Category Archives: Organ donation

If You Oppose Paying Kidney Donors, You Should Oppose Paying Football Players And Boxers Too: Wrap-Up

In this series of posts, I’ve discussed a new draft that Phil Cook and I are circulating, If We Allow Football Players and Boxers to Be Paid for Entertaining the Public, Why Don’t We Allow Kidney Donors to Be Paid for Saving Lives?. Our claim, which I laid out in my first post, is that there is a stronger case for compensating kidney donors than for compensating participants in violent sports. If this proposition is accepted, one implication is that there are only three logically consistent positions: allow compensation for both kidney donation and for violent sports; allow compensation for kidney donation but not for violent sports; or allow compensation for neither. Our current law and practice is perverse in endorsing a fourth regime, allowing compensation for violent sports but not kidney donation.

A common argument in support of the ban on kidney donation is that if people were offered the temptation of substantial compensation, some would volunteer to donate against their own “true” best interests. This argument is often coupled with a social justice concern, namely that if kidney donors were paid, a large percentage of volunteers would be poor and financially stressed, and for them the offer of a substantial financial inducement would be coercive. In sum, a system of compensated donation would provide an undue temptation, and end up exploiting the poor.

To these arguments we offer both a direct response, and a response by analogy with violent sport. My posts have touched on a few key points. First, the medical risks to a professional career in football, boxing, and other violent sports are much greater both in the near and long term than the risks of donating a kidney. On the other hand, the consent and screening process in professional sports is not as developed as in kidney donation. The social justice concerns stem from the fact that most players are black and some come from impoverished backgrounds.

Note that these arguments focus on the donors’ welfare, and ignore the welfare of people in need of a kidney. A comprehensive evaluation of amending NOTA to allow compensation requires that both groups be considered. Such an evaluation, conducted by Philip Held and colleagues, reached the following conclusion about a regime in which living donors were offered enough compensation ($45,000) to end the kidney shortage: “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.”

As stated by Held et. al., “dialysis is not only an inferior therapy for end-stage renal disease (ESRD), it is also almost 4 times as expensive per quality-adjusted life-year (QALY) gained as a transplant.” This means that the Medicare (which pays for the bulk of ESRD treatments) dollars currently spent on dialysis could be reallocated to compensating kidney donors, saving lives and tax dollars in the process.

As I said, even a series of posts gives only an introduction to our arguments and evidence, so download the full paper here.

Prior related posts:

If You Oppose Paying Kidney Donors, You Should Oppose Paying Football Players And Boxers Too

Paying Kidney Donors, Football Players, And Boxers: Medical Risks

Paying Kidney Donors, Football Players, And Boxers: Informed Consent And It’s Limits

Paying Kidney Donors, Football Players, And Boxers: Exploitation, Race, Class

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Paying Kidney Donors, Football Players, And Boxers: Exploitation, Race, Class

In prior posts, I introduced the question, If We Allow Football Players and Boxers to Be Paid for Entertaining the Public, Why Don’t We Allow Kidney Donors to Be Paid for Saving Lives?, and argued that the medical risks to a professional career in football, boxing, and other violent sports are greater than the risks of donating a kidney and that the consent and screening process in professional sports is not as developed as in kidney donation.

Although the primary focus of our paper is on the medical risk associated with living kidney donation, we also briefly discuss concerns about exploitation, coercion, race, and class, again with an analogy to violent sports. Living kidney donors in the United States have above-average incomes (after adjusting for sex and age). In a new regime in which donors were paid a substantial fee, it is predictable that the influx of volunteers would have below-average incomes. The prospect of financially stressed individuals attempting to make ends meet by “selling” a kidney raises a red flag for some ethicists. A compensation regime would expand the choice set for those in comfortable circumstances, but those in desperate circumstances might feel compelled to sell a kidney; in that sense, the option of selling could be seen as “coercive.” Furthermore, a system that in part depended on the poor to supply kidneys could be seen as “exploiting” the poor.

