Decreasing kidney discards--review, and a call for clinical trials

 A review of discarded kidneys from a large OPO revealed only modest margins for improved utilization.

Bunnapradist, Suphamai MD1; Rosenthal, J. Thomas MD1; Huang, Edmund MD2; Dafoe, Donald MD3; Seto, Tom PharmD4; Cohen, Aaron BS4; Danovitch, Gabriel MD1. Deceased Donor Kidney Nonuse: A Systematic Approach to Improvement. Transplantation Direct 9(6):p e1491, June 2023. | DOI: 10.1097/TXD.0000000000001491

"Background. A large number of procured kidneys continue not to be transplanted, while the waiting list remains high.

"Methods. We analyzed donor characteristics for unutilized kidneys in our large organ procurement organization (OPO) service area in a single year to determine the reasonableness of their nonuse and to identify how we might increase the transplant rate of these kidneys. Five experienced local transplant physicians independently reviewed unutilized kidneys to identify which kidneys they would consider transplanting in the future. Biopsy results, donor age, kidney donor profile index, positive serologies, diabetes, and hypertension were risk factors for nonuse.

"Results.  Two-thirds of nonused kidneys had biopsies with high degree of glomerulosclerosis and interstitial fibrosis. Reviewers identified 33 kidneys as potentially transplantable (12%).

"Conclusions. Reducing the rate of unutilized kidneys in this OPO service area will be achieved by setting acceptable expanded donor characteristics, identifying suitable well-informed recipients, defining acceptable outcomes, and systematically evaluating the results of these transplants. Because the improvement opportunity will vary by region, to achieve a significant impact on improving the national nonuse rate, it would be useful for all OPOs, in collaboration with their transplant centers, to conduct a similar analysis."

...

"One posited cause for continued high nonuse rates is that transplant physicians are overly conservative, content with doing a small number of cases relative to the need. Both the existence of a “weekend effect”8 and a paper by French investigators stating 62% of kidneys not transplanted in the United States would be transplanted in France9 are used in support of this contention. Mistaken reliance on kidney biopsies is an additional factor implicated in inappropriate kidney nonuse.10 An alternative explanation is that transplant physicians and surgeons have not been persuaded that it is safe to transplant high-risk kidneys into older recipients based on retrospective registry studies.

"With this background in mind, and with a strong desire to respond to the imperative of increasing the use of heretofore nontransplanted kidneys, we undertook an analysis of unused kidneys in our OPO service area. Goal one was to understand the interplay of factors causing nonuse including donor demographics and biopsies. Goal two was to use the information from goal one to devise a plan to increase the kidney utilization rate in our service area.

"OneLegacy is the federally designated OPO for 7 counties in Southern California with a population of approximately 20 million. In 2019, which was chosen as the year of study because it was the last full year before the COVID-19 pandemic, OneLegacy served 10 centers with kidney transplant programs.11

"There were 1064 kidneys procured from 552 donors; 740 were transplanted and 324 were not transplanted. Forty-seven of the 324 (14.5%) were not offered for transplant because of absolute contraindications including cancers in the kidney, infections discovered during procurement, and abnormalities such as multicystic dysplastic kidneys. There were 5 surgical injuries (0.47%)—1 stripped ureter and 4 vascular injuries—all of which were determined to be nonrepairable by a transplant surgeon highly experienced with repair techniques. These kidneys were excluded from the study. The remaining 272 kidneys were offered for transplant and turned down by all local centers and, in turn, by all regional and national centers. Fourteen kidneys were provisionally accepted by and transported to nonlocal centers but, ultimately, not utilized due to prolonged cold ischemic times or findings on biopsies performed at the export center.

...

"One reason that the nonuse problem has proven intractable is that, even though it has been asserted that most nonused kidneys in the United States are safe to transplant, clinicians making the decisions in real time seem not to agree. Nor is there widespread enthusiasm for transplanting suboptimum kidneys into elderly recipients, despite papers promoting it,15 possibly because it is not entirely clear which older dialysis patients really benefit from transplantation.16

"The thought experiment of experienced local physicians reviewing procured but not transplanted kidneys appears to confirm this hypothesis. Despite French studies suggesting that 62% of kidneys not utilized in the United States would be transplanted in France, only 12% of kidneys were thus identified by our team of physicians, each of whom were highly motivated to reduce nonuse kidneys and highly knowledgeable about registry studies claiming safety of expanded donor criteria.10 If highly knowledgeable and experienced transplant physicians and surgeons—highly motivated to decrease nonuse—have not significantly changed kidney acceptance criteria, they are unlikely to be persuaded or respond to regulatory pressure to cause them to perform transplants that they feel would violate their responsibility to patients. Reducing the nonuse rate to ≤5% is unlikely under these conditions. Nonetheless, this experience does inform how improvement can occur.

