To celebrate the book of the same name, the Simons Institute is hosting a conference today and tomorrow on
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Thursday, Oct 26:
Here's an article suggesting why England should pilot a program to compensate kidney donors. Perhaps the argument is generalizable to other countries as well...
Rodger, Daniel, and BonnieVenter, A fair exchange: why living kidney donors in England should be financially compensated. Medicine, Health Care and Philosophy (2023). https://doi.org/10.1007/s11019-023-10171-x
Abstract: Every year, hundreds of patients in England die whilst waiting for a kidney transplant, and this is evidence that the current system of altruistic-based donation is not sufficient to address the shortage of kidneys available for transplant. To address this problem, we propose a monopsony system whereby kidney donors can opt-in to receive financial compensation, whilst still preserving the right of individuals to donate without receiving any compensation. A monopsony system describes a market structure where there is only one ‘buyer’—in this case the National Health Service. By doing so, several hundred lives could be saved each year in England, wait times for a kidney transplant could be significantly reduced, and it would lessen the burden on dialysis services. Furthermore, compensation would help alleviate the common disincentives to living kidney donation, such as its potential associated health and psychological costs, and it would also help to increase awareness of living kidney donation. The proposed system would also result in significant cost savings that could then be redirected towards preventing kidney disease and reducing health disparities. While concerns about exploitation, coercion, and the ‘crowding out’ of altruistic donors exist, we believe that careful implementation can mitigate these issues. Therefore, we recommend piloting financial compensation for living kidney donors at a transplant centre in England."
They set the stage in their Introduction:
"In 2019, the Human Tissue Act 2004 (HT Act) was amended to allow England to adopt an opt-out system of organ donation, which was subsequently passed as The Organ Donation (Deemed Consent) Act 2019 and implemented in May 2020. This amendment aims to change the way donor consent is given for transplantable organs and tissues. Its intention is to increase the number of organs available for transplantation to save lives and improve the quality of life of those on the wait list. It was estimated by the United Kingdom (UK) Government that this amendment would save 700 lives per year (Dyer 2019). Despite these intentions, this amendment is unlikely to make a significant difference to the number of available organs.
"Currently, there is no definitive evidence to suggest that merely adopting an opt-out system will increase the pool of available organs (Etheredge 2021). Nevertheless, even if the pool of organs were to increase, it is not necessarily a panacea. Spain, though not strictly an opt-out system because it does not have an opt-out register (Etheredge 2021), is considered the gold-standard system for organ transplantation. But despite their success, Spain still has an insufficient number of organs, a growing kidney transplant wait list, and patients still die waiting for a transplant (Crespo et al. 2021). Kidney transplant wait lists continue to increase despite improving infrastructure, education, and the adoption of opt-out systems. Because only around 1% of people who die each year in the UK are eligible to donate their organs (NHS Blood and Transplant, 2022), it is becoming increasingly necessary to consider alternative approaches to increase the number of available organs for transplant."
Nature has the story (despite the somewhat inflammatory headline).
Scientists deliberately gave women Zika — here’s why. ‘Human challenge’ results suggest that such trials could be used to test vaccines when Zika incidence is low. by Mariana Lenharo, Nature, 21 October 2023
"For the first time, scientists have deliberately infected people with Zika virus to learn whether such a strategy could help to test vaccines against the pathogen.
The virus can cause severe birth abnormalities in babies born to parents infected during pregnancy. It also has been associated with neurological problems in adults, although those cases are rare. But infected study participants had only mild symptoms, and none became pregnant during or immediately after the trial. The results raise hopes that ‘human challenge’ programmes — in which volunteers are exposed to a pathogen in a controlled setting — could make it feasible to test vaccines at a time when Zika incidence is low.
“This is a great scientific gain in terms of the development of a vaccine,” said Rafael Franca, an immunologist at the Oswaldo Cruz Foundation in Ribeirão Preto, Brazil. The results are scheduled to be presented today at the annual meeting of the American Society of Tropical Medicine and Hygiene in Chicago, Illinois.
...
"In 2022, after a long process to address ethical concerns around the study, Durbin and her team recruited 28 healthy women, aged 18 to 40, who were neither pregnant nor lactating. All agreed to be admitted to a research facility and remain there until they were no longer infectious; they stayed at the unit for 9 to 16 days. They were tested for pregnancy several times before receiving the virus, to avoid the risk of congenital problems associated with Zika, and were counselled to use birth control for at least two months after the study.
