Results for “organ donation”
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Changing Views on Organ Prohibition

I spoke recently at the Kidney and Urology Foundation of America on using incentives to increase organ donation.  Also speaking was Nancy Scheper-Hughes, the courageous UC Berkeley detective/anthropologist responsible for busting international rings of organ traffickers.

Scheper-Hughes is well known as an opponent of kidney vending, especially because it has often involved the exploitation of poor people in the developing world (fyi, there is no question that exploitation has occurred even if you take the view, as I do, that payment per se is not exploitation.)  In her impassioned talk, Scheper-Hughes presented many pictures of poor people with large scars.  

Thus, I was very surprised that Scheper-Hughes favors a trial of compensation for deceased donation and is even supportive of a trial for compensated live donation saying:

"There are penalties for buying, selling and brokering the sale of organs in this country, but still it goes on, often with an attitude of 'don't ask, don't tell.' I believe that if the laws are not going to be followed, then the laws should change. First, though, a controlled study must take place, in an ethical manner, with a sample of volunteer organ donors being compensated appropriately."

As with alcohol and drug prohibition, many people who do not favor organ sales are coming to recognize that a regulated market or compensation system could be preferable to an illegal market.

Addendum: My powerpoint slides Using Incentives to Increase Organ Donation, cover the problem and some potential solutions which are being adopted around the world.  Also included at the end are some slides especially designed for teaching this material in a principles of economics class.

Innovative Solutions to the Shortage of Transplant Organs

Millions of people suffer from kidney disease, but in 2007 there were just 64,606 kidney-transplant operations in the entire world.

Today in the WSJ I discuss innovative solutions to the worldwide shortage of transplant organs from places like  Iran, India, Singapore, Israel and elsewhere.  One interesting bit I haven't blogged about before is routine removal of organs without the donor's or their families consent.  China?  No.  America.  It's been legal here for decades.

In a number of U.S. states, medical examiners conducting autopsies may and do harvest corneas with little or no family notification. (By the time of autopsy, it is too late to harvest organs such as kidneys.) Few people know about routine removal statutes and perhaps because of this, these laws have effectively increased cornea transplants.

Here is another bit on the shadowy definition of death:

Organs can be taken from deceased donors only after they have been declared dead, but where is the line between life and death? Philosophers have been debating the dividing line between baldness and nonbaldness for over 2,000 years, so there is little hope that the dividing line between life and death will ever be agreed upon. Indeed, the great paradox of deceased donation is that we must draw the line between life and death precisely where we cannot be sure of the answer, because the line must lie where the donor is dead but the donor's organs are not.

In 1968 the Journal of the American Medical Association published its criteria for brain death. But reduced crime and better automobile safety have led to fewer potential brain-dead donors than in the past. Now, greater attention is being given to donation after cardiac death: no heart beat for two to five minutes (protocols differ) after the heart stops beating spontaneously. Both standards are controversial–the surgeon who performed the first heart transplant from a brain-dead donor in 1968 was threatened with prosecution, as have been some surgeons using donation after cardiac death. Despite the controversy, donation after cardiac death more than tripled between 2002 and 2006, when it accounted for about 8% of all deceased donors nationwide. In some regions, that figure is up to 20%.

More on markets for organs, presumed consent, and point systems at the WSJ,

Organ Transplants

Bob Hickey, who lives near Vail, had needed a transplant since 1999 because of kidney disease. He met donor Rob Smitty of Chattanooga, Tenn., through Matching Donors.com, a for-profit Web site created in January to match donors and patients for a fee.

On Wed. the transplant was performed. It is the first “publicly brokered” transplant to occur in the United States. It is currently illegal to pay donors so Rob Smitty, the donor, was not paid (Hickey did cover Smitty’s expenses). Hickey did pay to have his name listed by MatchingDonors.com and this has upset a lot of people. No one seems upset, however, by the fact that the Hickey’s doctors were paid, his nurses were paid, the hospital was paid etc.

See my article for more on organ donation. Kieran Healy at Crooked Timber comments on the definition of death and another organ donation case in the recent news.

Thanks to Taggert Brooks for the link.

Is Alex an organ protectionist? Should he be?

In a recent post, Alex suggests that we should use market incentives to encourage organ donations from cadavers. I am all for this. But I also read Alex as suggesting that cadaver organs will form the bulk of the organ sales market, if such a market is allowed to develop. He is trying to present a relatively attractive picture of a market in organs, no fear of the desperate poor selling their organs for a pittance, and then squandering the windfall.

