Increasing kidney transplants by reducing discards of risky kidneys

 Kidneys from deceased donors are too often discarded. Dr. Joshua Mezrich, a transplant surgeon at U. Wisconsin, writes in Stat about how to reduce the rate at which high risk kidneys are discarded (after being on ice for a long time while being rejected by many patients). He proposes that kidneys that can be identified as high risk even before being recovered from the deceased donor  be offered promptly to patients/transplant centers that have indicated a willingness to take them. It would require transplant centers to keep current blood tests available for patients who are candidates for high risk kidneys (who may be candidates in part because they are far from the front of the waiting list...)

Too many donor organs go to waste. Here’s how to get them into the patients who need them  By Joshua Mezrich, Stat, March 2, 2024 

"So here is the fix. High-risk kidneys should immediately be offered to transplant centers that opt into a high-risk program as an open offer to their wait list rather than to a specific patient, on a rotating schedule with weight put on proximity to the donor hospital. Ideally the offer should be made prior to procurement of the organ, with final acceptance once it is removed and anatomy and biopsy results can be reviewed by the accepting surgeon.

"If the biopsies show significant disease and the function of the kidney would be inadequate for a recipient, the receiving center can request both kidneys for a single patient, termed a dual transplant (which has been shown to have good outcomes). If a center accepts a kidney, it can then choose the patient who will benefit the most from the transplant and has a long predicted wait time for a low-risk transplant, with informed consent. That would entail a discussion with the patient about expectations regarding the quality of the kidney, how long and how well it might work, and how much longer they might need to wait for a lower-risk kidney. The ability to match the kidney to a recipient is important, as high-risk kidneys need to go into patients who can tolerate the slow initial function. Centers that opt into the high-risk program will need to maintain an updated list of informed patients who are predicted to benefit from these kidneys, who can be called in as soon an offer becomes available. For them, taking a chance beats remaining on dialysis.

France amends its constitution to protect access to abortion

 The decision of the U.S. Supreme Court to overturn Roe v.Wade and end a constitutional right to abortion in the U.S. prompted France to amend its constitution to guarantee access to abortion.

Here's the WSJ story:

France becomes first country to explicitly enshrine abortion rights in constitution  By Karla Adam

"With the endorsement of a specially convened session of lawmakers at the Palace of Versailles, France on Monday became the first country in the world to explicitly enshrine abortion rights in its constitution — an effort galvanized by the rollback of protections in the United States.

"The amendment referring to abortion as a “guaranteed freedom” passed by a vote of 780 in favor and 72 against, far above the required threshold of support from three-fifths of lawmakers, or 512 votes.

"French President Emmanuel Macron announced that a “sealing ceremony,” a tradition reserved for the most significant laws, would take place Friday, coinciding with International Women’s Day.

“We’re sending a message to all women: Your body belongs to you, and no one can decide for you,” Prime Minister Gabriel Attal told lawmakers assembled in Versailles."*

#########

Le Monde has the story, in an editorial supporting the amendment:

Enshrining abortion access in the French Constitution is a win for feminism and democracy, EDITORIAL, Le Monde, March 4

"The joint session of both houses of Parliament convened in Versailles on Monday, March 4, to enshrine access to abortion in the French Constitution, marks an important moment in the life of the nation. And a proud moment, too. A few days before International Women's Rights Day on March 8, women's freedom to control their own bodies should be anchored in French law. It also comes at a time when abortion, once thought to be a widely accepted procedure, is being undermined in a number of democracies, most notably the United States.

...

"The three-fifths majority required in Parliament means that a consensus has been reached, despite the fact that abortion still disgusts some on the right and far right. It's a sign that democracy works, despite the distress signals it is sending out.

"At every stage of the lengthy procedure initiated in November 2022, the drafting of the Constitutional reform constantly required perseverance and tact. First in the Assemblée Nationale, where, in response to the shockwave caused in June 2022 by the US Supreme Court's decision to revoke the federal right to abortion, the radical-left La France Insoumise party and the center-right presidential majority agreed to work together on a common cause.

"Then the fight continued in the Sénat, where, in loyalty to Simone Veil's 1975 battle to decriminalize abortion, a number of right-wing Les Républicains elected representatives fought hard to ensure that the debate, which they had reframed, could continue against the advice of their group's president, Bruno Retailleau, and Sénat President Gérard Larcher. Finally, in the government, Justice Minister Eric Dupond-Moretti facilitated the drafting and adoption of the final text. The compromise consists of enshrining the notion of "guaranteed freedom" for women to have access to abortion, without introducing an enforceable "right" to abortion as demanded by the left."

#######

*Regarding the Prime Minister's remark to women that "no one can decide for you" I note that surrogacy remains illegal in France.

Friday, October 18, 2019

Will IVF become more widely legal in France?

Oregon is re-criminalizing drugs

 The war on drugs is unforgiving, and neither criminalization nor decriminalization seems to be a winning strategy.  The NYT has the latest from Oregon, where there were high hopes for decriminalization and harm reduction, and where there are now second thoughts. 

Oregon Is Recriminalizing Drugs, Dealing Setback to Reform Movement. Oregon removed criminal penalties for possessing street drugs in 2020. But amid soaring overdose deaths, state lawmakers have voted to bring back some restrictions.  By Mike Baker

"Three years ago, when Oregon voters approved a pioneering plan to decriminalize hard drugs, advocates looking to halt the jailing of drug users believed they were on the edge of a revolution that would soon sweep across the country.

