To Split, or not to Split?

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That is the question (apologies to Shakespeare!) addressed in our manuscript:

Ethics of Split Liver Transplantation: Should a Large Liver Always Be Split If Medically Safe?

Using Organ Transplantation as the context, we are exploring:

What Philosophy can do for Operations Management

What Operations Management can do for Philosophy

My first introduction – when a teenager in India, steeped in Hindu philosophy of the immortal soul, reincarnation affected by deeds (कर्म, karma) and so on – to Western (European) Philosophy came from reading Spinoza’s Ethics (not Aristotle, whose Nicomachean Ethics I read much later).

Bento (in Hebrew, Baruch; in Latin, Benedictus) Spinoza is one of the most important philosophers—and certainly the most radical—of the early modern period. 

As a boy he had undoubtedly been one of the star pupils in the congregation’s Talmud Torah school. He was intellectually gifted, and this could not have gone unremarked by the congregation’s rabbis. It is possible that Spinoza, as he made progress through his studies, was being groomed for a career as a rabbi.

And then, on July 27, 1656, Spinoza was issued the harshest writ of herem, ban or excommunication, ever pronounced by the Sephardic community of Amsterdam; it was never rescinded. We do not know for certain what Spinoza’s “monstrous deeds” and “abominable heresies” were alleged to have been, but an educated guess comes quite easy. No doubt he was giving utterance to just those ideas that would soon appear in his philosophical treatises. In those works, Spinoza denies the immortality of the soul; strongly rejects the notion of a transcendent, providential God.

It was also then I became enchanted with the word excommunicated! 😏

Many years later, I enjoyed reading Justice, by Michael Sandel. I hoped that someday I might be able to apply structured philosophic principles and reasoning to a practical problem, and write a paper about it, or even better, put it into practical operation in our real physical world. This was also the time I delved deeper into the work of John Rawls, and found several of his ideas appealing, and wondered, again, if I could do something concrete with his frameworks. 

John Bordley Rawls was an American moral and political philosopher. Rawls’s theory of “justice as fairness” recommends equal basic rights, equality of opportunity and promoting the interests of the least advantaged members of society. Rawls’s argument for these principles of social justice uses a thought experiment called the “original position,” in which people select what kind of society they would choose to live in if they did not know which social position they would personally occupy.

I had always felt that Soren Kierkegaard’s Either/Or framing, of having to choose between an aesthetic life (that he assumed would be entirely frivolous) or an ethical one (where the self remains intact in spite of external circumstances distracting from one’s duty), was flawed. I understand now that he was being playful and created this exaggerated dichotomy for effect. It is possible, I believed, that an intellectual aesthete in constant search for new stimulations (some even whimsical) can also contribute significantly to the improvement of human condition and bring increased economic prosperity through their intellectual wanderings. Indeed:

Not everyone who wanders is lost.

Yes, I am quoting Gandalf from:

The Lord of the Rings: The Fellowship of the Ring is an epic fantasy adventure film directed by Peter Jackson, based on the 1954 novel The Fellowship of the Ring, the first volume of J. R. R. Tolkien’s The Lord of the Rings. It is widely regarded as one of the greatest and most influential films ever made. The film was nominated for thirteen Academy awards, winning four: Best Cinematography, Best Makeup, Best Original Score and Best Visual Effects. It had a box office revenue of $897 million on a budget of $93 million.

Little did I know then, through my work in Organ Transplantation, these dreams of an intellectual aesthete achieving

Practical Operational Philosophy

and improve fairness would come true.

Few things in life are more exhilarating than coming up with a whimsical idea that works!

With OrganJet, the geographic disparity reduces, thus minimizing the maximum wait time, while increasing the number of transplants, as we described in our Management Science paper (with Baris Ata and Anton Skaro) and is also discussed in the HBS Case OrganJet and GuardianWings

For those curious about how this HBS Case is actually discussed by Julie Battilana (who wrote it), here is the transcript of one of the sessions where I was present:

Now importantly, let’s turn to the case for today. The first thing I’d like to do is introduce you to our very special guest. It’s a pleasure and honor for me to have the opportunity to welcome Sridhar Tayur to class. Sridhar, we’re very grateful. Thank you so much for being here with us today.

Of course, my favorite is this fetching video created by Tepper School of Business:

And then there is this (since 2013, first reported in Mashable):

Need a Kidney or Liver? There is an App for that!

