Access to transplantation around the world, at the International Congress of The Transplantation Society (TTS 2022) in Buenos Aires

I'm attending the 29th International Congress of The Transplantation Society (TTS 2022) | Buenos Aires - Argentina, and will speak in the first plenary session, on Access and Transparency in transplantation around the world.  I'll be the third of three speakers:

Plenary on access and transparency

 Monday, September 12, 2022 – 09:40 to 11:10

Transplantation in a moving world: Migrants, refugees & organ trafficking

Dominique Martin, Australia

Short Biography

Steps towards increasing deceased donation worldwide

Beatriz Dominguez-Gil, Spain

Short Biography

Transplant sufficiency in an unequal world

Alvin E. Roth, United States

Short Biography

Organ donor joke from the Edinburgh fringe

 “My dad suggested I register for a donor card. He’s a man after my own heart.” 

That's a joke by Masai Graham, who won the most popular joke vote this year at the Edinburgh fringe, with 52% of 2,000 votes for another one-liner: “I tried to steal spaghetti from the shop, but the female guard saw me and I couldn’t get pasta.”

Here's the Guardian with more:

Pasta one-liner wins best joke award at Edinburgh festival fringe. West Midlands comedian Masai Graham, who works as a part-time care worker, wins title for second time. by Harriet Sherwood 

Kidney exchange launched between the U.S. and Italy

 Here's the announcement from Italy (in Italian), on the site of the Centro Nazionale Trapianti, the National Transplant Center: 

Al via programma di trapianti incrociati di rene tra Italia e Usa, firmato l'accordo, 

Google translate: "The pilot phase will cover the first three cases and will be limited to  three hospitals : for Italy, the kidney transplant center of the  Agostino Gemelli Polyclinic in Rome will participate, directed by Professor Franco Citterio, present at the signing of the agreement, while for the USA the  University of Toledo Medical Center  and the hospitals of  Thomas Jefferson University in Philadelphia will be involved . Once the operational and management experimentation has been completed, the program will be re-evaluated for a possible consolidation of the protocol and for the progressive expansion to other living kidney transplant centers of the Italian network. 

"The one with the United States is  the second international exchange protocol  activated by our country: since 2018 an agreement has been in force involving France, Portugal and  Spain  and which has resulted in three cross transplants with the latter nation. From 2015 to date, the Italian national crossover kidney transplant program has allowed  77 interventions to be carried out . Overall, 2,043 kidney transplants were performed in Italy in 2021, of which 341 from living donors: of these, 5 were carried out through an exchange between donor and recipient pairs. "

*******

Here's the announcement from the Alliance for Paired Kidney donation, the U.S. partner (in English):

PILOT KIDNEY EXCHANGE TRANSPLANT PROGRAM LAUNCHED BETWEEN US, ITALY

""The goal of the memorandum of understanding, which was signed at the Ministry of Health in Rome, is to provide for the possible treatment of thousands of patients awaiting kidney transplants in both the U.S. and Italy. The agreement was signed on behalf of CNT by its director, Massimo Cardillo, and by Michael A. Rees, MD, PhD, the CEO of APKD and the surgical director of kidney transplantation at the University of Toledo Medical Center in Ohio.

"The new US-Italy program concerns kidney exchange transplantation, in which incompatible living donor and recipient pairs are matched with other incompatible pairs for kidney transplants. Thanks to the agreement between APKD and CNT, incompatible American and Italian donor-recipient pairs will be able to exchange with each other based on a shared algorithm that will verify the level of compatibility between those on the countries’ transplant waiting lists. In this way, patients with kidney failure, who also have an incompatible volunteer donor, will have a greater chance of receiving the transplant they need.

"In addition to the technical-operational aspects – such as the requirements of the participating hospitals, matching algorithm and overall governance of the transplant process – the agreement provides that the costs related to the transplant procedure are borne by the U.S. insurance coverage for the U.S. recipient and the Italian donor, while the Italian National Health Service will cover the expenses for the Italian recipient and the American donor. Transplant surgeries will take place in the country where the recipient is located.

********

A critical role was played by Dr. Ignacio Marino, the transplant surgeon who took time off to be the mayor of Rome and is now at Jefferson Hospital in Philadelphia.

His facebook post yesterday describes some details of the proceedings (first in Italian and then in English:

"The agreement was signed by the Italian National Transplant Centre (NTC), represented by director Massimo Cardillo, and the Alliance for Paired Kidney Donation (APKD), a non-profit organisation that runs one of the largest living kidney exchange programmes in the United States, represented by its CEO, Professor Michael A. Rees, MD PhD, director of the Kidney Transplant Centre at the University of Toledo Medical Center, Ohio. The signing of the protocol was attended by the Italian Deputy Minister for Health Pierpaolo Sileri, who has wholeheartedly supported this innovative project from the outlet."

Drs. Mike Rees and Ignazio Marino

**********

 ******** 

Update, October 3:

Here's an Italian news article from Sanita24 taking note of the agreement.