Hope for smaller trials
The researchers injected 20 participants with one of two strains of Zika virus and eight with placebo. All of the participants who received the virus were infected; of those, 95% developed a rash — a common symptom of Zika — and 65% had joint pain. None of the placebo recipients had those symptoms.
Durbin says the findings indicate that the two strains of Zika administered in the trial can be safely and effectively used to infect participants in a Zika vaccine trial. She estimates that the controlled human infection model could be used in a phase III clinical trial for vaccine efficacy with as few as 50 to 100 participants. “With the challenge model, where you have 100% of infections, you could get an efficacy result with many fewer people” than in a conventional trial, says Durbin.
...
The new study represents a turnaround in the thinking about challenge trials. In early 2017, a report by researchers convened by the National Institute of Allergy and Infectious Diseases and the Walter Reed Army Institute of Research concluded that the risks of a human-infection study for Zika, at that time, surpassed the potential benefits.
...
But “from that time to now, we learnt a lot,” says Palacios. “Now we know that the risk of the virus being transmitted to another person through sexual relationships is limited and something that can be controlled,” he says. And regulators have signalled that they might consider data from human challenge trials in vaccine development, “in particular for those diseases that don’t have enough incidence to test in the field.”
Despite the low number of Zika cases, researchers say that it’s important to continue the efforts to develop a vaccine, because the virus might make a comeback. “Infections are much lower than they were during the epidemic in 2016. However, they are still occurring,” says Neil French, an infectious-disease specialist at the University of Liverpool, UK, who is involved in a Zika vaccine-development project. “The justification for a vaccine remains strong.”
Patients waiting for deceased donor kidneys are given priority in part by how long they have been on dialysis, while patients waiting for livers are prioritized according to how sick they are, sickest first. When the wait is long, not everyone has an equal chance of surviving long enough to receive an organ. Here's a paper that suggests that service in random order (SIRO) has desirable equity properties. Efficiency depends on how patients' welfare and future prospects change while they wait.
Equity and Efficiency in Dynamic Matching: Extreme Waitlist Policies, by Afshin Nikzad and Philipp Strack, Management Science, forthcoming, Published Online:3 Oct 2023https://doi.org/10.1287/mnsc.2023.01212
Abstract: Waitlists are commonly used to allocate scarce resources, such as public housing or organs. Waitlist policies attempt to prioritize agents who wait longer by assigning them priority points (à la first come, first served). We show that such point systems can lead to severe inequality across the agents’ assignment probabilities unless they use randomization. In particular, deterministic point systems lead to a more unequal allocation than any other rule that prioritizes earlier arrivals, an axiom that ensures that agents who wait longer are treated (weakly) better. Among the policies abiding by this axiom, we show that service in random order (SIRO) leads to the most equal allocation. From a utilitarian perspective, we show that the planner faces no trade-off between equity and efficiency when the flow utility from waiting is nonnegative or negative and increasing over time. In these cases, SIRO is also the most efficient policy. However, when the flow cost of waiting increases over time, then the planner may face an efficiency–equity trade-off: SIRO remains the most equitable policy but may not be the most efficient one.
1. Introduction: Waitlists are a common way to allocate scarce resources, such as public housing,1 organs,2 or services such as call center support.3 There are many ways to decide who among the waiting agents receives an object once it becomes available. Some waitlists operate in a service-in-random-order (SIRO) manner and use lotteries to allocate objects to waiting agents, such as in the Diversity Immigrant Visa Program in the United States4 or Beijing’s license plate allocation.5 Many other waitlists follow designs akin to first come, first served (FCFS), in which whoever has waited for the longest time receives (priority points for) an object. For example, in the national kidney transplant waitlist in the United States, enrolled patients earn priority points for each day that they remain on the waitlist.6 Such rules ensure that an agent who waits longer is not treated worse than an agent with a shorter waiting time and otherwise identical characteristics.