What about outsourcing, so to speak? If we had a truly free market in organs, I suspect that most organs would come from the living, and mostly from poor countries. The going rate for a kidney, for instance, runs between $1000 and $2000, which is probably cheaper than the incentives needed to garner many more kidneys from the dead in America. So if we wish to defend a trade in organs, we still need to face up to its less savory aspects, gains from trade or not, most people blanch at the idea of cutting live people open to pull out their kidneys. We can avoid this scenario if Alex is an organ protectionist, though I doubt that he is.

One more palatable option would involve harvesting kidneys from the poor dead, in poor countries. This is the best case scenario, as it would combine both free trade and harvesting from the dead rather than from the living. Needy patients get the kidneys, many lives are saved, but without cutting open desperate kidney sellers. But how easy is it to evaluate the quality of a kidney from abroad, much less ship the kidney from somewhere like India? Most likely, the cheapest way to ship kidneys is to put a living body, the kidney owner, on a plane. I could be wrong, indeed I hope I am wrong. But if I am right, perhaps there is at least some argument for organ protectionism. (Imagine the political rhetoric, “no more cheap kidneys from abroad!”. etc., Gephardt could mention this to kidney-selling states in the debates and get all the heads nodding.) If you, like I, believe that most poor organ sellers benefit little from their trades, it could be better to harvest organs from the American dead, than buying them from the living poor abroad.

Compensating Kidney Donors

The Trump administration will allow greater compensation for live kidney donors.

Supporting Living Organ Donors.  Within 90 days of the date of this order, the Secretary shall propose a regulation to remove financial barriers to living organ donation.  The regulation should expand the definition of allowable costs that can be reimbursed under the Reimbursement of Travel and Subsistence Expenses Incurred Toward Living Organ Donation program, raise the limit on the income of donors eligible for reimbursement under the program, allow reimbursement for lost-wage expenses, and provide for reimbursement of child-care and elder-care expenses.

While pure compensation is still illegal this goes a long way to recouping costs. In addition the executive order improves the rules that govern the organ procurement organizations with the goal of deceasing the number of wasted organs. Compensating kidney donors is a policy that I have long supported. Together the two changes could save thousands of lives. Even Dylan Matthew, a living organ donor who writes for Vox, is pleased.

Hat tip: Frank McCormick

Presumed Consent in Wales Falls Short

In 2003, Johnson and Goldstein published what would become a famous paper in Science, Do Defaults Save Lives? The paper featured a graph which showed organ donor consent rates in opt-in countries versus those in opt-out countries. The graph is striking because it seems to suggest that a simple change in the default rule can create a massive change in organ donor rates and thus save thousands of lives.

The graph, however, does NOT show organ donor rates. It shows that in opt-in countries few people explicitly opt-in and in presumed consent countries few people explicitly opt-out. But when a potential organ donor dies the families of people in opt-in countries who did not opt-in are still asked whether they would like to donate their loved one’s organs and many of them say yes. Similarly, in the presumed consent countries the families of people who did not opt-out are still typically asked whether they would like to donate their loved one’s organs and some of them say no.

The actual difference in organ donation rates between opt-in and presumed consent countries is much smaller than the differences in the graph, as Johnson and Goldstein made clear later in their paper. Nevertheless, the simple story in the graph encouraged many people to put excess weight on presumed consent as the solution to low organ donor rates.

The best estimates of presumed consent suggested that switching to presumed consent might increase organ donor rates by 25%. 25% isn’t bad! But we don’t have many examples of countries that have switched from one system to another so that estimate should be taken with a grain of salt.

The latest evidence comes form Wales which switched to presumed-consent in 2013. Unfortunately, there has been no increase in donation rates.

The most significant analysis of the new system is the Impact Evaluation Report, released by the Welsh Government in November 2017. Whilst focusing on the positives, such as increased understanding among medical staff, the report cannot escape the donation statistics, which clearly show no improvement. Covering the period from January 2010 or January 2011 to September 2017, all donation data show no change since the legislation’s introduction. The 21-month period before the Act came into effect saw 101 deceased donors, whereas the same period after showed 104; an increase, but one that can be properly attributed to expected annual fluctuation.

I still favor presumed consent or better, mandated choice, but I don’t think the binding constraints on organ donation are default rules. More important are preferences and fears about donation, the existence of a professional system using people who are trained to ask for donations, an institutional organization that can use donations when they are available (minimizing waste), and, of course, incentives.

Hat tip: Frank McCormick.

Monday assorted links

1. “With Choi Soon-sil-gate, Park Geun-hye put the entire country into the Tyson Zone.

