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10 Questions with
Sally Satel, MD Sally Satel, MD, is a resident scholar at the American
Enterprise Institute and the staff psychiatrist at the Oasis Clinic in
Washington, DC. She has written widely in academic journals and has
published articles on cultural aspects of medicine and science in the New York Times, New Republic, Commentary,
Atlantic Monthly, New York Times Magazine, and the Wall Street Journal. She is also a
notable voice on the controversial topic of organ donor compensation.
Dr. Satel has graciously agreed to answer 10 questions for this issue
of Renal Express.You are the recipient of a kidney donation. Please tell ASN members about your personal experience with donation. In August 2004, I went to the doctor for a routine check-up. I was feeling fine, but basic lab tests showed creatinine over 5 and a subsequent GFR of 16. I do not have diabetes or hypertension or any of the other usual predisposing conditions, so it seemed to be idiopathic. Obviously, renal function had been deteriorating quietly over many years. One nephrologist I went to predicted that within roughly six months to a year I would need to begin dialysis. The obvious place to find a donor is one’s own family, but that was not really an option for me. A few friends promised they would donate but backed out. In the fall of 2005, I went on matchingdonors.com. Within a week I “met” a potential donor who pursued some of the work-up but then he disappeared around Thanksgiving 2005. In early November 2005, a few weeks before the matchingdonor guy withdrew, I received an e-mail message from a friend—a fond acquaintance really—whom I knew from the think-tank circuit. "Serious offer" was the message in the subject line. She had heard from a mutual friend that I was looking for a donor and, thank God, she went through with it in March 2006. It leaves one speechless with gratitude. You are an outspoken advocate for organ donor compensation. In your recent article, “Kidney for Sale: Let’s legally reward the donor” (Tuesday, March 10, 2009, Globe and Mail, Toronto) you write that “we should offer well-informed individuals a reward if they are willing to save a stranger’s life.” Please elaborate. The woeful inadequacy of our nation’s transplant policy is due to its reliance on “altruism.” According to the guiding narrative of the transplant establishment, organs should be a “gift of life,” an act of selfless generosity. It’s a beautiful sentiment, no question, and I consider myself a poster girl for the glories of altruism. My donor was moved by empathy and altruism as purely as anyone could ever be. Yet it is lethally obvious that altruism is an untenable basis for transplant policy. If we keep thinking of organs solely as gifts, there will never be enough of them. We need to encourage more living and posthumous donation through rewards, say, tax credits or lifetime health insurance. The Declaration of Istanbul is a consensus of more than 150 representatives of scientific and medical bodies from around the world (endorsed by ASN). It proclaims that transplant commercialism (when an organ is treated as a commodity) is an unethical practice because donors who sell their kidneys are often financially desperate, ill-informed, unfairly compensated, and receive little post-surgical care. How do you respond to this declaration? I think the Declaration is a well-meaning but dangerously incomplete document. The only way to prevent an unauthorized market is to increase the supply of available kidneys—through a regulated form of exchange that can offer some form of compensation or reward. Unfortunately, most of the world transplant establishment does not share this view. Instead, organizations such as the WHO and the International Transplantation Society focus solely on the obliteration of illicit markets. The latest country to "get tough" is the Philippines. Last year, the government banned the sale of kidneys to foreigners. Soon after Jerusalem Post reported that there were "Kidney Transplant Candidates in Limbo after Philippines Closes Gates." Similarly, patients from Qatar who traveled to Manila are "looking for alternative solutions," according to The Peninsula. Many had turned to the Philippines because countries such as China, India, and Pakistan have begun cracking down on illicit organ sales. Prohibition policy imposed on these countries will only end up pushing organ markets further underground, or cause them to blossom elsewhere. World health authorities should direct their passion toward promoting a legal apparatus for exchange. A single pronged approach will make things worse. The way to stop illicit transactions—and the depredations of underground markets—is to sanction legal exchanges. Until we do so, the fates of third-world donors and the patients who need their organs to survive will remain morbidly entwined. You disagree with the notion that any system of legal exchange will eventually become as corrupt as the current black market system. Please share your perspective. Opponents allege that a legal system of exchange will inevitably replicate the sins of the black market. This is utterly backward. The remedy to this corrupt and unregulated system of exchange is its mirror image: a system regulated by state or federal governments and a transparent regimen devoted to donor protection. My colleagues and I suggest a system in which compensation is provided by a third party (government, a charity or insurance) and overseen by the government. Because bidding and private buying will not be permitted, available organs will be distributed to the next in line—not just to the wealthy. We also suggest that lump-sum cash payments not be offered. By providing in-kind rewards—such as a down payment on a house, a contribution to a retirement fund or lifetime health insurance--the program would not be attractive to people who might otherwise rush to donate on the promise of a large sum of instant cash. Would prospective donors lie about their health to be eligible for