Frank McCormick points out this recent collection of short pieces in the summer issue of Regulation.
Ideas to Increase Transplant Organ Donation, edited by Ike Brannon, in Regulation / SUMMER 2022
Introduction BY IKE BRANNON
Emulate Israel’s Program of Covering Donors’ Expenses BY JOSH MORRISON AND SAMMY BEYDA
Give Donors a Tax Credit BY SALLY SATEL AND ALAN D. VIARD
Expose OPOs to Competition BY ABE SUTTON
Help People Understand the Benefits of Donation BY MARIO MACIS
The situation of children with kidney failure in low and middle income countries is particularly dire. Most transplants in LMICs are from living donors. Here's a recent paper on that, with a case report that makes clear the need for kidney exchange, and for a relaxation of the policies that limit access to transplantation generally.
Pais, Priya, and Aaron Wightman. "Addressing the Ethical Challenges of Providing Kidney Failure Care for Children: A Global Stance." Frontiers in Pediatrics 10 (2022).
"Case 2: An 11 year old boy with kidney failure due to FSGS* has been on the deceased donor wait-list for 5 years without receiving a transplant. He has no compatible living donors and paired exchange, or ABO incompatible transplants are not accessible. National transplant policies do not allow unrelated living organ donation. The deceased donor transplant rates in the country are very low ..."
HT: Martha Gershun
*Focal segmental glomerulosclerosis
Novel pronouns haven't been widely adopted in English, but committees now have chairs or chairpersons, and there are some attempts not merely to avoid assigning male or female genders to words when they're not needed (like chairman), but also to avoid suggesting genders at all. That's going to be tougher in languages in which all words have genders, or in which the conjugation of verbs involves choosing a gender. Take Spanish for instance.
The NY Times has the story:
"Instead of “amigos,” the Spanish word for “friends,” some Spanish speakers use “amigues.” In place of “todos,” or “all,” some write “todxs.” And some signs that would say “bienvenidos,” or “welcome,” now say “bienvenid@s.”
...
"Similar gender-neutral language is being increasingly introduced across Latin America, as well as in other languages, including English and French, by supporters who say it helps create a more inclusive society.
...
"The city government in Buenos Aires, the nation’s capital, last month banned teachers from using any gender-neutral words during class and in communications with parents.
...
"The policy, among the first anywhere to specifically forbid the use of gender-neutral language, provoked a swift backlash. Argentina’s top education official criticized the rule and at least five organizations, a mix of gay rights and civil rights groups, have filed lawsuits seeking to overturn it.
"Jaime Perczyk, Argentina’s education minister, compared the measure to prohibitions against left-handed writing under the fascist dictatorship of Francisco Franco in Spain.
...
"Argentina is a surprising place for such a heated debate on gender-neutral language because the country has largely embraced transgender rights. In 2012, it became one the first countries in the world to pass a law allowing people to change their gender on official documents without requiring the intervention of a doctor or a mental health therapist."
In Norway, where surrogacy is illegal, there is a debate about whether surrogacy conducted legally in other countries should also be criminalized for Norwegians.
The Norwegian Broadcasting Co. (NRK) has the story (with a little help from Google translate):
Familieminister mener surrogati skal kunne være straffbart The Minister of Family Affairs believes that surrogacy should be punishable by Chris Burke Marthe and Ingrid Tinmannsvik
"The debate about surrogacy has created debate in Norway over several years. In 2022, surrogacy is illegal in Norway.
"Minister for Children and Families Kjersti Toppe (Sp) believes it should still be illegal to have children in this way.
...
"surrogacy in itself can be compared to human trafficking. A commercial industry where there is a great danger of exploiting vulnerable women. Shall we make children an item you can order and buy?"
...
"No one knows how many surrogate children come to Norway each year. But last year, 61 Norwegian fathers said that they became the father of a child in one of the countries it is most common to go to for surrogacy. It shows figures the Ministry of Foreign Affairs has obtained from the foreign service missions.
"About 10 years ago, the Storting passed an exemption which means that people who have children through surrogacy abroad cannot be punished.
"Tops voted against the law change and still disagrees.
...
"Anette Trettebergstuen (Labor Party), Minister of Culture and Gender Equality, reacts to Toppe's comparison of surrogacy and human trafficking.
...
"She believes a ban on punishment would not work in practice.