2. Transmissible vaccines? (speculative)

3. Will machines run Singaporean food courts?

4. Daniel Drezner, The Ideas Industry, due out in April you can now pre-order.

5. Zombies for organ donation.

6. The flattening of the internet through video.  And is it better to record reel-to-reel than digital?

Altruistic Kidney Donors Favoring Financial Compensation

Dmitri Linde joins Alexander Berger and Virginia Postrel as altruistic kidney donors who advocate for lifting the ban on financial incentives. Here is Linde:

Two policies would address the shortfall of kidneys in the U.S.: instituting a priority-scoring system for donors and their kin and paying donors.

Israel pioneered the former in 2012. Prioritizing organ allocation by donor status—a system that economist Alex Tabarrok termed “no give, no take”—incentivized people to register as organ donors. It also removed a hurdle to living donation: The incentive to abstain because of a hypothetical (What if my son needs a kidney?) went away since the policy guarantees that a donor’s kin will be prioritized in the event that they need a transplant. The results? Both living and deceased donations have gone up, and the number of people who have died on the waitlist fell by 30% between 2010 and 2013.

To obviate the kidney shortage, we should heed the recommendation of Nobel Prize-winning economist Gary Becker and others by making it legal to compensate donors.

Linde donated a kidney with the aid of the excellent National Kidney Registry. The registry matched him to a recipient whose own willing but incompatible donor donated to another patient in need. Bravo Dmitri.

Here are previous MR posts on organ donation.

Counter Intuitive Nudges

Incentives don’t always work in the way we expect and neither do nudges. The British found that different slogans to encourage organ donation had markedly different effects.

 …the least successful message was: “Every day thousands of people who see this page decide to register [as an organ donor],” which ran alongside a picture of a group of smiling people.

….The most successful slogan was one which read: “If you needed an organ transplant, would you have one? If so, please help others.”

Ex-post it’s easy to come up with explanations for these differences but ex-ante these are difficult to predict. The unsuccessful slogan, for example, lets people know about a social norm; an approach that has been said to be very successful at reducing binge drinking and electricity consumption, so why didn’t it work for organ donation?

Here’s another peculiar nudge in NYC:

A counterintuitive “pilot program” aimed at reducing garbage in subway stations by removing trash cans appears, against all logic, to be working.

The idea of removing the trash cans came to the MTA in 2011 as a possible method of combating rats…But when the cans were removed from 10 stations, the agency found that not only did rat populations decrease, the amount of litter decreased, too.

My suspicion is that if this is true (and not random noise) then it’s a non-generalizable partial-equilibrium effect. If the trash cans have been removed only in some stations then people may be holding on to their trash knowing that they can dump it at the next station or in a trash can on the street. If you were to remove all or most of the cans this won’t happen.

Do you have other examples of counter-intuitive nudges? And what other explanations can you offer for the trash can effect?

Hat tip: Holman Jenkins.

The Oocyte Cartel

The Society for Assisted Reproductive Technology (SART) represents more than 85 percent of the assisted reproduction industry. SART requires that its members work only with agencies that limit compensation to egg-donors to around $5000 or a maximum of $10,000 (figures decided upon by the ethics committee of an affiliated organization, The American Society for Reproductive Medicine (ASRM)). In other words, ASRM-SART acts as a buyer’s cartel.

In 2011, Lindsay Kamakahi launched a class action suit against ASRM-SART challenging  their horizontal price-fixing agreement as per se illegal under the Sherman Antitrust Act. ASRM-SART tried to have the case dismissed but a judge recently denied the dismissal in the process making it clear that the plaintiffs have a good case.

ASRM-SART argue that their maximum price is really about protecting women and that compensation “should not be so excessive as to constitute undue inducement.” Egg donation does involve extensive screening, time and some health risks. One would think, however, that the proper response for those interested in protecting women would be to ensure that the women are fully informed and that they are paid high wages not low wages.

The paternalistic policy of the ASRM-SART especially rankles because it applies only to women, sperm donations are not regulated. Of course, sperm donation isn’t risky but we also don’t see laws limiting the wages of miners to protect miners (mostly men) from “undue inducement.” The societal expectation seems to be that men are appropriately motivated by self-interest but women may be appropriately motivated only by altruism.