compensation? This is not a major worry in the context of regulated exchanges, since they would have to undergo rigorous medical testing over several months, which is the standard of care for altruistic donors. And donors or health-care professionals could be made legally liable for any harm suffered by a patient as the result of receiving a diseased or substandard organ. What specific policy solutions might be implemented in the United States to create a system of legal exchange? The government should devise a safe, regulated system in which would-be donors are offered incentives to donate a kidney—not necessarily cash payment but material reward of some kind. Creative ideas abound. Perhaps a donor could receive something as simple as lifelong health insurance. The most efficient plan would be for states to implement their own creative ways of giving a combination of incentives to donors: tax credits, tuition vouchers or a contribution to a tax-free retirement account. Keep in mind, it would not be the sick person who reaches into his own bank account to reward the donor, rather the government would provide compensation. That way, no matter how big or modest one's income, everyone in need of a kidney would benefit. And, in keeping with the current system for distribution of organs from the newly deceased, the kidney would go to the next person in line. Donors, of course, would receive education, undergo careful medical and psychological screening and receive quality follow-up care. Would the promise of a reward exploit poor donors who saw it as an offer they couldn't refuse? Unlikely. A months-long screening process and a non-cash reward won't appeal to those in desperate need of financial help. What they want is quick cash. And that's not what our proposal calls for. Within such a framework, altruistic donation would proceed in parallel with a system that offers compensation. But first Congress must revise the 1984 National Organ Transplant Act (NOTA) so it is no longer a felony for donors to receive compensation. This would clear the way for pilot studies of incentives. Imagine the case of the Good Samaritan donor. He presents to his local transplant center, say in Minnesota, offering a kidney to the next person on the center’s list. He passes all the screening tests, undergoes surgery, and allows a debilitated person to resume his or her full, active role as a spouse, parent, and worker. The donor is a savior. Truly. The only difference between this scenario and the one I have in mind is that the donor might get, say, $40,000 wired to his retirement account, or a generous tax credit, or in-state tuition for his child, to name some possibilities. Some of the money saved by the Centers of Medicare and Medicaid Services now that the patient is off dialysis could be sent back to Minnesota to underwrite the cost of the benefits it offers. The mechanism for such a change exists. Senator Arlen Specter (D-PA) is circulating a draft bill that simply clarifies that NOTA had never intended to preclude government action to reward organ donation. Thus, if the Specter bill passes, there will be no doubt that donors accepting state-sponsored in-kind incentives, such as a tax credits for living kidney donor or funeral benefits for deceased donors, are not violating the law. Meanwhile, the bill existing penalties for organ brokering are increased. For countries that are resource-poor and have less established health-care infrastructure, what might be done to implement a system of legal exchange? If resource-rich countries implemented some variant of the program I described above, the world-wide demand for organs would go down, perhaps even plummet, and the underground markets would be starved. The key issue here, as my colleague Benjamin Hippen, MD, says is that the barriers to increasing donation are specific to individual countries and cultures. The first step is to identify the barriers specific to the countries one is talking about. The second is to gauge the funding for infrastructure. Without this, it is difficult to set up a robust deceased donor program, because one doesn't have the same luxury of time that one has with an all living-donor program. With deceased donation, there are significant time pressures to get a lot of sophisticated testing done. Even if a legal exchange could be implemented in a way that was safe for everybody, there is still the cost of the surgery, long-term immunosuppression, care of complications, and so on. Sadly, in the poorest countries, the cheapest alternative is that people with ESRD will die if there is no dialysis or transplantation. What is your perspective on transplant tourism (when organs are given to patients from outside a particular country)? It is tragic evidence of a dire shortage. But how can you blame people for trying to save their own lives? The responsible and humane thing to do is to enlarge the supply of transplantable organs through rewarding healthy, well-informed donors. What would be the financial benefits of a government regulated kidney exchange program? Dialysis costs about $72,000 per year (see 2008 USRDS, vol 2, Ch. 11 "Costs of ESRD") The cost of transplantation (for patient and donor) is roughly equivalent to the cost of 18 months on dialysis. Thereafter, assuming the post-transplant course is uneventful, the major continuing expense comprises $12,000 to $15,000 per year for immunosuppressant medication. Patients who are transplanted will live longer than they would have survived on dialysis but the cost-effectiveness calculus still comes out in favor of transplantation. In addition, once transplanted, some portion of dialysis patients under 65 would re-enter the workforce and pay taxes contributing to revenue. Would organ compensation have an effect on organ donation? We can be 100% certain of one thing: maintaining the status quo will guarantee more needless suffering and death. Even if we went to a presumed consent regime (which is acceptable to me) we would not come close to even cutting the list by a third. And that