"But even as the state’s landmark law took effect in 2021, the scourge of fentanyl was taking hold. Overdoses soared as the state stumbled in its efforts to fund enhanced treatment programs. And while many other downtowns emerged from the dark days of the pandemic, Portland continued to struggle, with scenes of drugs and despair.

"Lately, even some of the liberal politicians who had embraced a new approach to drugs have supported an end to the experiment. On Friday, a bill that will reimpose criminal penalties for possession of some drugs won final passage in the State Legislature and was headed next to Gov. Tina Kotek, who has expressed alarm about open drug use and helped broker a plan to ban such activity.

“It’s clear that we must do something to try and adjust what’s going on out in our communities,” State Senator Chris Gorsek, a Democrat who had supported decriminalization, said in an interview. Soon after, senators took the floor, with some sharing stories of how addictions and overdoses had impacted their own loved ones. They passed the measure by a 21-8 margin."

50th anniversary of Shapley and Scarf (1974), and of the Journal of Mathematical Economics

Now available online is the first in what I understand will be a series of papers commemorating the 50th anniversary of the Journal of Mathematical Economics.  The paper by Shapley and Scarf appeared in volume 1, number 1. (Thayer Morrill and I will have a paper surveying the literature on the Top Trading Cycle (TTC) algorithm, which was introduced in that first paper.)

Housing markets since Shapley and Scarf by Mustafa Oğuz Afacan, Gaoji Hu, and Jiangtao Li, Journal of Mathematical Economics, Available online 1 March 2024, In Press, Journal Pre-proof, https://doi.org/10.1016/j.jmateco.2024.102967

Abstract: Shapley and Scarf (1974) appeared in the first issue of the Journal of Mathematical Economics, and is one of the journal’s most impactful publications. As we approach the remarkable milestone of the journal’s 50th anniversary (1974–2024), this article serves as a commemorative exploration of Shapley and Scarf (1974) and the extensive body of literature that follows it.

Telephones and telephone operators, as telephone exchanges became automated

 Earlier experiences in automation may be helpful in thinking about current technologies. Here's a paper about automation that replaced telephone operators, largely in the early 20th Century.  (But in 1980, when I lived in Farmer City Illinois, our telephone provider was GTE (General Telephone & Electronics Corporation), not AT&T, and they still relied in part on human operators.)

Answering the Call of Automation: How the Labor Market Adjusted to Mechanizing Telephone Operation by James Feigenbaum and Daniel P Gross, The Quarterly Journal of Economics, forthcoming

Abstract: In the early 1900s, telephone operation was among the most common jobs for American women, and telephone operators were ubiquitous. Between 1920 and 1940, AT&T undertook one of the largest automation investments in modern history, replacing operators with mechanical switching technology in over half of the U.S. telephone network. Using variation across U.S. cities in the timing of adoption, we study how this wave of automation affected the labor market for young women. Although automation eliminated most of these jobs, it did not reduce future cohorts’ overall employment: the decline in operators was counteracted by employment growth in middle-skill clerical jobs and lower-skill service jobs, including in new categories of work. Using a new genealogy-based census-linking method, we show that incumbent telephone operators were most impacted, and a decade later more likely to be in lower-paying occupations or no longer working.

Planet money plus-- interview on repugnant transactions

 Behind a paywall :(, but here's some more of the interview that I did with Planet Money last month:

Extended Play: Al Roth on money and 'repugnant markets' (Planet Money+)Planet Money

• • Business

Listen on Apple Podcasts 

Requires subscription and macOS 11.4 or higher

Repugnant markets. We heard about them from economist Al Roth in a recent Planet Money episode. These are markets that aren't allowed because people feel icky about putting a price on something. For example, it's basically illegal to buy and sell kidneys in much of the world. In today's bonus episode, Mary Childs talks with Al about other repugnant markets that didn't make it into the original show, like surrogacy and blood plasma. They also discuss how money can change relationships.You can hear that original Planet Money episode here: https://www.npr.org/1197956769 Show your support for Planet Money and the reporting we do by subscribing to Planet Money+ in Apple Podcasts or at plus.npr.org. You'll be able to unlock this episode and other great bonus content. Regular episodes remain free to listen! Email the show at planetmoney@npr.org.

Earlier:

hursday, February 8, 2024

Morally contested markets on NPR's Planet Money (including kidneys, revenge and insider trading)

Medical aid in dying--the ongoing debate in Britain

 The Guardian has this opinion piece, connected to the current debate in England about medically assisted dying, and the slippery slope:

I’m glad the debate on assisted dying is forging ahead. But few understand why it frightens so many  by Frances Ryan

"On Thursday, MPs published the findings of a 14-month inquiry into assisted dying. The inquiry – which attracted more than 68,000 responses from the public – made no conclusive statement but instead collected evidence as a “significant and useful resource” for future debates.

That debate is no longer abstract. Legislation is making its way through the parliaments of Scotland, Jersey and the Isle of Man that, if passed, would enable competent adults who are terminally ill to be provided at their request with assistance to end their life.

...

"And yet it also feels a disservice to pretend that any of this is simple or that giving autonomy to some would not potentially harm others. It is deeply telling that among the many voices calling for a new assisted dying law, I have heard no human rights groups, celebrity or politician mention concerns – as advocated by many disability activists – that a law change could lead to disabled people being coerced into euthanasia, or feeling they had no other option.