"The alternative pathway to improvement in our service area is a more systematic prospective approach, in other words, an authentic clinical trial. The elements of such a trial would include codifying as precisely as possible the inclusion criteria for transplantable “suboptimal” donors, determining recipient criteria, extensive informed consent conversations, optimization of the organ offer process to minimize cold ischemia times, and outcomes tracking including quality of life and cognitive assessment. It should be decided in advance what will constitute an acceptable outcome for primary nonfunction and 1-y graft and patient survival."

More kidney exchange in the UAE--

 Kidney exchange in the UAE, with the assistance of the Alliance for Paired Kidney Donation (AKPD), took another step forward, with a three way exchange.

Here is the press release fron the Cleveland Clinic Abu Dhabi:

Cleveland Clinic Abu Dhabi supports Abu Dhabi’s Paired Kidney Donation Program by successfully completing a triple swap kidney transplant 

"Cleveland Clinic Abu Dhabi, a Mubadala Health partner, played a major role in a groundbreaking triple ‘kidney swap’ transplant case in the UAE where three patients received life-saving organs under Abu Dhabi’s Paired Kidney Donation Program."

Snowden and state surveillance: the view from The Guardian, ten years later

 Here's a look back at the Snowden affair (publication of documents about government surveillance) by the then editor in chief of the Guardian, one of the newspapers that took the lead.

Ten years ago, Edward Snowden warned us about state spying. Spare a thought for him, and worry about the future by Alan Rusbridger

"one story the Guardian published 10 years ago today exploded with the force of an earthquake.

"The article revealed that the US National Security Agency (NSA) was collecting the phone records of millions of Verizon customers. In case anyone doubted the veracity of the claims, we were able to publish the top secret court order handed down by the foreign intelligence surveillance court (Fisa), which granted the US government the right to hold and scrutinise the metadata of millions of phone calls by American citizens.

...this was but the tip of a very large and ominous iceberg.

...

"the Guardian (joined by the Washington Post, New York Times and ProPublica) led the way in publishing dozens more documents disclosing the extent to which US, UK, Australian and other allied governments were building the apparatus for a system of mass surveillance

...

"It led to multiple court actions in which governments were found to have been in breach of their constitutional and/or legal obligations. It led to a scramble by governments to retrospectively pass legislation sanctioning the activities they had been covertly undertaking. And it has led to a number of stable-door attempts to make sure journalists could never again do what the Guardian and others did 10 years ago.

"Even now the British government, in hastily revising the laws around official secrecy, is trying to ensure that any editor who behaved as I did 10 years ago would face up to 14 years in prison.

...

"The British government believed that, by ordering the destruction of the Guardian computers, they would effectively silence us. In fact, we simply transferred the centre of publications to New York, under ​the paper’s then US editor, Janine Gibson.

...

"The notion that the state has no right to enter a home and seize papers was established in English law in the famous case of Entick v Carrington (1765), which later became the basis for the US fourth amendment. In a famous passage, Lord Camden declared: “By the laws of England, every invasion of private property, be it ever so minute, is a trespass.”

"When I went out to talk about the Snowden case to assorted audiences (including, after a suitable gap, at MI5 itself), I would begin by asking who in the audience would be happy to hand over all their papers to a police officer knocking on their front door, even if they assured them they would only examine them if there was sufficient cause.

"Never, in any of these talks, did a single member of any audience raise a hand. Yes, people valued their security and were open to persuasion that, with due process and proper oversight, there would be occasions when the state and its agencies should be granted intrusive powers​ in specific circumstances​. But the idea of blanket, suspicionless surveillance – give us the entire haystack and we’ll search for the needle if and when it suits us – was repellent to most people."

Interview in the Brazil Journal

 I was interviewed for the Brazil Journal by Giuliano Guandalini. The interview was conducted in English, but appears in Portuguese. We discussed controversial markets generally, including kidney exchange, which is not legal yet in Brazil.