is optimistic. I have heard representatives of the National Kidney Foundation (NKF) claim that compensating donors will “cheapen the gift.” Such an affront to would-be donors will cause them to hold onto their organs. On one level, this seems absurd. Can you imagine a brother telling his ailing sister, “Gee, sis, I would have given you my kidney but now that I hear that someone across town is accepting a tax credit for his donation, well, forget it.” But if NKF is correct—that some people will withhold voluntary action if remuneration is available to others—then, paradoxically, a regime of donor compensation would be quite the boon to such “altruists.” They would have bragging rights. They were the ones who acted out of generosity, not for material gain, a distinction that not only allows them to retain the “warm glow” that comes from performing acts of charity but also intensifies it. Given the importance of “social signaling” through gift-giving (“look at me, so generous, so civic-minded!”) the opportunity to accentuate the distinction should be most welcome. Dr. Hippen and I examined motivation crowding theory in our book: When Altruism Isn’t Enough: The Case for Compensating Kidney Donors. The evidence clearly does not support the assertions of critics such as Richard Titmuss or David and Sheila Rothman that the introduction of market exchanges simply reduces either a desired motive (altruism) or a desired behavior (donation/procurement). This is a rich topic and I suggest reading our chapter (view PDF) but the literature indicates that altruism is not suppressed when the symbolism is preserved (i.e., the person who prefers not to be compensated can direct the benefit to his favorite charity) or when the compensation is sufficiently robust. |
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 ASN is pleased to introduce the first ASN Kidney News
Podcast. How should deceased donor kidneys be allocated? Who should decide what constitutes a fair allocation system? Does a new kidney allocation policy foretell a God squad ressurection, or would it more effectively allocate a scarce medical resource? In coordination with two articles appearing in the May 2008 special issue on transplantation, “New Kidney Allocation Policy: God Squad Resurrection. . .” and “. . . Or Allocating a Scarce Medical Resource?,” the first ASN Kidney News Podcast focuses on the controversial topic of kidney allocation. Pascale Lane, MD, Editor of ASN Kidney News, interviews authors Mark Stegall, MD, and John Curtis, MD, about their recent articles and positions on potential revisions to a kidney allocation policy. The podcast can be heard (streaming audio) or downloaded from the ASN website or accessed via iTunes. ASN members can comment on the articles in the Discuss and Debate Forum on the ASN website (read below). |
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| ASN is pleased to introduce the
ASN Kidney News Discuss
and Debate Forum, a moderated web page that links to articles of
interest. This month’s forum focuses on the articles featured in the
ASN Kidney News Podcast (see above). The articles “New Kidney Allocation Policy: God Squad Resurrection. . .” and “. . . Or Allocating a Scarce Medical Resource?,” appear on pages 14–15 in the ASN Kidney News special section, “Transplantation: Issues and Controversies.” The forum will be open for comment from May 18 to June 3. ASN welcomes your comments on this important topic. This is a moderated forum. All comments submitted must be reviewed and approved before appearing. Please review carefully the Guidelines for Posting. By commenting, you agree that you have read and will abide by these guidelines. ASN looks forward to receiving your feedback on these articles. |
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 Registration is now
available for the 14th Annual Board Review Course & Update.
This year’s meeting will once again take place at The Palace Hotel in
San Francisco from August 29-September 4, 2009. The week-long intensive
review is patterned after the ABIM nephrology examination blueprint and
serves as the primary preparatory course for the ABIM’s initial
certification and maintenance of certification examinations in
nephrology. Visit www.asn-online.org/brcu
for details including program schedule, faculty, and travel
information. |
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| ASN is pleased introduce its first online
curriculum to address aging and the kidney. Based on the
Accreditation Council for Graduate Medical Education’s (ACGME)’s six
core competences of patient care, medical knowledge, practice-based
learning and improvement, interpersonal and communication skills,
professionalism, and systems-based practice, the curriculum answers
questions about the management of elderly patients. Twenty-five percent of institutions with accredited US nephrology training programs do not have accredited geriatric nephrology training programs, but the ACGME has mandated that fellows receive formal training in geriatric nephrology. The ASN online curriculum will serve as a primary source of educational material for geriatric nephrology training nationwide. A grant was provided by the Association of Specialty Professors (ASP) for this curriculum, which includes 38 chapters and addresses the most significant aspects of caring for aging patients with kidney disease, including assessing GFR in the elderly, drug dosing and renal toxicity, management of ESRD in elderly patients, and end of life decision making.The online resources will be expanded over the next few months to include power point presentations that distill the information written in each chapter. The entire curriculum will be freely available for anyone to access and utilize. ASN members, leadership, and staff are grateful to the task force and chapter authors, including co-chairs Dimitrios G. Oreopoulos, MD, PhD, and Jocelyn Wiggins, BM, BCh, who devoted considerable time and expertise to developing this text. Providing the best medical care for geriatric patients requires a host of special skills and training. This curriculum will be freely accessible to all ASN members and other members of the renal community, to physicians and other providers. The curriculum will make a tangible difference to the care of the aging patient. ASN thanks ASP for supporting the Society's continued efforts to lead the fight against kidney disease. For more information about the curriculum, the Society's efforts related to geriatric nephrology, or ASN, please contact ASN Senior Policy Coordinator Susan Owens at sowens@asn-online.org. |