"- Should parents who bring a baby to the country be imprisoned? It will definitely be against the best interests of the child. And even if fines were imposed, many would probably think it was worth it", she says."
HT: Øivind Schøyen
In many countries, national exams serve as the gateway to college admissions and other prizes, and many applicants incur great costs in time and treasure preparing for these exams. Here's a recent NBER working paper that suggests that reporting the grades in intervals rather than by individual scores has the potential to reduce the costs devoted to exam prep sufficiently to be a Pareto improvement for students, i.e. to make them all better off, even those who obtain the highest grades, if the cost of doing so is sufficiently high.
Pareto Improvements in the Contest for College Admissions by Kala Krishna, Sergey Lychagin, Wojciech Olszewski, Ron Siegel & Chloe Tergiman, NBER WORKING PAPER 30220, DOI 10.3386/w30220, July 2022
Abstract: "College admissions in many countries are based on a centrally administered test. Applicants invest a great deal of resources to improve their performance on the test, and there is growing concern about the large costs associated with these activities. We consider modifying such tests by introducing performance-disclosure policies that pool intervals of performance rankings, and investigate how such policies can improve students’ welfare in a Pareto sense. Pooling affects the equilibrium allocation of studentso colleges, which hurts some students and benefits others, but also affects the effort students exert. We characterize the Pareto frontier of Pareto improving policies, and also identify improvements that are robust to the distribution of college seats.
"We illustrate the potential applicability of our results with an empirical estimation that uses data on college admissions in Turkey. We find that a policy that pools a large fraction of the lowest performing students leads to a Pareto improvement in a contest based on the estimated parameters. We then conduct a laboratory experiment based on the estimated parameters to examine the effect of such pooling on subjects’ behavior. The findings generally support our theoretical predictions. Our work suggests that identifying and introducing Pareto improving performance-disclosure policies may be a feasible and practical way to improve college admissions based on centralized tests."
The paper notes that:
" In many Asian countries, including China, Japan, South Korea, and Taiwan, students attend specialized “cram schools,”1 which focus on improving students’ performance on the tests. This often consists of rote learning, solving a large number of practice problems, and practicing test-taking strategies tailored to the specific test. In other countries, students hire tutors, buy books, and take specialized courses, all geared entirely toward improving their test scores. These activities likely improve students’ performance on the test, but are far less likely to generate substantial long-term improvements in students’ productive human capital. These activities do, however, carry significant costs in terms of time, money, and effort. In South Korea, for example, it is not uncommon for high school students to spend several hours a day in cram schools, and the high stakes competition for college admissions is seen as one of the main causes for the high rates of unhappiness and suicide among teenagers.2 Similar concerns have also been raised in the United States.3"
The paper explains that:
"We are interested in performance-disclosure policies that benefit all students, and refer to such policies as Pareto improving. In particular, we do not need to consider welfare tradeoffs across students. A key finding of our analysis is that Pareto improving policies often exist. This may seem surprising, since a fixed set of college seats implies that a student can be admitted to a better college only if another student is admitted to a worse college. The crucial element that makes Pareto improvements possible is that test preparation is costly. The costs students incur, as well as the resulting college assignment, are determined in equilibrium, and the equilibrium is affected by the performance-disclosure policy. Relative to the baseline contest with no coarsening, introducing a performance-disclosure policy leads to some students being admitted to better colleges; this makes them better off even if they incur higher costs, as long as the cost increase is not too large. Other students are admitted to worse colleges; if they also incur lower costs they are made better off as long as the reduction in the costs is large enough."
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I'm reminded of a paper that suggests that the very best students may not pay the highest costs for exam prep:
Feltovich, Nick, Richmond Harbaugh, and Ted To. "Too cool for school? Signalling and countersignalling." RAND Journal of Economics (2002): 630-649.
Here's the announcement of the Nemmers Prize, from Northwestern University:
"Northwestern University has announced the winners of the 2022 Nemmers Prizes in Earth sciences, economics and mathematics. The biennial prizes recognize top scholars for their lasting significance, outstanding achievements, contributions to knowledge and the development of significant new modes of analysis.
"This year’s recipients are Emily Brodsky for Earth sciences, Ariel Pakes for economics and Bhargav Bhatt for mathematics. Each will receive $200,000 and will interact with Northwestern faculty and students through lectures, conferences or seminars.
...
