Category Archives: Organ donation

GKE Debate in Current Issue of The American Journal of Transplantation

Figure showing the first GKE (to date)

Both Al Roth at his Market Design blog and Timothy Taylor on his blog, the Conversable Economist, have discussions today about our paper reporting the first Global Kidney Exchange (GKE) and the pushback it has received in the current issue of the American Journal of Transplantation. I’ve blogged about GKE (which Mike Rees and I previously referred to as Reverse Transplant Tourism or “RTT) before (see, e.g. here).

As Al says:

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. (emphasis mine)

Taylor also has a nice summary of our paper:

Basically, the notion is to involve pairs of people from low-income countries–one needing a kidney, one offering to donate a kidney–in these interlocking chains of kidney donation. For those in high-income countries, the advantage is potentially a lot more compatible kidney donors. Because getting a kidney donation saves money on dialysis, it is possible to use that saved money and provide the kidney donation for free to recipients from the low-income country. The result is healthier people, and overall cost savings.

And of the accompanying editorial:

The same issue of the journal includes a short editorial called “Financial Incompatibility and Paired Kidney Exchange: Walking a Tightrope or Blazing a Trail?” by A. C. Wiseman and J. S. Gill (pp. 597-98). As they write, “there are numerous considerations that require equipoise …” They point out issues that could arise in how donors in other countries are identified, whether the benefits are equitably distributed, whether consent is freely given, how this might affect providers of transplant services in low-income countries, and more. All fair enough, and I suppose only a benighted economist could bristle against their request for “sensitivity to the ethical pitfalls.” I would only point out that while we are being sensitive to ethical pitfalls of global kidney exchange, 2-7 million people are dying every year without access to treatment for their kidney disease, and we should spare a little sensitivity for them, too. (emphasis mine)

I would go even further than Taylor or Roth. The editorial is very thoughtful and worth reading in its entirety, here. It also raises some important ethical issues that have to be considered as GKE goes forward and I am grateful to the authors for having so carefully engaged our paper. At the same time, though, the argument that GKE may be ethically problematic because the benefits are unequally distributed between the US and developing world patients is, for me, just a nonstarter (and, to be clear, I speak for myself here and not for any of my coauthors).

As Roth says:

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.”

Given the Filipino patient’s lack of access to transplantation (and possibly even dialysis – we discuss this in the paper) GKE almost certainly saved his life. To paraphrase Taylor, perhaps only a benighted lawyer could question how this life saving transaction is exploitative of a Filipino patient, just because some Americans also benefit from the trade. The Filipino patient doesn’t care whether one or one hundred Americans were transplanted because of the chain he enabled – only that he received a healthy, compatible kidney that he otherwise could not have.

Here’s our full abstract:

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.

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.

Related posts:

Global Kidney Exchange (GKE) to Overcome Financial Barriers to Kidney Transplantation

Reverse Transplant Tourism

Reverse Transplant Tourism (cont.)

RTT Conclusion

Reverse Transplant Tourism Goes Live!!

More News Coverage Of Reverse Transplant Tourism

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Global Kidney Exchange (GKE) to Overcome Financial Barriers to Kidney Transplantation

Over at his Market Design blog, Al Roth has posted about our new article, forthcoming in the American Journal of Transplantation. From his post:

Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation

by

Michael A. Rees, Ty B. Dunn, Christian S. Kuhr, Christopher L. Marsh, Jeffrey Rogers, Susan E. Rees, Alejandra Cicero, Laurie J. Reece, Alvin E. Roth, Obi Ekwenna, David E. Fumo, Kimberly D. Krawiec, Jonathan E. Kopke, Samay Jain, Miguel Tan, Siegfredo R. Paloyo

Accepted manuscript online: 7 November 2016

“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.14106”

Abstract:

Organ shortage is the major limitation to kidney transplantation in the developed world. Conversely, millions of end-stage renal disease patients in the developing world 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 utilizing 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 healthcare 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 one-year experience of an initial Filipino pair, whose recipient was transplanted in the US with an American donor’s kidney at no cost to him. The Filipino donor donated to an American in the US through a kidney exchange chain. Follow-up care and medications in the Philippines were supported by funds from the US. We show that the logistical obstacles in this approach, although considerable, are surmountable.

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

And here’s that first GKE chain to date: it started with an American non-directed donor (blood type A) donating to the Filipino patient, and this chart shows the first 11 transplants that resulted.

