German organ transplant law should be amended or reinterpreted to allow kidney exchange: my op-ed in Der Tagesspiegel

During my recent visit to Germany, I spoke with a number of people about the fact that the German transplant law effectively outlaws kidney exchange.  I was invited to write an op-ed on the subject for the German newspaper Der Tagesspiegel, and it has just appeared:

OrganspendenDeutschland muss sein Transplantationsgesetz ändern

In den USA können Patient-Spender-Paare untereinander ein Organ spenden, in Deutschland ist dieser Tausch verboten. Das muss sich ändern. Eine Position. 

ALVIN E. ROTH

Normally at this point I would use Google Translate to give a sense of the article, but in this case, since I wrote the op-ed in English, I can give you the original:

German organ transplant law should be amended or reinterpreted to allow kidney exchange

By Alvin E. Roth[i]

Kidney failure is epidemic around the world, and a shortage of organs for transplantation condemns many patients to dialysis, and early death. 

Most transplantable organs come from deceased donors, and there aren’t enough to fill the need. But because healthy people have two kidneys and can remain healthy with one, a healthy person can donate a kidney to a sick person.  A living-donor kidney works better than a deceased-donor kidney.

In the U.S. we now have around as many living donors as deceased donors (although we still have more deceased-donor transplants, since a deceased donor donates both kidneys).

But living donation isn’t always possible, even when a willing donor is available, because a kidney must be well-matched to its recipient. Often the life-saving gift cannot be given, because the donor’s kidney is incompatible with the patient. (It is now sometimes possible to successfully transplant an incompatible kidney, but, like a deceased-donor kidney, this does not keep the patient as healthy for as long as would a compatible living-donor kidney.)

In the U.S., there is a way for incompatible patient-donor pairs to help each other, through what we call kidney exchange, or kidney paired-donation. In its simplest form, two incompatible patient-donor pairs are identified by their doctors such that each patient is compatible with the kidney of the other patient’s donor. Then four surgeries are performed, two nephrectomies and two transplants, so that each donor gives a kidney and each patient receives a compatible kidney. Kidney exchange has become a standard form of transplantation in the U.S., and has saved thousands of lives. (This is one of the “matching” markets I helped design, and wrote about in my recently translated book, Wer kriegt was - und warum?.)

Notice that no money changes hands in this paired donation. It is just an exchange of gifts between two patient-donor pairs, which allows each donor to save a life and see his intended recipient restored to good health.

Laws around the world prohibit buying a kidney for transplantation, because of fear that allowing organs to be sold would exploit the poor and vulnerable. (The single exception is Iran, which has a monetary market for kidneys.) But German transplant law  imposes a severe further restriction: a patient may receive a living-donor kidney only from a member of his or her immediate family. This means that, unless a judge intervenes, kidney exchanges are illegal in Germany. (This law also restricts the number of direct living donations in Germany compared to countries like the U.S., in which uncles, cousins, friends, colleagues, members of the same church, etc., are often living donors.)

I surmise that the reason for this strict limitation in German law is to remove any possibility that a kidney being transplanted has been purchased rather than freely given. But if when you want to give a kidney to your brother there is no suspicion that you are a paid organ-seller, you should remain above suspicion even if your kidney is incompatible with your brother. Kidney exchange allows you to give a kidney and save a life, and have your brother’s life saved. Kidney paired donation is a mutually beneficial exchange of life-saving gifts, not a commercial transaction.

The U.S. law that includes the prohibition on organ sales is the National Organ Transplant Act of 1984.  When American surgeons explored kidney exchange in the first decade of this century, it wasn’t initially clear what its legal status might be, but in 2007 Congress passed an amendment to the NOTA making kidney exchange explicitly legal.  Kidney exchange is legal elsewhere in Europe, and is well developed in the Netherlands and Britain. A similar amendment to the German law, or even instructions to judges that kidney exchanges should be allowed after being examined, could save the lives of many patients in Germany, without opening to door to commercial transactions in body parts.

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[i] Alvin Roth, a professor of economics at Stanford University, shared the 2012 Nobel Prize in Economics for his work on market design. His recent book about markets has just appeared in German translation, Wer kriegt was - und warum?: Bildung, Jobs und Partnerwahl: Wie Märktefunktionieren

Anticipating kidney exchange in Germany in the Frankfurter Allgemeine Zeitung

  Here's an op-ed in the Frankfurter Allgemeine Zeitung, celebrating the anticipated beginning of kidney exchange in Germany.

Der Volkswirt Hoffnung durch Tausch  by Ágnes Cseh, Christine Kurschat, Axel Ockenfels und Alvin E. Roth

Here's the English translation (from a slightly earlier draft):

Hope through exchange

Germany's new draft law on kidney donation

Imagine this: Your child needs a kidney transplant, but due to tissue incompatibility you cannot be a donor yourself. And it's the same for me. What if you donated a kidney to my child and I donated a kidney to yours in return? Through this ‘cross-donation’ we could give our children the chance of a longer life with a better quality of life.

In Germany, such cross-donations are not usually permitted. Only people who are ‘obviously close in a special personal relationship’, such as relatives and spouses, are allowed to donate kidneys. This is now set to change. The Federal Cabinet has presented a draft bill to amend the Transplantation Act, which would allow cross-donations and other forms of living kidney donation. These include ring exchanges with more than two participating couples as well as longer donor chains initiated by a non-directed, anonymous donation.

People who hear about cross-donation for the first time are sometimes skeptical. However, these concerns can be dispelled on closer inspection. In our neighboring countries and in many other countries, such donations have long been successfully established in compliance with the highest ethical standards.