Ariel Pakes received the Erwin Plein Nemmers Prize in Economics, honored for his “fundamental contributions to the development of the field of empirical industrial organization as it is applied to the study of market power, prices, mergers and productivity.” He is the Thomas Professor of Economics at Harvard University.
"In his research, Pakes develops methods for empirically analyzing market responses to environmental and policy changes. He and his collaborators have developed ways to estimate and analyze consumer demand patterns that underlie pricing and product placement incentives, the production functions that underlie the analysis of firm productivity and the investment decisions that underlie the evolution of markets over time.
"Pakes and collaborators have demonstrated the usefulness of these tools by analyzing deregulation in the telecommunication industry, demand and product placement decisions in the auto industry, the impact of incentives on doctors’ hospital allocations and consumers’ choices of health insurance plans, the evolution of bidding strategies in a new electric utility market and the development of improved consumer price indices. Subsequently, these tools have become a mainstay of market interactions in much of economics and are often employed by consultancies and regulatory agencies to analyze the likely outcomes of regulatory decisions. They have also been used for internal firm planning.
"Pakes is a member of the Econometric Society, the American Academy of Arts and Sciences and the National Academy of Sciences. He has received the Frisch Medal of the Econometric Society, the Jean-Jacques Laffont Prize for research that integrates theory with empirical analysis and the BBVA Frontiers of Knowledge Award in Economics, Finance and Management. Pakes is a laureate of the Web of Science and an honoree of the American Antitrust Institute for Outstanding Antitrust Achievement in Economics. He also is a distinguished fellow of both the Industrial Organization Society and of the American Economic Association. Pakes is a founding member of Microeconomic Insights, a home for summaries of microeconomic research that informs the public about societally relevant microeconomic issues."
I don't have a twitter account, but for those of you who do, there are some accounts that tweet daily about market design and adjacent subjects, mostly by posting links. Here are three that I know about, and the urls at which they can also be viewed on the web.
U.S. law makes it illegal to sell deceased donor organs for transplant, i.e. to save a life, but it's otherwise legal to sell body parts or whole cadavers, for research, for instruction, etc. Nevertheless, alongside the legal, regulated market, which requires consents and precautions, is an illegal black market which is occasionally prosecuted. Here's a recent case, as reported in the NYT:
Funeral Home Operator Pleads Guilty in ‘Illegal Body Part Scheme’. Megan Hess, who pleaded guilty to mail fraud, sold body parts without families’ consent... By Alex Traub
"The operator of a Colorado funeral home who was accused of stealing body parts and selling them to medical and scientific buyers, making hundreds of thousands of dollars in what the authorities called an “illegal body part scheme,” pleaded guilty to mail fraud on Tuesday, the Justice Department said.
...
"Here’s how prosecutors said the scheme worked: From about 2010 to 2018 Ms. Hess was in charge of Donor Services, a nonprofit “body broker service,” and Sunset Mesa Funeral Directors, which offered to arrange cremations, funerals and burials in the small western Colorado city of Montrose.
"Ms. Hess and her mother sometimes obtained consent from families to donate small tissue samples or tumors of their dead relative, according to an indictment in the case. On other occasions, their request was rejected, and sometimes, they never brought up the topic at all.
"In any case, the documents say, on hundreds of occasions the funeral home operators would sell heads, torsos, arms, legs or entire human bodies. Frequently, they delivered cremated remains to families with the suggestion they were the remains of their relative when, in fact, they were not, according to the indictment.
...
"The scheme included forging paperwork, such as signatures on authorization forms for donating body parts, and misleading buyers about the results of medical tests performed on the deceased, court documents said. Ms. Hess altered lab reports so that they said that people had tested negative for diseases like H.I.V. and hepatitis when they had actually tested positive, according to the authorities."
On May 7, 2022 the University of Chicago hosted a Symposium on "The Future of Living Donor Kidney Transplantation: Evolving National Perspectives in Kidney Transplant "
Philip Held, one of the organizers, has provided the following guide, concluding with a link to an elegant Data Handbook that gives direct access to each talk.
"A Symposium: The Future of Living Kidney Donor Transplantation
Earlier this year, we presented a virtual
symposium on the Future of Living Kidney Donor Transplantation. A
primary focus was on the ethics of rewarding organ donors with an opening
presentation by:
· Janet Radcliffe Richards, a philosopher and ethicist from Oxford University.
Other speakers and topics included:
· Nobel Laureate Alvin Roth Ph.D. of Stanford University who laid out the case for paired kidney donation (aka kidney exchange), the only major technical improvement in transplantation in years.