We only need look to the countries that have legalised assisted dying in recent years to see these fears realised. One study reported the euthanasia of a number of Dutch people who were said simply to have felt unable to live with having a learning disability or autism. Many included being lonely as a key cause of unbearable suffering.

...

"This is not to say that the UK shouldn’t go down the path of legalising assisted dying, but we must at least do so with eyes wide open. The right to die does not exist in a vacuum: it fundamentally alters the doctor-patient relationship, and risks making members of society who are already vulnerable that little bit more insecure. Perhaps that is a price worth paying to end some terminally ill people’s suffering. Perhaps it is too much to ask. There are no black and white boxes to tick labelled “right” and “wrong” – just the messy, painful grey of being human.

In the coming months, politicians will correctly dedicate hours to discussing the right to a good death. Imagine, though, if they were to give equal attention to the right to a good life: from building social housing, exploring a basic income, investing in mental and physical health services, to – as the inquiry recommends – funding universal coverage of palliative care and more specialists in end-of-life pain."

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Earlier:

Friday, January 12, 2024

Medical aid in dying, and slippery slopes--the debate in Britain

Education (and age) versus fertility in the U.S. marriage market

 Markets change over time, including the marriage market.  American marriages have become more assortative in recent years, and it appears that, in the 21st Century, women no longer pay a 'marriage penalty' (measured in spousal income) for graduate education.

The Human Capital–Reproductive Capital Trade-Off in Marriage Market Matching, by Corinne Low, Journal of Political Economy Volume 132, Number 2, February 2024

"Abstract: Throughout the twentieth century, the relationship between women’s human capital and men’s income was nonmonotonic: while college-educated women married richer spouses than high school–educated women, graduate-educated women married poorer spouses than college-educated women. This can be rationalized by a bidimensional matching framework where women’s human capital is negatively correlated with another valuable trait: fertility, or reproductive capital. Such a model predicts nonmonotonicity in income matching with a sufficiently high income distribution of men. A simulation of the model using US Census fertility and income data shows that it can also predict the recent transition to more assortative matching as desired family sizes have fallen."

Notable sentence about the ancien regime: "I provide a simple condition such that there always exists a man rich enough that he prefers a higher fertility but poorer woman to a richer and less fertile woman."

*******

And here's an earlier paper on fertility (through IVF) and age of marriage in Israel:

Gershoni, Naomi, and Corinne Low. 2021. "Older Yet Fairer: How Extended Reproductive Time Horizons Reshaped Marriage Patterns in Israel." American Economic Journal: Applied Economics, 13 (1): 198-234.

"Abstract: Israel's 1994 adoption of free in vitro fertilization (IVF) provides a natural experiment for how fertility time horizons impact women's marriage timing and other outcomes. We find a substantial increase in average age at first marriage following the policy change, using both men and Arab-Israeli women as comparison groups. This shift appears to be driven by both increased marriages by older women and younger women delaying marriage. Age at first birth also increased. Placebo and robustness checks help pinpoint IVF as the source of the change. Our findings suggest age-limited fertility materially impacts women's life timing and outcomes relative to men."

Global pacemaker retransplantation

 There are innovative approaches to global health care.  Here is one, that involves reusing pacemakers recovered from deceased donors and refurbished for use in countries where pacemakers are too expensive for wide use.  Unlike some of what we encounter in kidney transplants across borders, the legal bans that have to be overcome may not come from the war against the poor.  A careful clinical trial is underway. There is also an unregulated black market...

Here's the encouraging story from Helio.com:

After death, a new life for refurbished pacemakers in low-, middle-income countries, February 23, 2024

"Lack of access to pacemakers is a major challenge to the provision of CV health care in low- and middle-income countries; however, postmortem pacemaker utilization could offer an opportunity to deliver this needed care, according to Thomas Crawford, MD, an electrophysiologist and associate professor of internal medicine at University of Michigan Health and the medical director of My Heart Your Heart, a cardiac pacemaker reuse initiative at the University of Michigan Cardiovascular Center

...

"Crawford: The need is great. Each year, somewhere between 1 million and 2 million people worldwide die due to a lack of access to pacemakers and defibrillators. There is literature reflecting this. When you query pacemaker implantation data for the United States, it is roughly 800 pacemakers per 1 million population. When you query countries like, for example, Nigeria, it says four pacemakers per million. Quite a difference.

"Per capita gross domestic product is such that, in many countries, a pacemaker costs more than a person’s annual income.

...

"Healio: What are the regulations around using a refurbished pacemaker?

"Crawford: Pacemaker reuse is illegal in all jurisdictions. The FDA states that pacemaker reuse is an “objectionable practice.” We know we can do it, but we need to develop partnerships with other entities to give us credibility. One of those methods to do this is by engaging the government. FDA issues export permits for this type of activity. We created a protocol where we reprocess the device, working with Northeast Scientific, which provides the pacemaker cleaning and sterilization. We have received permission from the FDA to export them. We have to put a sticker on them saying “not for use in the United States.” We are doing this in countries in which governments will allow it. One of the limitations is needing a government letter from each of the recipient countries. We have about 12 countries now, and the collection of countries we are working with is purely accidental. It is not a normal methodological process. A lot of it is through contact with individuals and opportunities that arise.

...

"Healio: You are leading a randomized controlled trial called Project My Heart Your Heart: Pacemaker Reuse. What is the study design, and what do you and your colleagues hope to learn?

