Global kidney exchange and repugnance in the AJT: comments and replies

The forthcoming issue of the American Journal of Transplantation is going to have a number of conflicting views about Global Kidney Exchange (GKE).  Just as yesterday's post showed how Kidney Exchange faced some repugnance at the turn of this century, these interactions show that GKE will have to overcome some repugnance too. (I just returned from Geneva where I talked about GKE among other things, in an attempt to start bridging this divide.)


It all started with our article proposing GKE and reporting the case of a Philippine patient-donor pair, which came out in March, along with an accompanying editorial suggesting that maybe the whole idea is repugnant.

Here's the original article:

Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation
by M. A. Rees, T. B. Dunn, C. S. Kuhr, C. L. Marsh, J. Rogers, S. E. Rees, A. Cicero, L. J. Reece, A. E. Roth, O. Ekwenna, D. E. Fumo, K. D. Krawiec, J. E. Kopke, S. Jain, M. Tan, S. R. Paloyo
American Journal of Transplantation, Volume 17, Issue 3 March 2017, Pages 782–790

And here's the accompanying editorial:
Walking a Tightrope or Blazing a Trail?
by A. C. Wiseman, J. S. Gill

Here is our forthcoming reply to the editorial

Global kidney exchange: Financially incompatible pairs are not transplantable compatible pairs

M. A. Rees, S. R. Paloyo, A. E. Roth, K. D. Krawiec, O. Ekwenna, C. L. Marsh, A. J. Wenig and T. B. Dunn

Version of Record online: 1 SEP 2017 | DOI: 10.1111/

And here is a letter saying that GKE is essentially organ trafficking…

Opposition to Irresponsible Global Kidney Exchange

Francis L. Delmonico and Nancy L. Ascher

Accepted manuscript online: 21 AUG 2017 09:05AM EST | DOI: 10.1111/ajt.14473

·        Abstract  Article  PDF(63K)

And our replies:

You have free access to this content

People should not be banned from transplantation only because of their country of origin

Alvin E. Roth, Kimberly D. Krawiec, Siegfredo Paloyo, Obi Ekwenna, Christopher L. Marsh, Alexandra J. Wenig, Ty B. Dunn and Michael A. Rees

Accepted manuscript online: 1 SEP 2017 09:25AM EST | DOI: 10.1111/ajt.14485

• Abstract
• Article
• PDF(65K)

1. 
   
2. You have free access to this content

   Open dialogue between professionals with different opinions builds the best policy
   

   Ignazio R. Marino, Alvin E. Roth, Michael A. Rees and Cataldo Doria

   Version of Record online: 11 SEP 2017 | DOI: 10.1111/ajt.14484

   • Abstract
   • Article
   • PDF(119K
    have free access to this content
3. Here's the text of the Roth et al. letter:

"Previously [1,2], we described how a Filipino husband-and-wife patient–donor pair were included in an American kidney exchange.1,2 Delmonico and Ascher object in the strongest terms.3 They write that ethical Global Kidney Exchange (GKE) with patient–donor pairs from the developing world “is not feasible when the culture is so experienced with organ sales.”

Among the proposers of GKE are experienced surgeons and clinicians, a senior lawyer, and a veteran market designer. We take black markets with the utmost seriousness. That’s why the first GKE pair was started with a husband and wife. We think the right course of action is to proceed carefully, slowly at first, and with constant monitoring. The second GKE pair from Mexico were cousins cared for by Dr. Ricardo Correa-Rotter, a world-renowned nephrologist and signatory of the Declaration of Istanbul.4,5

We also take seriously long-term postoperative care for both patients and donors. That’s why we propose GKE in partnership with developing countries that already have some first-rate hospitals that perform living donor transplantation. Rees et al. describe how we coordinated care with the Philippine General Hospital and St. Luke’s Medical Center in Manila.2 We also provided an escrow fund for long-term continuing care. Ivan Carrillo describes our care of the donor and recipient in the second GKE and it is clearly celebrated by Mexican media as a beautiful way to help citizens of both Mexico and the United States.4,5

Kidney exchange (KE) itself is a relatively new “matching market,” of a kind that does not involve any payments to donors. It has been successfully launched in many countries, and proposals for international cooperation are underway.6 What makes KE special is that two or more patient–donor pairs help each other. What makes GKE special is that helping first-world patients get transplants saves money, because dialysis is so expensive, and these savings can benefit poor patients and donors in poor countries who would otherwise be unable to help themselves, but can participate in GKE for free.