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| The application
for the ASN Residents Program is now available. This program will
provide $800 in travel support to Renal Week 2009 for the first 150
qualified residents who apply. Meeting registration for participating
residents will be waived. There is a
limit of two awards per training program. The Residents Program
also includes a 45-minute presentation geared towards residents and a
welcome reception and closing luncheon with nephrology fellowship
directors and ASN leadership at Renal Week. Residents must be nominated by a program director. The online nomination/application process will be open from Monday, May 18, 2009, to Friday, July 10, 2009. Only online applications will be accepted. |
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Obama
Administration Releases FY 2010 Budget President
Barack Obama released his complete fiscal year (FY) 2010 budget request
Thursday, May 7, 2009, which offers a mixed bag of funding
opportunities for programs of importance to the medical community. National Institutes of Health (NIH) President Obama proposed a $443 million, or 1.4 percent, increase in funding for NIH in FY 2010 (this increase is over the FY 2009 appropriation and does not include the Recovery Act funds). The $30.833 billion appropriation request includes the first increase in funds for cancer research under the President's eight year strategy to double cancer research support. Meanwhile, the National Institute of Diabetes and Digestive and Kidney Diseases is set to receive $1.931 billion in FY 2010, a 1.0 percent increase over FY 2009. According to the budget proposal, NIH will fund a total of 9,849 new and competing renewal research project grants (RPGs) in FY 2010, an increase of 7 RPGs over FY 2009. However, the budget does include funds for the NIH Director's Bridge Award program, as the agency announced that "Recovery Act funds enabled NIH to support additional awards just missing the nominal payline." Department of Veterans Affairs (VA) Medical and Prosthetic Research The president proposed funding the VA Medical and Prosthetic Research Program at $580 million, a $65 million increase over the FY 2009 appropriation, and the same amount requested by ASN and the Friends of VA Medical Care and Health Research (FOVA). According to the budget, "new research initiatives in 2010 totaling $48 million will provide Operation Enduring Freedom and Operation Iraqi Freedom veterans with critical needs research activity." Approximately $20 million of the proposed appropriations is required to keep pace with inflation. Agency for Healthcare Research and Quality (AHRQ) For AHRQ, the president requested $372 million, the same as allocated in FY 2009, not including Recovery Act funds. Congress granted $300 million for comparative effectiveness research at AHRQ under the Recovery Act; however, AHRQ research goes well beyond the comparative effectiveness arena and funds for those projects will see a net decline under the President's budget due to inflation. The release of President Obama's budget is only one step in the long appropriations process. ASN will continue to lobby and call on its members to implore Congress to ensure appropriate sustained funding for medical research. |
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| Abstract
Submission Site The abstract submission site for Renal Week 2009, October 27-November 1 in San Diego, CA, is now open. Please note that ASN only accepts electronic submissions. The deadline for submitting scientific abstracts is Wednesday, June 17, 2009, 11:59 p.m. EDT. Abstracts must be submitted or sponsored by ASN members. If you need to renew your membership, please do so by Friday, May, 22, 2009. Late-Breaking Clinical Trials ASN is again soliciting abstracts for late-breaking clinical trials. All accepted abstracts will be presented as oral presentations in a special symposium during Renal Week. ASN will only consider abstracts that describe the results of late-breaking clinical trials. Abstract submission site opens: Monday, August 3, 2009, at 9:00 a.m. EDT. Abstract submission deadline: Wednesday, September 16, 2009, at 11:59 p.m. EDT. ASN will notify abstract submitters of their selection status during the week of September 28, 2009. There is a fee of $55 for each submitted late-breaking clinical trial abstract. Call for Informational Posters The ASN Program Committee is again soliciting abstracts (300 words or fewer) that contain information about ongoing clinical trials or research services available in core facilities at academic institutions. These abstracts will be displayed in informational poster sessions during the ASN Annual Meeting in San Diego, CA. Submitted abstracts should include a brief background; study goals, hypotheses, or description of available core services; trial inclusion/exclusion recruitment criteria, if appropriate, and funding agency. The purpose of these abstracts is to stimulate enrollment in clinical trials and increase utilization of research from core facilities. Please do not submit abstracts describing results of clinical studies. Preference will be given to studies and resources supported by government and non-profit agencies. Abstracts should be submitted to education@asn-online.org no later than Tuesday, August 18, 2009, at 11:59 p.m. EDT. These abstracts will be reviewed and decision for inclusion made no later than Monday, September 14, 2009. |
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