"Crawford: The objective of the clinical trial is to determine if pacemaker reutilization can be shown to be a safe means of delivering pacemakers to patients in low- and middle-income countries without resources. The target enrollment is 270 patients, all from outside the United States, who each have a class I indication for pacing and who attest that they do not have the ability to purchase a device on their own. They must consent to be randomly assigned to receive either a brand-new pacemaker, which we purchase, or a reprocessed pacemaker, for which we provide the leads and accessories. Donated devices are inspected according to specific protocols that evaluate physical and electrical suitability, including battery longevity, for future use. Devices deemed to be acceptable are shipped to a third-party vendor, Northeast Scientific, for disassembly, cleaning and re-sterilization. There will be about 130 participants in each arm. We will follow those patients and report any adverse events. The countries that have contributed patients include Kenya, Nigeria, Paraguay, Sierra Leone and Venezuela. We hope to soon begin enrolling patients in Mexico and Mozambique.

"I have had clinicians outside the U.S. who tell me they removed a pacemaker device, cleaned it, reprocessed it and then implanted it in someone else — but the government does not know about it. This practice does happen and it is not regulated in any way; patients and physicians know about it and keep it quiet. The difference with what we are doing and these other efforts is we bring it to a much higher level, because that is what the FDA requires. "

Stanford Impact Labs announces support for kidney exchange in Brazil, India, and the U.S.

 Stanford Impact Labs has announced an investment designed to help the Alliance for Paired Kidney Donation (APKD) increase access to kidney exchange in Brazil, India, and the U.S.  Here are three related web pages...

1. Stanford Impact Labs Invests in Global Collaboration to Increase Access to Kidney Transplants.  $1.5 million over three years will support solutions-focused project led by Stanford’s Dr. Alvin Roth and the Alliance for Paired Kidney Donation (APKD)  by Kate Green Tripp

"Stanford Impact Labs (SIL) is delighted to announce a $1.5 million Stage 3: Amplify Impact investment to support Extending Kidney Exchange, a solutions-focused project established to increase access to lifesaving kidney transplants.

"The team, led by Stanford’s Dr. Alvin (Al) Roth, who shared the 2012 Nobel Prize in Economics for his work on market design, and the Alliance for Paired Kidney Donation (APKD) is working in close partnership with organ transplant specialists and medical centers in Brazil, India, and the U.S., including Santa Casa de Misericórdia de Juiz de Fora, the Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences (IKDRC-ITS), and Walter Reed National Military Medical Center.

"Over the course of the next three years, the team aims to increase the number of transplant opportunities available to patients who need them by creating and growing kidney exchange programs in Brazil and India, where millions of people suffer from kidney disease yet exchange is minimal; and explore the effects of initiating donor chains with a deceased donor kidney (DDIC) in the U.S., an approach which could unlock hundreds more transplants each year.

..."

2. How Does Applied Economics Maximize Kidney Transplants? A project aimed at expanding kidney exchange and saving lives puts Nobel Prize-winning matching theory into practice.  by Jenn Brown   (including a video...)

"APKD uses open source software developed by Itai Ashlagi, Professor of Management Science and Engineering at Stanford University, to facilitate the matching process for its NEAD chains, and they currently average 5 non-simultaneous transplants per chain.

3. Extending Kidney Exchange

"In Brazil, our team has launched a kidney exchange program within Santa Casa de Misericórdia de Juiz de Fora and Hospital Clínicas FMUSP in São Paulo and aims to expand to facilitating exchanges between these centers and others with the ultimate goal of kidney exchange transitioning from a research project to an officially approved practice in Brazil.

"In India, our team has deployed kidney matching software and resources for growth to the Institute of Kidney Diseases and Research Center and Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS) to support kidney exchange programs. We aim to develop an evidence base for potential updates to organ transplantation laws that expand criteria for who can give and receive lifesaving kidneys.

"In the U.S., we are working with Walter Reed National Military Medical Center to test the use of deceased donor-initiated chains (DDIC) so as to generate hundreds of additional life-saving transplants each year that are not currently supported by today's practice of utilizing a deceased donor kidney to save the life of a single person on a transplant waitlist. "

 

Prison gangs, in Latin America and in the U.S.

 It's one thing to be able to capture and confine prisoners. When gangs are involved, it's quite another thing to control the prisons, or the ability of prisoners to continue to control gang activity outside of prison.

The NYT has the story, from Latin America:

In Latin America, Guards Don’t Control Prisons, Gangs Do. Intended to fight crime, Latin American prisons have instead become safe havens and recruitment centers for gangs, fueling a surge in violence. By Maria Abi-Habib, Annie Correal and Jack Nicas

"Inside prisons across Latin America, criminal groups exercise unchallenged authority over prisoners, extracting money from them to buy protection or basic necessities, like food.

"The prisons also act as a safe haven of sorts for incarcerated criminal leaders to remotely run their criminal enterprises on the outside, ordering killings, orchestrating the smuggling of drugs to the United States and Europe and directing kidnappings and extortion of local businesses.

"When officials attempt to curtail the power criminal groups exercise from behind bars, their leaders often deploy members on the outside to push back.

“The principal center of gravity, the nexus of control of organized crime, lies within the prison compounds,” said Mario Pazmiño, a retired colonel and former director of intelligence for Ecuador’s Army, and an analyst on security matters.