In cross-donation, no prices are paid for kidneys and there is no trading in kidneys. A system in which potential cross-donors are registered and referred centrally can be implemented in an abuse-proof manner, as experience abroad has shown. The Ministry of Health's draft calls for a close relationship to continue to exist between donor and recipient who register together in the kidney donation program, but no longer necessarily between the donor of an organ and the recipient of the same organ. The couples involved can be guaranteed anonymity, so that mutual influence can be ruled out and at the same time the altruistic motive for donating to the next of kin remains unchanged.

But what happens if the donor has already donated their kidney, but the cross-donor suddenly cancels? To avoid such situations, the two kidneys are removed from the two donors at the same time, and the two patients also receive the two organs at the same time. The four surgical teams communicate in order to coordinate the procedure safely.

The argument that authorizing cross-donation could increase the pressure on potential donors does not stand up to closer scrutiny either. The option of cross-donation does not create any additional pressure that is not already exerted on compatible donors. Instead, cross-donation merely expands the pool of potential donors. 

Incidentally, cross-donation also shortens the waiting list for post-mortem donations, so that patients without donors can also be helped. At the same time, cross-donation can protect the legitimate interests of those people who do not wish to donate if it is implemented in a suitable institutionalized manner and the best possible information is provided.

Germany now has the opportunity to learn from the existing systems in Europe in order to avoid mistakes in the regulations and their implementation for the benefit of organ recipients and donors. This applies, for example, to the establishment of a nationwide kidney donation program, from funding and equipment to biomedical expertise. The Federal Ministry of Health is making important proposals here. The large gaps in data on potential donors and recipients could soon be closed, the option of enabling international coordination of cross-donations is being considered from the outset, and the transplant centres are being encouraged to register all donor-patient pairs centrally for referral. Without such regulations, individual clinics could be incentivized to only selectively register pairs, with the result that fewer transplants can be carried out overall.

Other aspects of the draft should be reconsidered. For example, it is not advisable that couples can only participate in the kidney exchange program if donor and recipient are incompatible. Compatible couples can receive a more suitable kidney through participation and at the same time other patients can be helped, as more cross-donations are made possible through participation. This in turn can shorten the waiting list for all patients who do not have their own donor and therefore cannot participate in the kidney exchange program.

It is good news that new forms of living organ donation are now also to be made possible in Germany. The precise organization of these new forms of organ donation is crucial to their success. It can be modelled on the experiences of other countries and at the same time adapted to the specific legal, historical and ethical framework conditions in Germany. The initial investment would be amortized very quickly through the savings in treatment costs for expensive dialysis. 

In view of the draft law, we are optimistic that the wish of many potential donors to help can be fulfilled in the future, thus improving the care situation for kidney patients in Germany.

Ágnes Cseh (University of Bayreuth), Christine Kurschat (University of Cologne), Axel Ockenfels (University of Cologne and Max Planck Institute for Research on Collective Goods in Bonn) and Alvin E. Roth (Stanford University)

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Here's the (rather opaque) graphic the newspaper created (maybe it's a celebration by kidneys):

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Here's a link to what I think was my first op-ed in German on allowing kidney exchange there...

Thursday, March 17, 2016

German organ transplant law should be amended or reinterpreted to allow kidney exchange: my op-ed in Der Tagesspiegel

Kidney exchange in Germany: draft of a proposed law

 Yesterday the German Federal Cabinet published the draft of a law that would allow kidney exchange in Germany. Below is the text of the press release from the Ministry of Health,  via Google Translate. (Prof. Dr. Karl Lauterbach is the Federal Minister of Health.)

Lauterbach: Überkreuzspende gibt Nierenkranken Hoffnung  Cross-donation gives hope to kidney patients

July 17, 2024

"In the future, kidney donations should also be possible between two different couples. This is the aim of the draft of a third law amending the Transplantation Act - amendment of the regulations on living organ donation, which was approved by the Federal Cabinet today.

This makes it possible for a donor's kidney to go not only to their partner, but also to a recipient from a second couple who in turn donates a kidney (living cross-donation). At the same time, the law ensures increased protection for donors, who should receive better information and medical and psychosocial support.

Dying on the waiting list must come to an end. In the long term, we therefore need the opt-out solution. In the short term, we can make more organ donations possible through cross-donation: those who donate themselves can be helped more quickly in their personal environment. Up to now, living donations have only been possible between partners. In the future, it should also be possible between couples who are not so close. This initially gives hope to many kidney patients.

Federal Minister of Health Prof. Karl Lauterbach

The main changes

Cross-living kidney donations are made possible

Donation and receipt of a kidney “crosswise” by another organ donation partner in medically incompatible organ donation couples.

In the case of a cross-donation, the two couples no longer have to know each other - but the close relationship between the incompatible partners remains mandatory.

Regulation of non-directed anonymous kidney donations.

The tasks of the transplant centers in the context of a cross-living kidney donation and a non-directed anonymous kidney donation are regulated. The transplant centers decide on the acceptance of incompatible organ donation pairs and non-directed anonymous kidney donations from donors and transmit the data required for the placement to a central office for the placement of kidneys in the context of the cross-living kidney donation. After the placement decision has been made, the transplant centers concerned organize the removal and transfer jointly.

Establishment of a national program for the arrangement and implementation of cross-living kidney donations. A body for the arrangement of kidneys within the framework of cross-living kidney donations will be established or commissioned. The arrangement procedure will be laid down by law.

Distribution of kidneys in the context of cross-living kidney donations exclusively according to medical criteria and while maintaining anonymity. The authorization of the German Medical Association to determine the state of medical science in guidelines is expanded to include the rules for accepting and distributing kidneys from incompatible organ donation pairs and from non-directed anonymous kidney donations in the context of cross-living kidney donations.

The previously applicable principle of subsidiarity in Section 8 Paragraph 1 Sentence 1 Number 3 TPG is repealed in order to also enable preemptive kidney transplants.

