Category Archives: Organ donation

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

Share:Tweet about this on TwitterShare on FacebookDigg thisShare on RedditShare on StumbleUponEmail this to someone

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

Share:Tweet about this on TwitterShare on FacebookDigg thisShare on RedditShare on StumbleUponEmail this to someone

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

 

Share:Tweet about this on TwitterShare on FacebookDigg thisShare on RedditShare on StumbleUponEmail this to someone

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

Share:Tweet about this on TwitterShare on FacebookDigg thisShare on RedditShare on StumbleUponEmail this to someone

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!!

 

 

Share:Tweet about this on TwitterShare on FacebookDigg thisShare on RedditShare on StumbleUponEmail this to someone

Reverse Transplant Tourism Goes Live!!

Regular readers will recall that I’ve blogged here before about Reverse Transplant Tourism (RTT), a new form of cross border kidney paired donation that Mike Rees and I propose in a recently published article. RTT leverages the substantial cost savings of transplantation over dialysis to pay for immunosuppressant drugs for a foreign recipient, in exchange for an agreement to enter into a kidney swap or NEAD (non-simultaneous, extended, altruistic donor) chain. The transaction is fairly complex, but I give a reasonably short and easy to understand summary in the posts linked below if you want a better understanding of RTT and its benefits.

Well, I am pleased to report that the first RTT took place in a series of transplants arranged by Mike Rees here in the US and Don Paloyo in the Philippines!

You can watch the video about Jose and Kristine below:

I can attest from first hand observation that this first RTT had to overcome major hurdles before getting off the ground. Dozens of folks dedicated time, money, and expertise to make it happen. But as we state in our paper, and Mike reiterates in the video, RTT cannot survive on philanthropy alone. In order to be sustainable, the insurance companies and (eventually) Medicare – who save thousands of dollars from each RTT transplant – have to fund RTT and other transplant innovations in order to really make a dent in the ever-growing waitlist.

HT: Al Roth for the video

You can also read my prior posts about RTT here:

RTT Conclusion

Reverse Transplant Tourism (cont.)

Reverse Transplant Tourism

And you can download the article here.

Share:Tweet about this on TwitterShare on FacebookDigg thisShare on RedditShare on StumbleUponEmail this to someone

Never Let Me Go With Duke Science & Society

If you’re in the Durham area, feel free to drop by the Duke campus on Feb. 17 for a screening of Never Let Me Go, followed by a discussion of the film with me and Professor William Hurd, M.D., M.P.H.  We”ll discuss the concept of humanity, the source of personhood, and how it does, and how it should, change with science.

Tuesday, February 17, 6:30 – 8:45 p.m.

Science & Society Classroom, North Building 232

RSVP scienceandsociety.duke.edu

Never Let Me Go S&S S&S-Film Series-Never Let Me Go-021715

Share:Tweet about this on TwitterShare on FacebookDigg thisShare on RedditShare on StumbleUponEmail this to someone

RTT, Conclusion

Figure 2In my last two posts, I introduced a new form of cross border kidney paired donation – Reverse Transplant Tourism (or “RTT”) — that Mike Rees and I propose in a recently published article. To recap, under RTT a biologically incompatible US pair, Amanda and Bob, engages in a kidney swap with a compatible Mexican pair, Carlos and Diana, who have no practical access to transplantation because the Mexican public health care system pays for transplantation but not immunosuppression. RTT leverages the substantial cost savings of transplantation over dialysis to pay for immunosuppressant drugs for Diana, in exchange for an agreement by Carlos and Diana to enter into a kidney swap with Amanda and Bob.

Bob has a new kidney, Diana has a new kidney, Bob’s insurance company saves money, and the Mexican government is on the hook for no more than its usual expenses. But NOTA (The National Organ Transplant Act), which prohibits “valuable consideration” for the acquisition, receipt, or transfer of any human organ lurks in the background. Why does RTT not violate NOTA? We argue that RTT passes muster under NOTA due to a combination of three unusual characteristics of the exchange: (1) Carlos’s perfect-world donative intent, (2) Carlos’s altruistic motivation, and (3) the medical necessity of the benefit received in the swap (Diana’s immunosuppression).

First, let me explain the concept of “perfect world donative intent,” which we think is very important to an analysis of the legality of RTT or any other transplant transaction. RTT differs in one important respect from other inducement schemes that arguably qualify as valuable consideration under NOTA: RTT does not provide an inducement to donate an organ. Rather, RTT provides an inducement for someone who, in a perfect world free of financial and immunological barriers, would altruistically donate an organ to a friend or family member, to instead donate that same organ to someone else. Once this is recognized, it becomes clear how and why RTT does not run afoul of standard objections to inducements to donate.