“That’s where let’s say the management positions are, the command positions,” he added. “It is where they give the orders and dispensations for gangs to terrorize the country.”

##########

I wrote a related post in November (see below) about a Brazilian prison gang, and received an illuminating email from Professor David Skarbek of Brown University, saying

"I enjoyed your blog post about the PPC Brazilian prison gang. I thought that you might be interested to know that the same phenomenon exists in the US as well. I'm attaching a piece I published in the American Political Science Review on the Mexican Mafia in Southern California."

Here's the link to that article:

Skarbek, David. "Governance and prison gangs." American Political Science Review 105, no. 4 (2011): 702-716.

Abstract: How can people who lack access to effective government institutions establish property rights and facilitate exchange? The illegal narcotics trade in Los Angeles has flourished despite its inability to rely on state-based formal institutions of governance. An alternative system of governance has emerged from an unexpected source—behind bars. The Mexican Mafia prison gang can extort drug dealers on the street because they wield substantial control over inmates in the county jail system and because drug dealers anticipate future incarceration. The gang's ability to extract resources creates incentives for them to provide governance institutions that mitigate market failures among Hispanic drug-dealing street gangs, including enforcing deals, protecting property rights, and adjudicating disputes. Evidence collected from federal indictments and other legal documents related to the Mexican Mafia prison gang and numerous street gangs supports this claim.

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Earlier

Tuesday, November 21, 2023

Balance of violence: prison-based criminal cartels, the case of Brazil's PCC.

Mark Satterthwaite interviewed by Sandeep Baliga (video)

After listening to this interview with the great Mark Satterthwaite, I now understand the independent origins of the Gibbard-Satterthwaite theorem, and the collaborative origins of the Myerson-Satterthwaite theorem. 

In the final ten minutes or so of the interview, Mark describes worthwhile future research directions (and methods:), starting just after minute 28:30, particularly about appropriately matching patients to medical specialists.

   

xxxxxxxx

Earlier interviews by Sandeep Baliga:

Tuesday, August 1, 2023

Ted Groves interviewed by Sandeep Baliga (video)

Friday, June 16, 2023

Ehud Kalai, interviewed on the past and future of game theory

Foreign surrogacy in Denmark is becoming less restrictive

 Above the Law has the story:

Denmark Passes New Pro-Surrogacy Regulations. The new rules in Denmark focus on two areas of surrogacy.  By ELLEN TRACHMAN  February 14, 2024

 "On February 5, 2024, the Danish government announced new surrogacy-supportive rules scheduled to come into effect on January 1, 2025. The rules address parentage for families formed by surrogacy — including commercial (compensated) surrogacy outside of Denmark — as well as for families formed by altruistic (noncompensated) surrogacy within Denmark.

...

"In Denmark, compensated surrogacy is illegal, and altruistic surrogacy has traditionally fallen into a legal gray area, pushing most hopeful parents who want to have a genetic connection to their child, but who are unable to carry a pregnancy themselves, to go abroad. The Danish government estimates that about 100 children are born to Danish parents each year by surrogacy outside of Denmark, while about five children each year are born within Denmark in altruistic surrogacy arrangements.

...

"Denmark has a history of denying parental rights to the intended parents of children born by surrogacy abroad. But on December 6, 2022, the European Court of Human Rights ruled against Denmark in K.K. and Others v. Denmark. In that case, a married heterosexual couple had twins with the assistance of a Ukrainian surrogate. Under Ukrainian law, both Danish intended parents were recognized as parents of the child, and the surrogate was not a parent of the child.

...

"The ECHR found that Denmark’s refusal to recognize the parent-child relationship between the mother and child was a human rights violation — not a violation of the mother’s human rights, but of the two children, to have a recognized legal relationship with their mother.

To its credit, Denmark is reacting to the ECHR’s definitive ruling. In the announcement by the Danish government last week, the government made it clear that the country’s new rules are intended to go beyond the minimum requirements of the ECHR to merely not violate the human rights of Danish children.  (The bare minimum requirement would be to just allow stepparent adoptions.) Instead, the Danish government’s new rules go farther to protect children and their parents.

...

"The new rules permit Danish family courts to quickly make a decision on parenthood in the case of a foreign surrogacy agreement, even permitting a court ruling to be made prior to the family’s return to Denmark. The rules also require that the court assess the best interest of the child, but with a presumption that it is, of course, in the child’s best interest to have a timely recognition of their parents.

"Moreover, the court decisions are permitted to be retroactive to the birth of the child, permitting parents to have access to parental leave work benefits, inheritance rights, and all other benefits of that legal relationship. And, in contrast to a stepparent adoption, the new rules will allow recognition of the parent-child relationship with the mother or nongenetic parent even if parents have separated, or if one parent died before they had a chance to apply for parenthood.

...

"In a stated attempt to address the risk of child trafficking, the rules require that at least one intended parent be genetically related to the child. Additionally, the surrogate is required to confirm in a notarized declaration after the birth that she wishes to transfer parenthood of the child to the intended parents."

Directed and semi-directed living donation of kidneys: a current debate in Israel and elsewhere

 Israel leads the world in per capita living kidney donation. A good part of that comes from the work of Matnat Chaim (gift of life), an organization of religious Jews, who donate kidneys to people they don't know.  They are "semi-directed" rather than non-directed donors, in that the organization allows them to indicate some criteria they would like their recipients to have.  Sometimes they want their recipients to be fellow Jews, and this has generated some controversy in Israel.

