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

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


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

Here's the original article:

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

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

Here is our forthcoming reply to the editorial

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

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

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

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

Opposition to Irresponsible Global Kidney Exchange

Francis L. Delmonico and Nancy L. Ascher

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

·        Abstract  Article  PDF(63K)

And our replies:

You have free access to this content

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

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

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

• Abstract
• Article
• PDF(65K)

1. 
   
2. You have free access to this content

   Open dialogue between professionals with different opinions builds the best policy
   

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

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

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

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

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

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

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

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

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

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

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

Today I'm in D.C. at a meeting of NLDAC, the National Living Donor Assistance Center.

Kim Krawiec on selling virginity

Kim Krawiec has a post commenting on recent news stories and linking to a new paper: Like A Virgin? We Sell That Here!

"A few days ago, an anonymous 19-year-old New Zealand student offered her virginity to the highest bidder on the Web site http://www.ineed.co.nz/ under the name "Unigirl," saying she would use the money to pay for her tuition. According to Unigirl, more than 30,000 people have viewed her ad and over 1,200 made bids before she accepted a $32,000 offer. Story from NPR. (HT: Tonja Jacobi)
Though the story is creating a ruckus, including international press, the attention pales in comparison to that bestowed on the very similar story of “Natalie Dylan,” a pseudonym adopted by a 22-year old UC San Diego graduate who auctioned her virginity on the website of the Moonlight Bunny Ranch, a Carson City brothel, in January of 2009 in order to foot the bill for graduate research in women’s studies. In contrast to Unigirl’s paltry returns, Dylan reportedly received over 10,000 bids, the highest of which was $3.8 million, receiving both condemnation and praise in the auction process. Critics have argued that she is degrading herself and women generally, risks exporting Nevada’s poor morals to the rest of the country, and is selling something (virginity) for profit that should be cherished and freely given.
In an article I posted to SSRN over the weekend, A Woman’s Worth, I consider the reactions to Dylan’s virginity auction plan and the possible motivations underlying those reactions. What drives the attention and controversy generated by the Dylan auction? What are the perceived harms associated with Dylan’s actions, and in what ways are they greater than the harms associated with similar common activities? "

And here's the abstract to her paper on SSRN:

A Woman's Worth
Kimberly D. Krawiec Duke University - School of LawFebruary 6, 2010 North Carolina Law Review, Forthcoming

Abstract: This Article examines three traditionally “taboo trades”: (1) the sale of sex, (2) compensated egg donation, and (3) commercial surrogacy. The article purposely invokes examples in which the compensated provision of goods or services (primarily or exclusively by women) is legal, but in which commodification is only partially achieved or is constrained in some way. I argue that incomplete commodification disadvantages female providers in these instances, by constraining their agency, earning power, and status. Moreover, anticommodification and coercion rhetoric is sometimes invoked in these settings by interest groups who, at best, have little interest in female empowerment and, at worst, have economic or political interests at odds with it.

Keywords: Sex Work, Virginity, Prostitution, Oocyte Donation, Sperm Markets, Surrogacy, Medical Marijuana

See also her related post Chicago Students Have All the Fun

Kim Krawiec interview about WHO demands for national self sufficiency in blood donation and kidney exchange

 The University of Virginia takes note of the recent Krawiec & Roth paper I blogged about in August.

Here is their interview with Kim about the paper:

WHO Stifles International Blood and Organ Donations, Argue Professors. Professor Kimberly Krawiec, Nobel Prize Winner Alvin E. Roth of Stanford Argue World Health Organization Policies Need Revision

Here are the first two Q&As

"What motivated you to critique the WHO principles of self-sufficiency and nonremuneration in organs and blood? ​

"The severe shortage of both blood products and transplantable organs, especially kidneys, was our motivation and has motivated much of our other work, both together and separately. In the United States alone, the organ transplant waiting list is approximately 100,000 people, and if current trends continue, it will only grow in the coming years.

"Shortages of blood products present a similar challenge. Although wealthy countries are typically able to satisfy domestic whole blood needs, the vast majority of low- and middle-income countries (LMIC) are not. As a result, in many LMIC, shortages of blood for transfusion contribute to maternal death, death from traffic accidents and complications from childhood anemia. Moreover, even wealthy countries experience seasonal shortages of whole blood or deficiencies in some blood components, such as platelets, which are harder to collect and have a shorter shelf life.

