly a joy to celebrate today with you our tenth anniversary of the work between IKDRC and APKD as we commemorate all that we have accomplished together!"
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Over the last decade I've blogged many times in connection with transplant progress in India. Here's a selection related to this ten-year anniversary:
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