Below is a study of this phenomenon, and in an accompanying editorial, a criticism of it.

Nesher, Eviatar, Rachel Michowiz, and Hagai Boas. "Semidirected Living Donors in Israel: Sociodemographic Profile, Religiosity, and Social Tolerance." American Journal of Transplantation (in press).

Abstract: Living kidney donations in Israel come from 2 sources: family members and individuals who volunteer to donate their kidney to patients with whom they do not have personal acquaintance. We refer to the first group as directed living donors (DLDs) and the second as semidirected living donors (SDLDs). The incidence of SDLD in Israel is ∼60%, the highest in the world. We introduce results of a survey among 749 living donors (349 SDLDs and 400 DLDs). Our data illustrate the sociodemographic profile of the 2 groups and their answers to a series of questions regarding spirituality and social tolerance. We find SDLDs to be sectorial: they are mainly married middle-class religious men who reside in small communities. However, we found no significant difference between SDLDs and DLDs in their social tolerance. Both groups ranked high and expressed tolerance toward different social groups. Semidirected living donation enables donors to express general preferences as to the sociodemographic features of their respected recipients. This stirs a heated debate on the ethics of semidirected living donation. Our study discloses a comprehensive picture of the profile and attitudes of SDLDs in Israel, which adds valuable data to the ongoing debate on the legitimacy of semidirected living donation.

Danovitch, Gabriel. "Living organ donation in polarized societies." American Journal of Transplantation, (Editorial, in press).

"Nesher et al are to be congratulated for reporting on a unique, effective, yet ethically problematic manifestation of living kidney donation in Israel. To summarize, living kidney donation has become “de riguer,” a “mitzvah” (a religiously motivated good deed) among a population of mainly orthodox Jewish men living in religiously homogenous settlements. According to the authors, the donors view themselves as donating altruistically within a larger family. The donations, over 1300 of them, 60% of all living donations in the country, have changed the face of Israeli transplantation, reduced the waiting time for all transplant candidates on the deceased donor waiting list,2 and minimized the temptation of Israeli transplant candidates to engage in “transplant tourism,” a phenomenon that was an unfortunate feature of Israeli transplantation before the passage of the Israeli Transplant Act of 2008 that criminalized organ trading.3

So, what’s the problem? Matnat Chaim (“life-giving”), the organization that facilitates the donations, permits the donors to pick and choose among a list of potential recipients using criteria that according to its own website,4 and as Nesher et al note,1 are not transparent. ... frequently the donors elect to donate to other Jews.  ... " Israel is a country with an 80% Jewish majority; a decision to only donate to other Jews, thereby excluding non-Jews, is a practice that, were it reversed in a Jewish minority country, would likely be labeled antisemitic. Concern that the process encourages racist and nationalistic ideation has been raised in the past6 and only emphasized by the public pronouncement of some media-savvy kidney donors.7

"What lessons does the Israeli experience hold for the US and other countries, faced as all are, with a shortage of organs for transplant? Conditional living donation exists to a limited extent in the US: DOVE is an organization that works to direct living kidney donation to US army veterans9; Renewal is an organization that encourages and facilitates living donation from Jews to other Jews but also to non-Jews10; in the 1990s an organization called “Jesus Christians” made organ donation one of its precepts.11 But in each of these cases, it is a minority group whose interests are being promoted.

...

"What now for Matnat Chaim? Given its prominent impact on Israeli transplantation, its allocation policies must be transparent and subject to public comment. Criteria must be medical in nature and religious or political considerations excluded. Fears that as a result living kidney donation rates will plummet are likely exaggerated. "

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I can't help reading this discussion while being very aware that Dr. Danovitch is an ardent opponent of compensating kidney donors, for fear that inappropriate transplants would take place if that were allowed.  In much of that discussion, inappropriateness of transplants focuses on possible harm to the (paid) donors, but the donors in the Israeli case are unpaid. Here his concern is that donor autonomy about to whom to give a kidney comes at the expense of physician autonomy in choosing who should receive a transplant, by "medical" criteria. But frequently those criteria have a big component based on waiting time, rather than any special medical considerations. So maybe in general he thinks that privileging the physician's role in this way is worth having fewer organs and consequently more deaths.

Still, I think he has a point about how we perceive what is repugnant. Having minority donors donate to fellow minority recipients seems much less repugnant than having majority donors specify that they aren't interested in donating to minority recipients.

But, speaking of donor autonomy, I'm not sure that there are practical ways around it, since semi-directed donors could always present as fully directed donors to a particular person that some organization had helped them find. So, we may just have to live with the increase in donations and lives saved that donor autonomy can support.

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Earlier posts:

Thursday, July 27, 2023

Kidney brouhaha in Israel: is a good deed still good when performed by a shmuck?

I ended that post with this:

"I'll give the last word to a Haaretz op-ed, also in English:

 Is It Kosher to Donate Kidneys Only to Other Jews?  A well-known religious journalist in Israel declared the " -only" donation of his kidney. His act is imperfect, but not immoral by Robby Berman"

Monday, July 31, 2023

Altruistic kidney donors in Israel

...

and, here in the U.S.:

Friday, March 12, 2021

Kidneys for Communities

" A new organization, Kidneys for Communities, plans to advocate for living kidney donation by seeking donors who identify with a particular community.  Their come-on is "Put your kidney where your heart is.  Share your spare with someone in your community"

Directed deceased donation of organs for transplant. (Legal in U.S. but not yet in Europe.)

