Monday, September 1, 2014

Banks for blood and sperm

At The Atlantic,  Rebecca Rosen writes about Banks of Blood and Sperm: How the idea of a "bank" shapes the way people think about storing and distributing body fluids, in an interview of  Kara Swanson, the author of Banking on the Body (which I blogged about here).

Very interesting.  For example:

"What happened as the metaphor [of a bank] became more used in the 1950s and 1960s, was that a backlash developed against the market implications of the metaphor. The doctors and lay people who ran blood banks in the 1950s and 1960s, pushed the metaphor to its extremes—they told patients that each transfusion was a “loan” that needed to be repaid. Patients could repay in kind, or pay stiff replacements fees instead—fees that a bank could use to buy blood from a professional donor—always with the goal of keeping sufficient inventory.

The emphasis on buying and selling led blood banks into trouble in the courts—attorneys for patients injured from transfusions (which happened sometimes, if mismatched blood was given, or the blood contained a disease) argued that banked blood was a product. Product liability law was developing to find the manufacturer of a dangerous product liable even without negligence. Doctors, blood banks, and hospitals were horrified to have themselves considered product manufacturers. They began to backpedal from the banking metaphor by trying to make banked blood seem less like a product exchanged in markets.

What happened, with blood banks, and also with other kinds of banks, is that the banking metaphor and the backlash encouraged doctors, patients, and those of us who might be suppliers, to focus on one aspect—the supplier. Was the supplying body paid or unpaid? Paid suppliers, who were obviously entering into a market transaction, were treating their bodies as a source of private property, and were acting as though they were selling a product. Unpaid suppliers, were seen as giving gifts, out of altruism, and keeping themselves out of a market."
"In law, we thus divide body products into two categories: those which we legally mandate as gifts only—all organs—and everything else, which can be gifted or sold, at the discretion of the supplier. Organs is defined broadly—bone marrow, for example, is an “organ.” This means that bone marrow, which can now be extracted from the blood in a procedure similar to the way blood plasma is harvested, cannot be sold by anyone. (Blood plasma is routinely sold, by the way.)
"I argue in the book that the simple pay-suppliers/don’t-pay-suppliers approach to thinking about body products, which resulted from the banking metaphor, needs to be replaced with more nuanced thinking. Should we treat different types of organs (hearts v. bone marrow) differently? Can we think about compensation schemes that are not free markets, but are managed to support the public goals of increasing body-product supply? Can those schemes protect suppliers and recipients alike by keeping suppliers safe from exploitation, and recipients safe from diseased products? I use history to suggest that the answers can sometimes be yes. Body products used to be routinely paid for, and doctors thought about these potential problems and addressed them. Over time, we have forgotten this past, and come to assume that buying body products is always dangerous and bad.

I like to remind people that lots of altruistic gestures are compensated—the doctors, and nurses, and everyone who works on a transplant operation are all in caring professions. They are doing those jobs because they want to help people (at least we hope and assume so). But we wouldn’t suggest that they shouldn’t be paid because to offer payment for such efforts would be insulting or immoral or cause their altruistic tendencies to be replaced by mercenary concerns.

Yet that is how we treat organ supply—that offering money would do all those bad things. Why should the supplier of a body product be the only person in that life-saving supply chain who is not compensated? People might choose not to be compensated, but if they want to be, and if more folks will act as suppliers with that incentive, why not?

To give a more specific historical example, let’s think about mothers’ milk stations in the 1930s. At that time, in most cities, such a station existed. It was established and supervised by a doctor or doctors, and its daily operations were run by nurses. Lactating women came to the station to express their breast milk and were paid by the ounce. Payment was used to ensure an adequate supply. The supply was used for sick and/or premature infants who lack a maternal source of milk."

In the meantime, here's a news article published around the same time, from the business side:
More blood banks merging to cut costs--Officials cite need for new model

"The proposed merger of Green Tree’s Institute for Transfusion Medicine with Florida-based OneBlood is the latest in a series of blood bank consolidations nationally, symptomatic of lean times for hospitals as they try to cut costs and reduce transfusions.

The deal, announced July 25, would create one of the largest blood banks in the country, with combined revenues of $480 million, if it goes through. The two firms jointly distribute nearly 2 million units of blood annually, serving 313 hospitals in eight states.

Only the American Red Cross would collect and distribute more blood."