Delmonico and Ascher propose that poor people with ESRD in poor countries, and the donors who love them, must all be regarded as potential criminals who would inevitably corrupt first-world medicine by being included in it. In the current political climate this is a bit like proposing a blanket ban on granting asylum to refugees from some countries. We do not adopt this point of view. On the contrary, GKE is a proposal that says there are many deserving patients who need our help, who we can help, and who can help us—if we invite them carefully and take care of them attentively.

Fear is not the path forward. Bold, careful innovation has led transplantation to where it is today, and remains our best collective future.

Disclosure The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

References
1. Rees MA, Paloyo S, Roth AE, et al. Global Kidney Exchange: Financially Incompatible Pairs Are Not Transplantable Compatible Pairs. Am J Transplant. 2017;17:782-90.
2. Rees MA, Dunn TB, Kuhr CS, et al. Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation. Am J Transplant 2017;17:782-90.
3. Delmonico FL, Ascher NL. Opposition to Irresponsible Global Kidney Exchange. Am J Transplant 2017;17:IN PRESS THIS ISSUE.
4. A bridge of life: Global kidney exchange between Mexico and the U.S. (Accessed 8/23/2017, at http://marketdesigner.blogspot.com/2017/04/a-bridge-of-life-global-kidney-exchange.html.)
5. Carrillo I. Un puente de vida (English Translation: A bridge of life). Newsweek en Español 2017 April 14, 2017:16-25.
6. Biró P, Burnapp L, Haase B, et al. Kidney Exchange Practices in Europe, First Handbook of the COST Action CA15210: European Network for Collaboration on Kidney Exchange Programmes (ENCKEP)2017.
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Today I'm in D.C. at a meeting of NLDAC, the National Living Donor Assistance Center.

Kidney exchange in Switzerland in 1999, and some early repugnant reaction

Kidney exchange is well established and growing in Europe today, but the first exchange was greeted in some quarters as a repugnant transaction.

The first kidney exchange in Europe was actually an international exchange, involving a German couple and a Swiss couple. It was conducted in Basel on May 23rd 1999, and reported in

G. Thiel, P. Vogelbach, L. Guerke, T. Gasser, K. Lehmann, T. Voegele, A. Kiss, and G. Kirste  ”Crossover renal transplantation: hurdles to be cleared!”, Transplant Proc , 2001

They report that
"The Swiss Health Insurance paid the hospital bill without hesitation. The German insurance, however, refused to pay, despite the fact that the cost (including donor nephrectomy) was lower in Basel than cadaveric transplantation alone would have been in Germany and despite huge savings for the German insurance by being released from further payments for dialysis treatment. The insurance agency argued that crossover transplantation is not allowed in Germany, and that they would not pay for an illegal procedure. …Crossover transplantation is legal in Switzerland”

Following the publication of the paper, press coverage reflected a good deal of repugnance for kidney exchange and criticized the German surgeon Prof Dr. Gunter Kirste (with whom I have discussed these matters prior to my recent talk in Geneva). Muriel Niederle pointed me to this story from Der Spiegel 12.02.2001: “[Opening the] Door to Commerce”

Here's another, from the Suddeutsche Zeitung, also in 2001, kindly supplied by Dr. Kirste, which compares kidney exchange to organ trafficking: "Organs of a Travelling Salesman"

Why don't museums sell art (except to buy more art)?

Brian Frye over at the Faculty Lounge published three nice posts about the professional repugnance that art museums have about selling art.

Here's the first:
Are Deaccessioning Norms Ethical?

It's about the rules that associations of art museums have to prevent museums from selling art. It's a professionally repugnant transaction.
 He argues that it's a way to make sure that capital gains on the secondary market accrue only to private collectors...

And here's the second:
Watching the Deaccessioning Police
"One of the biggest stories in the art world this week is the Berkshire Museum's plan to "deaccession" (read "sell") 40 artworks from its "permanent collection" worth about $50 million, in order to pay for renovations and shore up its endowment. The museum plans to auction at Sotheby's works by Norman Rockwell, Frederic Church, Albert Bierstadt, Alexander Calder, and Charles Wilson Peale, among other artists."
...
"Predictably, the deaccessioning police went ballistic. The American Alliance of Museums (AAM) and the Association of Art Museum Directors (AAMD) issued a joint statement saying they are “deeply opposed to the Berkshire Museum’s plans to sell works from its collection to provide funds for its endowment, to make capital investments, and to pay for daily operations.” The AAM and AAMD also noted that their "ethical" codes prohibit museums from selling artworks in order to cover operating costs. And their art world allies piled on, with perennial deaccessioning critics like Lee Rosenbaum lamenting the museum's decision."