In 2016, I happened to accidentally see Amartya Sen, outside Harvest (in Harvard Square) – wish I had with me a copy of The Country of First Boys (a collection of essays that discuss the deprivations related to class, caste and gender in India) for him to sign  – as we were both finishing our lunches there. Liz Cheng of GBH snapped the photo you see on top of the post. I could not resist approaching him and introducing OrganJet. He instantly understood what was happening, and gave me perhaps the greatest compliment I have received for this work:

John Rawls would have been very happy to know about OrganJet.

Sen was not the first Nobel Laureate to find OrganJet innovative. In 2012, Al Roth posted my upcoming Stanford GSB talk in his Market Design blog (and has mentioned OrganJet many more times in following years):

Sridhar Tayur proposes an entrepreneurial way to reform organ waiting lists.

In 2014, Peter Ubel (who previously with Arthur Caplan, in 1998 or so, in NEJM) had advocated against multiple listing emailed me to set up a call to discuss OrganJet. I was a bit apprehensive. As I braced myself to be berated by a medical ethicist, I was pleasantly surprised that Peter was now actually not against what I was doing, and he wrote an article in NEJM:

Transplantation Traffic—Geography as Destiny for Transplant Candidates.

Additionally, he wrote a three-part article for Forbes (in 2015):

Your New Liver Is Only A Learjet Away.

OrganJet was also the subject of an article by Daniela Lamas (also in 2014) in The Atlantic:

A Private Jet Is Waiting to Take You to Your Kidney Transplant.

Can Forbes and The Atlantic cater to more different audiences? Love it.

Just like:

Can a Management Science paper that analyses selfish routing on a network of overcrowded queues be more different than a HBS Case (on the same topic!)?

Moving beyond OrganJet (and Nudge Videos), I was instantly attracted to split liver transplantation (SLT) when I first heard about it. For some years, however, I was pre-occupied with other initiatives, and so put SLT in the back burner. Last year, I decided to dig deeper into SLT, and found that there were three areas worth investigating.

 The first is an ethical question. Why and when would we not split it? 

The second is developing a decision support tool to decide when (and who) will get the (large) liver (and if it will be split)? 

The third, germane to US and other countries where SLT is not yet widespread, is figuring out how to optimally train surgeons over time to build this competence.

I have previously mentioned (in Back to School (for post-quantum filmology) that a stretch goal of mine was to give a seminar in Film School. Let me stretch it in a different direction to also aim for:

 Philosophy Department.

There are, of course, other interesting problems in liver transplantation. In the upcoming ATC (June 4-9 2021; John Roberts, I think we first met in ATC Boston in 2012!), in collaboration with UCSF transplant surgeons, we study:

Liver Simulated Allocation Model (LSAM) of a Height-Based Policy Change to Improve Sex Disparity in Liver Transplantation (LT).

Who ever thought that I would be involved in mathematical modeling and data-driven approaches to study (some aspect of) gender disparity

Simply put, the issue is this: a large-size patient can receive a large-size liver or a medium-size liver; a medium-size person can receive a medium-size liver or a small-size liver; a small-size patient can only receive a small-size liver (or if SLT is allowed, part of a large liver!).  In Operations Management, we call this:

limited downward substitutability. 

 Data collected by UCSF researchers shows that:

Asian women are 30% less likely to get transplanted than typical American male (and die with a 20% higher rate) while waiting on the transplant list.

This is entirely due to height differences. The goal of our analysis is to suggest UNOS provide additional exception points to small-size individuals, increasing their priority beyond just “today’s medical urgency” to incorporate that their wait times to receive suitable organ is longer, and so make their access to transplant more equitable. This is a mathematical adjustment to offset the natural lottery. Scroll right on the picture on the top of the post to see the analytics. Our recommendation can be succinctly stated as follows:

Awarding 1-2 exception points to the shortest 8% of the population can improve waitlist outcomes for women with minimal impact on men.

What would Rawls think about this operationalization to achieve fairness?

It is worth noting – as Jon Kush and I found during our Nudge Video activities — that Asians (and women) donate organs and tissues (both through First Person Consent and as Next-of-Kin) as highly as any other demographic in the US. 

Of course, if SLT becomes widespread, then some of these existing inequities can be reduced and such exception points may not be needed. 

Back to School. Even more of a stretch, how about I also aim to give a seminar in


with the title:

Stop Asian Wait.😏




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