Troca de rins. Drogas. Barriga de aluguel. Este Nobel sugere liberar tudo  (Kidney exchange. Drugs. Surrogacy...)

 Here's a snippet that comes through pretty clearly in retranslation back into English by Google Translate:

"In the US and many other countries, his work and that of other researchers has contributed to improving the waiting list for kidney transplants. In Brazil, we continue with the traditional system, with a long wait for donors. Why is it so difficult to make reforms of this kind in public services based on the teachings of modern economics?  

"A transplant always depends on an organ donation, whether from a dead person or a living individual. It is natural that family members and society in general are concerned about how this will be done in an ethical and careful manner. 

"Brazil does a lot of transplants. So there is no restriction on the medical capacity side so that more transplants can be done. But when we look at total kidney transplants in relation to population size, the number is not that big. 

"Meanwhile, there are thousands of people on dialysis because transplants have not been enough. The issue, therefore, is to allow more donations to occur in life, and changing kidneys is a way for people to help save someone they love. 

"Brazil may be one of the next countries to carry out the exchange of kidneys. Some experimental surgeries have already been performed, with legal authorization. Researchers will be able to gain support to perform more operations of this type and then, perhaps, society will be able to convince itself of the importance of changing kidneys. 

"What are the obstacles that prevent the adoption of organ exchange? Are they ethical, moral, religious issues? 

"A little bit of all those things. There are those concerned that poor and vulnerable people may have their organs stolen. Evidently, there must be complete assurance that this will not happen. But of course the poor would also like to save the lives of loved ones by giving them a kidney. "

Alex Chan makes his 'final presentation' at Stanford.

 

Note Alex's shoes

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.

*********

Earlier: 

Tuesday, May 30, 2023

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

The critical role of Kelso & Crawford in the development of the stable matching literature

 In the physics literature there has long been an interest in economics (econophysics) that takes many forms. Here's a review of stable matching, which identifies Kelso and Crawford as a critical step in the evolution of the matching literature following Gale and Shapley.

Danilov, V.I. Review of the Theory of Stable Matchings and Contract Systems. Computational Mathematics and Mathematical Physics. 63, 466–490 (2023). https://doi.org/10.1134/S0965542523030065

"The real development was started by the work of Kelso and Crawford [123], who considered the more general problem of hiring workers (many-to-one). Their problem statement differed from the college admission problem in that the behavior of firms was more flexible than simply setting a quota in [81]. When hiring workers, the firm dealt with a “crowd” of candidates and chose the group of workers it needed from among this crowd. The description of the behavior of such a firm was no longer given by a simple ranking of candidates, but by a choice function. Below, we consider such functions in more detail. An important merit of Kelso and Crawford was that they found the “correct” condition on the choice function, which generalized the Gale–Shapley “linear” choice and which had previously appeared in economics as a substitutability condition. (Later it turned out that such a condition had already been introduced in the choice theory [152] under the name path independence.) Using this condition, Kelso and Crawford [123] showed that the Gale–Shapley algorithm works and gives a stable distribution of workers among firms. In [88], the notion of substitutability was used in the case of indivisible goods and led to a series of papers on this topic (see [79, 51, 65, 103]). Two years later, Roth [158] showed that the same substitutability condition also works well in a many-to-many situation, when firms could hire many workers and workers could work in several firms, see [62]. The results of this direction were summed up in the monograph [160]."

Dissertation advisors and job market outcomes by Rose and Shekhar

 Here's a paper on the economics job market, and the influence of dissertation advisers.

Adviser Connectedness and Placement Outcomes in the Economics Job Market, by Michael E. Rose and Suraj Shekhar, forthcoming in Labour Economics

Abstract: We study the role of social networks in the academic job market for graduate students of Economics. We find that the connectedness of a student’s advisor in the coauthor network significantly improves her job market outcome. We use two identification strategies and find that a) higher Eigenvector centrality of an adviser leads to her student getting placed at a better ranked institution, and b) larger distance between an adviser and an institution decreases the probability that her students are placed there. Our study sheds light on the importance of social connections in a labour market where information frictions regarding job openings are virtually absent.

...

"Our setting, the academic job market for Economists, is special in that information frictions regarding job openings are (almost) absent due to Job Openings for Economists. Thus, our finding that social networks play a role in this market is likely because they help decrease the uncertainty about an applicant’s quality."