We believe that using words like “coercion” and “exploitation” to characterize the introduction of a new option by which poor people (and others) could earn a substantial amount of money provides more heat than light on this situation. The legitimate ethical concern is that so many Americans are poor, with inequality increasing over time. But that observation does not support a ban on compensation, which in fact limits the options available to the poor and thereby makes a bad situation (their lack of marketable assets) worse. But for anyone not persuaded by this argument, we note that these social-justice concerns apply with at least equal force to compensating boxers; most American professional boxers were raised in lower-income neighborhoods, and are either black or Hispanic.

As more has become known about the dangers of the repeated head trauma, similar arguments regarding football have become more prominent. About 70% of NFL players are black, and Pacific Islanders are also overrepresented as compared to the American population. Accordingly, much attention has been paid to the concussion crisis as a race and class problem. As one observer recently noted, “What’s a little permanent brain damage when you’re facing a life of debilitating poverty?” In reality, NFL players are better educated themselves, and come from better educated homes, than is average for Americans, in part because the NFL typically recruits college students. Still, some NFL players, like some would-be kidney donors, come from poverty.

Of course, this is only a taste of our arguments and evidence, so read the full paper here. In my next post, I’ll recap and wrap up.

Prior related posts:

If You Oppose Paying Kidney Donors, You Should Oppose Paying Football Players And Boxers Too

Paying Kidney Donors, Football Players, And Boxers: Medical Risks

Paying Kidney Donors, Football Players, And Boxers: Informed Consent And It’s Limits

 

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Paying Kidney Donors, Football Players, And Boxers: Informed Consent And It’s Limits

In prior posts, I introduced the question, If We Allow Football Players and Boxers to Be Paid for Entertaining the Public, Why Don’t We Allow Kidney Donors to Be Paid for Saving Lives?, and argued that the ban against paying kidney donors cannot rest on the basis of medical risk when we pay professional athletes to incur far greater risks. Today, I will talk about the consent process and the extent to which we might expect the system to protect participants – whether organ donors or professional athletes – from making bad choices against their own interests in exchange for the lure of money.

We believe that if NOTA were amended to allow payments to donors, potential kidney donors could be protected against being unduly tempted through the existing structure of screening, counseling, and delay, perhaps with some additional protections to prevent hasty decisions. On the other hand, it is not clear that NFL recruits have such protections in place.

Whether and when sane, sober, well-informed, adults should be banned by government authority from choosing to engage in an activity that risks their own life and limb is an ancient point of contention. There are a variety of hazardous activities that are permitted with no legal bar to receiving compensation. Included on this list are such occupations as logging, roofing, commercial fishing, and military service. Also included are violent sports such as football, boxing, and mixed martial arts (MMA). These examples illustrate a broad endorsement of the principle that consenting adults should be allowed to exchange (in a probabilistic sense) their physical health and safety for financial compensation, even in some instances where the ultimate product is simply providing a public entertainment.

One potentially distinguishing feature of kidney donation is that the harm is not the result of an accident, but rather of the deliberate action (of the surgeon and medical team). But this is also the case with fighting sports and with egg donors, who are compensated.

It is helpful to deconstruct the decision to donate a kidney under both the current regime (no compensation) and a hypothetical regime (in which the donor would be financially compensated). A well-developed organ procurement process in the American system seeks to ensure that potential donors are fully capable of making a good decision. Potential kidney donors are not only provided with full information, but also screened for mental and physical disability. While there is the possibility of “mistakes” (a decision to donate against the true best interests of the individual) under both a compensated and uncompensated system, the screening, consent process, and delays should minimize the chance for the kind of errors that behavioral economics has demonstrated are common. There is nothing intrinsically irrational about a willingness to assume medical risk in exchange for a substantial amount of money. But the quality of the choice may be influenced by a variety of factors, and we recommend some “nudges” designed to overcome the most common causes of faulty decision-making under such circumstances.