"Prioritizing agents with longer waiting times, however, has a drawback: it implies that an agent with a longer lifetime, that is, an agent who can wait longer for an object, has a higher probability of receiving an object. This naturally leads to inequality in assignment probabilities across agents with varying lifetimes. For example, a first-come, first-served list would lead to many of the sickest patients never receiving an organ as they depart the system before having waited long enough to receive an organ. Such equity concerns, for example, play an important role in the context of organ allocations (Organ Procurement and Transplantation Network 2015). The high-level question we ask here is, what policy induces the least inequality among policies that give priority to agents who arrive earlier? Furthermore, is minimizing inequality aligned with the objective of a planner who maximizes the average of the agents’ utilities, or are there efficiency–equity trade-offs to be considered here?"
Do markets complement virtues, or sideline them? Here's another entry into that discussion.
Reese, A., Pies, I. Solidarity Among Strangers During Natural Disasters: How Economic Insights May Improve Our Understanding of Virtues. J Ethics (2023). https://doi.org/10.1007/s10892-023-09460-7
"Abstract: The renaissance of Aristotelian virtue ethics has produced an extensive philosophical literature that criticizes markets for a lack of virtues. Drawing on Michael Sandel’s virtue-ethical critique of price gouging during natural disasters, we (1) identify and clarify serious misunderstandings in recurring price-gouging debates between virtue-ethical critics and economists. Subsequently, (2) we respond to Sandel’s call for interdisciplinary dialogue. However, instead of solely calling on economics to embrace insights from virtue ethics, we prefer a two-sided version of interdisciplinary dialogue and argue that virtue ethics should embrace economic insights. In particular, we argue that if virtue ethics is to preserve its social relevance under modern conditions, it should re-conceptualize its notion of virtue and re-evaluate the self-interested but effective—and in this sense solidary—help among strangers via markets as virtuous rather than devaluate it as greed, that is, as vicious price gouging.
...
"Most forms of virtue ethics share a central concern for the moral character of a person, the development of excellence, and an emphasis on avoiding vices and pursuing virtues. This means that in essence, the virtue ethics perspective focuses on good intentions and intended consequences. In contrast, modern economics fosters a systems approach to situational incentives and thus shifts the perspective to focus on the unintended consequences of intentional actions.
...
" Roth (2007) acknowledges repugnance and other kinds of assumed moral inappropriateness as real constraints on market design. He takes moral feelings seriously and proposes market arrangements that do not evoke such feelings. For example, many people experience a feeling of unease with the idea of being able to buy and sell kidneys, which is currently possible for Iranians in the Islamic Republic of Iran. By designing in-kind kidney exchanges, Roth has shown ways to facilitate market transactions that operate entirely without money and, as such, do not evoke repugnant reactions (Leider and Roth 2010; Roth 2016). Surely, there are still too many people desperately waiting for a kidney. However, the implementation of in-kind exchanges has saved lives. It has helped a significant number of people obtain a kidney that would have obtained none without such a system. In line with Roth, we take the virtue argument seriously. However, we choose a longer time horizon where the assumed moral inappropriateness is no longer a given constraint on market design but becomes, at least in principle, a variable.
...
"Sandel insists on deciding case by case whether we should give the virtue of (probably less effective) selfless help precedence over the assumed repugnance of (probably more effective) self-interested help via markets, or vice versa.
...
"Reassessments of social practices are not uncommon throughout history. Most people today perceive the practices of charging interest rates, dueling, and paying opera singers for their performance differently than their ancestors.
Widespread repugnance, or its absence, is hard to predict. Why do the U.S. and western Europe have almost opposite positions on the legality of surrogacy and prostitution for example?
Here's a paper that carefully looked for, and failed to find evidence of a repugnance reaction from consumers about a scandal involving a company spokesperson (but unrelated to the company's business).
The Role of Repugnance in Markets: How the Jared Fogle Scandal Affected Patronage of Subway by John Cawley, Julia Eddelbuettel, Scott Cunningham, Matthew D. Eisenberg, Alan D. Mathios & Rosemary J. Avery NBER WORKING PAPER 31782 DOI 10.3386/w31782 October 2023
Economics has long studied how consumers respond to the disclosure of information about firms. We study a case in which the disclosed information is unrelated to the product or firm leadership, but which could still potentially affect consumer patronage through the mechanism of repugnance, as described in Roth (2007). The information in this case concerns the arrest of Jared Fogle, the advertising pitchman for the Subway sandwich franchise, who was arrested in 2015 on charges of sex with a minor and child pornography. We study how the disclosure of this information, which was widely covered in the media, affected patronage of Subway. We estimate synthetic control models using data from a large nationwide survey of consumers regarding the restaurants they patronize. Despite the close and long-standing association of Jared Fogle with Subway, and heavy publicity of his crimes, we consistently fail to detect any effect of the Jared Fogle scandal on the probability of visiting a Subway restaurant. These results contrast with past studies of negative information disclosure, which tend to find negative impacts on sales, revenue, or stock price of the relevant companies. The absence of an effect in this case suggests that repugnance did not drive demand, and that consumers largely separated the offenses of a symbol of the firm from the products of the firm.