********

I'm reminded of the timeless joke about how rabbits eat wolves: if you don't know it, there are many versions on the internet, here  (and this one comes with a bonus joke: Rabbit's Ph.D. Thesis and Lion's Watch Repair Business).

Canadian kidney exchange reaches 1000 transplants

 The May 2023 update from Canadian Blood Services shows that Canada's kidney paired donation program recently performed its 1,000th transplant.

Earlier:

Wednesday, December 8, 2010

National kidney exchange in Canada

Here's a recent announcement from Canadian Blood Services: Kidney Exchange Registry Goes National, Living Donor Paired Exchange becomes first Canada-wide organ donation registry

Kidney exchange progress in Europe

 The program on European Cooperation in Science and Technology  (COST) has just published an update on steps being taken to advance kidney exchange in Europe, including the goal of more cross-border exchange.

The crucial role of Kidney Exchange Programmes and the ENCKEP and KEP-SOFT innovations making it possible

"Setting up KEPs is difficult due to the ethical, legal, practical, and logistical considerations that must be faced. These include ratifying policy decisions, establishing a software infrastructure, and satisfying clinical requirements. Additionally, KEPs vary across European countries in terms of policy, clinical practice, and optimisation methods. For instance, the maximum number of recipients allowed to exchange donors in a single “cycle” differs between the Netherlands and the UK. Furthermore, some countries allow non-directed donation while others prohibit it. Crossmatching** processes also vary. The ENCKEP and KEP-SOFT network has proved instrumental in meeting many of these challenges. And its associated software addresses many of these variations.

...

"On 15 June 2023, EU4Health will publish a call for proposals to implement an EU-wide KEP. On page 65, the announcement makes specific reference to the KEP-SOFT software. This presents an exciting potential future opportunity to influence further developments in KEPs in the European context and to widen the user-base of the KEP-SOFT software"

HT: David Manlove

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

When I first read the last paragraph above I thought that "KEP"  probably stood for "Kidney Exchange Program," and that the proposal was to make that EU-wide rather than country by country. But it turns out that "KEP" stands for Knowledge Exchange Platform (KEP), so the progress is a bit less specific than I had hoped. But on page 65 it does include a "Call for proposals: action grants on facilitating organ paired exchange." It states that "In view of the scarcity of organs available for transplantation, there is a need to strengthen the exchange schemes among Member States, with a clear added value for European patients, as such exchange schemes can save the life of patients."

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.

Further progress on course allocation, by Budish, Gao, Othman, Rubinstein and Zhang

 Here are some new developments in the course allocation mechanism used initially in Wharton and now elsewhere.  It turns out that strategy-proofness in the (very) large doesn't imply strategyproofness in samples of realistic size, but this seems to be fixable (and profitable manipulations were not easy to find). The paper concludes with some far ranging thoughts on the econ-cs interface.

Practical algorithms and experimentally validated incentives for equilibrium-based fair division (A-CEEI)   by ERIC BUDISH, RUIQUAN GAO, ABRAHAM OTHMAN  AVIAD RUBINSTEIN, and QIANFAN ZHANG

Abstract: "Approximate Competitive Equilibrium from Equal Incomes (A-CEEI) is an equilibrium-based solution concept for fair division of discrete items to agents with combinatorial demands. In theory, it is known that in asymptotically large markets:

•For incentives, the A-CEEI mechanism is Envy-Free-but-for-Tie-Breaking (EF-TB), which implies that it is Strategyproof-in-the-Large (SP-L).

•From a computational perspective, computing the equilibrium solution is unfortunately a computationally intractable problem (in the worst-case, assuming PPAD≠FP).

We develop a new heuristic algorithm that outperforms the previous state-of-the-art by multiple orders of magnitude. This new, faster algorithm lets us perform experiments on real-world inputs for the first time. We discover that with real-world preferences, even in a realistic implementation that satisfies the EF-TB and SP-L properties, agents may have surprisingly simple and plausible deviations from truthful reporting of preferences. To this end, we propose a novel strengthening of EF-TB, which dramatically reduces the potential for strategic deviations from truthful reporting in our experiments. A (variant of ) our algorithm is now in production: on real course allocation problems it is much faster, has zero clearing error, and has stronger incentive properties than the prior state-of-the-art implementation"

Here's an intriguing passage:

"In Section 6 we use our manipulation-finding algorithm in combination with our fast A-CEEI finding algorithm to explore the plausibility of effective manipulations for students bidding in ACEEI. Originally, we had expected that since our mechanism satisfies the EF-TB and SP-L properties, it would at least be practically strategyproof — if even we don’t really understand the way our algorithm chooses among the many possible equilibria, how can a student with limited information learn to strategically bid in such a complex environment? 