The same concerns that apply to the quality of kidney donor decisions also apply, and more obviously, to the decision to sign a contract to play in the NFL. Yet the consent and screening process in professional sports is not as developed as in kidney donation. Players are provided with little information about the risks, and indeed, the longer-term risks (including the risk of CTE in middle age) have not been well quantified, but appear to be far higher than for kidney donation. The payoff in both financial terms and status is also very high, and in part conveyed immediately. Any counseling or screening that might occur is up to the player to pursue.

In short, to the extent that the ban on compensated kidney donation is grounded in a concern that the lure of money may cause donors to disregard the risks of the procedure and subsequent long-term effects, that concern applies with even more force to participation in violent sport.

This, of course, is just a taste of our analysis and evidence, so read the full paper for more.

Prior related posts:

If You Oppose Paying Kidney Donors, You Should Oppose Paying Football Players And Boxers Too

Paying Kidney Donors, Football Players, And Boxers: Medical Risks

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Paying Kidney Donors, Football Players, And Boxers: Medical Risks

Yesterday, in If You Oppose Paying Kidney Donors, You Should Oppose Paying Football Players And Boxers Too, I introduced a new paper, written by Phil Cook and me, arguing that the case for paying kidney donors is much stronger than the case for paying participants in football, boxing, and other violent sports, and promising to follow up with subsequent posts outlining our arguments and evidence.

Today, I’ll discuss the central argument in our paper: the medical risks to a professional career in football, boxing, and other violent sports are much greater both in the near and long term than the risks of donating a kidney. Injuries in such sports are common, and retired players are very often disabled by the long-term effects of these injuries as well the cumulative effect of thousands of blows to the body.

One challenge in making a meaningful comparison between the risks entailed in kidney donation and the risks entailed in participation in contact sports is that the latter may stretch out for many years and involve not one choice (donate or not) but rather a series of choices regarding participation. While it is difficult to quantify these effects in a way that provides a natural comparison with kidney donation, we provide some statistics that suggest that, for example, a man who signs a contract to play in the NFL for a year is consenting to be exposed to far greater medical risks than someone who volunteers to donate a kidney.

We focus our analysis on football, because the epidemiology of injury and disability is better developed than for fighting sports. It is worth noting, however, that there has always been concern about the risk posed by fighting sports, and that concern has accelerated in recent years, due to a better understanding of the long-term effects of head trauma. As a result of these risks, medical associations around the world, including the American Medical Association and various state medical associations, have called for limitations or bans on boxing and MMA.

As to kidney donation, we analyze both the post-operative risk from surgery and the post-recovery chance of death or disability resulting from loss of function of the remaining kidney. Both risks – while greater than zero — are quite low, both in an absolute sense and in comparison to the typical risks of participation in violent sport. For example, post-operative complications (most of them minor, such as bleeding or wound infection) are present in 7.3% of cases, and donors face a higher cumulative incidence of end stage renal disease than nondonors – 0.31% versus 0.04%. While that risk is thus significantly elevated for donors, it remains very low in an absolute sense, representing an increased chance of about 1 in 400.

With respect to football, we discuss injury rates at the youth, high school, collegiate, and professional level. While that data is far too extensive to fully discuss here, I’ll provide a few highlights:

  • In 2016, the 2,274 active players in the NFL experienced 2066 injuries during the preseason and regular season, 244 of which were concussions. That’s .073 concussions per player-season – about equal to the rate of surgical complications (again, most of them minor) in kidney donation.
  • Official injury reports and survey information suggest that for a substantial majority of former players, injuries ended their career or contributed to the decision to end their career. Nine of 10 former players have nagging aches and pains from football when they wake up, and for most the pain lasts all day. For those age 30-49, the ability to work is impaired by injury.
  • A recent postmortem study of a sample of donated brains of former NFL players found that 110 of 111 indicated either mild or (more commonly) severe CTE.