I am in agreement with Kimberly D. Krawiec who writes in her excellent paper Sunny Samaritans and Egomaniacs: Price-Fixing in the Gamete Market:

It is ASRM’s paternalistic and misguided attempts to control oocyte donor compensation through the same type of professional guidelines that courts have rejected when employed by engineers, lawyers, dentists, and doctors that should raise an ethical red flag.

pricecontrolsrentsASRM-SART surely believe that they are doing good but I think it no accident that they also do well from a policy that reduces the price of their inputs. A price controlled below the market price generates rents. In the traditional analysis, the rents are dissipated away by long-lines, a form of rent seeking (see Modern Principles–first edition now a bargain!). It’s also possible, however, for suppliers to grab up the rents, especially suppliers of complementary goods.

For example, it’s often been pointed out that in the organ donor market the hospitals, surgeons and executives all get paid and paid well; the only person not getting paid is the person who provides the transplant organ. But we can say more–one of the reasons the hospitals, surgeons and executives get paid well is precisely that the donor is not paid. The shortage created by the price control drives the demander’s willingness to pay upward and some of the difference between the willingness to pay and the maximum legal price is captured by the suppliers of complementary inputs. How do we know? In the 1990s, entry into the transplant business grew much faster than did the supply of transplant organs. In fact, transplants were so profitable there was a rush to transplant that increased the number of centers but drove down center volume thereby reducing patient survival rates.

Similarly, by limiting egg-supply the suppliers of assisted reproductive services may be able to increase their share of the total gains from trade.

Although ASRM-SART may profit from restricting donor compensation there is another issue at large, the repugnance constraint. The repugnance and disgust centers of the brain are old and deep and often revolve around issues of body integrity, body products, hygiene, sex and death. Birth treads uneasily in many of these waters already and egg donation adds to this volatile mix issues of gender, personhood, identity and genetics all of which prime for a repugnance storm. The plaintiff’s case is sound but if the antitrust laws prevent ASRM-SART from limiting prices–or saying that they limit prices–and if egg donation were to become even more of a market in everything might there not be a backlash and an outright ban on compensated donors, as is the case in many other countries and for transplant organs in this country? I hope not but it is a real possibility.

The ban on compensated transplant organ donation has led to hundreds of thousands of excess deaths. A ban on compensated sperm and egg donation would lead to a dearth of lives.

Psychic Harm, Repugnant Conclusions and Presumed Consent

Steven Landsburg’s post on psychic harm has created a firestorm of controversy. Many people don’t understand thought experiments and that is part of the problem but it was also a bad idea to combine hypotheticals with a real case involving a real victim. Nevertheless, Landsburg’s post raised important questions about how pure psychic harm (“I don’t like the thought of other people having gay sex.”) differs from a physical transgression without physical harm (rape of someone who is unconscious and which leaves no trace).  The point is not about rape but about whether and why (some?) psychic harms should count in the moral calculus. As David Friedman argues, how we answer this question has deep implications.

Moreover, Landsburg’s stark hypothetical is closer to a real policy question than many might imagine. Consider the issue of presumed consent for organ donation, the policy used by many European countries where someone who dies is presumed to have agreed to be an organ donor barring evidence that they opted out. There are good (not necessarily definitive) arguments for presumed consent, namely that it would save some lives  at low cost. After all, what harm can be said to occur from taking organs from a dead person? The latter point is obvious to me but it’s only obvious because I think the dead can’t be harmed. Other people, think differently  Many religions consider cadaveric organ donation to be a kind of desecration. In fact, some people liken presumed consent to rape of the unconscious. Professor Hugh V McLachlan for example writes:

if someone had sex with an unconscious woman and tried to justify his action by saying that, when she was conscious, she did not indicate that she did not want to have sex, we would not accept this as a reasonable argument. The notion of presumed consent to the use of our organs after our deaths is no more reasonable.

and another commentator on presumed consent in Britain says

The difference between voluntary consent and presumed consent is at least the difference between consensual sex and rape of a drunk person.

Evidently for some people being dead is similar to being unconscious. Thus in both cases physical harms without physical consequence can be wrong because they generate psychic harm, either in expectation or in the afterlife. Clearly, distinguishing which psychic harms are to be counted and which not quickly becomes a question of metaphysics.

My own view is that as far as possible psychic harms should not be counted at all. Instead I would let ethics dictate the assignment of property rights and economics dictate the allocation. In particular, I would assign body ownership to the individual on strong libertarian and autonomy grounds but I would let individuals sell a kidney (or sex).

One of the virtues of markets is that markets make people pay for their preferences, if only in terms of opportunity cost. My suspicion is that the psychic harm from the thought that after death one’s organs might be used by someone else would quickly dissipate once some cash was on the table. Indeed, it’s often the case that the least cost way to avoid a psychic harm is to change one’s mind and, to paraphrase Upton Sinclair, it’s easier to get a man to change his mind when his salary depends upon him changing his mind.