1st GKE

 

I blogged about GKE before (back when we were calling it Reverse Transplant Tourism – admittedly a less palatable name than Global Kidney Exchange).  Mike Rees and I floated the idea as a hypothetical in Reverse Transplant Tourism, part of the Law & Contemporary Problems volume, Organs & Inducements. Back then, we proposed that a simple 2-way swap could help US incompatible pairs and developing world pairs (whether biologically incompatible or not), while also saving money, by leveraging the cost savings of transplantation over dialysis.  In practice, though, and as shown by the figure posted by Al, the first GKE helped a Filipino patient unable to afford transplantation on his own, while also facilitating a chain that has transplanted 11 US patients so far.

 

This video of the first GKE transplant is both informative and uplifting.

 

 

 

Related posts:

Reverse Transplant Tourism

Reverse Transplant Tourism (cont.)

RTT Conclusion

Reverse Transplant Tourism Goes Live!!

More News Coverage Of Reverse Transplant Tourism

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Gifts Versus Markets or Gifts Within Markets?

I’ll be giving a public lecture tonight at Washington & Lee University, as part of the Mudd Center for Ethics 2016-17 Speaker Series on Markets and Morals. The talk begins at 5:00 pm in Northen Auditorium, Leyburn Library and is free and open to the public. I’m honored to be included as a part of this great lineup of speakers, which includes Peter Singer, who discussed closely related issues. Singer’s talk, Permitting the Sale of Meat but not Kidneys or Sex? Some Questions about Markets and Morals, is available by video here.

Hope to see some of you there!

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Paying Bone Marrow Donors Is Not Unethical

bonemarrowSo says me and nearly two dozen others who work on questions of medical ethics, in a recent letter to The Department of Health and Human Services in response to an NPRM designed to reverse the decision in Flynn v. Holder.

Fellow Lounger Michelle Meyer and I have both written here a couple of times about current debates surrounding compensating bone marrow donors, as well as Flynn v. Holder (the 9th Cir. case holding that bone marrow donors could be legally compensated for peripheral blood stem cells obtained through apheresis, and the HHS proposed rule that would overturn that ruling.

Now, a group of researchers (including myself and Michelle) have signed onto a letter in opposition to the proposed HHS rule. From the letter:

This Rule would effectively reverse the decision in Flynn v. Holder before the U.S. District Court of Appeals for the Ninth Circuit.1 That decision holds that compensating donors of hematopoietic stem/progenitor cells (hereafter: “hematopoietic cells”) through a procedure called apheresis was not contrary to the National Organ Transplant Act.

We oppose the Rule. We maintain that the ethical arguments against a compensatory model for hematopoietic cell donation through apheresis (hereafter: “the compensatory model”) fail. We further maintain that significant ethical considerations speak in favor of the compensatory model, and therefore against the Rule.

Below, we respond to the ethical arguments offered in favor of the Rule: that the compensatory model would result in wrongful exploitation (§2); that the compensatory model would promote the view that human beings, their bodies, or subparts thereof, are mere commodities (§3); and that the compensatory model would incentivize donation for personal gain over donation from altruistic motives (§4). Given the ethical importance of avoiding preventable death and the strong likelihood that the compensatory model would help avoid preventable death, as well as the ethical importance of free choice, we conclude that the Rule is unethical (§1).

Read the whole thing here.

Related Posts:

On To Bone Marrow

Flynn v. Holder – The Fight Continues

Flynn V. Holder Rehearing Denied

Cohen on Flynn v. Holder

HHS Proposes Rule to Amend NOTA, Nullify Flynn v. Holder

 

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Our Day Of Market Design

Al Roth with Taboo Trades seminar, March 23, 2016

Al Roth with Taboo Trades seminar, March 23, 2016

As I mentioned in my last post, 2012 Nobel Prize winner Al Roth visited Duke Law School this week as a guest of the Law & Markets project. We basically worked Al to death while he was here – he gave three talks in a single day: a casual morning discussion over coffee with my Taboo Trades students and select faculty; a lunchtime public lecture about his book, Who Get’s What And Why: The New Economics of Matchmaking and Market Design; and an afternoon faculty workshop on Global Kidney Exchange (sometimes called Reverse Transplant Tourism). And that’s not counting the breakfasts, lunch, and dinner he had with faculty who wanted to hear even more about market design. I was exhausted from just watching him in action.

Those who know Al won’t be surprised by that, I suspect. As I’ve discussed before in prior posts (here and here), Al is deservedly well-known for his generosity in sharing his time and expertise with students, colleagues, and even know-nothings like me.