And the third:
Deaccessioning Police Redux
"Predictably on cue, the "deaccessioning police" have raised their usual hue and cry. One of loudest voices in the claque is Christopher Knight of the LA Times, who has now gone "full nihilist" on deaccessioning. As Donn Zaretsky of the Art Law Blog observed, Knight's most recent column takes the anti-deaccessioning position to its inevitable reductio ad absurdumendpoint:

Here’s an idea: Don’t sell the art. Do close the museum. Start behaving like the charitable institution you are supposed to be. Spend the next several years responsibly overseeing the dispersal of the collection.

To paraphrase: "We had to destroy the museum in order to save it." 

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See this earlier post of mine, concerning university museums:

Tuesday, August 9, 2016

Repugnance watch: Deaccessioning art (i.e. selling it)

The Nephrology fellowship match

Nephrology is a subspecialty that has required fellowship programs to participate in the match ("All In")

Perspectives on the Nephrology Match for Fellowship Applicants

1. Michael J. Ross, 
2. Gregory Braden, 
3. for the ASN Match Committee
4. 1. "
   In recent years, there has been a marked decline in applicants to United States nephrology programs (1). Although a multipronged approach is clearly needed to increase interest in nephrology, it is important that we ensure that our applicants/future colleagues are treated in the most fair and equitable manner possible, and we believe that 100% participation in the National Residency Matching Program (NRMP) is vitally important to achieving that goal. In this perspectives article, we will briefly review the evolution of the Match since it was implemented for appointment year (AY) 2009, the successes achieved, and the challenges ahead."
   
   
   

The Medical Physics Residency Match

Ethical violations and discriminatory behavior in the MedPhys Match

Kristi R. G. Hendrickson, Titania Juang, Anna Rodrigues, Jay W. Burmeister

Journal of Applied Clinical Medical Physics

First published: 20 August 2017 DOI: 10.1002/acm2.12135   

"Thirteen percent of 2015 respondents and 20% of 2016 respondents were asked by at least one program how highly they planned to rank them or which program they would rank first. Thirty-seven percent of 2015 and 40% of 2016 program directors indicated that candidates communicated to the program their rank intent, with 22.0% in 2015 and 12.5% in 2016 being told that their program would be ranked first. Twenty-three percent of 2015 respondents indicated being asked by at least one program during the interview about children or plans to have children; including 19% of males and 33% of females. In 2016, these values were 28% overall, 22% male, and 36% female. Fifty-seven percent of 2015 respondents who were asked this question indicated being uncomfortable or very uncomfortable answering, including 27.3% of males and 88.9% of females. In 2016, 42.9% of all respondents indicated being uncomfortable or very uncomfortable answering, including 10.0% of males and 80.0% of females.

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See also the editorial in the same journal: The Dark Side of the MedPhys Match
by John A. Antolak PhD, Timothy D. Solberg PhD

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Here are earlier posts on the medphysics fellowship match, and radiation oncology.

U.S. transplant patients from overseas

Here's a paper presented at the ISODP meeting in Geneva, concerning which foreign patients receive deceased-donor organs in the U.S.   Bottom line, there are fewer than 1% of transplants going to foreign patients.  Half of them go to patients from Saudi Arabia and Kuwait.

Abstract

Transplant Tourism into the United States

Francis L. Delmonico1, Timothy Pruett2, Gabriel M. Danovitch3, Nancy L. Ascher4.

1Chief Medical Officer, New England Donor Services, Waltham, MA, United States; 2Chief Division of Transplantation, University of Minnesota, Minneapolis, MN, United States; 3Department of Nephrology, University of California Los Angeles, Los Angeles, CA, United States; 4Division of Transplant Surgery, University of California San Francisco, San Francisco, CA, United States

Introduction: Since 2012, the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) has required transplant centers to record the country residence of every patient undergoing transplantation in the United States. This policy replaced the quota 5% limit of non-US citizen/non-residents (NC/NR) traveling to the US for the purpose of transplantation.

Methods: Since April 1, 2015 the country of residence for the NC/NR on the wait list has also been recorded. The citizenship data of the candidate listed for transplantation was obtained from the Transplant Center Registrations (TCR) forms. These data excluded registrations of patients removed the wait list following living donor transplantation.