The shortage of plasma-derived medicinal products (PDMPs) is particularly severe and entirely preventable. PDMPs are life-saving treatments for multiple acute and chronic conditions for which there are no alternative treatments. Yet these life-saving therapies are unavailable to much of the world’s population. The United States, one of the few countries to pay plasma donors, supplies 70% of the world’s plasma needs, with Germany, Austria, Hungary, Czechia and Latvia (which also permit some form of payment for plasma donors) supplying another 20% of the world total. In other words, a handful of countries supply plasma to the rest of the world, including other wealthy countries. Meanwhile, LMIC who can neither collect and process their own nor afford to purchase blood products on the open market (or are prevented from doing so under the terms of the foreign aid that supports their health system) simply do without, to the detriment of their citizens.

"How do current WHO policies on organ and blood donation contribute to this problem?

"WHO policy mandates both national (or sometimes only regional) self-sufficiency and an absence of remuneration for both blood products and transplantable organs — what we refer to in the paper as “the twin principles.” These twin principles are unhelpful separately and unworkable together. Their effect on blood products is particularly stark — no country that fails to compensate donors is self-sufficient in plasma collection and few LMIC collect sufficient supplies of whole blood.

"The self-sufficiency mandate presents a real hurdle to progress in transplantation, especially for smaller countries and LMIC. This is especially the case because some of the most exciting and promising developments for increasing the availability of transplants have been in kidney exchange, a mechanism that leverages in-kind exchange, rather than financial compensation, to encourage and facilitate donation among those with willing but incompatible partners. But kidney exchange works best when a large pool of patient-donor pairs can engage with one another. So, requiring that transplantation be contained within national boundaries unnecessarily limits access to transplants that could be achieved only by cross-border exchange."

Taboo Trades: a new podcast by Kim Krawiec

 Who better to talk about forbidden markets than Kim Krawiec?  Her new podcast is off to a great start.

Taboo Trades

Kimberly D Krawiec

"A podcast about things we aren’t supposed to trade . . . But do anyway"

Recent Episodes

Kidneys and Challenge Trials with Josh MorrisonSEPTEMBER 01, 2020Plasma with Peter JaworskiAUGUST 25, 2020

Kim Krawiec interviews Frank McCormick on the kidney shortage (and how to end it)

Here is Kim Krawiec's latest podcast (click on this link to listen, not the picture below...:): 

Taboo Trades 

AUGUST 06, 2022 KIM KRAWIEC

Taboo Trades

Bonus Episode: Ending the Kidney Shortage with Frank McCormick

00:00|44:40

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Frank McCormick is an economist and the author of numerous articles focused on the shortage of kidneys for transplantation. He is retired from the Bank of America where he was Vice-president and Director of U.S. Economic and Financial Research. Today, we’re discussing his recent article, Projecting the Economic Impact of Compensating Living Kidney Donors in the United States: Cost-Benefit Analysis Demonstrates Substantial Patient and Societal Gains, co-authored with Philip J. Held, Glenn Chertow, Thomas G. Peters, and John P. Roberts. It is published in the journal, Value in Health and is available here: https://www.sciencedirect.com/science/article/pii/S109830152201957X/

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

In an email to his extensive mailing list, McCormick writes:

If you don’t have 45 minutes to spare, the key points I have to make are:

1. The death toll due to the shortage of transplant kidneys is much greater than is generally realized.  The Health Resources and Services Administration (HRSA) misleads everyone by saying only 19 people a day die waiting for a transplant organ -- because it counts only patients who die while on the waiting lists (for kidneys alone that number is about 13 deaths per day).

But HRSA does not count:

A. Patients who are removed from the wait list because their health has become so poor they may not survive a transplant operation (or for other reasons) who soon die;

B. Patients who are never placed on the waiting list to begin with, but who could be saved from a premature death by transplantation if there were no kidney shortage.

Adding the latter two groups raises the death toll due to the kidney shortage to more than 110 deaths per day (40,000 per year).