UnknownWhether by design or happy accident (I’m not sure which, though he is a market designer, hmm . . . ) there was little overlap in the content of the three talks, though each one built on the other and someone who attended all three (as many of us did) could gain new insight into market design at each stage. The morning session focused primarily on labor markets, especially the judicial clerkship market and market for summer associates and how that compared to the market for new medical residents. As Al discusses in the book, the market for judicial clerks, unlike the market for medical residents, is one in which attempts to prevent market unraveling have been largely unsuccessful. We talked a bit about why that might be and it was interesting to have that discussion among someone who has studied that market (Al), current market participants (the students), prior participants (law professors) and those who have negotiated some of the earlier (failed) agreements – law school administrators.

The lunch talk focused on the concept of market design more generally, but with an emphasis on school choice, kidney exchange, and high frequency trading as examples. The afternoon session was devoted to Al’s current work on repugnant transactions and Global Kidney Exchange, an issue we have both worked on with Mike Rees.

It was a really special day all around, but I was especially happy to get a chance to share Al in person with my Taboo Trades students. They have already spent more time thinking about repugnant transactions than most people ever will, and it was great for them to have a chance to meet “The Pied Piper of Repugnance,” as I referred to Al some years ago, in person. We memorialized his visit with us in the photo above.

Prior posts about Al Roth:

Tomorrow Is Al Roth Day!

Congratulations to Al Roth!

Al Roth: The Pied Piper of Repugnance?

Al Roth, Market Designer, in August Forbes

Scalping The Dalai Lama

Prior posts about Global Kidney Exchange/Reverse Transplant Tourism: collected here

Prior posts about the Taboo Trades seminar: collected here

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The Washington Post Debates Organ Donor Compensation

imrs.phpIn my black market Rhino horn post yesterday, I mentioned that a recent proposal to legalize a market in sustainably harvested Rhino horn:

. . . highlights some pretty standard debates about taboo markets in a new context. For example, one common point of contention is whether, when banning the market has failed to stop trading, society is better served by a regulated, legal market. This debate has occurred recently with respect to markets in prostitution and human organs, for example.

As if on cue, the Washington post began running a debate today on compensating organ donors. They begin with a “Primer” (my Kidney Transplantation Primer with Phil Cook is better, though 🙂 ) that emphasizes some of the points I made in the Rhino post:

The proponents for change also say that a ban on selling organs helped to create the global black market for organs, mostly in the developing world. The literature on this topic is terrifying: stories of political dissidents killed to have their organs harvested or impoverished citizens tricked into dangerous operations. Some advocates say that a government-regulated system of compensation could help end organ theft.

The participants are:

Sally Satel, resident scholar at the American Enterprise Institute and practicing psychiatrist at the Yale University School of Medicine,

Francis Delmonico, Harvard Medical School professor of surgery at the Massachusetts General Hospital, and Alexander Capron, professor of law and medicine at the University of Southern California,

Scott Sumner, economist at Bentley University and blogger at The Money Illusion,

Benjamin Humphreys, program director at the Harvard Stem Cell Institute,

Nancy Scheper-Hughes, founder of Organ Watch and anthropology professor at University of California, Berkeley.

So far, the posts from Sally Satel (Generosity won’t fix our shortage of organs for transplants) and Frank Delmonico, with USC Law Prof Alex Capron (Our body parts shouldn’t be for sale) have been posted.

Related Posts:

How Can the Shortage of Kidneys for Transplantation Be Rectified?

Reverse Transplant Tourism

Happy Birthday NOTA! (Now Go Away)

Flesh List Is Me

Cash for Kidneys: Reality is Complicated

Kidneys, Part II: The Limits of Deceased Donation Proposals

Innovation and Incentives: Beyond “Cash for Kidneys”

More Organs & Inducements

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A Cost-Benefit Analysis of Government Compensation of Kidney Donors

left Friends Philip Held and Frank McCormick (together with A. Ojo and J.P. Roberts) have just published A Cost-Benefit Analysis of Government Compensation of Kidney Donors in the latest issue of the American Journal of Transplantation. Here is the abstract:

From 5000 to 10 000 kidney patients die prematurely in the United States each year, and cost_benefit_analysisabout 100 000 more suffer the debilitating effects of dialysis, because of a shortage of transplant kidneys. To reduce this shortage, many advocate having the government compensate kidney donors. This paper presents a comprehensive cost-benefit analysis of such a change. It considers not only the substantial savings to society because kidney recipients would no longer need expensive dialysis treatments—$1.45 million per kidney recipient—but also estimates the monetary value of the longer and healthier lives that kidney recipients enjoy—about $1.3 million per recipient. These numbers dwarf the proposed $45 000-per-kidney compensation that might be needed to end the kidney shortage and eliminate the kidney transplant waiting list. From the viewpoint of society, the net benefit from saving thousands of lives each year and reducing the suffering of 100 000 more receiving dialysis would be about $46 billion per year, with the benefits exceeding the costs by a factor of 3. In addition, it would save taxpayers about $12 billion each year.