Previously: removal of organs from a living person only if no post-mortem organ was available.

Donor protection is further strengthened

Expansion of the regulations to clarify and specify donor suitability.

Introduction of compulsory psychosocial counseling and evaluation. The necessary knowledge and skills for the

Psychodiagnostic evaluation and psychotherapeutic treatment can only be carried out by medical or psychological specialists with specific training or further education in psychological, psychosomatic or psychiatric issues (so-called mental health professionals). The independence of the expert ensures that the consultation and evaluation is not influenced by the transplant medical managers in the transplant center, that there are no professional dependencies with these managers and that the expert is solely committed to the interests of the donor. The requirements for the qualifications of the independent expert will in future be set out in the guidelines of the German Medical Association.

Individual support for donors through the introduction of a living donation companion who accompanies and advises the donor throughout the entire donation process in the transplant center. The living donation companion must be a doctor, nurse or person experienced in psychological or psychotherapeutic issues and must be professionally experienced and independent of the specific transplant process. He or she may not be involved in the removal or transfer of the organs, nor be subject to instructions from a doctor who is involved in these measures.

Introduction of federal legal requirements for the activities of living donation commissions.

Granting of additional points

Living kidney donors who themselves require a kidney transplant later in life due to an illness should receive additional points when kidneys are arranged, the amount of which should be determined in the guidelines of the German Medical Association."

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Axel Ockenfels writes:

" I took a quick look at the draft bill that was passed by the federal cabinet in Germany today and that would allow kidney exchange. There are many good aspects in the bill, such as the mandatory participation of hospitals in a national exchange program and the possibility of non-directed donations (which was more controversial), as we suggested to the Ministry in a paper by Ashlagi, Cseh, Manlove, Ockenfels and Pettersson.   

"I am happy to see that the draft seems to agree that the details of matching should be delegated to experts and not overly specified in the law, as suggested by Tayfun Sönmez, Utku Ünver and me in a comment on the previous draft, as well as by others.  

"One consequence of the previous draft would have been that non-directed donations would almost always have gone to patients on the waiting list and would not have been included in the kidney exchange. We advised against this and are happy to see that the draft bill document now states that "a non-directed anonymous kidney donation is in principle initially made in favour of a recipient of an incompatible organ donor pair" (p. 67, DeepL translation), and that it also allows chains of kidney donations initiated by non-directed donors (although I find the wording of the draft somewhat unclear in this respect).  

"We also strongly recommended that compatible pairs be allowed to participate in kidney exchanges, yet the bill would still make this impossible: "Participation as a pair of compatible organ donors and organ recipients in a crossover living kidney donation, on the other hand, is not envisaged, as a living organ donation would be immunologically possible in these pairs. There is therefore no need to enable cross-living kidney donation for these couples as well" (p. 66, DeepL translation). 

"This is unfortunate because the inclusion of compatible pairs has many benefits and can sometimes make everyone better off, including the patient in the compatible pair, additional donor-patient pairs, and patients on the waiting list. However, this may not be the last word, as there is still room for change in the upcoming legislative process. 

"The document also comments on the possibility of cross-border exchanges: "Commissioning the institution that already handles the procurement of post-mortem donated organs [namely Eurotransplant] also opens up the option of establishing an international programme - comparable to the exchange of post-mortem donated organs - within the Eurotransplant Network" (p. 31, DeepL translation)."

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Here are all my posts on Germany and kidney exchange.

Obstacles to kidney exchange in Germany

An op-ed in yesterday's Handelsblatt Global (in English) proposes that kidney exchange should be allowed in Germany:
Germany should allow donating organs to strangers
by Fabian Kurz and Fred Roeder, July 2, 2018

An earlier brief discussion/blog post (in German) with some interesting links describes some of the current obstacles to kidney exchange in Germany:

Nieren-Tausch kann Leben retten (Kidney exchange can save lives)
von Alexander Fink & Fabian Kurz, 20. Juni 2018

Here's the German Transplant Act.

Here's a ruling of the German Federal Social Court, confirming the effective ban on kidney exchange.

Here's a 2005 news story about two patient-donor pairs who were allowed to engage in a kidney exchange after arguing that they had established a sufficient relationship with each other, to fit the requirement of the law that transplants can only be received from close relations, i.e. immediate family, or a "special personal bond" .
Nieren-Tausch soll Leben retten (Kidney exchange is supposed to save lives)
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Some earlier discussions and links:

Thursday, March 17, 2016

Transplants in Germany, further discussion of changing the transplant law, in Der Tagesspiegel

Sunday, January 21, 2018

The number of organ donors in Germany has fallen to its lowest level in 20 years.

Wednesday, February 21, 2018

Organ donation in Germany

Organ donation in Germany is declining, from an already low rate.

Simulating kidney exchange policies in Germany

 Here are a set of simulations designed to help Germany establish a national (rather than a fragmented) kidney exchange system.

Itai Ashlagi, Ágnes Cseh, David Manlove, Axel Ockenfels & William Pettersson,  Designing a kidney exchange program in Germany: simulations and recommendations. Central European Journal of Operations Research  (2024). https://doi.org/10.1007/s10100-024-00933-0

"Abstract: We examine some of the opportunities and challenges concerned with establishing a centralized national kidney exchange program in Germany. Despite the many advantages of a national program, without deliberate design and policy intervention, a fragmented kidney exchange program may emerge. We study a number of collaboration strategies, and resulting simulations suggest that transplant centers may find it advantageous not to fully participate, resulting in a net reduction in the number of transplants. These results also suggest that allowing more forms of kidney exchange, such as three-way exchanges and non-directed donations, can significantly increase the number of transplants while making participation in a national program more attractive and thus national coordination and cooperation more robust. We propose a multi-level policy approach that is easy to implement and would promote an efficient German kidney exchange program that benefits recipients, donors and hospitals."