Thwarted body part markets in everything

The Chicago-based nonprofit faces “the same challenge any business would have, whether I’m selling Hostess Twinkies or cadavers,” says Stephen Burnett, a professor of management and strategy at Northwestern University’s Kellogg School of Management.

To stay ahead, the association wants to supply body parts to the FBI and launch new products, including its own plastinated bodies, says Mr. Dudek, 62, executive vice president since 2005. He draws on his entrepreneurial experience as a co-owner of an MRI center in the south suburbs, which he sold to join the association.

Originally known as the Demonstrator’s Society, the association has not changed its business plan since its founding in 1918. Bodies are donated, embalmed and transferred to institutions such as med schools, where dissection remains a rite of passage.

Reasons for donations vary. Some gifts are part of estate planning, while others are made by relatives who cannot afford funerals.

By law, bodies cannot be sold, although groups like the association can be paid for processing. Member med schools pay about $1,300 per cadaver; nonmembers pay $2,300.

Nationwide, there’s a shortage of cadavers, in part because of the rise in organ donation. Cadavers without their organs are not suitable for medical education, Mr. Dudek notes. The association needs about 425 bodies a year for its members but missed that mark in 2009 and has barely met it in three of the last six years.

And yet globalization and government may come to the rescue:

The Middle East, where the culture discourages body donations, could be a new market. Schools in Lebanon and Saudi Arabia have recently expressed interest, he says. Law enforcement agencies also are prospects. Anatomical Gift is close to signing a contract to supply the FBI’s K-9 unit, which uses body parts to train dogs to find crime victims, he says. Limbs cost $570, plus $335 for HIV and hepatitis testing, since they are not embalmed, Mr. Dudek says. An FBI spokeswoman declines to comment.

There is more here, and for the pointer I thank G. Patrick Lynch.

Medical Self Defense

Americans have historically put great weight on the right of self-defense which is one reason why many people support the 2nd Amendment, as the Supreme Court noted explicitly in District of Columbia v. Heller. But what about medical self-defense? John Robertson argues:

A person can buy a handgun for self-defense but cannot pay for an organ donation to save her life because of the National Organ Transplantation Act’s (NOTA) total ban on paying “valuable consideration” for an organ donation. This article analyzes whether the need for an organ transplant, and thus the paid organ donations that might make them possible, falls within the constitutional protection of the life and liberty clauses of the 5th and 14th amendments. If so, government would have to show more than a rational basis to uphold NOTA’s ban on paid donations.

Unfortunately, the Supreme Court has rejected medical self-defense arguments for physician assisted suicide and let stand an appeals court ruling that patients do not have a right to access drugs which have not yet been permitted for sale by the FDA (fyi, I was part of an Amici Curiae brief for this case). Robertson argues, however, that these cases can be distinguished. Physician assisted-suicide doesn’t fall within a long-American tradition necessary to receive due-process rights and organ transplants are not untested or experimental. It’s a good argument although it’s disappointing that the medical self-defense principle must be unjustly delimited.

Hat tip: Law, Economic and Cycling.

No-give, No-take in Israel

In Entrepreneurial Economics I argued for a “no give, no take” system for organ donation–people who signed their organ donor cards would be given priority over non-signers should they one day need an organ. The idea has an element of justice to it but the primary goal is to increase the incentive to sign one’s organ donor card.

Israel recently adopted this policy by giving extra points on the allocation system to people who previously signed the organ donor card. In the case of kidneys, for example, two points (on a 0-18 point scale) are given if the candidate had three or more years previous to being listed signed their organ card.  One point is given if a first-degree relative had signed and 3.5 points if a first-degree relative had previously donated.

It’s early but so far the policy appears to be very successful:

Due to the population’s surge of interest in obtaining an organ donor card, the Adi-National Israel Transplant Center has extended through March 31 the deadline to register as a donor and receive special benefits.

…During the past few weeks, Adi’s phone system has collapsed several times due to the high demand.

Since Adi decided to give preferential treatment to those registering as a potential organ donor, tens of thousands of people have registered, raising the number of potential donors to over 600,000. Until last year, the rate of registration was among the lowest in the Western world.

Hat tip to David Undis whose excellent group Lifesharers (I am an adviser) is implementing a private version of no-give, no take in the United States.

Here is my piece on Life Saving Incentives and here are previous MR posts on organ donation.