 It is legal in the U.S. for a deceased donor organ for transplant to be directed to a particular recipient, if the recipient is compatible (and otherwise the organs are allocated as in the usual way for nondirected deceased donation.)  Because compatibility is tricky, directed deceased donation (DDD) is rare (but deceased donor kidneys can potentially be used to start a deceased donor initiated chain of kidney exchange).

But in most of Europe, it turns out, DDD isn't legal. (!) Here's a paper by the European Society of Transplantation's European Platform on Ethical, Legal and Psychosocial Aspects of Organ Transplantation. It cautiously argues that maybe this ban is "one thought too many," and that the ban should be lifted so that carefully regulated DDD would be allowed to increase organ donation in Europe and save more lives.

"When is directed deceased donation justified? Practical, ethical, and legal issues," by David Shaw1,2 , Dale Gardiner3, Rutger Ploeg4, Anne Floden5,6, Jessie Cooper7, Alicia Pérez-Blanco8, Tineke Wind9, Lydia Dijkhuizen10, Nichon Jansen10 and Bernadette Haase-Kromwijk10; on behalf of the ESOT ELPAT Working Group on Deceased Donation, Journal of the Intensive Care Society, 2024.

Abstract: This paper explores whether directed deceased organ donation should be permitted, and if so under which conditions. While organ donation and allocation systems must be fair and transparent, might it be “one thought too many” to prevent directed donation within families? We proceed by providing a description of the medical and legal context, followed by identification of the main ethical issues involved in directed donation, and then explore these through a series of hypothetical cases similar to those encountered in practice. Ultimately, we set certain conditions under which directed deceased donation may be ethically acceptable. We restrict our discussion to the allocation of organs to recipients already on the waiting list.

"The persistent shortage of organs available for transplantation demands fair and objective allocation of the scarce available organs, based on preset transparent and regulated criteria. In most European countries, organs from deceased donors are allocated to patients on the organ waiting list by national Competent Authorities.3 The current worldwide norm is that organs donated after death are considered as an unconditional gift to the patients on the transplant waiting list according to the allocation system. This implies that donors (prior to their death), or their family members (after it), cannot determine to whom the available organs will be assigned, nor exclude any potential recipients.

...

"In a few countries, like the United States, United Kingdom, Japan, and recently Australia, directed deceased donation is possible in restricted cases, since national legislation does not prohibit it. In living donation however, directed donation is permitted in many countries, even when there is no genetic or emotional relationship between the donor and the intended recipient. This inconsistency between the living donation- and deceased donation system has been noted.4

"This paper explores whether directed deceased donation should be allowed, and if so under which conditions.

...

"The main argument against DDD is that this violates the  basic principle of an altruistic, unconditional gift to society; allowing DDD may turn out to be a “slippery slope” in the direction of conditional donation and discrimination against particular patient groups. Conditional donation could also reduce public support for the transplantation system, since it could reduce transparency and fairness of the system.

...

"What, then, are the conditions for ethical DDD at the present time?

1. DDD under strict conditions should not be prohibited by legislation or policy.

2. There must be evidence that the donor wanted or would have been willing to direct the organ to a particular family member or close friend.

3. The donor/family should generally not be able to  insist on only donating the organ intended for DDD; where other organs are transplantable there should be a willingness to donate other organs (at least one) to patients on the waiting list to preserve the societal altruistic aspect of donation and diminish the overall effect on the waiting list.

4. DDD should proceed only if there is no patient on the waiting list in extremely urgent need of an organ transplantation to avoid imminent death.

5. DDD should proceed only if there is a reasonable chance of successful transplantation.

6. The intended recipient should be on the waiting list or be under assessment for being included.

"If these conditions are met, the medical team should do their best to facilitate the wishes of the deceased patient and his/her family by enabling DDD to take place. Letting deceased donors direct their organs to loved ones under carefully controlled conditions could further enhance trust in organ donation and transplantation systems, and hence willingness to become a donor."

Nondirected living kidney donors--Abundant (the movie, in progress)

 Abundant is a movie in the making,  a documentary about altruism, focused on non-directed living kidney donors, who start kidney exchange chains. It isn't done yet, but now they are in the editing process...

"Abundant is a feature-length documentary film about the complex, human experience of giving.  To fully understand giving, Abundant enters the world of extreme altruism.  And there are no more extreme altruists than non-directed living kidney donors.  These rare individuals give a kidney away to a complete stranger.  It’s all risk, no reward.  Or is it? 

"Abundant features true stories of non-directed kidney donors recorded live on stage at the performance art show CrowdSource for Life.  Their stories illustrate the unimaginable impact of extreme giving.  It’s obvious their kidney donations saved another person’s life, but there is so much more involved.

"Insights from experts from the worlds of economics, spirituality, business, the arts, psychology and neuroscience, frame and explain the altruistic psyche. In his interview for Abundant, Buddhist monk Bhante Sujatha described giving with a literal translation from his Sri Lankan language, Sinhala.  In Sinhala, giving means, “It leaves my hand.”  That’s a clear, simple and elegant concept.  Yet so many of us struggle with the genuine act of giving and the abundance required to give openheartedly.

"Through stories, commentary and experiences, Abundant explores how our culture struggles with abundance and what we can do to become more altruistic as a community."