One of the curious things about donating blood is that you are asked about your sex life. Last Thursday the Stanford Blood Center implemented the updated FDA blood donation guidelines known as the Individual Donor Assessment, emphasizing a more equitable and inclusive donor assessment process.
"As of Thursday, October 19, Stanford Blood Center (SBC) has implemented the updated FDA blood donation guidelines, which eliminate questions based on sexual orientation.
....
About the Individual Donor Assessment (IDA)
"The new process focuses on assessing all donors equally, regardless of gender, reflecting a data-driven approach to maintaining blood safety. This ensures fairness and recognizes that infectious diseases can affect anyone. Ultimately, a thorough donor history questionnaire and extensive testing remain in place to ensure the safety of our blood supply.
The Changes
"Previously, a man who had sex with another man within the last three months was deferred for three months following their last sexual encounter. Additionally, a woman was deferred in the past three months if she had sex with a man who had sex with another man in the past three months. Individuals were assessed based on the gender they identified with, and nonbinary individuals were evaluated using both criteria.
Under the new guidance, the FDA recommends an “individual donor risk assessment” approach that does not depend on gender or sexual orientation, and all donors will be asked the same questions about high-risk sexual behavior. More specifically, any donor who reports having a new partner or more than one partner in the past three months will be asked a follow-up question about anal sex. If anal sex with a new partner or multiple partners is reported in the past three months, the donor will be deferred for three months following the sexual encounter.
The new guidance also requires a three-month deferral for anyone who has taken an oral PrEP (pre-exposure prophylaxis) or PEP (post-exposure prophylaxis) medication to prevent HIV transmission. A two-year deferral is required if an injectable, long-acting PrEP or PEP medication is taken. A permanent deferral remains for anyone with a history of HIV infection."
Here are a collection of articles, some of which suggest that we may in the not so distant future face a shortage of whole blood in the U.S., the need for which is so far filled by uncompensated donors (unlike the need for plasma, which is presently filled by compensated donors...). One issue is that apparently ambulance companies aren't easily compensated for beginning transfusion on the way to the hospital, which could save lives.
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Original Investigation Caring
for the Critically Ill Patient Red Blood Cell Transfusion in the Intensive Care Unit Senta
Jorinde Raasveld, MD; Sanne de Bruin, MD, PhD; Merijn
C. Reuland, MD; et al. "RBC transfusion was common in patients admitted to ICUs worldwide between 2019 and 2022, with high variability across centers in transfusion practices." blood transfusion practice has come a long way, but further efforts toward precision medicine are required to ensure that patients receive the most effective components. These products should be matched to patients as individuals who have unique antigens and a variable host response, and how to use the appropriate blood components in different clinical settings must be understood." Caring
for the Critically Ill Patient Deborah
M. Siegal, MD; Emilie P. Belley-Côté, MD, PhD; Shun
Fu Lee, PhD; et al. Caring
for the Critically Ill Patient Jan
O. Jansen, PhD; Jemma Hudson, PhD;
Claire Cochran, MSc; et al. Caring
for the Critically Ill Patient Ross Davenport, PhD;
Nicola Curry, MD; Erin E. Fox, PhD; et al. Special Communication Red Blood Cell Transfusion: 2023 AABB International Guidelines Jeffrey
L. Carson, MD; Simon J. Stanworth, MD, DPhil;
Gordon Guyatt, MD; et al. Viewpoint From Product to Patient—Transfusion and Patient Blood
Management Matthew
A. Warner, MD; Linda Shore-Lesserson, MD;
Carolyn Burns, MD "Recent years have also exposed vulnerabilities in blood inventories. As the most prominent example, the COVID-19 pandemic led to cancellations of many community-based and mobile blood collections, culminating in the declaration of a national blood crisis by the American Red Cross for the first time in history. In response, the American Medical Association, in partnership with the American Hospital Association and American Nurses Association, issued a joint statement in January 2022 describing the worst blood shortage in more than a decade and urging blood donation from all eligible persons. Not long after, the AABB, in collaboration with 17 leading US health care and blood collection organizations, launched the Alliance for a Strong Blood Supply to track and coordinate information and public communications about blood inventories and explore mechanisms to improve blood supply resilience." The Bloody Transfusion Problem John