...

The concluding sentence of the paper is:

"Germany should establish a robust, well-functioning national KEP that can be easily and straightforwardly integrated into an international KEP."

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Background:

Thursday, July 18, 2024

Kidney exchange in Germany: draft of a proposed law

Organ donation day in Germany

 Yesterday was organ donation day in Germany. Here's a post from the German Health Economics Association (DGGÖ): Day of Organ Donation on June 3, 2023

"In Germany, there are about 8,500 people waiting for an organ donation (www.Bundesärztekammer.de). On the Day of Organ Donation, the German Society for Health Economics (dggö) wants to emphasize the urgency of increasing organ donation rates to improve the lives of these individuals. This applies equally to deceased organ donation and living donation. An international comparison also shows that there is room for improvement in Germany: Both in terms of living and deceased donations per million population, Germany lags behind in the EU (see Figure 1).

...

"On Wednesday, May 31, 2023, Nobel laureate in economics and professor at Stanford University, Alvin Roth, spoke to a broad audience in the 6th virtual dggö Talk (see https://www.dggoe.de/aktuelles for details) about the possibilities of kidney exchange between compatible but previously unknown pairs and the implementation of cross-over donations and exchange chains in the US.

"Unlike in the US, in Germany, living donation outside of close family is only possible if a close relationship between the donor and recipient has been officially confirmed. Alvin Roth noted in the case of cross-over kidney donations, that it was very complicated for German hospitals to build up and prove a close relationship between two pairs of donors in front of a commission. This should be simplified, especially considering the overall strong support for kidney exchange among the German population. As Figure 2 from a survey conducted by Roth and Wang (2020) illustrates, 79% even agree to kidney exchange across borders and outside of family and friends, although such an exchange is currently not legally possible in Germany.

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Earlier: 

Tuesday, May 30, 2023

Kidney exchange, around the world and in Germany? German Health Economics Association (DGGÖ) webinar 

Paired kidney donation performed in Germany--a guest post by Ágnes Cseh

 Below is a post written by Ágnes Cseh, about a kidney exchange conducted legally in Germany, in October, after being identified outside of the medical establishment. (The links she supplies are all worth looking into, and Google translate works well enough.)

"The legal basis for a living organ donation in Germany is a relationship or close personal connection between donor and recipient. This well-meant rule implicitly forbids paired kidney donation, because even though recipient and donor are closely related in each of the two pairs participating in a paired donation, the physical graft a patient receives technically comes from the relative of the other recipient.

A cumbersome, but legal way around the regulation is to establish a close personal connection between all four persons involved in a paired donation. Then, an ethical committee might approve of the two transplants separately. This constellation even inspired filmmakers to shoot a fictional movie about such a venture -- the genre is supposed to be comedy. In reality, paired transplants have been performed very sporadically in the past years in Germany.

A new initiative offers a centralized platform for paired kidney donations. It is run by Susanne Reitmaier, an activist fighting for the complete legalization of paired donations and Ágnes Cseh, a researcher specialized in matching theory. They maintain a database of the voluntarily submitted medical data of incompatible recipient-donor pairs. If a possible match among these pairs is found, then the two pairs are put into contact with each other so that they can establish the personal connection required by the law.

The first match in this program was identified in July 2020. After a long journey (see the detailed report in English here and in German here), the transplants were finally performed in October 2021 in Berlin. The ethical committee first rejected their claim, but then approved of the two transplants as one paired donation, not as two separate donations. This might be a milestone in the practice and potentially lead to more standardized procedures in the future.

As time goes by and word gets around, more and more incompatible pairs enter their data into the database. A handful of already identified pairs for paired donations are currently in different stages of the medical and legal process. The first step taken by Charité Berlin encouraged other hospitals to show interest in conducting paired transplants.

Despite of this recent progress, an efficient kidney exchange program would clearly require a law change in Germany. It would be sufficient to modify the current regulation marginally, by stating that the close personal connection is meant for the pairs entering the pool together and not for the matched pairs."

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Here's a link to (and translation of) an op-ed I published in a German newspaper in 2016 urging that the law be amended to allow regular kidney exchange:

German organ transplant law should be amended or reinterpreted to allow kidney exchange: my op-ed in Der Tagesspiegel

And here are all my posts on kidney exchange in Germany.

A glimmer of hope for German kidney transplants: a discussion of kidney exchange

 Axel Ockenfels (who, along with Dorothea Kubler has been at the forefront of advocating for kidney exchange in Germany) forwards me this announcement (translated from German):

"the German Federal Ministry of Health is organizing a digital symposium on Tuesday, June 29, 2021, from 09:30 to approx. 15:30 on the topic of "Expanding the donor pool for living organ donation - a perspective for Germany?", to which we cordially invite you. Please feel free to forward the invitation to interested parties from your industry.

"An organ transplant is often the only way to save the lives of seriously ill people or to restore their quality of life. In view of long waiting times for a post-mortem organ donation, the question of living donation sometimes arises. Living organ donation has been permitted in Germany since 1997 within narrow limits and under special conditions. The donor and recipient must be "manifestly close in a special personal bond." However, living donation may be excluded in such cases for medical reasons. In order to increase the chances of organ transplantation for patients who are affected by this, some countries have established so-called kidney exchange programs.

"The symposium will take a look at various possibilities for extending organ donation: What are the opportunities and risks associated with cross over donation, pooled donation and so-called non-directed living donation? What procedures are necessary to protect donors? These and other questions will be discussed from a medical, legal and ethical perspective with an interdisciplinary audience. 