Trapianti di rene: attese più brevi grazie all'algoritmo del premio Nobel Alvin Roth  di Paolo Castiglia

G translate of first paragraph: "In no country in the world is there a sufficient number of donors to cover the transplant needs of all patients suffering from end-stage renal failure and who therefore have to resort to dialysis. To address this need, a memorandum of understanding was signed for the launch of an organ donation program in a “cross” mode between different continents, to offer a new possibility of treatment to patients on dialysis."

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

Related earlier posts

Tuesday, September 4, 2018

Ignazio Marino on global kidney exchange

Sunday, December 20, 2020

Jefferson University celebrates Dr. Ignazio Marino

Do (some) kidney donors have a right to donate?

 Here's an article that considers whether some potential kidney donors, who have more appetite for risk than some transplant teams, might nevertheless have a right to donate.

Donor Autonomy and Self-Sacrifice in Living Organ Donation: An Ethical Legal and Psychological Aspects of Transplantation (ELPAT) View  , by Nizam Mamode, Kristof Van Assche2, Lisa Burnapp, Aisling Courtney, David van Dellen, Mireille Houthoff, Hannah Maple, Greg Moorlock, Frank J. M. F. Dor, and Annette Lennerling, Transplant International, 35, 2022, https://www.frontierspartnerships.org/articles/10.3389/ti.2022.10131, DOI=10.3389/ti.2022.10131    

ABSTRACT: "Clinical teams understandably wish to minimise risks to living kidney donors undergoing surgery, but are often faced with uncertainty about the extent of risk, or donors who wish to proceed despite those risks. Here we explore how these difficult decisions may be approached and consider the conflicts between autonomy and paternalism, the place of self-sacrifice and consideration of risks and benefits. Donor autonomy should be considered as in the context of the depth and strength of feeling, understanding risk and competing influences. Discussion of risks could be improved by using absolute risk, supra-regional MDMs and including the risks to the clinical team as well as the donor. The psychological effects on the donor of poor outcomes for the untransplanted recipient should also be taken into account. There is a lack of detailed data on the risks to the donor who has significant co-morbidities."

"The donation of a solid organ for transplantation by a person who is alive at the time represents a unique event in healthcare, since the donor will gain no physical benefit from undergoing major surgery, which has a low but nevertheless significant rate of major complications and death (1, 2). Living donors are usually highly motivated individuals, whose appetite for risk differs substantially from that of the healthcare team (3). This may lead to conflicts between the clinical team and potential donors-some examples are given in Figure 1. Were the decisions of the clinical teams correct? This article explores the issues raised by these cases and others, and considers the principles which might help to guide decision-making. It is an overview aimed at healthcare professionals, and is not intended to be an in-depth ethical review."

***********

And here's a news story from People.com about just such a donor, who exercised his right to donate:

When His Patient Couldn't Find a Kidney Donor, This Doctor Gave His: 'It's a Feeling That's Hard to Describe'  "I was always in awe of people who donated organs. It fascinated me. And I soon decided that I didn't just want to talk the talk," said Dr. Aji Djamali    

By Johnny Dodd 

"Djamali, a nephrologist who chairs the department of medicine at Maine Medical Center Department, was wheeled into an operating room and surgeons removed his kidney. Within minutes another team went to work transplanting the organ into Jartz, who had been diagnosed with polycystic kidney disease (PKD) — an inherited disorder that causes the kidneys to enlarge and stop working — seven years earlier. (The two men met when Jartz was Djamali's patient at the UW Health Transplant Center in Madison, Wisconsin.)

"For Djamali, who was back at work two days later (Jartz was discharged after five days), being able to donate an organ was the culmination of a dream that began decades earlier while in medical school.

...

"Looking back on the experience, Djamali struggles to find the words to properly convey what it feels like to give a part of his body to another person.

"It's a feeling that's hard to describe," he says. "It's like watching your child being born. It's just this sensation of freedom, elation and happiness."

"But, of course, there was another reason why he did it. The veteran physician knew that the story of his actions might spur someone else to perform a similar act.

"Half of the reason was to help John," says Djamali, who is in touch with Jartz on a daily basis. "But the other reason was to encourage people to help others, to inspire them to consider stepping up and helping the 90,000-plus patients across the nation who are on waiting lists to get a transplant."

Three living kidney donors talk about their experience

 Tonight at 6pm Eastern, three donor stories from the National Kidney Donation Organization (NKDO)

Click Here to Register

Kidney exchange in China?

 Here's a video about kidney exchange, proposing that it should be adopted in China. (The author does not reveal his/her identity.)

 https://www.bilibili.com/video/BV1og411D7qu

Decriminalizing drugs at the head of the supply chain--Colombia

 The criminalization of drugs has different consequences on different parts of the supply chain. Here's a harm reduction proposal from Columbia--the Washington Post has the story.

Colombia, largest cocaine supplier to U.S., considers decriminalizing. By Samantha Schmidt and Diana Durán 

"It’s the largest producer of cocaine in the world, the source of more than 90 percent of the drug seized in the United States. It’s home to the largest Drug Enforcement Administration office overseas. And for decades, it’s been a key partner in Washington’s never-ending “war on drugs.”