B. Holcomb, MD; William K. Hoots, MD; Travis
M. Polk, MD "Preventable death after injury is a national crisis. Worldwide, injury accounts for more deaths than malaria, tuberculosis, and HIV combined and is increasing.1 Trauma is largely a condition of young people and is the leading cause of life-years lost between 1 and 75 years of age, and costs to the US are estimated at $4.2 trillion a year.2 As is always the case, lessons learned on recent battlefields have improved civilian care, and the most impactful intervention has been the increased use of blood products as a primary resuscitation fluid. "During the past decade several large, prospective, multicenter, randomized, federally funded studies have improved outcomes and changed practice.3,4 Transfusing blood as early as possible to patients with hemorrhagic shock saves lives, and fewer patients die from exsanguination when receiving a balanced transfusion of platelets, red blood cells, and plasma or whole blood. This is true in the hospital but is especially so in the prehospital setting, where blood products decrease mortality from 33% to 23%.4 When all indicated blood products are available and given early, deaths due to hemorrhage decrease and care is cost-effective. However, of the 2045 hospitals to which the American Red Cross supplied blood components in 2019, 33% did not routinely have platelets ready to transfuse to bleeding patients, and more than 78% of those hospitals are in a rural setting.4 Emergency medical services (EMS) agencies and hospitals that do not have all blood products immediately available cannot provide optimal care. Unfortunately, the blood products required to save lives are not uniformly available to all persons, and implementation of these proven lifesaving interventions is uneven, largely because of supply and policy reasons. "To remedy this disparity, we believe there are 3 significant hurdles to overcome: (1) enabling a reliable strategy for insuring an adequate blood product supply by developing new shelf-stable blood products and by providing greater financial support for donor blood collection and processing; (2) insuring adequate reimbursement for current and new blood products in the hospital setting and removing the limitation of prehospital provider scope of practice and ability to bill for all blood products; and (3) sustaining consistent and appropriate research funding for trauma studies of hemorrhagic shock in both pediatric and adult populations. ... "Blood collection and processing centers are operating at a loss because remuneration has not kept pace with ever-increasing costs of regulatory required infectious disease testing. ... "More than 55 000 additional donors will be required for just the prehospital blood program implementation.6 Increasing the blood supply will require novel solutions combining remuneration for donors, increased reimbursement for blood collection centers, modern efforts to recruit younger donors, and streamlined regulatory and financial reimbursement pathways for new blood products that are shelf stable at room temperature for years. ... "scope of practice, reimbursement barriers, and the inability to bill for transfusions provided in air or ground ambulances are significant obstacles to the widespread availability of prehospital blood programs." Redefining Blood Donation—Path to Inclusivity and Safety Pampee
P. Young, MD, PhD; Paula Saa, PhD "The journey to establish equitable blood donation policies can be likened to the myth of Theseus navigating the Labyrinth. Just as Theseus ventured into the complex maze to save Athenians from the Minotaur, the blood industry has been navigating the intricacies of research, regulation, and public sentiments to secure a safe blood supply and equitable policies. With the advancements in testing and the changing policies as our guiding thread, we are dedicated to ensuring fairness, equality, and safety, led by evidence and a deep commitment to humanity." Editorial Precision in Transfusion Medicine Matthew
D. Neal, MD; Beverley J. Hunt, MD Contemporary Adjuncts to Hemorrhage Control Samuel
A. Tisherman, MD; Megan L. Brenner, MD Medical News & Perspectives Could Universal Donor Blood Be Made in the Laboratory? Bridget
M. Kuehn "In the face of chronic national and international blood supply shortages, scientists are renewing efforts to achieve the holy grail of transfusion—laboratory-made universal donor blood." JAMA Revisited The Status of Blood Transfusion "Originally Published September 29, 1923 | JAMA. 1923;81(13):1114- 1115." JAMA Patient Page Kristin Walter, MD,
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