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Update: here's a link to join the email list for updates on the movie:  https://abundantmovie.com/

Frozen embryos are children: Alabama Supreme Court ruling

 The Washington Post has the story, which emphasizes the implications this ruling could have on in-vitro fertilization (IVF).  That would also impact surrogacy, and possibly deceased donor transplantation (depending on how it impacts the definitions of who is alive and who isn't...) 

Frozen embryos are children, Ala. high court says in unprecedented ruling. By Dan Rosenzweig-Ziff, February 19, 2024 

"The Alabama Supreme Court ruled Friday that frozen embryos are people and someone can be held liable for destroying them, a decision that reproductive rights advocates say could imperil in vitro fertilization (IVF) and affect the hundreds of thousands of patients who depend on treatments like it each year.

"The first-of-its-kind ruling comes as at least 11 states have broadly defined personhood as beginning at fertilization in their state laws, according to reproductive rights group Pregnancy Justice, and states nationwide mull additional abortion and reproductive restrictions, elevating the issue ahead of the 2024 elections. Federally, the U.S. Supreme Court will decide this term whether to limit access to an abortion drug, the first time the high court will rule on the subject since it overturned Roe v. Wade in 2022.

"The Alabama case focused on whether a patient who mistakenly dropped and destroyed other couples’ frozen embryos could be held liable in a wrongful-death lawsuit. The court ruled the patient could, writing that it had long held that “unborn children are ‘children’” and that that was also true for frozen embryos, affording the fertilized eggs the same protection as babies under the Wrongful Death of a Minor Act.

...

"The push for defining personhood has even affected tax law: Georgia now recognizes an “unborn child” as a dependent after six weeks of pregnancy.

Kidney exchange in the U.S. from 2006-2021

 Here's an interesting look at the (ongoing) development of kidney exchange in the U.S

Temporal trends in kidney paired donation in the United States: 2006-2021 UNOS/OPTN database analysis, by Neetika Garg, Carrie Thiessen, Peter P. Reese, Matthew Cooper, Ruthanne Leishman, John Friedewald, Asif A. Sharfuddin, Angie G. Nishio Lucar, Darshana M. Dadhania, Vineeta Kumar, Amy D. Waterman, and Didier A. Mandelbrot, American Journal of Transplantation,  24, 1, P46-56, JANUARY 2024.

Abstract: Kidney paired donation (KPD) is a major innovation that is changing the landscape of kidney transplantation in the United States. We used the 2006-2021 United Network for Organ Sharing data to examine trends over time. KPD is increasing, with 1 in 5 living donor kidney transplants (LDKTs) in 2021 facilitated by KPD. The proportion of LDKT performed via KPD was comparable for non-Whites and Whites. An increasing proportion of KPD transplants are going to non-Whites. End-chain recipients are not identified in the database. To what extent these trends reflect how end-chain kidneys are allocated, as opposed to increase in living donation among minorities, remains unclear. Half the LDKT in 2021 in sensitized (panel reactive antibody ≥ 80%) and highly sensitized (panel reactive antibody ≥ 98%) groups occurred via KPD. Yet, the proportion of KPD transplants performed in sensitized recipients has declined since 2013, likely due to changes in the deceased donor allocation policies and newer KPD strategies such as compatible KPD. In 2021, 40% of the programs reported not performing any KPD transplants. Our study highlights the need for understanding barriers to pursuing and expanding KPD at the center level and the need for more detailed and accurate data collection at the national level.

"Kidney paired donation (KPD) is rapidly evolving and reshaping the landscape of living donor kidney transplantation (LDKT). Since the initial KPD transplants performed in the United States in 1999,1 the scope of KPD has expanded substantially. With the inclusion of nondirected donor,2 it has progressed from simple 2-way or multiple-way exchanges to nonsimultaneous kidney donor chains3 and, more recently, to advanced and voucher donations.4 Downstream from nondirected donors, chains often conclude with end-chain kidneys allocated to candidates on the deceased kidney donor waitlist without a living donor (LD).5 Historically used to overcome the barrier of ABO/human leukocyte antigens (HLA) incompatibility, KPD is being increasingly used by compatible donor-recipient pairs to obtain more suitable kidneys for the respective recipients.6 KPD programs can be single center or internal, regional, or national.7,8 The largest multicenter or national KPD programs in the United States are the National Kidney Registry,9 the Alliance for Paired Donation,10 the MatchGrid/Medsleuth program,11 and the program operated by the Organ Procurement and Transplantation Network (OPTN).12 While multicenter KPD often expands the pool of candidates to improve match possibilities, there are examples of very successful single-center programs."

When "demand can't keep up with supply"

Headlines catch my eye more often than subheadlines, but the story below was the exception that proves the rule (a confusing saying in itself, until you realize that "proves" can mean "tests" as in proof reading...) 

The WSJ reports that pork producers are having a problem that is usually associated with some kinds of production in planned economies: demand can't keep up with supply of pork. It makes you wonder if prices are also an issue...

We’re Not Eating Enough Bacon, and That’s a Problem for the Economy. The American pork industry has become so efficient that demand can’t keep up with supply.  By Patrick Thomas

"The American pork industry has a problem: It makes more tenderloin, ham, sausage and bacon than anybody wants to eat. 

"From giant processors to the farmers who supply them, they are in a predicament largely of their own making. They made production so efficient that demand can’t keep up with supply. "