"Now, Colombia is calling for an end to that war. It wants instead to lead a global experiment: decriminalizing cocaine.

"Two weeks after taking office, the country’s first leftist government is proposing an end to “prohibition” and the start of a government-regulated cocaine market. Through legislation and alliances with other leftist governments in the region, officials in this South American nation hope to turn their country into a laboratory for drug decriminalization.

“It is time for a new international convention that accepts that the war on drugs has failed,” President Gustavo Petro said in his inaugural address this month."

Paul Milgrom on auctions for water rights

 ZME Science (in Romania) interviews Paul Milgrom about water shortages (in California):

Could auctions help California make better use of its water? This leading economist believes so.  by Mihai Andrei  

"“People get confused when they think about auctions, they think about bidding for a piece of art or something like that,” Milgrom told ZME Science in an interview. “What economists mean when we talk about auction is a process of decentralized resource allocation using prices. It means that we’ve got people who have knowledge about what they need and how valuable things are to them, and we take account of that information to allocate resources specifically, we make bids, and those things are converted to determine prices.”

“If you’re not using an auction you either mean you’re not using prices to guide the resource allocation or you’re not using individual bids. If you don’t use that information, you’re gonna have waste.”

"Waste also means opportunity, and the opportunity Milgrom sees would be transferring water use from those who value it less to those who value it more (and are willing to pay more for it).

...

“In California, less than 5% of water is reallocated, even in the most severe drought,” Milgrom says

“The prices adjust [water gets more expensive], but the reallocation doesn’t adjust even when there is insufficient water. The prices are responsive, but the value of trade isn’t very responsive. So why doesn’t the market work, and what can we do to fix it?”

“It’s not what you expect in a market. What you would expect in a well-functioning market is that the water allocation would increase more to adapt to sending more water into higher value uses and less water into less-value uses. So we’d expect more trading to go on. The fact that it didn’t suggests there’s a problem with the market.”

...

"Designing a large-scale market for water isn’t without precedent. In Australia, a much larger proportion of water is being traded (about 50%); with a roughly similar standard of living, and similar environmental challenges, people in Sydney use about half that amount. But while Australia can serve as an inspiration for California, the same system can’t be replicated exactly.

“We can’t apply the Australian model to California because there are different property rights regimes, the rights are defined differently. They also don’t take into account return flows, which California water law does.”

...

"“I’m cautiously optimistic,” Milgrom says, drawing from his experience with auctioning broadcast spectrum space. “Part of what’s making me optimistic that this is the right time is the progress in measurements and hydrological models.”

Crowd control of misinformation, by limiting fast forwarding, by Jackson, Malladi and McAdams in PNAS

 Here's a paper in PNAS about limiting the spread of misinformation by changing the network of information flows:

Learning through the grapevine and the impact of the breadth and depth of social networks by Matthew O. Jackson, Suraj Malladi, and David McAdams

"Abstract: We study how communication platforms can improve social learning without censoring or fact-checking messages, when they have members who deliberately and/or inadvertently distort information. Message fidelity depends on social network depth (how many times information can be relayed) and breadth (the number of others with whom a typical user shares information). We characterize how the expected number of true minus false messages depends on breadth and depth of the network and the noise structure. Message fidelity can be improved by capping depth or, if that is not possible, limiting breadth, e.g., by capping the number of people to whom someone can forward a given message. Although caps reduce total communication, they increase the fraction of received messages that have traveled shorter distances and have had less opportunity to be altered, thereby increasing the signal-to-noise ratio."

Further unraveling of law firm offers to (first year) law students, and offers to new (first week) bankers from private equity

Eric Budish writes with a pointer to a Business Insider story on the current unraveling of the market for new lawyers and big law firms.

Inside the 'Wild West' of law-school recruiting that has Big Law reeling in talent earlier and more aggressively than ever

"this year, some legal-industry professionals say the competition has gotten out of control.

"Latham & Watkins, which hires about 300 students a year for its 10-week summer program, has told law schools that it has made 2023 summer-job offers to so many students ahead of the traditional period for on-campus interviews, or OCI, that it expects to conduct fewer OCI interviews this year, three people familiar with the firm's strategy said.

"Other elite firms — including Weil, Skadden, and Davis Polk — have also been making large numbers of early offers. At Simpson Thacher, a partner said, "We probably did half our interviewing before the formal OCI process."

"Working at a law firm after a student's second year, or 2L, has long been a rite of passage for students bound for Big Law. "Summer associates" are paid about $4,000 a week at top firms and get the chance to do legal research, eat nice meals on the company's dime, and meet the people they'll likely be working with after graduation — because upwards of 90% of them get an offer to return full time.

...

"Some law students are now entering recruiting talks in the spring of their 1L year. School administrators say it's often the students who get the ball rolling by submitting résumés via a firm's website after meeting a partner at a school meet and greet.

...