Sunday, August 31, 2014

Patients can register at multiple transplant centers to get on multiple (regional) organ waiting lists

You don't have to be Steve Jobs to get a transplant in Memphis.
Here's an interview on multiple-listing yourself.

Multiple Listing to Reduce Wait Times for Transplant Patients
Mediaplanet sat down with Dr. Sridhar Tayur, owner of OrganJet, to learn how to list smartly.

MP: How does geographical location affect an organ transplant?
ST: The wait times are strongly correlated to geography. In New York, New Jersey, Boston, Atlanta, Chicago and Los Angeles, the wait times for kidney and liver transplants are very high compared to those at centers elsewhere. Patients in the high wait areas can list in a center with low wait in other geographies, depending on their insurance coverage and ability to travel or move.
MP: How can one find a low wait transplant center near their home?

ST: The data is available publicly through Scientific Registry of Transplant Recipients' website and is updated periodically.

MP: What can early transplantation mean for patients?

ST: In the case of kidney transplantation, you could get a transplant before you even go on dialysis. If you are already on dialysis, earlier transplantation has two benefits: better outcomes and less time on dialysis. It is also important to know, for kidney patients who have been on dialysis for a while or have been listed in one center for a while, they can transfer this wait time so far to a different center and so take credit for "time served." For a liver patient, getting a transplant at a lower Model for End Stage Liver Disease (MELD) score also means better outcomes and less inconvenience during pre-transplant time. In all cases, the outcomes are better and life before and after transplant is better. Listing in more than one place is allowed and patients should look into the many benefits of multiple listing. 

Saturday, August 30, 2014

Kidney exchange makes inroads in Florida

3-way kidney exchange at Jackson Memorial Hospital first in Fla. history

..."Jasko and Figueroa are just one pair in a three-way kidney exchange that happened at Jackson Memorial Hospital on July 9. It's the first of its kind in Florida.
"In all, six people took part in six life-saving surgeries. The four-hour procedure had to happen at the same time.
"All donor surgeries have to start at the same time," said Dr. Giselle Guerra, medical director of the Living Kidney Donor Program. "(We) can't have a donor back out. If they back out, it breaks the pair and we can't proceed."

Kidney exchange is coming to New Zealand

 Here's an announcement from New Zealand: Govt to launch kidney exchange service

"An extra 100 people could receive kidney transplants over the next four years under a new donor service the Government is establishing.
Health Minister Tony Ryall says there's a serious shortage of kidneys - while there were around 110 transplants last year there are still more than 600 people waiting for a transplant.
A National Renal Transplant Service is being set up which will coordinate services across the country.
There will be a kidney exchange system allowing donors and recipients who are not compatible with each other to be listed for possible swaps with other pairs.
A $4 million campaign to raise awareness and encourage more people to donate organs is already under way."

Friday, August 29, 2014

A bump on the road to the private sale of public parking spots

San Francisco orders parking spot auction app to cease-and-desist

he City Attorney of San Francisco has sent an immediate cease-and-desist letter to the makers ofMonkeyParking, a smartphone app that allows drivers to auction off their parking spaces.
In the Monday letter, City Attorney Dennis Herrera cited a city code that forbids drivers who "enter into a lease, rental agreement, or contract of any kind" for public parking spots. The violation is punishable by up to $300 in fines.
The Rome-based makers of the app have until July 11, 2014 to comply, and they could then face a lawsuit brought by the city. In addition to the City by the Bay, the startup also operates in the Italian capital.
"Technology has given rise to many laudable innovations in how we live and work—and MonkeyParking is not one of them," Herrera said in a statement. "It's illegal, it puts drivers on the hook for $300 fines, and it creates a predatory private market for public parking spaces that San Franciscans will not tolerate. Worst of all, it encourages drivers to use their mobile devices unsafely—to engage in online bidding wars while driving. People are free to rent out their own private driveways and garage spaces should they choose to do so. But we will not abide businesses that hold hostage on-street public parking spots for their own private profit."
The city said that it will also be sending similar letters to two other parking-related smartphone app-based startups.
MonkeyParking told Ars that it strongly believed in the company’s business model.
“As a general principle we believe that a new company providing value to people should be regulated and not banned,” Paolo Dobrowolny, MonkeyParking’s CEO, wrote to Ars in a statement. “This applies also to companies like Airbnb, Uber, and Lyft that are continuously facing difficulties while delivering something that makes users happy. Regulation is fundamental in driving innovation, while banning is just stopping it.”
HT: Scott Kominers

Thursday, August 28, 2014

The market for marijuana in Washington State, prior to legalization.