"Indeed, in 2 out of 3 schools that we tested, our manipulation-finding algorithms finds very few or no statistically significant manipulations at all. However, when analyzing the 3rd school, we stumbled upon a simple and effective manipulation for (the first iteration of) our mechanism. We emphasize that although the manipulation is simple in hindsight, in over a year of working on this project we failed to predict it by analyzing the algorithm — the manipulation was discovered by the algorithm. 

"Inspired by this manipulation, we propose a natural strengthening of envy-free (discussed below), which we call contested-envy free. We encode the analogous contested EF-TB as a new constraint in our algorithm (specifically, the integer program for finding optimal budget perturbations). Fortunately, our algorithm is still very fast even with this more elaborate constraint. And, when we re-run our manipulation-finding experiments, we observe that contested EF-TB significantly reduces the potential for manipulations in practice."

...

"Conclusion:  In this work, we give a significantly faster algorithm for computing A-CEEI. Kamal Jain’s famous formulation “if your laptop cannot find it then neither can the market” [Papadimitriou 2007] was originally intended as a negative result, casting doubt on the practical implications of many famous economic concepts because of their worst-case computational complexity results. Even for course allocation, where a heuristic algorithm existed and worked in practice, Jain’s formulation seemed to still bind, as solving A-CEEI involved an intense day-long process with a fleet of high-powered cloud servers operating in parallel. The work detailed in this paper has significantly progressed what laptops can find: even the largest and most challenging real course allocation problems we have access to can now be solved in under an hour on a commodity laptop. 

"This significant practical improvement suggests that the relationship between prices and demand for the course allocation problem—and potentially other problems of economic interest with complex agent preferences and heterogeneous goods—may be much simpler than has been previously believed and may be far more tractable in practice than the worst-case theoretical bounds. Recalling Jain’s dictum, perhaps many more market equilibria can be found by laptops—or, perhaps, Walras’s original and seemingly naive description of how prices iterate in the real world may in fact typically produce approximate equilibria. 

"Our fast algorithm also opens the door for empirical research on A-CEEI, because we can now solve many instances and see how the solution changes for different inputs. We took it in one direction: empirically investigating the incentives properties of A-CEEI for the first time. For course allocation specifically, this faster algorithm opens up new avenues for improving student outcomes through experimentation. For instance, university administrators often want to subsidize some 6 group of students (e.g., second-year MBA students over first-year MBA students), but are unsure how large of a budget subsidy to grant those students to balance equity against their expectations. Being able to run more assignments with different subsidies can help to resolve this issue."

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

Earlier related posts:

Thursday, April 23, 2009

Course allocation, by Eric Budish

Sunday, October 4, 2009

Course allocation by Budish, updated

Thursday, May 30, 2013

Wharton's new Course Match for MBA students to choose their classes: market design in action

Monday, August 3, 2015

Course allocation at Wharton: looking under the hood

Tuesday, June 9, 2020

Cognomos--course allocation software by Eric Budish et al.

How do (should?) economists study repugnance?

 Here's a recent paper by Peter Cserne that looks at different ways that economists study repugnance:

Cserne, P. (2023). Economic analyses of repugnant market transactions: A modest typology. Journal of Institutional Economics, 1-14. doi:10.1017/S1744137423000139

"Abstract: Economic accounts of repugnance concern two broad questions: the rationalisation of sentiments of repugnance (do emotional and visceral reactions of repugnance track valid reasons for not engaging in or condemning certain (trans)actions?) and institutional design (how to institute, regulate, or restrict markets in response to reasonable objections). If repugnance expresses valid practical reasons for regulating or limiting markets, our institutions should acknowledge and express these. If attitudes of repugnance are not rationalisable in the sense of instrumental or moral values, we should disregard or eventually counteract or reduce them. Focusing on a special case of repugnance, when commodification, i.e., the sale of goods or services for money meets societal disapproval, this paper identifies three characteristic ways to combine conceptual, empirical, and normative arguments and map repugnance into a disciplinary ‘epistemic frame’ of economics: repugnance as taste; repugnance as proxy for market failures or moral reasons; repugnance as hypocrisy or contingent cultural fact. Correspondingly, economists advise to (1) work around; (2) make sense of; and (3) explain away people's sentiments of repugnance."