· Frank McCormick, Ph.D. presented recently published (Value in Health) research showing how the government can completely end the kidney shortage and save more than 40,000 kidney failure patients each year from premature death by rewarding living kidney donors.
The Symposium took place on May 7, 2022. It was hosted by John Fung M.D. Ph.D. at the University of Chicago’s Transplantation and Transplant Institute and was funded by the National Kidney Donation Organization (NKDO) and WaitListZero.
This Symposium presented a broad education on the subject of living kidney donation, and indeed was presented for Continuing Medical Education (CME) credits by the University of Chicago.
The audio-visual recording of the entire University of Chicago’s CME symposium is available, for free. Access is extremely easy and one can access any and all presentations with 3 simple clicks starting with 2 clicks here: Data Handbook."
If you prefer you can binge on the sessions in order:
Session 1: The Future of Living Kidney Donor Transplantation
Session 2: The Future of Living Kidney Donor Transplantation
Session 3: The Future of Living Kidney Donor Transplantation
My talk, called "Kidney Exchange (and Kidney Controversy)" is the first half hour of the video below of the second of three symposium sessions.
From time to time there are stories of prosecutions for organ trafficking in connection with kidney transplants.
Here's a story developing in England. (Early reports were that the alleged donor/seller/victim was a child, but apparently he's not a minor):
From the BBC:
Ike Ekweremadu: Nigerian senator faces London organ-harvesting trial
"A prominent Nigerian senator and his wife who are accused of plotting to harvest a man's kidney in the UK will face trial at the Old Bailey.
"Ike Ekweremadu, 60, and Beatrice Nwanneka Ekweremadu, 55, are alleged to have transported a 21-year-old man from Nigeria to London.
"Prosecutors allege the couple planned to have his kidney removed so it could be given to their daughter.
...
"The alleged victim is said to have refused to consent to the procedure after undergoing tests at the Royal Free Hospital in Hampstead."
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Not long ago I participated in an online conversation including Professor Janet Radcliffe Richards, who recalls that her view that bans on kidney sales are ill-conceived arose from news in the 1980's about a case involving Turkish sellers (here's an LA Times story from then):
London Kidneys-for-Cash Scandal Prompts Action to Ban Sale of Organs BY ROBERT BARR JULY 16, 1989
"“The concept of organs being bought and sold for money is entirely unacceptable in a civilized society,” Health Minister Roger Freeman told a House of Commons committee during debate on proposed legislation outlawing organ sales. The bill is expected to pass Parliament later this month.
"Not all lawmakers agree.
“The bill will cause death where there could be life, and to prolong suffering where we could provide relief,” said Sir Michael McNair-Wilson, a Conservative Parliament member awaiting a kidney transplant.
...
"Neil Hamilton, who cast the only vote against the bill in committee, said he had pondered the dilemma facing one Turk who allegedly sold a kidney.
“His daughter was suffering from a medical problem which threatened her life, but it could not be solved in Turkey without money,” Hamilton said. “If he did not get the money for the operation, his daughter would die.”
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The situation in India is complex, since there is or was something of a long tradition of kidney sales, which are against the law, and are guarded against by authorization committees that have to approve each living donor transplant. Recently, kidney exchange has become legal in India, but the law only allows close family to be the intended donor in an incompatible patient-donor pair. Below is a report of a case where it's alleged that an attempted donor was paid, and also illegally claimed to be a family relation.
Here's the Hindustan Times story:
Ruby Hall Clinic kidney transplant ‘malpractices’ probe handed over to crime branch
"Earlier on Wednesday, police officials probing the case told Magisterial court that more cases of kidney transplants based on the relationship claims have been unearthed during the interrogation of agents Ravindra Rodge and Abhijit Gatane. Both have been arrested by the police. These two agents having donated their kidneys earlier and also played the role of middlemen in at least four kidney transplants where alleged malpractices were involved.
...
"The case pertains to a kidney swap procedure, also known as paired kidney exchange, between the Moshi man and the Kolhapur woman posing as his wife, and a mother-daughter duo from Baramati."
And here's the story in the Indian Express:
Two middlemen arrested in Pune kidney transplant malpractice case. The other accused in the case, including Ruby Hall Clinic doctors, the patient who received the kidney, and the unrelated donor who was passed off as his wife--are yet to be arrested.