"We would be delighted if you could contribute your expertise to the discussion and if we could welcome you at the event on

"Tuesday, June 29, 2021, 09:30 - approx. 15:30 hrs.

...

"welcome to the event. The invitation is explicitly transferable. 

"If you would like to attend the event, please register by June 28, 2021 at the following link: Event Management Tool link.

Yours sincerely

"Joachim Becker

"Head of the Department of Medical and Professional Law, Prevention

Translated with www.DeepL.com/Translator (free version)"

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This seems like a potentially very positive first step, despite (or maybe because) of the fact that it seems to be signed by the Ministry of Health's department of prevention... (Leiter der Abteilung Medizin- und Berufsrecht, Prävention)

A previous post observed that kidney exchange receives popular support in Germany:

Thursday, July 30, 2020

Surrogacy and global kidney exchange receive popular support even where banned, in PNAS by Roth and Wang

(It turns out that I have a lot of previous posts related to kidney exchange in Germany...)

Kidney exchange, in French, in Forbes

Here's a short interview in French about kidney exchange, in Forbes France:

Alvin Roth, Lauréat Du Prix Nobel D’Economie Veut Revolutionner Les Dons De Reins
Philippe Branche   10 janvier 2020

Here's one bit:

Are you currently working with politicians, legislators or medical administrators to resolve this problem ? 

Alvin Roth: I am, but not with great success. I recently spoke to decision makers in several countries: India, China, Germany, Canada and of course the United States. In October, renowned bioethicist Peter Singer expressed strong support for the Global Kidney Exchange Program, so that recently the idea of ​​expanding kidney exchange to include international exchanges has gained momentum. I also recently debated with a member of the Bundestag, the German parliament. In Germany, kidney transplantation from a living donor is legal, but a patient can only receive a kidney from an immediate family member, and therefore the literal interpretation of the law makes it impossible to exchange kidneys. German law provides that monetary exchanges of parts of the human body are illegal and, apparently, it is to avoid any possibility of payment for a kidney that the limitation to family members is applied. A minimal amendment to German law could allow immediate family members to make an indirect donation, via the kidney exchange system, which would preserve the confidence that the donor was not paid to make an exchange. By designing this market in this way, we are trying to expand the database and reduce the waiting time for sick people.

It's time to allow kidney exchange in Germany: Axel Ockenfels in the Handelsblatt

 As I noted last month, there's a conclave on kidney transplantation at the end of June in Germany. Axel Ockenfels keeps the focus on kidney exchange, in the Handelsblatt:

Die Regeln für Organspenden in Deutschland sollten reformiert werden

Google Translate: "The rules for organ donation in Germany should be reformed.

In the Federal Republic of Germany only close relatives can be considered as living organ donors. This is unnecessarily restrictive, thinks Axel Ockenfels and promotes cross-donations."

...

"In Germany, the necessary reforms for cross-donation can be accomplished within the current value framework, which presupposes the voluntary and altruistic nature of organ donation. Organ trafficking can be reliably excluded through institutional arrangements.

In a new survey, cross-donation receives great approval, both in Germany, where it is still prohibited, and in countries where it is permitted. There is much to be said for reform."

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Here's a link to a (the?) survey of attitudes in Germany and elsewhere:

Thursday, July 30, 2020

Surrogacy and global kidney exchange receive popular support even where banned, in PNAS by Roth and Wang

Kidney exchange in Germany?

 A draft law to make kidney exchange legal in Germany, and to allow nondirected donation, is making some progress: here (with the help of Google Translate) is a news story on the proposed new law.

Living kidney donation should be made easier

"In order to reduce the organ shortage in Germany, Federal Health Minister Karl Lauterbach (SPD) wants to make living kidney donations easier. This emerges from a draft amendment to the Transplantation Act. The Star first reported.

"According to the draft, the previously prescribed “proximity ratio” for so-called cross donations will no longer apply in the future. To date, couples in which one person wants to donate a kidney to the other but this is not possible due to incompatibility are only allowed to “cross-donate” with another couple in a comparable situation if there is a close relationship between the couples. This is intended to prevent organ trafficking and commercialization.

"In the future, this cross donation could be made without proximity, thereby significantly expanding the circle of recipients. According to the draft bill, the donation should be anonymous and organized by transplant centers. The aim of anonymity is to prevent money from being paid for an organ.

"Anonymous kidney donations should also be possible in principle. In the future, people in Germany could donate a kidney for selfless reasons without knowing who it is going to. In countries like the USA, this option has existed for a long time."

HT: Dorothea Kubler

Some movement towards kidney exchange in Germany

Axel Ockenfels writes:

"On 9 November 2018, members of the parliament of the German liberal party FDP submitted a petition ("Chancen von altruistischen Organlebendspenden nutzen – Spenden erleichtern") to ask the German government to draft a law that makes kidney exchange, non-directed altruistic kidney donations into a pool and, under certain circumstances, directed kidney donations to strangers possible in Germany": 
Chancen von altruistischen Organlebendspenden nutzen – Spenden erleichtern
"Make use of the opportunities of altruistic organ donation - make donations easier"

It calls for specific amendments to remove the current legal restrictions on kidney exchange.

German market design economists have been at the forefront of efforts to change the transplant law in this and other respects.

Here's an earlier post on the subject, whose links contain links to still earlier ones--maybe this series will converge soon in a way that reverses the decline in transplantation in Germany:

Tuesday, July 3, 2018

Obstacles to kidney exchange in Germany

Kidney exchange explained in 1 minute (video), and a BBC story

Here's a link to a 1 minute BBC video that was recorded when I was in Berlin recently, discussing how changes in the German transplant law (which presently allows only immediate family members to donate a kidney to someone) could be minimally modified to allow kidney exchange also.