...

"In recent decades, the economic discourse on repugnance has become rich and dense. While the moral limits of markets have been discussed in philosophy and various social and policy sciences for centuries, in the last decades, repugnance as a possible limit to markets has been increasingly subject to technical economic analysis as well (Khalil and Marciano, Reference Khalil and Marciano2018; Roth, Reference Roth2007; Tirole, Reference Tirole2017: 33–50). To be sure, from a longer historical perspective, economists have always been concerned with moral sentiments, including repugnance.

...

"Regarding the moral limits of markets, there is a range of (a) substantive views. For the purposes of this paper, we roughly distinguish three stances: commodification, anti-commodification, and anti-anti-commodification. These are expressed in different (b) conceptual categories: as moral preferences; moral externalities or merit goods; and hypocrisy or cultural facts. Together, they allow to express the substantive concerns in (c) analytical frameworks, in other words, they provide the technical terms for economists to, respectively: work around; rationalise, i.e., make sense of; and explain away people's repugnance. Thus, I suggest distinguishing three substantive stances on repugnance in economics, combining conceptual choices and normative commitments into analytical frameworks.

"First, economists may conceptualise repugnance as a taste or (moral) preference. Following the dictum de gustibus non est disputandum (Stigler and Becker, Reference Stigler and Becker1977), they engage in technical normative analysis and institutional design in an engineering mode (Roth, Reference Roth2002). Normatively, they orient themselves in favour of commodification, i.e., extending the scope of markets. Correspondingly, their analytical strategy is to propose policies to ‘work around’ social sentiments of repugnance.

"Second, economists may conceptualise repugnance in terms of (moral) externality or merit goods, i.e., as versions of or proxies for market failures. In doing so, they make sense of sentiments of repugnance, in terms of ordinary economic analysis. Correspondingly, they propose policies to justify limiting or regulating markets. They engage in the rationalisation of anti-commodification sentiments in terms of public reasonableness.

"Third, economists may conceptualise repugnance as an expression of hypocrisy or as a cultural fact of no independent normative weight. Normatively, they engage in demystifying repugnance either by naturalising it or philosophically debunking sentiments of repugnance as unreasonable ‘romance’; their analytical strategy could be characterised as anti-anti-commodification insofar as they aim to explain away anti-commodification arguments as irrelevant for policy debates around institutional design."

An upside to dowries, by Natalie Bau, Gaurav Khanna, Corinne Low & Alessandra Voena

 Dowries (like bride prices*) are often criticized, but may have indirect effects that aren't so easy to see, as in this recent NBER paper:

Traditional Institutions in Modern Times: Dowries as Pensions When Sons Migrate by Natalie Bau, Gaurav Khanna, Corinne Low & Alessandra Voena  NBER WORKING PAPER 31176, DOI 10.3386/w31176

Abstract: This paper examines whether an important cultural institution in India - dowry - can enable male migration by increasing the liquidity available to young men after marriage. We hypothesize that one cost of migration is the disruption of traditional elderly support structures, where sons live near their parents and care for them in their old age. Dowry can attenuate this cost by providing sons and parents with a liquid transfer that eases constraints on income sharing. To test this hypothesis, we collect two novel datasets on property rights over dowry among migrants and among families of migrants. Net transfers of dowry to a man's parents are common but far from universal. Consistent with using dowry for income sharing, transfers occur more when sons migrate, especially when they work in higher-earning occupations. Nationally representative data confirms that migration rates are higher in areas with stronger historical dowry traditions. Finally, exploiting a large-scale highway construction program, we show that men from areas with stronger dowry traditions have a higher migration response to reduced migration costs. Despite its potentially adverse consequences, dowry may play a role in facilitating migration and therefore, economic development.

********

*Recall this earlier paper:

Ashraf, Nava, Natalie Bau, Nathan Nunn, and Alessandra Voena. "Bride price and female education." Journal of Political Economy 128, no. 2 (2020): 591-641.