A RAND report assesses the marijuana market in the State of Washington prior to the legalization of marijuana through Initiative 502. Among the key findings are that consumption was estimated at over 120 metric tons annually, and that King, Snohomish and Pierce counties are happening places.

Before the Grand Opening: Measuring Washington State's Marijuana Market in the Last Year Before Legalized Commercial Sales

by Beau Kilmer, Jonathan P. Caulkins, Gregory Midgette, Linden Dahlkemper, Robert J. MacCoun, Rosalie Liccardo Pacula

Research Questions: What is the size of the marijuana market of Washington state in 2013?  How much marijuana do users in Washington consume and how to they obtain it?

Abstract: In 2012, Washington state voters passed Initiative 502 (I-502), which removed the prohibition on the production, distribution, and possession of marijuana for nonmedical purposes and required the state to regulate and tax a new marijuana industry. Legalization of possession went into effect almost immediately, but the revolutionary aspect of the law — allowing businesses to openly produce and distribute commercial-scale quantities for nonmedical use — is expected to be fully implemented in 2014.

...This report estimates the total weight of marijuana consumed in Washington in 2013 using data from existing household surveys as well as information from a new web-based consumption survey. Although the principal motivation for the study was estimating the size of the market, the report also describes various characteristics of the market, including traits of marijuana users in Washington and how they obtain marijuana.

While the Washington Office of Financial Management projected that 85 metric tons (MT) of marijuana would be consumed in the state in 2013, this report suggests that estimate is probably too low, perhaps by a factor of two. There is inevitable uncertainty surrounding estimates of illegal and quasi-illegal activities, so it is better to think in terms of a range of possible sizes, rather than a point estimate. Analyses suggest a range of 135–225 MT, which might loosely be thought of as a 90-percent confidence interval, with a median estimate close to 175 MT.

Key Findings

Marijuana consumption in Washington in 2013 is larger than the 85 metric tons (MT) previously projected by the Washington Office of Financial Management.
Even before adjusting for survey undercounting, our estimates suggest a 90-percent confidence interval of approximately 120–175 MT. The difference is largely driven by our use of more recent data.

It is difficult to know by how much surveys understate actual consumption.
Many of the relevant studies were published over a decade ago and times have changed; the NSDUH methodology has been improved substantially, and a national increase in marijuana use over the 2000s may have influenced willingness to self-report.
It is also unclear how applicable national and regional studies are to the state of Washington. After reviewing the evidence and attempting to adjust for undercounting, results from our simulation suggest consumption likely falls within the interval of 135–225 MT, with a median estimate close to 175 MT.

Three counties account for about 50 percent of marijuana users in Washington.
King County accounts for about 30 percent of the marijuana users, while Snohomish and Pierce counties each account for roughly 11 percent.

The literature is surprisingly thin concerning how much marijuana users consume during a typical day of use.
That general deficit becomes all the more acute when focusing on a particular jurisdiction and time, such as Washington in 2013. The emphasis has traditionally been on counting users, not counting grams.
However, by augmenting that thin literature with data from the web-based consumption survey developed by RAND, we estimate that Washington residents who use marijuana 21 or more times per month consume, on average, 1.3–1.9 grams during a typical use day.

Multiple datasets provide information about the potency of the marijuana consumed in Washington.
None is ideal, and there is no way to take a random sample of the universe of marijuana that is sold or consumed. But the available information suggests that lower-potency forms account for only a modest share of the Washington market and probably a smaller share than they do nationwide.

Wednesday, August 27, 2014

Surrogacy in Thailand

The NY Times discusses the market for surrogate child birth in Thailand, and possible new legislation making it illegal to pay for surrogacy:
In Thailand’s Surrogacy Industry, Profit and a Moral Quagmire

"PAK OK, Thailand — Soon after the first surrogate mother from this remote village gave birth, neighbors noticed her new car and conspicuous home renovations, sending ripples of envy through the wooden houses beside rice paddies and tamarind groves.
"In the two years since, carrying babies for foreigners, mainly couples from wealthier Asian nations, quickly became a lucrative cottage industry in the farming communities around Pak Ok, a six-hour drive from Bangkok. Officials say at least 24 women out of a population of about 13,000 people have since become paid surrogate mothers.
"The baby boomlet here was just one of several bizarre and often ethically charged iterations of Thailand’s freewheeling venture into what detractors call the womb rental business, an unguided experiment that the country’s military government now says it is planning to end.