Results: Between April 1, 2015 and May 31, 2016, there were 42,754 waitlist additions for kidney transplantation, 551 of whom were NC/NR. Of the 14,394 waitlist additions for liver transplantation there were 191 NC/NR. The most NC/NR registrations for kidney and liver combined were from Saudi Arabia (70 total, 15 kidney and 55 liver) and Kuwait (37 total, 15 kidney and 22 liver).

Of the 14,798 kidney transplants performed from deceased organ donors there were 163 NC/NR. Of the 8168 liver transplants performed from deceased organ donors there were 124 NC/NR. 49% of the NC/NR patients undergoing liver and kidney transplantation were from Saudi Arabia and Kuwait. 7% of the kidney and 20% of the liver allografts from deceased donors were allocated to NC/NR children. There were 44 NC/NR that were removed from the list because of death or severity of illness (21 kidney and 23 liver).

A tabulation of the wait list duration, MELD score, UNOS Regions, and transplant centers that performed NC/NR transplants will be presented. The severity of illness of the wait listed candidates and the mortality rate of patients awaiting transplants in the specific UNOS region should be addressed.

Conclusions: Since the adoption of the transparency policy, < 1% of waitlist additions and < 1% of transplants have been NC/NR recipients. However, there is a disproportionate representation from 2 Middle East Countries. Review of NC/NR data is intended to promote public trust and the US to be model for the WHO principle of transparency.

References:

[1] Organ transplantation for nonresidents of the United States: a policy for transparency. Glazier AK, Danovitch GM, Delmonico FL. Am J Transplant. 2014 Aug;14(8):1740-3.

Organ Donation in Geneva

I'll be attending the 2017 Organ Donation Congress of the International Society for Organ Donation and Procurement, September 6-7 in Geneva.

Here's the program and the list of plenary and keynote speakers.

I'll be speaking on Thursday,September 7, on the ongoing design of kidney exchange.

UNOS proposal: Allowing Deceased Donor-Initiated Kidney Paired Donation (KPD) Chains

Earlier I posted about our 2016 paper proposing that some kidney exchange nondirected donor chains be started with deceased donor kidneys.

Melcher, Marc L., John P. Roberts, Alan B. Leichtman, Alvin E. Roth, and Michael A. Rees, “Utilization of Deceased Donor Kidneys to Initiate Living Donor Chains,” American Journal of Transplantation, 16, 5, May 2016, 1367–1370. http://onlinelibrary.wiley.com/doi/10.1111/ajt.13740/full

Now UNOS has put out a proposal for public comment.  Here's the proposal

Allowing Deceased Donor-Initiated Kidney Paired Donation (KPD) Chains

Here's the request for comments:
Deceased donor initiated KPD chains      Public Comment  

Scott Kominers' Market design course at Harvard

http://scottkom.com/courses/Market-Design_2017-2018/index.html

Date	Topic	Guest(s)
September 5, 2017	Introduction/Overview
September 12, 2017	The Market Designer's Toolbox
September 19, 2017	Food Supply, Scrip Systems, and Pseudo-Markets
September 26, 2017	School Choice	Parag Pathak
October 3, 2017	Signaling in Matching Markets
October 10, 2017	Internet Markets	Ben Edelman, Andrey Fradkin
October 17, 2017	Auction Theory	Shengwu Li
October 24, 2017	The US Spectrum Incentive Auction
October 31, 2017	Organ Allocation	Carmen Wang
November 7, 2017	Refugees, Immigration, and Economic Development	Ilya Vidrin
November 14, 2017	Markets for Intellectual Property
November 21, 2017	New Horizons	Ravi Jagadeesan, David Parkes, Ben Roth, Utku Ünver
November 28, 2017	Student Talks/Course Wrap

Internal Harvard Website:

https://canvas.harvard.edu/courses/29888/.

The Iranian kidney market--Associated Press

The Associated Press has a nice story on the Iranian market in which donors can be compensated for kidneys. Here's the version in the Denver Post

In Iran, unique system allows payments for kidney donors

Some interesting paragraphs:

"Iran started kidney transplants in 1967 but surgeries slowed after the 1979 Islamic Revolution and the storming of the U.S. Embassy in Tehran, in part due to sanctions. Iran allowed patients to travel abroad through much of the 1980s for transplants — including to America. But high costs, an ever-growing waiting list of patients and Iran’s grinding eight-year war with Iraq forced the country to abandon the travel-abroad program.