This last point requires some explanation, because the findings do not imply that 99% of former NFL players will have CTE. The brains in the study were voluntarily submitted for examination by family members who were often motivated by a desire to know the cause of their loved ones dementia or other neurological problems. But the 111 brains do represent 8.5% of the 1300 former NFL players who died during the period that these brains were donated. That places something of a logical lower bound on the prevalence of CTE. Presumably the true prevalence is much higher than 8.5%.

While it is not possible to do a precise “apples to apples” comparison of the medical risks associated with kidney donation` and the risks associated with a professional football career, it seems clear that the acute risk of injury and of long-term disability are far higher for the football player. As discussed above, most NFL veterans live out their lives following retirement with serious physical and mental disabilities. The vast majority of kidney donors lead entirely normal lives following recovery from the initial operation.

In other words, the ban against paying kidney donors cannot rest on the basis of medical risk when we pay professional athletes to incur far greater risks. This is just a short preview of the evidence on medical risk, so read the whole paper, If We Allow Football Players and Boxers to Be Paid for Entertaining the Public, Why Don’t We Allow Kidney Donors to Be Paid for Saving Lives?

Prior related posts:

If You Oppose Paying Kidney Donors, You Should Oppose Paying Football Players And Boxers Too

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If You Oppose Paying Kidney Donors, You Should Oppose Paying Football Players And Boxers Too

Having concluded that simply advocating for compensated kidney donation was not sufficiently controversial, Phil Cook and I are now turning our sights on professional sports – specifically, professional football and boxing. In a piece just posted to SSRN, we contrast the compensation ban on organ donation with the legal treatment of football, boxing, and other violent sports in which both acute and chronic injuries to participants are common. While there is some debate about how best to regulate these sports in order to reduce the risks, there appears to be no serious debate about whether participants should be paid. Indeed, for the best adult football players, college scholarships and perhaps a professional contract worth multiple millions are possible.

Phil and I will likely spend part of the winter break as television viewers contributing to the NFL teams’ collective $56 billion valuation. But our position on paying kidney donors saves us from hypocrisy. If, however, you are one of the many, many people who believe it is unethical to compensate kidney donors, then you should be out protesting the NFL. And don’t even think about watching the latest boxing or MMA matches.

Over the next couple of posts, I’ll outline the gist of our argument and evidence. We focus on the core argument for a ban on compensation for kidney donation, namely the paternalistic concern that even well-informed adults will sometimes be enticed by a financial reward to donate a kidney when in fact that is not in their “true” self-interest. In this view, the allure of money, especially for those who are in debt and struggling to make ends meet, will overcome good sense, leading to “exploitation” and even “coercion” to which people with less income and education are particularly vulnerable. But the same concerns apply with still greater force to participation in violent sports. Whatever one concludes about the ethics of regulating risky choices, and the problematic aspects of choices involving money and risk, the current circumstance – ban compensation for kidney donors, permit compensation for participation in violent sports – appears difficult to defend.

Over the next few days, I’ll touch on these key points: the medical risk to participants, the consent process, social justice concerns, and social welfare considerations. The medical risks to a professional career in football, boxing, and other violent sports are much greater both in the near and long term than the risks of donating a kidney. On the other hand, the consent and screening process in professional sports is not as developed as in kidney donation. The social justice concerns stem from the fact that most players are black and some come from impoverished backgrounds. Finally, the net social benefit from compensating kidney donors – namely, saving thousands of lives each year and reducing the suffering of 100,000 more receiving dialysis – far exceeds the net social benefit of entertaining the public through professional sports.

Download the piece here. And check back in over the next few days for subsequent posts.