"Commercial surrogacy has been available for at least a decade in Thailand, one of only a handful of countries where it is allowed, and one of only two in Asia, making it a prime destination for couples in the region from countries where the practice is banned.

"Officials estimate that there are several hundred surrogate births here each year, a number that does not include foreign surrogates, including many hired by Chinese couples, who come to Thailand for the embryo implantation then return home to carry out the pregnancy.

"But a pair of recent scandals have focused scrutiny on the largely unregulated industry, raising ethical questions and prompting the government’s crackdown.
"More recently, police raids on surrogacy clinics in Bangkok uncovered the case of a Japanese man who had fathered around a dozen babies through surrogates — the exact number is not known — whose births were only weeks or months apart. Last week the global police agency, Interpol, said it had begun an investigation into the motives and background of the Japanese man.

"Commentators have lamented that Thailand, which already had a reputation for prostitution, was now becoming, as one television anchor called it, the “womb of Asia.”

"Others described surrogacy as the exploitation of the weak and poor by wealthy couples from more developed nations.
"Thai officials say surrogates are paid about $10,000 for a successful pregnancy, more for twins, in addition to a monthly allowance of around $450 and free lodging in Bangkok, where the women are either instructed or choose to carry out their pregnancies.
Among the villagers, there is sympathy for the surrogates and anger at what is seen as a witch hunt by the authorities for women who took part in a practice that is not yet illegal.

“There’s nothing wrong with surrogacy — you are helping people who can’t have a baby,” said Pakson Thongda, 42, whose daughter twice sold eggs to a fertility clinic for about $1,000 each time. “I understand the feeling of a mother who really, really wants a child.”

"The surrogacy business in Thailand has provided a low-cost alternative to the United States, the world’s largest paid surrogacy destination, and was an outgrowth of the country’s effort to promote itself as a destination for medical tourism. The Thai industry also benefited from regulations in India, which prohibit same-sex couples from hiring surrogate mothers. India is the only other Asian country where surrogacy is legal.

"Commercial surrogacy has operated in a legal gray area. There are no laws banning it, but there are some hurdles. Thai law defines a mother as the person who gives birth, so in order for the biological parents to gain custody, the surrogate mother must renounce her parental rights — a concession that may require legal wrangling.

"The police investigations and the pending law have left a number of foreign couples wondering whether they will be able to bring their surrogate babies home. One Australian couple, unable to complete the legal procedures for twins born in July by a Thai surrogate, have been raising funds on the Internet to help pay for the legal costs.

"The authorities in Australia have requested that the Thai junta allow “transitional arrangements,” before the law banning commercial surrogacy comes into effect.

"The law, which the junta has vowed to pass soon through its rubber-stamp Parliament, would still allow surrogacy, but without payment. Surrogacy brokers and advertising offering surrogacy services would be banned.

"The junta has not publicly explained its decision, but Sriamporn Salikoop, a senior Supreme Court judge, said the ban was needed to prevent exploitation of Thai surrogates."

Tuesday, August 26, 2014

Non-directed kidney donation up in Britain

The Telegraph has the story: Why I wanted to donate a kidney to a complete stranger

"Altruistic kidney donation has, in the past year, increased by 55 per cent, with 118 living people donating a kidney. The practice only became legal in 2006, and the following year only six procedures were recorded. Since then the numbers have risen exponentially.
Transplant experts believe that cases such as that of the 85-year-old woman who this year became Britain’s oldest living kidney donor – “Why do I need two kidneys to sit at home knitting and watching television?”, she asked – have inspired others to follow suit.
Before 2006, only family and close friends were allowed to give up their kidney for people suffering from kidney dysfunction. The authorities were wary of a trade in organs that could lead to an exploitative or coercive relationship between recipient and donor.
The current legislation, drawn to prevent this, states that donors are not allowed to know the identity of the recipient, although recipients are allowed to get in touch with donors, if they choose to, after the operation. This is so that the recipient is not made to feel any moral or financial obligation.