Freakonomics replay and update on kidney exchange and organ donation

 Freakonomics Radio yesterday revisited some of their old podcasts about kidney exchange. In one, they interview me, and in another, they interview Ned Brooks, who listened to that interview and went on to become a non-directed kidney donor and to found an organization to support other kidney donors, the NKDO, National Kidney Donation Organization.  You can listen and/or read the transcript at this link:

EPISODE 209

Make Me a Match (Update)

"Sure, markets work well in general. But for some transactions — like school admissions and organ transplants — money alone can’t solve the problem. That’s when you need a market-design wizard like Al Roth. Plus: We hear from a listener who, inspired by this episode, made a remarkable decision.

"Last month, the federal government announced plans to modernize the U.S. organ-donation system. They want to speed up the process by which organ-transplant patients are matched with donated organs, and they also want to reduce racial inequities in the system. When we saw this news, we decided to go into our archive and put together the episode you’re about to hear. It’s a mashup of a 2015 episode, No. 209, called “Make Me a Match,” and a portion of a 2016 episode, No. 237, which includes a personal story from a listener who was inspired by that earlier episode to make a remarkable decision. All the relevant facts and figures have been updated. As always, thanks for listening."

***********

Here are my previous posts on Freakonomics episodes.

HRSA's Organ Procurement and Transplantation Network Modernization Initiative

 The Health Resources and Services Administration (HRSA) has announced a timeline for moving forward on the proposal to reorganize the system for obtaining and distribution deceased donor organs for transplant, aiming for a request for proposals in the Fall.

Organ Procurement and Transplantation Network Modernization Initiative   May 2023 Updates

"On March 22, 2023, the Health Resources and Services Administration (HRSA) announced a Modernization Initiative to strengthen accountability and transparency in the Organ Procurement and Transplantation Network (OPTN). The initiative is focused on five key areas: technology, data transparency, governance, operations, and quality improvement and innovation. As part of our commitment to transparency around the Modernization Initiative, HRSA is providing an update on our upcoming action steps.

The OPTN Modernization Initiative is centered on putting patients first, prioritizing information flow to clinicians, promoting innovation through continuous competition, and enhancing transparency and accountability. HRSA's planned approach and timelines for the first year of the multi-year modernization process focuses on design, implementation, and oversight, including contract solicitations that will be released Fall 2023 and Spring 2024. In addition, HRSA continues to pursue the legislative changes and increased funding included in the President's Fiscal Year 2024 budget to implement and advance the Modernization Initiative.

Summer 2023

Phase 1: OPTN Modernization Design & Strategy Development  

External Engagement and Design Planning Contract  – HRSA is currently conducting market research to inform the development of the upcoming Fall contract solicitations and will host an Industry Day for interested parties and vendors this Summer. Building on our outreach efforts over the past year, HRSA also will continue to ensure that patient, family, and clinician voices are engaged in this work, including through focus groups and other approaches. HRSA recently awarded a program management contract to support this stakeholder engagement as well as strategic and operational planning and change management.

Fall 2023

Phase 2A: OPTN Transition Management

HRSA recognizes the vital need to maintain uninterrupted access to the critical systems and functionality that support organ matching and transplantation during the modernization process. Working with the best technologists in the U.S. Government, HRSA expects to conduct this work on a dual track so that there are appropriate safeguards to ensure no disruptions in service as part of modernization implementation. Therefore, HRSA will support two significant multi-vendor solicitations between now and Spring 2024 – with the first solicitation to be issued this Fall 2023. This action will be followed by a Spring 2024 solicitation to further the next generation OPTN, as noted below. 

Competitive OPTN Transition Contracts – This Fall, HRSA plans to release a solicitation to establish new contracts that will support and enhance OPTN operations while the modernization process is underway. These contracts will ensure the continuation of critical OPTN support functions and enable appropriate upgrades on a parallel track with modernization. The Fall 2023 solicitation will seek multiple vendors for distinct functions – including supporting a separate OPTN Board of Directors – to ensure service continuity and increase oversight and accountability.

To ensure that the OPTN Transition contracts are developed in a way that meets the needs of all stakeholders, HRSA is committed to soliciting feedback from interested parties during the development and implementation of this work. By involving stakeholders in the process, HRSA can ensure that the Transition contracts advance the goals of the OPTN Modernization Initiative, provide optimal support to protect patient safety, and ensure the efficient functioning of the OPTN.