"Stanford and the University of Pennsylvania still ban pre-OCI recruiting, their websites said. Other schools require pre-OCI offers to stay open until OCI, so a student can compare firms. But not all firms respect the rules, and students sometimes are afraid to invoke them, said David Diamond, an assistant dean at Northwestern University's Pritzker School of Law.

"We've seen situations where a student receives an offer, and the offer deadline follows our policy, but the offer is accompanied by a diversity scholarship, and the diversity scholarship expires before or during" OCI, Diamond said.

...

"Some people trace the boom in early recruiting to a 2019 decision by the NALP to scrap rules that limited firms from courting first-semester law students. The rules were replaced by nonbinding guidelines."

**********

And even more frenzied are the job offers that new bankers (in their first week(s) on the job) are getting from private equity firms:

Wall Street just kicked off an annual Hunger Games-style recruiting ritual for junior talent that has young bankers interviewing till 2 a.m. for jobs that don’t start until 2024. https://advance.lexis.com/api/document?collection=news&id=urn:contentItem:668V-4FD1-DXY7-W4MT-00000-00&context=1516831 

"As Insider reported on Tuesday, the frenzied process appears to have kicked off on Monday evening when recruiters for a handful of firms sent out blast emails to select junior bankers suggesting meetings ASAP — before the window of opportunity closes.

"The emails forced these young bankers — many of whom have just started their first Wall Street jobs at places like Goldman Sachs and Citi — to figure out ways to quietly leave their desks to interview for jobs that won't start until the fall of 2024. 

...

"In recent years, the PE recruiting process has moved earlier and earlier, from October to September, but never to late August, as it has done now. It's forcing firms to figure out how to interview candidates with no real job experience. "

The market for prison beds and prisoners

 Kim Krawiec points me to this article about prison space for rent, from the Brennan Center at NYU:

A Market for Holding Humans: The Correctional and Detention Bed Trade, by Lauren-Brooke Eisen and Ram Subramanian

"For decades, sher­iffs, correc­tions agen­cies, and for-profit firms have sought to alle­vi­ate prison and jail over­crowding by offer­ing avail­able beds to other juris­dic­tions in need of space. And the need is great. Despite the over­all decline in impris­on­ment rates since 2009, many places still have too many people to safely house. The same goes for deten­tions by U.S. Immig­ra­tion and Customs Enforce­ment.

"This market can be a much-needed source of revenue for local­it­ies. In Louisi­ana, for example, ICE pays $74 per day — nearly three times what the state prison system reim­burses local sher­iffs. Midland County, Michigan, where the local budget depends on jail bed rent­als, charges $45 per bed per day to other counties and $35 to the state.

...

"At one point, a website called Jail­Bed­Space.com covered 48 states, serving more than 150 agen­cies. The company matched jail admin­is­trat­ors with empty beds in facil­it­ies in other counties or states. Other so-called “bed brokers” have popped up over the years, all receiv­ing fees for each bed they rent out.

...

"The detained people bear the cost as they are shuttled across juris­dic­tional lines, hundreds or even thou­sands of miles from their famil­ies, friends, and communit­ies. Addi­tional miles and state lines present finan­cial and prac­tical barri­ers to retain­ing these import­ant ties. One man incar­cer­ated in Vermont who was moved in the middle of the night to Kentucky without warn­ing said, “This prac­tice of trans­fer­ring inmates out-of-state is horrendous. You’re taking people who, whatever support network they may have, is gone. . . . you’re alone. You’re isol­ated.”

Elizabeth "Betsy" E. Bailey (1939-2022)

 Betsey Bailey, an economist of many parts, has passed away.

I knew of her both as an academic dean at CMU and as a proponent of airline deregulation, in theory and practice.  The theory had to do with the idea that even markets with big players who had lots of market share might be perfectly competitive (and hence not need lots of regulation) if they were "contestable," i.e. if new entrants could enter the market at low cost if they saw profitable opportunities.  The idea was that the airline market would keep prices low to ward off new entrants, or entry by competitors into profitable routes.  Her stint on the Civil Aviation Board led to much reduced regulation of commercial airlines, after which airlines adopted the 'hub and spoke' patterns we see today. (When they were regulated, airline routes looked more like railroads, e.g. some had northern routes, some southern...)

Here's the Washington Post obituary:

Elizabeth Bailey, pathbreaker for women in economics, dies at 83. She was the first woman to receive a PhD in economics from Princeton and helped deregulate airlines as the first woman on the Civil Aeronautics Board  By Emily Langer

"Dr. Bailey, 83, who died Aug. 19 at her home in Reston, Va., was widely credited with opening opportunities for women in her field.

"In 1972, she became the first woman to receive a PhD in economics from Princeton University. Five years later, President Jimmy Carter appointed her the first female member of the Civil Aeronautics Board, where she helped provide the intellectual framework for the deregulation of the airline industry.

...

"Later, at Carnegie Mellon University in Pittsburgh, Dr. Bailey became the first woman to serve as dean of a Top 10 graduate business school."

*******

See 

Morrison, Steven A., Clifford Winston, Elizabeth E. Bailey, and Alfred E. Kahn. "Enhancing the performance of the deregulated air transportation system." Brookings Papers on Economic Activity. Microeconomics 1989 (1989): 61-123.