 (a short ad comes on first--my part is only 48 seconds:-)


Here's an accompanying story that somewhat confusingly (it seems to me)  mashes together discussions of kidney exchange, global kidney exchange, and compensation for donors.

How an economist helped thousands get a new kidney By Ian Rose, BBC News
Berlin
...
"Roth, working with Tayfun Sönmez and Utku Unver, has revolutionised kidney donation around the world by using an economic theory to make kidneys more available.
...

"German exchange change?
"We meet in Berlin as Nobel laureates and other luminaries gather to discuss the future of healthcare. Alvin Roth is there in part because Germany is one of the only major industrialised countries where kidney exchange is not lawful.

"I think that the bureaucratic rules and regulations for kidneys as for every market have to be revisited from time to time in the in the light of new developments, and should be modernized and adapted to current capabilities," he says.

"When contacted about the issue the German Health Ministry tells me that they are planning to organise a public debate on the issue but have no schedule for that yet.

"Prof Roth says he understands the concerns behind the German ban. "They're worried about organ trafficking.

"They're worried that if I showed up and wanted to give you a kidney, it would mean that you had paid me and it may be I was a poor and desperate person. But on the other hand, if your brother shows up and wants to give you a kidney, they're not worried about that."
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update:
The BBC publishes in many languages, and so you can read the story in Chinese, Indonesian, Turkish, Spanish, Portuguese, and here's a site that has translated it to Hungarian.

Two faces of kidney transplantation

Two men who have played significant roles in kidney transplantation are both named Sonmez.

One is the great Boston College economist Tayfun Sonmez, one of the pioneers of kidney exchange.

The other is the (also) Turkish kidney transplant surgeon Yusuf Sonmez, who is once again in the news for his alleged role in both kidney black markets and in war crimes in Kosovo. In a recent interview in the NY Times, focusing primarily on the black market allegations, he is asked about both the recipients and the donor/vendors: Monster or Savior? Doctor Draws New Scrutiny.

“There are two Yusufs, one my family and friends know and the one created in the press who is a monster— this is a drama, a tragedy,” said Dr. Sonmez, 53, a trim, angular man with intense, gray-green eyes and a graying goatee. “Up to now, I didn’t kill anybody. I didn’t harm anybody, counting donors or recipients. I have not committed any kind of social harm to anyone. This is the main thing that I am proud of.”
...
"Dr. Sonmez is wanted with regard to one of the most troubling prosecutions to emerge recently— a European Union investigation into trafficking in Kosovo in which seven people, mostly prominent local doctors, have been charged with illegal kidney transplants in a private clinic. Dr. Sonmez has not been charged in Kosovo, but the prosecution contends he played a central role in the ring.


"That case has become intertwined with a volatile two-year Council of Europe inquiry that made links between the Kosovo prime minister, Hashim Thaci, and a criminal enterprise of some former Kosovo Liberation Army fighters accused of executing Serbian prisoners in 1999 and 2000 for their organs.

"Dr. Sonmez has denied wrongdoing in either situation, but a Turkish immigrant who lost consciousness at an airport in Kosovo after a kidney removal, and the patient who investigators say received his kidney, both identified Dr. Sonmez as part of the operating team. He says he was only in the operating room offering advice to others.


"Investigators have focused on the role of Dr. Sonmez in 2008 as a surgeon for the Medicus private clinic in a rundown neighborhood in Pristina, Kosovo’s capital, where they said kidneys were removed from impoverished immigrants recruited on false promises of payment that they never received. The organs were transplanted to wealthy patients from Canada, Germany, Poland and Israel who paid up to €90,000, or $122,000.
...
"By his estimate, most of the thousands of transplants he has performed since he began in 1992 involved live, unrelated donors. He said his survival rate was high because he presided over the removal and transplant of kidneys, monitoring patients side by side for 48 hours.


“This is amazing,” he said of the transplant process. “I love it — to watch the changes with the new organ, the changes in the body, to move with the changes, to make changes in the medication.”

"Typically, he said, he requires donors and recipients to submit signed, notarized statements to declare that money has not been exchanged.


"How does he know that desperately poor kidney donors are not being exploited by a murky world of brokers, fixers and wealthy donors with lavish insurance?

“I don’t need to ask these questions,” he said, “because I do believe that people have their own authority over their own body. They are not stealing, they are not cheating. So this is the shame of the system. Not their shame.”
...
"In the next few weeks, Dr. Sonmez and his lawyer are poised to head to Kosovo to give his statements.


“They want information about bigger fish,” said Murat Sofuoglu, an old friend and lawyer for Mr. Sonmez, who has been shuttling between Istanbul and Pristina to negotiate terms for the doctor to give a statement to prosecutors.

“Not me,” Dr. Sonmez said, picking at a honey-drenched piece of baklava. “I am not the big fish.”

Market Design in El Mercurio--Chile's oldest newspaper

Last Tuesday, in Chile I was interviewed by Eduardo Olivares, the editor for Economics and Business of El Mercurio,  which published the interview yesterday. We talked for an hour about market design generally, about how markets work when they're working well or working badly, and we spoke about school choice (where Chile is a leader) and transplantation (where it is not). The interview is behind a paywall, but below are some extracts (retranslated back into English via Google Translate).

On markets generally:

—Many people ask that “markets be free,” as has recently happened in Argentina. Should they be free?

“That's a complicated question. Markets should be free to function well, but they need conditions that allow them to function well. Having a free market does not necessarily mean a market without rules. A wheel can spin freely because it has a well-greased axle and bearings. A wheel by itself cannot turn very well, and the same goes for the market.”

—Who puts the oil in the wheel gears?