"In 1988, Iran created the program it has today. A person needing a kidney is referred to the Dialysis and Transplant Patients Association, which matches those needing a kidney with a potential healthy adult donor. The government pays for the surgeries, while the donor gets health coverage for at least a year and reduced rates on health insurance for years after that from government hospitals.

"Those who broker the connection receive no payment. They help negotiate whatever financial compensation the donor receives, usually the equivalent of $4,500. They also help determine when Iranian charities or wealthy individuals cover the costs for those who cannot afford to pay for a kidney.

"Today, more than 1,480 people receive a kidney transplant from a living donor in Iran each year, about 55 percent of the total of 2,700 transplants annually, according to government figures. Some 25,000 people undergo dialysis each year, but most don’t seek transplants because they suffer other major health problems or are too old.

"Some 8 to 10 percent of those who do apply are rejected due to poor health and other concerns. The average survival rate of those receiving a new kidney is between seven to 10 years, though some live longer, according to Iranian reports.
...

"Poverty around the world drives black market kidney sales, a lucrative business the World Health Organization estimated represented at least 5 percent of all transplants in 2005, though it acknowledges that figure is only a guess. The U.N. health agency’s guiding principles on organ transplantation call for banning organ sales, though it allows for “reimbursing reasonable and verifiable expenses,” including the loss of income by a living donor."

AEA continuing education programs, demise of AER P&P and other AEA announcements

Those of you who are members of the American Economic Association recently received an email with several announcements. Here are some that might particularly appeal to readers of this blog.

The AEA's 2018 Continuing Education Program will be held at the Sheraton Philadelphia Downtown on January 7-9, 2018, immediately following the close of ASSA. Participants can choose from three concurrent programs. Topics and speakers will include Mechanism Design - Atila Abdulkadiroglu (Duke), Nikhil Agarwal (MIT), and Parag Pathak (MIT); Machine Learning and Econometrics - Guido Imbens (Stanford) and Susan Athey (Stanford); and DSGE Models and the Role of Finance - Lawrence Christiano (Northwestern) and Thomas Philippon (NYU). Registration opens September 12th. For more information and updates see https://www.aeaweb.org/conference/cont-ed/.

Locations for Future Annual Meetings will be Philadelphia, January 5-7, 2018, followed by: Atlanta (2019), San Diego (2020), Chicago (2021), Boston (2022), New Orleans (2023), San Antonio (2024), San Francisco (2025), and Philadelphia (2026).

Beginning in 2018, selected papers from the AEA Annual Meeting will be published in May each year as a standalone journal titled AEA Papers and Proceedings and will no longer be the May issue of the American Economic Review. For more information, see https://www.aeaweb.org/journals/pandp.

Matching refugees to localities once they have been granted asylum

Here's a new paper by Jones and Teytelboym:

The Local Refugee Match: Aligning Refugees’ Preferences with the Capacities and Priorities of Localities

Will Jones, Alexander Teytelboym

Journal of Refugee Studies, fex022, https://doi.org/10.1093/jrs/fex022

Published:

16 August 2017

Article history

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Abstract

Once refugees are granted protection in a particular host country, there is little concern about where in that country they are settled. Yet this matters enormously for refugees’ chances to prosper in the new country and for the willingness of the local community to welcome them. We propose a centralized clearinghouse—a ‘two-sided matching system’—to match refugees with localities. Drawing on the success of matching in domains such as public school choice, we outline principles underlying matching-system design, and illustrate in general terms how they could be applied to refugee protection. This matching system respects the priorities and capacities of localities and gives agency to refugees. As an example, we describe in detail how such a system could work to meet the British government’s commitment to resettle 20,000 Syrian refugees by 2020.

Biological markets--from primates to cleaner wrasses to plants

Evolution as the designer of market exchange between and among members of different species: here's a Bloomberg article about the work of the primatologist Ronald Noe, the mathematical biologist Peter Hammerstein and a variety of other biologists.

The Secret Economic Lives of Animals
Wasps do it, baboons do it. Economics isn’t just a human activity.

