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:
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:
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.