Bailey, Elizabeth E., David R. Graham, and Daniel P. Kaplan. Deregulating the airlines. Vol. 10. MIT press, 1985.

Bailey, Elizabeth E., and William J. Baumol. "Deregulation and the theory of contestable markets." Yale J. on Reg. 1 (1983): 111.

Singapore to repeal law against sex between men.

 The Guardian has the story:

Singapore to repeal law that criminalises sex between men. Scrapping of colonial-era section 377A law hailed as ‘a win for humanity’ by LGBTQ+ rights groups  by Rebecca Ratcliffe

"Singapore will repeal a colonial-era law that criminalises sex between men, a landmark decision described by LGBTQ+ groups as “a win for humanity”.

"In a national address on Sunday, the prime minister, Lee Hsien Loong, said that scrapping section 377A of the penal code would bring the law into line with current social attitudes and “provide some relief to gay Singaporeans”.

"However, Lee added that the government did not want “wholesale changes in our society”, including changes to the legal definition of marriage.

“Even as we repeal 377A, we will uphold and safeguard the institution of marriage. Under the law, only marriages between one man and one woman are recognised in Singapore,” he said.

"Section 377A, which was introduced under British colonial rule, criminalises “any act of gross indecency with another male person”. The law carries a sentence of up to two years in prison, though it is not believed to have been enforced for more than a decade."

Kidney news from Cambridge on possibility of removing blood type barriers

 Here's some very preliminary kidney news (a press release) in The Guardian and at Cambridge, that could have the potential to have an impact sooner rather than later in helping potential transplant recipients with blood type O, who can only receive blood type O kidneys (which can be received by patients of any blood type)...  

Researchers change blood type of kidney in transplant breakthrough University of Cambridge team’s work could significantly increase supply of organs for people with rarer blood types

"University of Cambridge researchers used a normothermic perfusion machine – a device that connects with a human kidney to pass oxygenated blood through the organ to better preserve it for future use – to flush blood infused with an enzyme through the deceased donor’s kidney.

"The enzyme removed the blood type markers that line the blood vessels of the kidney, which led to the organ being converted to type O."

*******

https://www.cam.ac.uk/stories/kidneybloodtype

The scientists mentioned are Professor Michael  Nicholson and PhD student Serena MacMillan .

ANTHONY PETER "TONY" MONACO M.D. 1932 - 2022--performed first kidney exchange in the U.S.

The eminent transplant surgeon Dr. Tony Monaco has passed away.  Here's the Boston Globe obit:

ANTHONY PETER "TONY" MONACO M.D. 1932 - 2022

I wrote about Dr. Monaco  in connection with the first U.S. kidney exchange surgery, which he conducted with Dr. Paul Morrissey in 2000.

Tuesday, April 6, 2010

The first kidney exchange in the U.S., and other accounts of early progress

The Student BMJ (a student run affiliate of the British Medical Journal) has an article interviewing the pioneering surgeons who conducted the first kidney exchange in the U.S., in 2000. (It's gated, but you can register for free.)

Anthony P Monaco and Paul E Morrissey: a pioneering paired kidney exchange
Transplant surgeons Anthony P Monaco and Paul E Morrissey performed the first paired kidney exchange in the United States
By: Prizzi Zarsadias
Published: 24 March 2010, Cite this as: Student BMJ 2010;18:c1562

Matching in Dynamic Imbalanced Markets, by Ashlagi, Nikzad, and Strack

 Greedy is good in thick kidney exchange pools.

Matching in Dynamic Imbalanced Markets,  by Itai Ashlagi, Afshin Nikzad, Philipp Strack Aug 2022 (Early Access) | REVIEW OF ECONOMIC STUDIES  (ungated on arxiv, here.)

Abstract: We study dynamic matching in exchange markets with easy- and hard-to-match agents. A greedy policy, which attempts to match agents upon arrival, ignores the positive externality that waiting agents provide by facilitating future matchings. We prove that the trade-off between a “thicker” market and faster matching vanishes in large markets; the greedy policy leads to shorter waiting times and more agents matched than any other policy. We empirically confirm these findings in data from the National Kidney Registry. Greedy matching achieves as many transplants as commonly used policies (1.8% more than monthly batching) and shorter waiting times (16 days faster than monthly batching).

Patient preferences for taking an offered kidney versus waiting for a better one

 Here's a paper whose title announces in its first two words that it's unusual for the transplant literature: "Patient Preferences."   It sensibly asks about preferences for a transplant now versus a long future wait.  That's relevant, because the waiting list for a kidney is often years long.

Patient Preferences for Waiting Time and Kidney Quality, by Sanjay Mehrotra, Juan Marcos Gonzalez, Karolina Schantz, Jui-Chen Yang, John J. Friedewald and Richard Knight, CJASN Aug 2022, CJN.01480222; DOI: 10.2215/CJN.01480222

Visual Abstract

Abstract

"Background and objectives Approximately 20% of deceased donor kidneys are discarded each year in the United States. Some of these kidneys could benefit patients who are waitlisted. Understanding patient preferences regarding accepting marginal-quality kidneys could help more of the currently discarded kidneys be transplanted.