"Police have arrested the two middlemen over the alleged malpractices in a kidney transplant conducted at Pune’s Ruby Hall Clinic in March in which an unrelated woman was allegedly presented as the organ receiver’s wife and promised Rs 15 lakh in return.
...
"Among the 15 people named in the FIR are the hospital’s managing trustee, Dr Purvez K Grant, deputy medical director Dr Rebecca John, legal advisor Manjusha Kulkarni, nephrologist Dr Abhay Sadre, urologists Dr Bhupat Bhati and Dr Himesh Gandhi and transplant coordinator Surekha Joshi. The police also booked the two middlemen, the patient—from Pimpri Chinchwad’s Moshi area—who received the kidney, his wife, their three family members, the woman from Kolhapur who was allegedly passed off as the patient’s wife to become the donor."
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Among the most vigorous opponents of paying kidney donors--e.g. among some of those who think it's a crime against humanity--there's also opposition to extending the scope of legal, ethical, unpaid kidney donation and transplantation, particularly in poor countries. One reason for this is the intuition that more transplantation will cause more paid transplantation. The cases reported above, although rare, help to support this view.
But a much stronger case can be made that it is the unavailability of transplants that causes exploitative black markets, and that increasing the availability of legal transplants will reduce the demand for illegal ones.
A discussion of kidney exchange in Brazil began with this letter to the editor, describing how kidney exchange (aka kidney paired donation) could increase transplantation in Brazil:
Bastos, J., Mankowski, M., Gentry, S., Massie, A., Levan, M., Bisi, C., Stopato,C., Freesz, T., Colares, V., Segev, D. and Ferreira, G., 2021. Kidney paired donation in Brazil-A single center perspective. Transplant International: Official Journal of the European Society for Organ Transplantation.
"Kidney paired donation (KPD) represents a strategy for increasing the number of LDKT, offering an incompatible donor/recipient pair, the chance to exchange with another pair in the same situation [4]. In Brazil, KPD is still prohibited by law. We designed a study to show mathematically how KPD could increase LDKT in a single center in Brazil.
Several comments followed in a forum.. The name of the forum is ""Kidney Paired Donation is necessary in Brazil." But not everyone agrees with that headline.
In particular, a letter to the editor from Mario Abbud-Filho & Valter Duro Garcia concludes that there are too many poor people in Brazil to allow kidney exchange:
"We do not condemn the KPD strategy, but we disagree that it should be proposed in the actual Latin American context, where such great socioeconomic disparities do exist and could fuel organ trafficking and commerce."
That letter drew this rejoinder, in favor of kidney exchange by Marcelo Perosa:
"We do not understand the rationale behind the claim that KPD could stimulate organ trafficking and trade if the LD of an eventual KPD swap would be submitted to the same steps and rigor currently used for unrelated LDKT to be approved.
"The acceptance of KPD is growing around the world. It brings a potential technological development with advanced algorithms and softwares, unites clinicians, surgeons, immunologists in fruitful discussions and analysis of match runs, expanding and exchanging knowledge among multidisciplinary teams that currently work separately. KPD still has the beauty of not dividing, but joining efforts among different centers since the more groups participating, the more patients in the database and more matches are found.
"The main goal of KPD was to increase the chance of KT among highly sensitized (HS) patients, preventing the onerous treatment of desensitization. For a country with more limited economic resources like Brazil, KPD makes perfect sense for always contemplating compatible, cheaper, and more successful transplants."
And a final summation from two of the authors of the original paper:
Bastos, Juliana, and Gustavo Ferreira. "Kidney Paired Donation in Brazil-It is time to talk about it." Transplant International: Official Journal of the European Society for Organ Transplantation (2021), 01 Oct 2021, 34(10):1757-1758 DOI: 10.1111/tri.14025 PMID: 34431143
"The history of kidney transplantation in Brazil began in 1965 when the first related living donor transplant. Since then, Brazil has established a public programme and now has the most extensive public kidney transplantation system in the world. Brazil has established a regulated, standardized and ethical organ procurement system, created awareness of transplantation in physicians and the public, upgraded facilities and standardized medical care, and enforced legislation for transplantation.
"The Aguascalientes document establishes that KPD and altruistic donation are acceptable. Its final recommendations also say that the country must provide access to transplantation based on ethical considerations and protect the most vulnerable population for a healthy transplant system [4]. We are failing to do that when we have a system that does not contemplate highly sensitized recipients, as shown by a recent Brazilian analysis: highly sensitized patients (PRA > 98%) had lower transplant rates (3.7% vs. 31.2%) and higher mortality (HR: 1.09, P = 0.05) in the waitlist when compared to nonsensitized patients [1]."