“That's the job of market design. Part of what makes markets work well are good market rules. The government has a role in regulating markets, concerning property rights and things like that. But on another level, entrepreneurs do things. Here in Santiago I [can]... call an Uber using the same app and rules I use in California. Uber is a marketplace for passengers and drivers. The rules can be made by both private organizations and the government.”

On prices:

—Do prices matter?

"A lot. “Prices are important to help allocate scarce resources, but also to make them less scarce.”

...

—When do they not matter?

“Let me start with when they matter a lot: in commodity markets. If you want to buy commodities, price is really the only thing that's happening. But when 'El Mercurio' wants to hire journalists, it doesn't limit itself to offering a salary: it wants it to be a good job, with special reporters. Price is important, but in other markets other things are also important. When you get a new job, the first question your friends ask you is not what the salary is, but who you work for.”

On school choice:

“Most markets are not commodity markets... In some markets we don't like prices to work at all. One of the places where Chile is a leader in market design is school choice: how people are assigned to schools and Chile has done a lot of work on this, although mainly for public schools.”

—What do you know about this system in Chile?

“Not long ago, before there was centralized and widespread school choice in Chile, there were the usual problems with decentralized school choice; That is, parents had to get up early to get in line, and they had a difficult process to register their children.”

—The new system has been criticized. Some claim it caused more people to choose the private system over the public school system. Isn't it similar to what is happening in New York, for example?

“There is something to that. In New York and Boston we also have a system that we call charter schools: free access schools, but organized by private entities, even if they are municipal schools. And they also have different standards. School choice is important, but it does not solve the problems of poverty or income inequality. Now, one of the reasons we have school choice in the United States and perhaps also in Chile is because we think that, otherwise, there is a danger that the poor will be condemned to send their children to poor schools. .

—Has there been any successful case in which parents can honestly rank the order of preference for the school they want their children to go to?

“In Chile, procedures are used that [make it] what game  theorists call a dominant strategy to express true preferences. The [remaining] problem is not in creating systems that make it safe to express preferences, but in distributing the information so that people can form preferences sensibly. In the United States, the hardest families to reach are those who don't speak English at home, so it's sometimes difficult to communicate with them. And different families have different feelings about what kind of schools their children should attend.”

“The benefits of school choice come from the fact that some schools may be high quality for some children but not for others, so we would like children to attend the schools that are best quality for them.”

On kidneys:

—You are famous for the proposal that allowed the “kidney exchange.” Years after the first experience, what do you see now in this type of market?

“Kidney exchange is working quite well in the US, but it works especially well for patients who are not too difficult to match. Even in the US, a fairly large country, we have patients who are so difficult to match that we have trouble finding a kidney for them.”

—And in other countries?

“Smaller countries, with 20 million inhabitants, like Chile, would benefit if we could make national borders not so important. When we look at transplants per million inhabitants, Chile is in the middle of the world. But since it is a small country, when the total number of transplants performed is analyzed, Chile has very few. Kidneys are obtained from both deceased and living donors. In Chile, as in much of the world, the majority of transplants come from deceased donors. Kidney exchange would allow more transplants to come from living donors ... “Twenty million is not enough, so it would be very good to see in South America an exchange of kidneys that can cross between countries, which is not so easy to do.”

Equality of exchange and the role of perceptions

“One of the things that worries people when talking about transplants is that [they think it might be] a medical process that exploits the poor. Of course, the thing about kidney exchange is that each pair of people gives one kidney and receives one kidney. It is very egalitarian. I think kidney exchange is a good place to combat this notion that transplantation is like trafficking,” he notes.

—Notions, perceptions are very important. Many people think of “exchange” as the exchange of securities in the stock market.

“That's right, but not every exchange involves money. One of the discussions about money in the world that is taking place in the European Union at the moment is about payment to blood plasma donors. In the EU, only Germany, Austria, the Czech Republic and Hungary pay blood plasma donors. And those are the only EU countries that have as much blood plasma as they need. The others have to import everything, and they do it from the United States. The United States is the Saudi Arabia of blood plasma (…) The World Health Organization says that plasma must be obtained in each country, and from unpaid donors. You have to be self-sufficient... an economist finds that a little funny. Blood is a matter of life and death. “When there is a pandemic, we do not tell countries that they must be self-sufficient [in vaccines].”

—When we talk about these exchanges of blood plasma and kidneys, school choice systems, we are talking about the same idea: coincident or paired markets. But the concept of the market has been so questioned, especially by some political groups, for so long...

"It's true. Now,  kidney exchange is special because money doesn't change hands. Money changes hands to get medical care, you have to pay doctors, nurses and hospitals. But we are not talking about buying kidneys from donors, but rather that, at the patient level, each pair receives a kidney and donates a kidney. It is radically egalitarian. Many people who think about markets may not think of it as a market, but I think that's a mistake. Many markets are not just about money… we would worry much less about markets if income and wealth inequality did not exist. “What worries us about markets is that some people are poor and some people are rich, and markets seem like a way to give the rich an advantage.”

“There is no doubt that being rich is better than being poor. The real question is what do we do to alleviate poverty. Making it invisible is not the same as alleviating it. One of the reasons I think many countries don't allow blood and plasma donors to be paid is because they don't like the way that looks. It reminds them that some people would like to get some money and would donate blood for it.”

Apparently, according to the caption, I'm "affable and smiling" (although not in this picture:)

I was in Chile to participate in what turned out to be a wonderful workshop on market design at the University of Chile, organized by Itai Ashlagi, José Correa, and Juan Escobar.