Design, setting, participants, & measurements This study uses a discrete choice experiment that presents a deceased donor kidney to patients who are waiting for, or have received, a kidney transplant. The choices involve trade-offs between accepting a kidney today or a future kidney. The options were designed experimentally to quantify the relative importance of kidney quality (expected graft survival and level of kidney function) and waiting time. Choices were analyzed using a random-parameters logit model and latent-class analysis.

Results In total, 605 participants completed the discrete choice experiment. Respondents made trade-offs between kidney quality and waiting time. The average respondent would accept a kidney today, with 6.5 years of expected graft survival (95% confidence interval, 5.9 to 7.0), to avoid waiting 2 additional years for a kidney, with 11 years of expected graft survival. Three patient-preference classes were identified. Class 1 was averse to additional waiting time, but still responsive to improvements in kidney quality. Class 2 was less willing to accept increases in waiting time for improvements in kidney quality. Class 3 was willing to accept increases in waiting time even for small improvements in kidney quality. Relative to class 1, respondents in class 3 were likely to be age ≤61 years and to be waitlisted before starting dialysis, and respondents in class 2 were more likely to be older, Black, not have a college degree, and have lower Karnofsky performance status.

Conclusions Participants preferred accepting a lower-quality kidney in return for shorter waiting time, particularly those who were older and had lower functional status."

HT: Martha Gershun

Morals and repugnance in markets, in Amsterdam, September 5.

 Theo Offerman writes:

"September 5, 2022, will be the inaugural workshop of the Amsterdam Center for Behavioral Change at CREED at the University of Amsterdam.

The workshop will focus on the theme of morals and repugnance in markets.

The speakers are: Sandro Ambuehl, Jana Friedrichsen, Klaus M. Schmidt, Florian H. Schneider, Nora Szech, Peter Werner and Andreas Ziegler. A detailed program is available on our website.

In the recent decades, the field of Behavioral Economics has generated important insights of the drivers of human behavior in economic decision making. The Amsterdam Center for Behavioral Change (ACBC) seeks to enhance our understanding of how these insights can be used to improve human behavior and economic outcomes. Founded in 2020, the ACBC encourages studies that aim to understand the effectiveness of behavioral interventions for societally relevant problems.

Please register here, participation is free.

Theo Offerman

(On behalf of the organizing committee: Theo Offerman, Giorgia Romagnoli, Andreas Ziegler)"

List of speakers:

Sandro Ambuehl, "Paternalism and in-kind poverty assistance"

Jana Friedrichsen, "Fairness in Markets and Market Experiments"

Klaus M. Schmidt, "How to regulate carbon emissions with climate-conscious consumers"

Florian H. Schneider: "Signaling Ideology through Consumption"

Nora Szech: "Competing Image Concerns"

Peter Werner: "Social norms, sanctions, and conditional entry in markets with externalities: Evidence from an artefactual field experiment"

Andreas Ziegler, "Morals in multi-unit markets"

Update: We will live stream the event:

https://uva-live.zoom.us/j/88159405808

Opt out organ donation in England and the Netherlands

 

Jansen, N. E., Williment, C., Haase-Kromwijk, B. J. J. M., & Gardiner, D. (2022). Changing to an Opt Out System for Organ Donation—Reflections From England and Netherlands. Transplant International, 133.

Abstract: Recently England and Netherlands have changed their consent system from Opt In to Opt Out. The reflections shared in this paper give insight and may be helpful for other nation considering likewise. Strong support in England for the change in legislation led to Opt Out being introduced without requiring a vote in parliament in 2019. In Netherlands the bill passed by the smallest possible majority in 2018. Both countries implemented a public campaign to raise awareness. In England registration on the Donor Register is voluntary. Registration was required in Netherlands for all residents 18 years and older. For those not already on the register, letters were sent by the Dutch Government to ask individuals to register. If people did not respond they would be legally registered as having “no objection.” After implementation of Opt Out in England 42.3% is registered Opt In, 3.6% Opt Out, and 54.1% has no registration. In contrast in Netherlands the whole population is registered with 45% Opt In, 31% Opt Out and 24% “No Objection.” It is too soon to draw conclusions about the impact on the consent rate and number of resulting organ donors. However, the first signs are positive."

...

"There had been many failed attempts to introduce Opt Out legislation to England over the last 30 years but was achieved on 20th May 2020. In October 2017 the Prime Minister stated her intention to shift “the balance of presumption in favour of organ donation” and “introduce an opt out system for donation.”

"Fortuitously a parliamentarian from the opposition party had successfully had his name drawn from a legislation ballot (a system which allows a few “Private Members Bills” to be considered by parliament from a randomly chosen subset of legislation suggestions), for a new Opt Out Bill. This led to an unusual alignment of opposing political parties, working together on a new policy. Due to this cross party support, the Bill progressed through Parliament and never had to be put to a vote.

