Kimberly D. Krawiec

Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation

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 nations 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 donors 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.

Don’t 'Screw Joe the Plummer': The Sausage-Making of Financial Reform

This article employs section 619 of the Dodd-Frank Act, popularly known as the Volcker rule, to examine agency level activity during the pre-proposal rulemaking phase – a time period about which little is known, despite its importance to policy outcomes. By capitalizing on transparency efforts specific to Dodd-Frank, I am able to access information on agency contacts whose disclosure is not required by the APA and, therefore, not typically available to researchers. I analyze the roughly 8000 public comment letters received by FSOC in advance of its study regarding Volcker rule implementation, and the meeting logs of the Treasury Department, Federal Reserve, CFTC, SEC, and FDIC prior to the Notice of Proposed Rulemaking. This analysis reveals significant public activity, but also a stark difference in investment by financial institutions versus other actors in influencing Volcker rule implementation. It also reveals a greater unity of interest among financial market participants than would be suggested by press reports and the provision’s legislative history. Finally, the data shed light on the efficacy of the notice and comment process as a means for federal agencies to engage the general public.

Is Informed Consent Enough

As illustrated by Flechner et al (1), patients with renal failure continue to benefit from rapid innovations within multiple Kidney Paired Donation (KPD) registries. The development of the Advanced Donation Program (ADP) facilitates transplants by enabling the donors to donate even when their intended recipients (IR) are not matched yet. However, as with any innovation, ADP introduces new challenges including risks to the IRs and registries, vagueness in the definition of priority granted to the IR, and concerns about fairness to the donor should the IR become untransplantable.

Price and Pretense in the Baby Market

Throughout the world, baby selling is formally prohibited. And throughout the world babies are bought and sold each day. As demonstrated in this Essay, the legal baby trade is a global market in which prospective parents pay, scores of intermediaries profit, and the demand for children is clearly differentiated by age, race, special needs, and other consumer preferences, with prices ranging from zero to over one hundred thousand dollars. Yet legal regimes and policymakers around the world pretend that the baby market does not exist, most notably through prohibitions against baby selling - typically defined as a prohibition against the relinquishment of parental rights in exchange for compensation. This Essay explores the costs of societal pretense that legal baby markets do not exist. Those costs include scarcity, foregone opportunities to address market failures, an inability to develop regulations designed to further particular public policies unlikely to be advanced solely through the goal of profit-maximization, and the promotion of rent-seeking. This Essay focuses specifically on the rent-seeking problem, arguing that, although frequently defended by those who contend that commercial markets in parental rights commodify human beings, compromise individual dignity, or jeopardize fundamental values, bans against baby selling (at least as currently written and enforced) serve little purpose other than enabling anti-competitive behavior by the most economically and politically powerful baby market participants.

Understanding Public Risk Perception and Responses to Changes in Perceived Risk

This chapter will introduce scholars and policy-makers interested in the public’s perception of risk and its effect on individual and collective responses to some psychological literature on these topics. Depending on the reader, the sections below will contain either too much or too little information. The latter (too little information) can be remedied by consulting the provided references to specific facts, theories, or arguments for more information. The former (too much information) can be solved by reading just the remainder of this introduction and the conclusions and by sampling from the intervening sections as needed. The section “Function of Risk Perception” argues that the general public only distinguishes between a small number of risk levels (present/ absent or negligibly low/need to monitor/unacceptably high) and that triggering events shift their perceptions from one level to another. This results in either an underor overreaction to existing risks in most situations, as illustrated in Figure 4.1. Real-world examples of such rapid shifts in reaction are provided in Boxes 4.1 to 4.3. “Individual Risk Perception” provides more background on several psychological processes that give rise to the discrepancy between actual and perceived levels of risk. Risk often is a feeling rather than a statistic based on objective outcomes, and this feeling is influenced by reactions (dread, feeling out of control) that may not closely connect to objective loss or risk statistics. Importantly, it is this feeling of being at risk that motivates action. However, this flag goes down when some action has been taken, giving rise to a single-action bias that discourages sustained attention to complex risks.

People should not be banned from transplantation only because of their country of origin