Some related recent posts:

Saturday, December 23, 2023

Market design: some press accounts in Chile

Wednesday, December 20, 2023

Public lecture today at the Casa Central de la Universidad de Chile:“Quién obtiene qué y por qué: La nueva economía del diseño de mercados”

Sunday, December 17, 2023

Market Design Workshop 18 - 20 December 2023 Santiago, Chile

Saturday, November 4, 2023

The EU proposes strengthening bans on compensating donors of Substances of Human Origin (SoHOs)--op-ed in VoxEU by Ockenfels and Roth

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Update (Dec. 27): Here's an account of my closing public talk from the U. Chile's Center for Mathematical Modeling, one of the hosts of the market design workshop.

Alvin Roth: “Markets are human artifacts, they are tools that we build ourselves to help us”.

And here's a picture at the close, including some of those mentioned above: At my far left in the picture is José Correa,  who in addition to his other roles is Vice Rector for Information Technologies. Next to him is Alejandra Mizala, prorrector (provost) of the university.  Next to her (immediately to my left) is Rector of the University of Chile, Rosa Devés, and immediately to my right is market designer and director of the MIPP Millennium Institute, Juan Escobar. Next to him is Héctor Ramírez, director of the Center for Mathematical Modeling. And next to him (at my far right) is professor Rafael Epstein who (along with Correa, Escobar, and his daughter Natalie Epstein) has been involved with school choice in Chile, among other things.

Kidney exchange, around the world and in Germany? German Health Economics Association (DGGÖ) webinar tomorrow

Tomorrow  I'll be giving a talk in Germany (8am California time, 17:00 in Germany), hosted by the German Health Economics Association (DGGÖ).  (Bob Slonim will be giving a talk in this series in the summer.)

My title will be Kidney Exchange to increase transplantation: around the world, and in Germany?

(One big issue is that kidney exchange isn't yet supported in Germany.) 

There is a webinar address at the above link for those who might like to listen.

Transplants in Germany, further discussion of changing the transplant law, in Der Tagesspiegel

My op-ed in Der  Tagesspiegel yesterday on changing the German transplant law has drawn some prompt further comment in today's paper (as near as I can tell from Google Translate).

Here's the new commentary (English courtesy of GT):

Ärzte und Politiker für mehr Lebendspenden

Deutsche Vorbehalte „passen nicht mehr in die Zeit“, kritisieren Mediziner. Auch der Austausch zwischen einander unbekannten Paaren sollte erlaubt werden. 

VON RAINER WORATSCHKA

[Organ transplant

physicians and politicians for more living donations German reservations "no longer fit into the time", criticizing physicians. The exchange between unacquainted pairs should be allowed.]

"The demand of the American Nobel Prize winner Alvin Roth, to facilitate in Germany living donation of organs and to amend the Transplantation Act accordingly, has met with doctors and politicians on consent.

The requirement that living donation - this question come kidney or parts of the liver - may come only from the direct family environment, are too strict, the economists had in Tagesspiegel criticizes. As in other European countries and the United States would also in Germany more distant relatives, friends or colleagues may donate writes Roth. In addition, an exchange between unacquainted pairs should be allowed (cross-donation, crossover Donation) at incompatible donor organs."

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

Here are my two earlier posts on the subject, with links to my earlier op-ed and the one by Axel Ockenfels and Thomas Gutmann

German organ transplant law should be amended or reinterpreted to allow kidney exchange: my op-ed in Der Tagesspiegel

Promoting kidney exchange in Germany: Axel Ockenfels and Thomas Gutmann

Surrogacy and global kidney exchange receive popular support even where banned, in PNAS by Roth and Wang

Popular repugnance contrasts with legal bans on controversial markets
Alvin E. Roth and  Stephanie W. Wang
PNAS first published July 29, 2020 https://doi.org/10.1073/pnas.2005828117

reviewed by Nicola Lacetera and Mario Macis

Abstract: We study popular attitudes in Germany, Spain, the Philippines, and the United States toward three controversial markets—prostitution, surrogacy, and global kidney exchange (GKE). Of those markets, only prostitution is banned in the United States and the Philippines, and only prostitution is allowed in Germany and Spain. Unlike prostitution, majorities support legalization of surrogacy and GKE in all four countries. So, there is not a simple relation between public support for markets, or bans, and their legal and regulatory status. Because both markets and bans on markets require social support to work well, this sheds light on the prospects for effective regulation of controversial markets.

"Our main result is that (unlike prostitution) the laws banning surrogacy and GKE do not seem to reflect popular demand. Neither do these bans reflect that opponents of legalization feel more strongly than supporters.

...

"All three transactions are the subject of current debate in at least one of the countries we surveyed.¶¶ Based on the results of our surveys, we do not see entrenched popular resistance to either surrogacy or GKE (or simple kidney exchange) where it is presently illegal, and thus, we anticipate that efforts to lift or circumvent current restrictions are likely to be increasingly successful, while efforts to legalize or decriminalize prostitution where it is presently illegal may face greater opposition from the general public.

"Understanding these issues is important, not just for the hundreds of Spanish couples stranded outside of Spain while they look for a way to bring their surrogate children home and not just for the people in need of kidney exchange but for whom it is out of reach in Germany or in the Philippines. These issues are also of importance to social scientists in general and economists in particular. When markets enjoy social support, when they are banned, and when, in turn, bans are socially supported are questions that touch upon many transactions, particularly as social and economic interactions are increasingly globalized.

"Our findings suggest that the answer to these questions may not be found in general public sentiment in countries that ban markets or legalize them. Rather, we may have to look to the functioning of particular interested groups, perhaps with professional or even religious interests, that are able to influence legislation in the absence of strong views (or even interest) among the general public about the markets in question."

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

Here's the published citation:

Roth, Alvin E. and Stephanie W. Wang, “Popular Repugnance Contrasts with Legal Bans on Controversial Markets,” Proceedings of the National Academy of Sciences (PNAS),  August 18, 2020 117 (33) 19792-19798; https://doi.org/10.1073/pnas.2005828117