"England’s Opt Out legislation built on the positive experience in Wales and Parliament was further reassured by the response to a public consultation on the draft Bill, which asked how Opt Out should be introduced. The Government usually expects between 200 and 500 responses; over 17,000 responses were received. The responses were supportive and gave a strong steer for the issues needing to be addressed.

"The main issues raised by the public were: the need for autonomy and individual choice; the role of the family; the need to respect faith and beliefs through the donation process. The government worked closely with NHSBT to identify ways to ensure that these issues were addressed. Ministerial commitments also secured additional resources such as increased recurrent funding.

"The final inspiration came from two young people—Max Johnson and Keira Ball. When the Bill was introduced, Max Johnson, a 9 year old boy, was in desperate need of a heart transplant. The UK media—particularly the Mirror newspaper—campaigned for the introduction of Opt Out legislation. Max’s life was saved through the gift of donation by Keira Ball, also aged nine, who tragically lost her life in a road traffic collision. The Opt Out legislation is known as Max and Keira’s Law, in their honour.

"Netherlands

"On the 1st of July 2020 the Opt Out system for organ donation was implemented in Netherlands. Changing the organ donation law from an Opt In consent system into an Opt Out system had not been easy. It took more than 12 years of political discussion to reach the milestone of a majority.

"In 2012 a member of the House of Representatives prepared a Bill to change the consent system into an “Active Donor Registration.” On the 16th of September 2016 the Bill was passed by the smallest possible majority in the House of Representatives, 75 members voted in favour of the Bill and 74 members against. On the 16th of February 2018 the vote in the Senate again ended in a close call, 38 senators voted in favour of the Bill and 36 members against. The Bill could only pass after a required amendment to develop a “Quality Standard Donation,” which describes the role of the doctor and the family in the donation conversation, based on the different outcomes of the Donor Register.

"The Active Donor Registration means that Dutch residents without a registration in the Donor Register, 7 million, will be asked by letter to register their donation preferences (same options as in the Opt In system). If they do not respond to a first and second letter, they will receive a third and final letter with the confirmation that they will be registered as having “No Objection” to organ and tissue donation. Under the new legislation “No Objection” would legally be considered the same as a registration of “Yes, I want to be an organ donor.” Registrations can be changed 24 h a day via the Internet. It could therefore be argued that while the change in law was to introduce Opt Out, it has similarities to a model of mandated choice for organ and tissue donation (6).

Learning and competition in the lab, in France, and in India

 Three NBER working papers this week particularly caught my eye: a lab experiment, a natural experiment, and a field experiment.

The first is a reminder of why simple reinforcement learning models have as much predictive power as they do. It's an experiment that shows that even when others' experience is made clearly visible, there's a tendency to rely on 'own experience'.

Not Learning from Others by John J. Conlon, Malavika Mani, Gautam Rao, Matthew W. Ridley & Frank Schilbach  WORKING PAPER 30378 DOI 10.3386/w30378 August 2022

Abstract: We provide evidence of a powerful barrier to social learning: people are much less sensitive to information others discover compared to equally-relevant information they discover themselves. In a series of incentivized lab experiments, we ask participants to guess the color composition of balls in an urn after drawing balls with replacement. Participants' guesses are substantially less sensitive to draws made by another player compared to draws made themselves. This result holds when others' signals must be learned through discussion, when they are perfectly communicated by the experimenter, and even when participants see their teammate drawing balls from the urn with their own eyes. We find a crucial role for taking some action to generate one's `own' information, and rule out distrust, confusion, errors in probabilistic thinking, up-front inattention and imperfect recall as channels.

******

The second is a careful study of affirmative action for women in French chess tournaments: a requirement that teams include a woman had many effects, including improvement in the quality of play by French women.

Trickle-Down Effects of Affirmative Action: A Case Study in France by José De Sousa & Muriel Niederle, WORKING PAPER 30367 DOI 10.3386/w30367 August 2022

Abstract: "The introduction of a quota in the French chess Club Championship in 1990, an activity many players engage in next to playing in individual tournaments, provides a quite unique environment to study its effects on three levels. We find that women selected by the quota improve their performance. We show large spillover and trickle-down effects: There are more and better qualified women. International comparisons confirm that the results are unique to France and that there are no substantial adverse effects on French male players. We discuss the properties of this quota and how to implement it in other environments."

The concluding paragraph:

"We speculate that one reason for the success of the French chess quota was due to the fact that it was an “output” rather than a “pure representation” quota. At least one ninth of the performance of teams in the Club Championship was determined by the performance of female players. Such an “output” based quota provides organization with different incentives than a pure representation quota does. We use economic departments to discuss the different gender quotas and how each of them might be implemented. We hope that future work will provide theoretical properties of various quotas as well as find other areas where output quotas are already, or could be, implemented."

*********

The third is about the difficulty of inducing competition in close quarters.