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GKE Debate in The Latest Issue of the American Journal of Transplantation

I’ve blogged a few times before about Global Kidney Exchange (GKE, formerly called Reverse Transplant Tourism). See, for example here, here, and here. The October issue of the American Journal of Transplantation (AJT) contains a news report and six letters to the editor about GKE (3 are replies by us to pushback on our original article in the March 2017 issue). You can see Al Roth’s discussion of the issue here.

The report, written by Lara Pullen, is very well done and worth reading in full here to get a sense of the debate.

As noted in the Report:

In a recently published paper, Dr. Rees and his colleagues stressed the financial inaccessibility of dialysis for most low-income individuals.[1] With the GKE, recipients from developing countries not only receive a kidney, but also financial support to help them pay for the medical costs of maintaining their organ after they return to their home country. “Because the GKE involves exchange, it benefits both the foreign pairs and the domestic pairs. It’s a win for patients and the donors who love them in both countries,” says Alvin Roth, PhD, professor of economics at Stanford University in Palo Alto, California, and co-developer of the GKE.. . .

In an editorial and series of letters, transplantation surgeons throughout North America have raised objections to GKE.[2-4] Among the concerns is that staggering numbers of financially incompatible yet biologically compatible pairs would desire entrance into the program, and would likely overwhelm it. Opponents also contend that cultural differences in developing countries will make it difficult to definitively determine potential donors’ motivations. The risk, then, is one of exploiting individual citizens in developing countries, as well as undermining national KEs that may be in their early stages in these countries.

Some have also raised concerns that kidney paired donation (KPD) transplants would violate the current U.S. law that limits paired donation transplants to biologically incompatible donors, as opposed to financially incompatible donors. Dr. Rees and colleagues voiced their opinion on this in a recent paper.[5] [KDK-Mike Rees and I address the legality of GKE at great length here]

Thus GKE remains the subject of very strongly held opposing points of view.

As I’ve already noted in a prior post, some of these concerns are valid, but addressable by proceeding carefully with GKE. Others are simply, in my opinion, ridiculous. In any event, we respond to these criticisms in our responses and I plan to say more on this in further posts.

My co-author (not on GKE, but on another paper concerning Advanced Donation – see here), Marc Melcher, is quoted in the Report and is characteristically thoughtful:

Dr. Melcher acknowledges the importance of cultural differences and corruption. He also suggests that these factors are not unique to transplantation, and that any time a non-governmental organization (NGO) enters a developing country to provide aid, there is risk of corruption and unintended consequences. This risk, however, does not stop NGOs from stepping in and trying to provide aid in a developing country. Dr. Melcher feels that Dr. Rees and the GKE should be viewed within the context of NGOs.. . .

Perhaps Dr. Melcher best articulates the middle-of-the-road response. Noting that there are always unintended consequences in any such venture, he suggests a deliberate approach. “On a case-by-case basis it certainly seems like a win-win situation,” he says. “My bias would be to lead with ‘yes’ and go slowly.”

The Report and Letters to the Editor are all free and available from the links below:

 

The AJT Report

Global Kidney Exchange: Overcoming the Barrier of Poverty (pages 2499–2500)

Lara C. Pullen

This month’s installment of “The AJT Report” debates the benefits, ethics and sustainability of Global Kidney Exchange. We also look at efforts to shore kidney paired donation implementation in the United States.

 

Letters to the Editor

Kidney Paired-Donation Program Versus Global Kidney Exchange in India (pages 2740–2741)

  1. Kute, R. M. Jindal and N. Prasad

 

Comment: Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation (page 2742)

  1. S. Baines and R. M. Jindal

 

Global kidney exchange: Financially incompatible pairs are not transplantable compatible pairs (pages 2743–2744)

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

 

Opposition to irresponsible global kidney exchange (pages 2745–2746)

Francis L. Delmonico and Nancy L. Ascher

 

People should not be banned from transplantation only because of their country of origin (pages 2747–2748)

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

 

Open dialogue between professionals with different opinions builds the best policy (page 2749)

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

 

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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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