 2. This appalling death toll due to the kidney shortage could be completely ended if the government compensates kidney donors about $77,000 per donor (with a wide range of uncertainty surrounding that estimate).  But even if the required compensation is two or three times this amount, it would be trivial compared to:

A. The value of a longer and healthier life to a kidney recipient (and their caregiver), which my co-authors and I estimate at about $1.5 million.

B. The savings (mainly to taxpayers) from the kidney recipient not needing expensive dialysis therapy, which we estimate at about $1.2 million per recipient.

In the long run, this program of government compensation of kidney donors would not cost taxpayers anything; rather it would save them about $7 billion per year.

 References:

1. McCormick F, Held PJ, Chertow GM.  The Terrible Toll of the Kidney Shortage.   J Am Soc Nephrol 2018;29:2775-2776. https://jasn.asnjournals.org/content/jnephrol/29/12/2775.full.pdf.

 2. McCormick F, Held PJ, Chertow GM, Peters TG, Roberts JP.  Perspectives: Projecting the Economic Impact of Compensating Living Kidney Donors in the United States: Cost-Benefit Analysis Demonstrates Substantial Patient and Societal Gains.  Value in Health, online 9 June 2022.  https://doi.org/10.1016/j.jval.2022.04.1732.

Do repugnant markets corrupt society? Kim Krawiec calls for evidence...

 Kim Krawiec, who studies taboo trades from a legal perspective, thinks that people who claim that repugnant transactions undermine society should be asked to provide evidence.

Krawiec, K. (2022). Markets, repugnance, and externalities. Journal of Institutional Economics, 1-12. doi:10.1017/S1744137422000157

Abstract: This Article considers one aspect of the ongoing debate about the moral limits of markets – namely, the purported harmful effects of market transactions on particular relations, goods, services, or society at large, due to an inappropriate valuation. In other words, the argument is that some markets are ‘repugnant’ because they degrade and corrupt a variety of nonmarket values and relations, not just to the willing parties to the exchange, but to larger segments of society. This objection contains both a (frequently unacknowledged) empirical component and a moral component. This Article critiques these empirical claims on two grounds. First, market skeptics fail to provide evidence of the negative effects they hypothesize, despite widespread variation over time and across legal regimes. Second, these objections fail to account for the well-documented human tendency to fashion repugnant exchanges in a manner that reinforces – rather than undermines – deeply held values and relationships.

...

"how do we, as a society, determine what is up for sale and what must be immune from market forces? Although all cultures and time periods have proclaimed some transactions too sacred for the marketplace, those boundaries vary greatly across times and cultures and are often contested at the margins (Fiske and Tetlock1997). Once-common practices such as slavery, commutation (a direct payment to the government in exchange for relief from military service), substitution (paying another for military service in one's place), and the purchase of indulgences are no longer acceptable in most societies ( Krawiec2009a; NY Times, 1864). At the same time, formerly taboo practices, such as charging interest on a loan or accepting money in exchange for the practice of law are now widespread – although, in the case of charging interest, not universally so (Rossman2014).

...

"Many justifications have been offered for limits on ‘repugnant’ (Roth 2007) or ‘taboo’ ( Fiske and Tetlock1997) markets. This article considers a single, but prominent, objection – that some markets degrade and corrupt a variety of nonmarket values and relations, not just to the willing parties to the exchange, but to larger segments of society. This objection often involves concerns about the purported harmful effects of market transactions on particular relations, goods, services, or society at large due to an inappropriate valuation and has both a (frequently unacknowledged) empirical component and a moral component.

"The objection is empirical because it contends that markets in certain items and activities change the way in which society and its members perceive those items and activities or the non-market relationships through which they would otherwise be supplied. It is also a moral claim, because it rests on a contention that the change is inevitably negative – that certain modes of valuation and visions of the world are superior to others, or at least unsuitable to certain situations ( Anderson1993).

...