Spring 2024

Phase 2B: OPTN Modernization Implementation

In Spring 2024, HRSA intends to release a solicitation for multiple vendors to support the next generation of the OPTN, which will include enhancements in technology, governance, data transparency and operations. The separate Board of Directors contract and the deliverables from this next generation solicitation will form the foundation of a new, modernized OPTN. 

OPTN Next Generation Contracts – The proposed OPTN Next Generation contracts will represent a significant step forward in modernizing the OPTN’s foundational IT systems. In Spring 2024, HRSA expects to release a solicitation seeking multiple vendors for the OPTN Next Generation contracts to provide a comprehensive approach to modernizing the OPTN. The goal of this solicitation is to find contractors who will use innovative, best in class approaches to carrying out specific functions, including initial prototyping, testing, scaling, integration, deployment, and adoption support.  

HRSA is committed to transparency in the OPTN Modernization process and will continue to provide updates on our iterative approach toward achieving enhanced accountability, equity, and performance in the organ transplantation system, as appropriate, as this work moves forward."

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Here's a NYT story covering the announcement, with some background:

U.S. Organ Transplant System, Troubled by Long Wait Times, Faces an Overhaul The Biden administration announced a plan to modernize how patients are matched to organs, seeking to shorten wait times, address racial inequities and reduce deaths.  By Sheryl Gay Stolberg

Egg freezing in China and Hong Kong

 The FT has the story:

China’s fertility treatment rules push single women to Hong Kong

Beijing faces calls to ease access to egg freezing and IVF amid demographic crisis

By Eleanor Olcott and Chan Ho-him 

“Beijing has long banned access to egg freezing or IVF for single women. While unmarried men can freeze their sperm, single women such as Sophia, who declined to give her surname, are not allowed to freeze their eggs.

…

“As a result, more and more Chinese women travel abroad for the procedure, with Hong Kong a top destination given its proximity and strong healthcare system.

…

“While it is possible for single or gay women to freeze their eggs in Hong Kong, only married heterosexual couples can access IVF treatment. In practice, that means eggs are stored until women get married and begin the IVF process.”

Quarantine in Dubrovnik

 I’m traveling home today after a good work/vacation trip to Croatia, ending in Dubrovnik. Dubrovnik has a long history of quarantining foreign visitors to prevent the spread of disease 

Over 100 Nobel Laureates join PEN International in support of Nobel Peace Prize winner Ales Bialiatski

“PEN International, the literary and free expression organisation, has released a letter signed by 103 Nobel Laureates, expressing solidarity with writer, human rights defender, Nobel Peace Prize winner, and PEN member Ales Bialiatski, and condemning the Belarusian authorities’ brutal, relentless, and systematic crackdown on independent voices. Today marks the International Day of Solidarity with Prisoners of Conscience in Belarus. The solidarity action was featured in the Guardian.”

Drug Overdose Deaths Topped 100,000 Again in 2022

 

The WSJ has the story: the headline speaks for itself  

Drug Overdose Deaths Topped 100,000 Again in 2022 https://www.wsj.com/articles/drug-overdose-deaths-topped-100-000-again-in-2022-37cd1709

Defining death for deceased organ donation

 Here’s a story from Science, about donation of a heart from a donor declared dead after circulatory death, ie after heart stoppage:

GIVING HEART: A new procedure for donating hearts and other organs is saving lives. But for some it challenges the definition of death   By 

Jennifer Couzin-Frankel

"As is customary regardless of whether organs will be donated, physicians waited 5 minutes to ensure that the heart didn’t start beating again on its own. It did not, and the man was declared dead. The baton then passed to the organ recovery and transplant team. They clamped blood vessels running from the torso to the brain and reconnected his body to machines that circulated oxygenated blood, causing the heart to begin pumping again. "These two interventions—initiating a heartbeat after death is declared and taking steps to prevent blood flow to the brain—are at the core of a raging debate about the ethics of such donations. To some people, the approach risks disrupting the dying process; to others, it allows that process to continue as the family desires, while also honoring individual or family wishes for organ donation.

“The debate touches on the definition of death, Moazami says. “When the heart stops, we say, ‘time of death, 5:20 a.m.’” But, “The fact of the matter is, death is a process. Death is not a time point.” Cells can take hours to die. Sophisticated machinery can induce a heartbeat hours after death, but does that make a person “alive”?