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Earlier related posts:
The American Journal of Transplantation has posted ahead of print a great article proposing clinical trials of a sensible system by which kidney donors might be compensated. It's main point is that evidence might be useful...
A Regulated System of Incentives for Living Kidney Donation: Clearing the Way for an Informed Assessment by Luke Semaru, and Arthur J. Matas
First published: 25 June 2022 https://doi.org/10.1111/ajt.17129
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi:10.1111/ajt.17129
Abstract: "The kidney shortage continues to be a crisis for our patients. Despite numerous attempts to increase living and deceased donation, annually in the United States, thousands of candidates are removed from the kidney transplant waiting list because of either death or becoming too sick to transplant. To increase living donation, trials of a regulated system of incentives for living donation have been proposed. Such trials may show: 1) a significant increase in donation, and 2) that informed, incentivized donors, making an autonomous decision to donate, have the same medical and psychosocial outcomes as our conventional donors. Given the stakes, the proposal warrants careful consideration. However, to date, much discussion of the proposal has been unproductive. Objections commonly leveled against it: fail to engage with it; conflate it with underground, unregulated markets; speculate without evidence; and reason fallaciously, favoring rhetorical impact over logic. The present paper is a corrective. It identifies these common errors so they are not repeated, thus allowing space for an assessment of the proposal on its merits."
The article begins with some relevant history:
"The concept of incentives for living donation arose early in the history of kidney transplantation. In the 1960s, the framers of the Uniform Anatomical Gift Act noted “every payment is not necessarily unethical”, but “until the matter of payment becomes a problem of some dimensions, the matter should be left to the decency of intelligent human beings”.1 In 1983, the matter of payment became a problem when, in response to the organ shortage, a physician (whose license had previously been revoked) established a company to broker international kidney sales. Impoverished residents of low-income countries were to be flown to the United States to sell their kidneys at a nominal price. This was met with general condemnation, and in part, led to passage of the National Organ Transplant Act (NOTA, Public Law 98-507) which made it a federal crime to “knowingly acquire, receive or otherwise transfer any human organ for valuable consideration for use in human transplantation...”. At the same time, the World Medical Association, the World Health Organization, the Council of Europe, and the International Council of the Transplantation Society, among others, issued statements of opposition to the sale of organs. "
...
"We are not tempted to conclude, for example, that, since in the 1920s Prohibition brought about an increase in political corruption and organized crime, the sale of alcohol, when legal and regulated, would do the same. For the same reason, we should not be tempted to conclude that, since participants in unregulated markets were swindled by outlaws, incentivized donors in a regulated system will fare the same."
A lot of the discussion of medical assistance in dying has focused on assisted suicide, but there is also the question of trying to die well by avoiding doomed heroic medical procedures at the end. Deborah James, an Englishwoman who chronicled how she dealt with her grim diagnosis, died recently, and is remembered in the British Press.
Here's a story, by a palliative care doc, from the London Sunday Times:
How to have a ‘good death’ like Deborah James by Dr Rachel Clarke
"As a palliative care doctor, I’m endlessly astounded by my patients’ capacity to savour their final days with a passion and intensity that can put the rest of us to shame. As time slips through their fingers, people find ways to be incandescent with life.
...
"I often ask patients: “What is the one thing you are most afraid of?” Invariably, the answer isn’t being dead per se, but the imagined horrors of the dying process. A conversation unfolds in which they learn that there are no upper limits on the doses of drugs we can give and that dying is rarely as dreadful as people fear. For the first time, they may start to feel a sense of control over their future.
"Practically speaking, planning ahead gives you the best chance of authoring how your life ends. Deborah, for example, died last week, aged 40, precisely on her terms — at her parents’ house, in the heart of her family, with domestic life quietly unspooling around her — by laying out her wishes clearly.
"Where would you like to be at the end — home, hospital or hospice? Who would you like to be with you when it happens? Sometimes patients regret being swept along by an impersonal medical machine that pushes endless rounds of gruelling treatment. Writing an advance care plan is the best way to ensure that what matters to you is placed centre stage. Appointing a legal power of attorney means that if you lose the capacity to make decisions for yourself, someone else can do so on your behalf.