"This Article critiques these empirical claims on two grounds. First, as noted by others, market skeptics fail to provide evidence of the negative effects they hypothesize, despite widespread variation over time and across legal regimes. Second, and more importantly, these objections fail to account for the well-documented human tendency to fashion repugnant exchanges in a manner that reinforces – rather than undermines – deeply held values and relationships. The fact that a particular transaction is deemed morally repugnant by large swathes of society does not, after all, mean that such transactions disappear, even in the face of strong legal sanctions and criminal prohibitions. But it does mean that such exchanges may be managed, obfuscated, or reframed in some way, acknowledging and reinforcing the taboo in the process.

...

"to the extent that some, including Sandel (2012), have explicitly contended that ‘market creep’ has occurred without public awareness or debate, that claim is undermined by the full extent to which participants in and third-party observers of repugnant exchange have, in fact, debated, modified, and managed those exchanges over time."

Lawsuits involving NKR's kidney exchange contracts

 Kim Krawiec, the Sullivan & Cromwell Professor of Law at the University of Virginia, sheds some light on recent legal exchanges between the kidney exchange nonprofit National Kidney Registry and some of the Transplant Centers that are (or were) members of its network. Both suits (which seem to have been settled out of court) involved the TC's desire to withdraw (or partially withdraw) from NKR's system, and NKR's attempt to charge them $1000/kidney/month in perpetuity (or until they supply the kidneys) for kidneys they received in excess of kidneys they supplied. (In particular, NKR wanted $8000 per month from Colorado forever, or until they supplied 8 kidneys.)  Her post is long and learned, and well worth reading in its entirety, but here are some snippets.

She leads off with this graphic of a judge's gavel hammering a stethoscope

Recent Contract Disputes In The Transplant World November 3, 2021 / By Kimberly Krawiec 

"Readers may be interested in two relatively recent lawsuits involving the National Kidney Registry (NKR) and the University of Colorado Hospital Authority (“UCH,” filed 3/26/21) and the University of Maryland Medical Center (“UMMC”, filed 4/2/2018), respectively. (Citations and links to both lawsuits are at the end of this post)

...

This option to specifically perform is interesting in its own right, and I may say more about it later, but what if a Member Center couldn’t deliver kidneys to the network, say because the UCH kidney transplant program had been closed? Or because they determined that kidney exchange was bad for their patients? In the event that delivering kidneys to NKR is impossible, is a court likely to award NKR these fees into perpetuity – a present value of nearly $5 million? (using an interest rate of 2%, which may understate the amount, given the current low interest rate environment)

"Under the penalty doctrine, NKR would have to describe its loss, and why $1000/kidney/month is a reasonable estimate of it, even if it can’t provide a precise amount. Here, the “in perpetuity” aspect may be troubling to courts, even if the present value is not high relative to whatever the alleged loss is, as it seems unlikely that NKR is harmed in perpetuity if a member center backs out.

...

"when federal law prohibits the exchange of valuable consideration for a kidney, by definition there is no market price for either the court or the contracting parties to reference. Here, the parties attempted to overcome that problem by specifying a recurring charge, but it’s continuation into perpetuity may raise eyebrows, even if the present value of the charges is otherwise reasonable.

***********

The various legal documents can be found at these links

https://kimberlydkrawiec.org/wp-content/uploads/2021/11/Member-Terms-and-Conditions.pdf

 https://kimberlydkrawiec.org/wp-content/uploads/2021/11/Complaint.pdf

 https://kimberlydkrawiec.org/wp-content/uploads/2021/11/May-7-motion-to-dismiss.pdf

 https://kimberlydkrawiec.org/wp-content/uploads/2021/11/1Summons-Complaint.pdf

***********

Given NKR's non-profit status, paragraph 30 of the Colorado complaint caught my eye:

Caps on payment to egg donors abolished in antitrust settlement

Kim Krawiec has the news at the Faculty Lounge:  below is her post

Egg Donors Get Pay Limits Axed With Antitrust Settlement

From Law360:

Egg Donors Get Pay Limits Axed With Antitrust Settlement

By Kelly Knaub

Law360, New York (February 1, 2016, 7:01 PM ET) -- A class of human-egg donors who allege the American Society for Reproductive Medicine violated antitrust laws by capping compensation to donors asked a California federal court Friday to approve a settlement requiring the organization to remove the compensation guideline, calling the agreement an “excellent resolution” of the case.