"In 1994, Noë and Hammerstein laid out their new theory of biological markets in the journal Behavioral Ecology & Socialbiology. The paper fused the biologists’ different styles: Hammerstein developed the mathematical models, while Noë dug through the scientific literature for evidence from the field. Examples turned up across the animal kingdom. Male scorpion flies offer females a “nuptial gift” of prey before mating. In some species of bird, such as the purple martin, a male will allow another male to occupy part of his territory in exchange for help raising his young. Lycaenid butterfly caterpillars produce a sweet “nectar” whose only purpose is to attract ants, which eat the nectar and protect the caterpillars from predators.
...
"Noë and Hammerstein admit that one of the hardest parts of their theory is to fix quantities and exchange rates; most of the time they can only say how a change in supply and demand will influence an exchange. And they are also careful to draw distinctions between human and biological markets. Animals obviously can’t use currency or sign contracts. And the animal kingdom has no third-party institutions to punish cheaters. Evolution may have produced fish dentists, but it has yet to produce fish lawyers."


Here are my earlier posts about work by Ronald Noe

The accidental experiment with legal prostitution in Rhode Island

A scholarly paper and an easy to read-or-listen-to NPR report recount the period in which indoor prostitution was legal in Rhode Island.

The paper (forthcoming in Review of Economic Studies):

Decriminalizing Indoor Prostitution:Implications for Sexual Violence and Public Health  by Scott Cunningham and Manisha Shah

Abstract:
Most governments in the world, including the United States, prohibit sex work.Given these types of laws rarely change and are fairly uniform across regions, our knowledge about the impact of decriminalizing sex work is largely conjectural.  We exploit the fact that a Rhode Island District Court judge unexpectedly decriminalized indoor sex work to provide causal estimates of the impact of decriminalization on the composition of the sex market, reported rape offenses, and sexually transmit-ted infections.  While decriminalization increases the size of the indoor sex market, reported rape offenses fall by 30 percent and female gonorrhea incidence declines by over 40 percent.
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And here's the NPR report and podcast:
Prostitution decriminalized: Rhode Island’s experiment

It's worth reading, with lots of interesting bits, and links.  Here is a section of the transcript that struck me:

"So, what did she and her colleague, Scott Cunningham at Baylor University, find?

The obvious: sex work exploded.

But then, the not so obvious: female gonorrhea rates statewide plummetedduring the overt decriminalization period.

"It goes down by around 40 percent," Shah said. "We spent a lot of time beating up the data and estimating these things in different ways, and we just can't get the results to go away, regardless of what we do, they're there.

A forty percent drop is a big deal in the world of public health. Shah thinks one of the reasons for this positive outcome is that legalization empowered sex workers to say no to riskier sexual behavior. She also wonders if newer people were entering the market and didn't have as big of an STD risk.

Still, perhaps even more surprising than the decrease in gonorrhea was another public health development. Sexual violence, or rapes, dipped dramatically. And this wasn't just amongst sex workers. It was across the board, according to FBI crime reports and jurisdiction level data.

"Reported rape offenses decreased by about 30 percent," Shah said.

That's another big decrease. Shah says, if anything, you'd expect rape to go up as when prostitution is decriminalized, sex workers are more likely to report rapes. She compared this to neighboring states, too. The drop was only in Rhode Island. So she examined other crime data in Rhode Island, like burglaries and murders, to see if there had just been a drop in crime generally.

It didn't match. So what happened?

That, she says is harder to answer. She has a theory, though, in that while she knows for some men rape is about power, "I think the argument that we're making is that that might not be true for all men, and for some, these activities could be substitutes."

In other words, for some men, rape may be just about sex. And if there's a legal and accessible market for it, the number of rapes in a community may go down.

This has not been a popular theory or study. And for many, it challenges the notion that rape is about violence and power, and not sex.

"So I consider myself a feminist, but I think this finding angers a lot of feminists," Shah said. "It is a very controversial idea."

And then there's that other controversial area: could decriminalization fuel sex trafficking and sexual exploitation?

"I definitely worry about that," Shah said. "It's an area that I would love to, to be able to do more with."

Still Shah believes there's no solid evidence yet that decriminalizing prostitution does lead to an increase in trafficking women and forcing them into prostitution.

"There is not good empirical evidence for this either way, and part of that is because it's just very, very hard to collect good data on numbers of human trafficking."

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Scott Cunningham has been studying black markets for some time, and I'm a long time fan of his work. Here are some of my earlier posts covering it.

Harry Potter and the Resident Match | ZDoggMD.com

To some medical students, the resident match seems like sorcery. Here's a video for them (and for everyone else who feels that things are not entirely under control in whatever labor market they're in...)






HT: Jacob Leshno