And from the accompanying press release:

In a just published paper, a team of researchers propose that the government compensate kidney donors to increase the supply of transplant kidneys, and they show the benefits of such a policy would greatly exceed its costs. Poor people in particular, they find, would enjoy the greatest net benefit, refuting the common allegation that compensation of donors would somehow “exploit” the poor. The proposal would also save a substantial amount of money for taxpayers, which should increase its political appeal. . . .

Given the controversial subject matter of this paper, the authors have appended 12 supplements to explain, justify, and document their key estimates and calculations. The paper — “A Cost-Benefit Analysis of Government Compensation of Kidney Donors” — and the 12 supplements are available online at:

http://onlinelibrary.wiley.com/doi/10.1111/ajt.13490/epdf

 

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How Can the Shortage of Kidneys for Transplantation Be Rectified?

BANNER

 

The July issue of Medical Law Perspectives is dedicated to the topic of “Organ Transplants: Saving Lives, Facing Risks, Minimizing Complications.Phil Cook and I are featured, with a piece on “How Can the Shortage of Kidneys for Transplantation Be Rectified?” (sorry, subscription required).

Here’s a bit from the text:

Recent innovations in immunosuppression, kidney matching algorithms, kidney swaps, and NEAD (nonsimultaneous, extended, altruistic donor) chains provide great hope. Yet, so far none of these mechanisms is sufficiently developed to make a serious dent in the kidney shortage. . .

For all of these reasons, we believe the time is ripe to reconsider inducements to kidney donation, and financial inducements in particular. Granted, pure “cash for kidneys” proposals are unlikely to garner popular support at this juncture, as evidenced by public opinion polls and the federal government’s reaction to incentives for bone marrow donations. . . .But an open market in kidneys is not the only option. Instead, any incentive system should build on the existing transplant frameworks and methods that already enjoy widespread acceptance. In particular, it would make sense to continue with a system where a government agency procures kidneys from carefully vetted donors and distributes them to transplant patients according to priority established by medical need. The main change is that the government agency would be in a position to provide some financial compensation to donors. . . .

For those interested in the topic, see also our recent article in Law & Contemporary Problems, A Primer on Kidney Transplantation: Anatomy of The Shortage.

The full slate of expert commentary from Medical Law Perspectives is below:

Expert Analysis

 What Proof Is Needed for a Transplant Malpractice Action?

Robert D. Kreisman, JD

 

How Can the Shortage of Kidneys for Transplantation Be Rectified?

Philip J. Cook, Ph.D; Kimberly D. Krawiec, JD

 

What Factors Impact the Success of Allogeneic Hematopoietic Cell Transplantation?

Hugo Fernandez, MD

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More News Coverage Of Reverse Transplant Tourism

08n1kidney-508n1rees-8Via Al Roth comes news of a detailed article in yesterday’s Toledo Blade about the first Reverse Transplant Tourism surgery that I blogged about the other day.

From the news article:

Dr. Rees calls his new program reverse-transplant tourism.

A husband and wife from the Philippines, Jose and Kristine Mamaril, are the first participants to benefit from this innovative system that allowed Mr. Mamaril to receive a life-saving transplant in Toledo from an American donor in Georgia. His wife, who has a coveted blood type, reciprocated by donating a kidney to a man in Minnesota who previously would have had to wait years for a match.

. . .

“In rich countries there’s not enough kidneys for people who have kidney failure, but there is plenty of money to pay for all the transplants. In poor countries, there’s lots of people that need kidney transplants and lots of available donors, but in poor countries they don’t have enough money,” Dr. Rees said.

This new program breaks down some of those barriers and helps bring people with the universal Type O blood into the U.S donor system, while helping someone from another country get access to free medical care.

One year of a kidney patient’s dialysis costs Medicare about $90,000, or nearly triple the $33,000 cost of a kidney transplant, Dr. Rees said. He argues his donor-matching system will ultimately save the federal government and private insurers money because it moves patients with kidney failure, also known as end-stage renal disease, off dialysis sooner.

You can download our recently published article on Reverse Transplant Tourism here.

You can also read my prior posts about RTT:

Reverse Transplant Tourism

Reverse Transplant Tourism (cont.)

RTT Conclusion

Reverse Transplant Tourism Goes Live!!

 

 

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