Second, Carlos’s motivation for the exchange is altruistic: He wants to benefit Diana rather than himself. These two factors distinguish RTT from other common proposals to increase the organ supply through inducements, such as financial incentives that accrue directly to the donor.

Finally, the benefit in question—Diana’s immunosuppression—is incidental to and medically necessary for the transplant to succeed. For all of these reasons and others, we believe that RTT is sufficiently similar to currently accepted practices, such as kidney-paired donation and NEAD (non-simultaneous, altruistic donor) chains, that it does not violate NOTA.

In sum, the need for transplantable kidneys far exceeds supply. In the face of NOTA’s restrictions on valuable consideration, creative solutions to the organ shortage are needed. It is even better when those solutions also reduce the costs associated with end stage renal disease.

RTT accomplishes both of those goals. Instead of non-U.S. kidney donors being offered money through a black-market middleman in exchange for one of their kidneys, we believe that RTT would provide a legal and ethical exchange of living-donor kidneys through kidney-paired donation. In this way, the donors will not receive money for their kidneys, but rather will receive a transplant for someone they love.

You can read the full paper here.

Related Posts:

Reverse Transplant Tourism Goes Live!!

RTT Conclusion

Reverse Transplant Tourism (cont.)

Reverse Transplant Tourism

Share:Tweet about this on TwitterShare on FacebookDigg thisShare on RedditShare on StumbleUponEmail this to someone

Reverse Transplant Tourism (cont.)

In my last post, I began discussing a new form of cross border kidney exchange, Reverse Transplant Tourism (or “RTT”), that Mike Rees and I propose in a recently published paper. To recap, RTT envisions a kidney swap between a biologically incompatible US pair and a foreign compatible pair who nonetheless have no practical access to transplantation for economic reasons. In the example chosen, Mexico, the state health care system pays for dialysis and transplantation, but not the immunosuppression necessary to prevent the body’s rejection of a transplanted kidney. As a result, transplantation is realistically available only to Mexican citizens with independent access to such drugs – i.e. they are wealthy enough to pay for it themselves or have access to philanthropic aid.

Figure 2RTT proposes to leverage the substantial cost savings of transplantation over dialysis to pay for immunosuppressant drugs for Diana, in exchange for an agreement by Carlos and Diana to enter into a kidney swap with Amanda and Bob. Thus, as shown in the accompanying figure, Amanda transplants to Diana, Carlos transplants to Bob, and the money saved from Bob’s ongoing dialysis is used to pay for the immunosuppressant drugs that Diana otherwise could not get.

Bob has a new kidney, Diana has a new kidney, Bob’s insurance company saves money, and the Mexican government is on the hook for no more than its usual expenses. Everyone is happy. Who could possibly object to such a welfare-improving transaction?

Arguably, someone familiar with the National Organ Transplant Act (“NOTA”), though as we detail at great length in the paper, neither the statute’s text, legislative history, nor underlying policy goals suggest that NOTA was meant to apply to RTT. NOTA prohibits the knowing acquisition, receipt, or transfer of “any human organ for valuable consideration for use in human transplantation if the transfer affects interstate commerce.” NOTA does not define the term valuable consideration and, as we detail in the paper and I have discussed in previous posts, the Act’s legislative history provides almost no guidance regarding the meaning of the term beyond the obvious legislative concerns of “buying,” “selling,” and “commerce” in human organs. Indeed, a careful reading of the legislative history of NOTA (which I undertake in the paper) suggests that Congress paid little, if any, attention to the possible meanings of and ambiguities in the phrase “valuable consideration.”

That leaves an analysis of the possible public policy goals animating NOTA’s ban against valuable consideration. In our paper, Mike and I analyze those public policy goals and demonstrate that RTT does not run afoul of any of them. In fact, RTT actually minimizes some public policy concerns better than current transplant practices do.

In my next post, I’ll discuss the public policy goals that might have animated NOTA in more detail, and demonstrate why those public policies suggest that RTT does not violate NOTA.

Related Posts:

Reverse Transplant Tourism Goes Live!!

RTT Conclusion

Reverse Transplant Tourism (cont.)

Reverse Transplant Tourism

Share:Tweet about this on TwitterShare on FacebookDigg thisShare on RedditShare on StumbleUponEmail this to someone