"Consider asking to be referred to a palliative care team as early as possible. We can help with logistics such as finding carers, equipment, financial advice, “just in case” medications to store at home, and psychological support for adults and children."
For all you practical ethicists out there, here's a story by the AP that has divided my email correspondents:
Texas inmate asks to delay execution for kidney donation By JUAN A. LOZANO
"A Texas inmate who is set to be put to death in less than two weeks asked that his execution be delayed so he can donate a kidney.
...
"In a letter sent Wednesday, Gonzales’ lawyers, Thea Posel and Raoul Schonemann, asked Republican Gov. Greg Abbott to grant a 30-day reprieve so the inmate can be considered a living donor “to someone who is in urgent need of a kidney transplant.”
...
"Gonzales’ attorneys say he’s been determined to be an “excellent candidate” for donation after being evaluated by the transplant team at the University of Texas Medical Branch in Galveston. The evaluation found Gonzales has a rare blood type, meaning his donation could benefit someone who might have difficulty finding a match.
“Virtually all that remains is the surgery to remove Ramiro’s kidney. UTMB has confirmed that the procedure could be completed within a month,” Posel and Schonemann wrote to Abbott.
"Texas Department of Criminal Justice policies allow inmates to make organ and tissue donations. Agency spokeswoman Amanda Hernandez said Gonzales was deemed ineligible after making a request to be a donor earlier this year. She did not give a reason, but Gonzales’ lawyers said in their letter that the agency objected because of the pending execution date.
...
"In a report, the United Network for Organ Sharing, a nonprofit that serves as the nation’s transplant system under contract with the federal government, listed various ethical concerns about organ donations from condemned prisoners. They include whether such donations could be tied to prisoners receiving preferential treatment or that such organs could be morally compromised because of their ties to the death penalty."
HT: Frank McCormick
A recent article in Néphrologie & Thérapeutique simulates how kidney exchange in France could possibly be made substantially more effective, following liberalizations in the law. (The article is in French, but also has an English abstract.) A promising feature is that the article is a collaboration between physicians and market design economists.
Perspectives pour une évolution du programme de don croisé de reins en France
Perspectives for future development of the kidney paired donation programme in France by Julien Combe, Victor Hiller, Olivier Tercieux, Benoît Audry, Jules Baudet, Géraldine Malaquin, François Kerbaul, Corinne Antoine, Marie-Alice Macher, Christian Jacquelinet, Olivier Bastien, and Myriam Pastural
Abstract: "Almost one third of kidney donation candidates are incompatible (HLA and/or ABO) with their directed recipient. Kidney paired donation allows potential donors to be exchanged and gives access to a compatible kidney transplant. The Bioethics Law of 2011 authorised kidney paired donation in France with reciprocity between 2 incompatible “donor-recipient” pairs. A limited number of transplants have been performed due to a too restricted authorization compared to other European practices. This study presents the perspectives of the new Bioethics Law, enacted in 2021, which increases the authorised practices for kidney paired donation in France. The two simulated evolutions are the increase of the number of pairs involved in a kidney paired donation to 6 (against 2 currently) and the use of a deceased donor as a substitution to one of living donor. Different scenarios are simulated using data from the Agence de la Biomedecine; incompatible pairs registered in the kidney paired donation programme in France between December 2013 and February 2018 (78 incompatible pairs), incompatible transplants performed during the same period (476 incompatible pairs) and characteristics of deceased donors as well as proposals made over this period. Increasing the number of pairs has a limited effect on the number of transplants, which increases from 18 (23% of recipients) in the current system to 25 (32% of recipients) when 6 pairs can be involved. The use of a deceased donor significantly increases the number of transplants to 41 (52% of recipients). This study makes it possible to evaluate the increase in possibilities of kidney transplants by kidney paired donation following the new bioethics law. A working group and an information campaign for professionals and patients will be necessary for its implementation."
While the paper focuses on the situation in France, it's opening lines could have been written anywhere:
"La France, comme l’ensemble des pays du monde, souffre d’une pénurie de greffons rénaux de sorte que le nombre de malades en attente d’une greffe de rein ne cesse de croître." [France, like all countries in the world, suffers from a shortage of kidney transplants so that the number of patients waiting for a kidney transplant continues to grow."
Here's hoping that the authors will succeed in their plans to use deceased-donor initiated chains to save more lives in France.
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Earlier related posts:
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