To the Editor: Previously,1,2 we described how a Filipino husbandandwife patientdonor pair were included in an American kidney exchange.1,2 Delmonico and Ascher object in the strongest terms.3 They write that ethical Global Kidney Exchange (GKE) with patientdonor pairs from the developing world “is not feasible when the culture is so experienced with organ sales.” Among the proposers of GKE are experienced surgeons and clinicians, a senior lawyer, and a veteran market designer. We take black markets with the utmost seriousness. That’s why the first GKE pair was started with a husband and wife. We think the right course of action is to proceed carefully, slowly at first, and with constant monitoring. The second GKE pair from Mexico were cousins cared for by Dr. Ricardo CorreaRotter, a worldrenowned nephrologist and signatory of the Declaration of Istanbul.4,5 We also take seriously longterm postoperative care for both patients and donors. That’s why we propose GKE in partnership with developing countries that already have some firstrate hospitals that perform living donor transplantation. Rees et al describe how we coordinated care with the Philippine General Hospital and St. Luke’s Medical Center in Manila.2 We also provided an escrow fund for longterm continuing care. Ivan Carrillo describes our care of the donor and recipient in the second GKE and it is clearly celebrated by Mexican media as a beautiful way to help citizens of both Mexico and the United States.4,5 Kidney exchange (KE) itself is a relatively new “matching market,” of a kind that does not involve any payments to donors. It has been successfully launched in many countries, and proposals for international cooperation are underway.6 What makes KE special is that two or more patientdonor pairs help each other. What makes GKE special is that helping firstworld patients get transplants saves money, because dialysis is so expensive, and these savings can benefit poor patients and donors in poor countries who would otherwise be unable to help themselves, but can participate in GKE for free. Delmonico and Ascher propose that poor people with ESRD in poor countries, and the donors who love them, must all be regarded as potential criminals who would inevitably corrupt firstworld medicine by being included in it. In the current political climate this is a bit like proposing a blanket ban on granting asylum to refugees from some countries. We do not adopt this point of view. On the contrary, GKE is a proposal that says there are many deserving patients who need our help, who we can help, and who can help us—if we invite them carefully and take care of them attentively. Fear is not the path forward. Bold, careful innovation has led transplantation to where it is today, and remains our best collective future.

Complete Chain of the First Global Kidney Exchange Transplant and 3-yr Follow-up

BACKGROUND Global Kidney Exchange (GKE) offers an opportunity to expand living renal transplantation internationally to patients without financial means. These international pairs are entered into a US kidney exchange program that provides long-term financial support in an effort to identify opportunities for suitable exchanges for both these international pairs and US citizens. OBJECTIVE While the promise of GKE is significant, it has been met with ethical criticism since its inception in 2015. This paper aims to demonstrate the selection process and provide >3 yr of follow-up on the first GKE donor and recipient from the Philippines. DESIGN, SETTING, AND PARTICIPANTS The first GKE transplant occurred with a young Filipino husband and wife who were immunologically compatible, but lacked the financial means to continue hemodialysis or undergo a kidney transplant in their home country. The pair was enrolled in the Alliance for Paired Donation matching system, several alternative kidney exchanges were identified, and the pair subsequently underwent renal transplantation and donation in the USA financed by philanthropy. The resulting nonsimultaneous extended altruistic chain provided transplantation for the Filipino husband and 11 US patients. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The Filipino donor and recipient were followed by transplant professionals in both the Philippines and the USA. Follow-up data were maintained as required by the Organ Procurement and Transplantation Network in the USA. RESULTS AND LIMITATIONS The Filipino donor has normal blood pressure and renal function, and the Filipino recipient is doing well 3.5 yr after their donation and transplantation. CONCLUSIONS While criticisms of GKE highlight concerns for possible exploitation of financially disadvantaged groups, these results demonstrate that these concerns did not come to fruition, and the outcome experienced by the GKE donor and recipient (and other US participants) was successful. PATIENT SUMMARY The first Filipino Global Kidney Exchange (GKE) donor-recipient pair continues to be followed by both US and Filipino transplant centers. Both are in good health, support the GKE program, and advocate for its expansion.

The Story of Risk: How Narratives Shape Risk Communication, Perception, and Policy

The organizing question of this volume is when and how events in the world lead to a recalibration of risk and a change of policy. A naïve model might assume a simple Bayesian process: the polity has regulations based on a prior assessment of risk, new information about the true risks becomes available, people update their assessments appropriately, and regulators adopt policies that minimize risks (at the lowest cost). Under some circumstances, to be fair, such a model might not be too far off the mark: in the cases of lead additives in gasoline, or drinking and driving, or smoking, viewed over a sufficiently long time period, regulatory change might be viewed as rational choice. But in myriad other cases, the path from risk to policy strays far from the policy analytic ideal.

Diversity and talent at the top: Lessons from the boardroom

This Article describes the results from fifty-seven interviews with corporate directors and a limited number of other persons of interest (including institutional investors, executive search professionals, and proxy advisors) regarding their views on corporate board diversity. Diversity challenges and successes in the boardroom make a useful jumping off point for the study of diversity in other professional fields, including law firms, for a number of reasons. First, corporate boardrooms remain remarkably non-diverse, representing a highly visible “old (and, we might add, white) boys’ club.” Second, this club has come under tremendous pressure in recent years, with criticisms ranging from simple business imperatives to social fairness—a debate that is strikingly similar to diversity debates in very dissimilar settings, such as higher education. And finally, the variety of responses around the world to this increased public pressure for boardroom diversity—from legally-mandated quotas in much of Europe to a reliance on market forces in the United States—allows a comparison of many possible approaches to diversity challenges.