Under the proposed settlement, ASRM will remove language stipulating that “[t]otal payments to donors in excess of $5,000 require justification and sums above $10,000 are not appropriate,” effectively benefiting all women who donate eggs in the future.

. . .

In addition, ASRM will pay a total of $1.5 million under the agreement to compensate the plaintiffs’ counsel for fees and costs incurred in in the litigation, as well as up to $150,000 to cover the costs of notice to the class.

They could have saved that $1.5 million dollars in legal fees if they had listened to me about this back in 2009.  :-)

Related posts:

The NY Times Weighs In On Egg Donor Price Fixing

If You Want A Market, Have A Market . . . Otherwise

“Feeble Even By Normal Litigation Standards”

Egg Donor Antitrust Suit In Today’s WSJ

Sunny Samaritans’ Suit Survives

ASRM Seeks Dismissal of Egg Donor Suit

Kamakahi v. ASRM et al. — Updates

Politics And Profits in The Egg Business (When Sunny Samaritans Sue, IV)

When Sunny Samaritans Sue, Part III

When Sunny Samaritans Sue, Continued

When Sunny Samaritans Sue

The Value of Smart Eggs

Posted by Kim Krawiec at 03:24 PM in Reproductive Markets, Taboo Trades | Permalink

Global kidney exchange (and pushback) in the American Journal of Transplantation

I've written earlier about the possibility of Global Kidney Exchange (GKE), in which foreign patient-donor pairs who cannot afford transplantation are invited to join American kidney exchange chains. The idea is that the cost of the foreign pair's surgeries and postoperative care can be paid for by the savings that result whenever an American is transplanted (because transplantation is so much cheaper than dialysis).

The March issue of the American Journal of Transplantation  contains a report of the first foreign pair, and the chain of exchanges that included them.

Curiously, the issue also contains an editorial that is profoundly ambivalent about GKE, in a way that makes clear that the issues of repugnance that surround organ donation, and incentives, and equity, and patients and donors from developing countries, are not vanishing in the face of the benefits that GKE provides to patient-donor pairs from developing countries.

Finally, for those in a hurry, here's a nice summary by Timothy Taylor on his blog the Conversable Economist: Global Kidney Exchange.

Here's our paper reporting the first global kidney exchange chain:

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

Abstract: Organ shortage is the major limitation to kidney transplantation in the developed world. Conversely, millions of patients in the developing world with end-stage renal disease die because they cannot afford renal replacement therapy—even when willing living kidney donors exist. This juxtaposition between countries with funds but no available kidneys and those with available kidneys but no funds prompts us to propose an exchange program using each nation's unique assets. Our proposal leverages the cost savings achieved through earlier transplantation over dialysis to fund the cost of kidney exchange between developed-world patient–donor pairs with immunological barriers and developing-world patient–donor pairs with financial barriers. By making developed-world health care available to impoverished patients in the developing world, we replace unethical transplant tourism with global kidney exchange—a modality equally benefitting rich and poor. We report the 1-year experience of an initial Filipino pair, whose recipient was transplanted in the United states with an American donor's kidney at no cost to him. The Filipino donor donated to an American in the United States through a kidney exchange chain. Follow-up care and medications in the Philippines were supported by funds from the United States. We show that the logistical obstacles in this approach, although considerable, are surmountable.

Here's an illustration of the idea:




And here's the first chain, to date: the Filipino pair is pair 1 (the chain was begun by an American nondirected donor who donated to the Filipino patient, whose donor in turn continued the chain...).

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

Abstract: Engaging compatible kidney donor–recipient pairs from other countries for participation in a paired kidney exchange program in the United States poses a number of ethical challenges that deserve close scrutiny. Rees et al's article is on page 782.

Here's one sentence that illustrates the power of repugnance (it suggests that maybe the Filipino pair who joined the kidney exchange were really being exploited...):
"At a societal level, American patients received a disproportionate share of the societal benefit enabled by the participation of the compatible Filipino pair in KPE, which may not be adequately remedied by the payment for transplantation and posttransplant care."
*************

Update: and here's our coauthor Kim Krawiec at the Faculty Lounge: GKE Debate in Current Issue of The American Journal of Transplantation