Does the Invisible Hand Efficiently Guide Entry and Exit? Evidence from a Vegetable Market Experiment in India by Abhijit Banerjee, Greg Fischer, Dean Karlan, Matt Lowe & Benjamin N. Roth, WORKING PAPER 30360 DOI 10.3386/w30360, August 2022

Abstract: "What accounts for the ubiquity of small vendors operating side-by-side in the urban centers of developing countries? Why don’t competitive forces drive some vendors out of the market? We ran an experiment in Kolkata vegetable markets in which we induced (via subsidizing) some vendors to sell additional produce. The vendors earned higher profits, even when excluding the value of the subsidy. Nevertheless, after the subsidies ended vendors largely stopped selling the additional produce. Our results are consistent with collusion and inertial business practices suppressing competition and efficient market exit."

Living Kidney Donor Transplantation and Global Kidney Exchange by Marino, Roth and Rees

 Here's a just-published article explaining global kidney exchange,  in Experimental and Clinical Transplantation (ECT), the journal of the Middle East Society for Organ Transplantation (MESOT):

Ignazio R. Marino, Alvin E. Roth, and Michael A. Rees, “Living Kidney Donor Transplantation and Global Kidney Exchange,” Experimental and Clinical Transplantation (2022), Suppl. 4, 5-9.

Update: here's a direct link to the paper.

Abstract: "Global kidney exchange offers an opportunity to expand living donor kidney transplants internationally to patients with immunologic barriers. The concept has been proven to be successful in a limited number of transplants. However, a number of misconceptions have created obstacles to its development. We suggest that a systematic application of this innovative tool would offer opportunities to treat thousands of patients worldwide who are presently denied a transplant and often even access to dialysis."

...

"The following 3 examples serve to demonstrate the financial challenges associated with GKE.

"The first GKE transplant involved an immunologically compatible husband and wife from the Philippines who were denied funding for a transplant in the Philippines by the government payer (PhilHealth). The husband-wife pair had no financial resources for travel, kidney transplant, or postoperative medications given their personal situation and the absence of a Philippine government payer for these costs (PhilHealth did not approve payment for this couple to receive a kidney transplant and also did not provide adequate payments for dialysis). The solution was a philanthropic solution whereby the APKD provided funding for travel and the transplant procedure and created an escrow account to pay for an estimated 10 years of recipient and donor follow-up care upon return to the Philippines.

"The second GKE transplant involved an immunologically incompatible donor and recipient who were cousins. They had government funding for a transplant in Mexico through the Mexican Institute of Social Security (known as IMSS by its Spanish acronym) but had not found a match from the Mexican deceased donor system in 5 years, and there was no viable kidney exchange program in Mexico.17 This pair raised sufficient financial resources to pay for travel to the United States and raised one-third of the cost of an uncomplicated kidney transplant in the United States. The IMSS agreed to provide postoperative medications and donor-recipient long-term followup care upon return to Mexico. The solution was a combination of government-financed postoperative care and private/philanthropic funding whereby the APKD partially subsidized the transplant procedures and fully managed financial aspects of potential complication costs.

"Two GKE transplants involved an immunologically incompatible pair of friends from Denmark and an immunologically incompatible mother-daughter pair from Mexico who were able to privately pay for travel, transplant, and postoperative care but were not able to manage the financial risk of a significant complication. The solution involved private/philanthropic funding whereby the patient paid for an uncomplicated kidney transplant in the United States, with APKD philanthropically fully managing the financial aspects of potential complication costs.

...

"The Philippines and Mexico do not offer kidney exchange to their citizens, so these patients had no choice but to look for an international option. In Mexico, it is possible that a living donor kidney could have been shipped from the United States to Mexico, but the patient’s transplant team in Mexico did not want to participate in the exchange. US regulations prevent a living donor kidney from being procured in Mexico, Denmark, or the Philippines and shipped to the United States. Thus, in each of these examples, the only option was for international pairs to travel to the United States and pay for transplant costs at US-based prices. Denmark offers kidney exchange through Scandiatransplant, but the program has less than 50 pairs participating, so matching for hard-to match patients is limited. For the Danish patient, who had panel reactive antibody levels greater than 90%, the only reasonable option was to look for a bigger kidney exchange pool outside of Scandiatransplant, such as the APKD pool in the United States.

...

"In conclusion, GKE provides personalized solutions by capturing relevant genetic, immunologic, physiologic, and social information to match patients with kidney failure and their willing donors to identify opportunities for living donor kidney transplant instead of dialysis or death.

"With GKE, a modality that can equally benefit rich and poor, industrialized world health care is made available to impoverished patients in less industrialized countries, while at the same time fighting unethical transplant tourism. In fact, with GKE, the exchange of a kidney for transplant is an altruistic gift and never an unethical and illegal commercial exchange. Moreover, with such a controlled system, every single donor and every single recipient of the GKE program can be scrutinized before the transplant procedure is performed and their data can be entered in a registry that can be accessed by transplant professionals to ensure ethical treatment of living donors and improved transition of care across national borders.

"Because one of the main motivations of GKE is to make transplantation more available in low- and middle-income countries, it would be helpful if the WHO revisited the ethics of GKE, ideally with an open discussion involving representatives of all WHO countries interested in this procedure."