Dr. Stanley Goldfarb Responds to Me on Race and Kidney Transplants

This piece is his response to my post criticizing of an article he wrote in the City Journal.

On April 14, I put up a post on "Race, 'Wokeness,' and Kidney Transplant Shortages," which was in part a critique of Dr. Stanley Goldfarb's article on the same subject, published by the City Journal. Dr. Goldfarb has sent me a thoughtful response to my piece, which I am happy to post here, at his request. I will likely put up a rejoinder in a separate post [update: now available here].

Here is Dr. Goldfarb's response to me:

Dear Professor Somin,

Thank you for the opportunity to respond to your article quoting my piece, "Reparations Come to Medicine" in City Journal. You described my position as favoring a race-based formula for determining kidney function. If the article conveys that idea, I apologize as that is not my position. The previous formulas that required a separate calculation for African Americans have been labeled as racist. That is simply and demonstrably untrue. They were verified in multiple clinical studies with hundreds of patients.  As part of the "racial awakening" of the health care enterprise, there was a push to eliminate all race-based algorithms in healthcare. I object to characterizing the older, empirically derived equations as racist as has become a standard trope for activists. It is all part of blaming health care disparities on discriminatory health care treatment and it is a canard. My article sought to make clear that the old formula was absolutely not an indicator of racism.

Adopting new formulae for calculating kidney function is fine if they are accurate and objective. The latest formula using readily available blood chemistries is not more accurate than the old formula and chosen since it produces the desired outcome of lowering the estimation of kidney function in Black patients. Counterintuitively, estimating lower kidney function in Black patients has a benefit: It allows them to enter the kidney transplant waiting list sooner. It is unlikely to increase the number of Black patients receiving a kidney as the actual basis for the disproportionately low number of Black kidney recipients is lack of willingness to pursue this very demanding form of treatment.

I object to the use of the new formula to retroactively alter previous estimates of kidney function and to revise the transplant wait list to reflect the newly calculated values. Using the new formula prospectively will likely have a minimal impact but using it retrospectively will force a to-be-determined number of White and Asian patients to lose their place on the transplant wait list and be forced to wait longer for their transplants. As the formula was knowingly constructed to achieve this result, this retroactive revision is unfair.

Sincerely yours,

Stanley Goldfarb MD

Chairman, Do No Harm

UPDATE: I have posted a rejoinder to Goldfarb here.

Comments

[Commenter_XY]

I think I like Dr. Stanley Goldfarb....a lot. 🙂

[Mr. Bumble]

Second that.

[Brett Bellmore]

Yup, no nonsense reply.

[hobie]

Agreed

[NOVA Lawyer]

I can see why you and the usual suspects like Stanley.

The only substance he brought was racial grievance.

Is the old formula better? He doesn’t argue that.

It’s just a shame, says Stanley, that some “to be determined number of White and Asian patients” will lose their spots to a “minimal” number of Black patients.

And, stupidly, he claims the Black patients basically won’t take advantage of their ability to get on the transplant list anyway, which undercuts his main complaint that White and Asian patients will lose their spots to Black patients, but logical consistency is obviously, for Stanley, the hobgoblin of little minds.

[Commenter_XY]

Well yes, Dr. Goldfarb spoke with unusual clarity; factually, simply and morally. Try it sometime. 🙂

[NOVA Lawyer]

He was clear about his preoccupation with white grievance.

[Rev. Arthur L. Kirkland]

Dr. Goldfarb is a hit at The Official Legal Blog Of White Grievance.

[NOVA Lawyer]

Dr. Goldfarb's position makes little sense.

"It is unlikely to increase the number of Black patients receiving a kidney as the actual basis for the disproportionately low number of Black kidney recipients is lack of willingness to pursue this very demanding form of treatment."

This makes no sense. No matter what percentage of Black patients choose to undo "this very demanding form of treatment", at least some of the estimated 31,000 Black patients who would make the waitlist without the race-based plus factor would make that choice. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8608882/). His statement is obviously false.

If he has a point, why make an obviously false statement?

Is it just to pretend that, even if the old formula disadvantages Black patients, it doesn't matter anyway because of their choices? That's a pretty brazen way to argue that there isn't any racism to see here.

As for the old eGFR race-based plus factor being confirmed by multiple studies, that's not what the record shows:

"Several studies suggest that the equations used to calculate eGFR may overestimate GFR in black Americans, potentially leading to underdiagnosis of CKD." UC Davis, Race and eGFR (https://health.ucdavis.edu/blog/lab-best-practice/race-and-egfr-addressing-health-disparities-in-chronic-kidney-disease/2021/04) (citing multiple studies which essentially show there is, at minimum, no confirmation of the results; also explaining self-identified race is an unscientific factor to use)

[Michael P]

"As noted in Omuse et al., the issue is not settled, and various studies have assessed the utility of the MDRD and CKD-EPI equations, with and without the race coefficient, for use in these populations with competing results."

Why cite a study that contacts what you claim it says?

And why cite a study that dismissed race as nothing more than a "Social Construct", or words something as incoherent as "Additionally, in a comment, without perpetuating racial phenotypes, there is acknowledgement that eGFR based on creatinine may have person-to-person variability."? Comments and acknowledgments do not perpetuate phenotypes! The UC Davis authors are deeply confused.

Also, you clearly don't understand what he meant in the sentence you quoted. You blindly assert he is wrong without doing anything to rebut his contention about the fraction of African Americans willing to undergo a renal transplant.

[NOVA Lawyer]

"Why cite a study that [contradicts] what you claim it says?"

What do you think "not settled" and studies with "competing results" means? If they were confirmed as accurate and valid, it would be settled and the results wouldn't be competing, they'd be consistent.

"why cite a study that dismissed race as nothing more than a 'Social Construct''"

Because, at bare minimum, self-identified race is a social construct and that's what the old formulas and the studies on which they are based use.

"Comments and acknowledgments do not perpetuate phenotypes!

Funny you left out "racial" phenotypes. As the authors point out, "clinicians may improperly assign race based on arbitrary phenotypic factors such as skin tone or hair", which are not medically or scientifically valid ways to categorize people for purposes of evaluating their kidney function.

(And the part you quote points out that there are individual differences, substantial differences, so using self-identified race based on scientifically illiterate phenotypical features to group people by race is a dumb way to adjust for actual normal baseline creatine levels in any one person.)

You're just upset that poor Stanley has nothing but racial grievance to sustain his crusade.....what, not in favor of the old formula, he's definitely not in favor of the race based formula!

But still he's upset that changing from the race-based formula may result in some Black patients being higher priority on the transplant list than some White and Asian patients, and so we definitely should keep using the old race-based formula, at least for now, but he's not for it. No way!

In short, the article (it's not a study, but instead it cites multiple studies, which is the point) is accurate, supports my premise that, at the least, Stanley's claim that the validity of the old formula has been confirmed is bunk (and there's evidence the old formula is bunk), and, further, your other criticisms are lamely misguided.

[Brett Bellmore]

"Because, at bare minimum, self-identified race is a social construct"

Well, of course, if you start out by defining away a variable by declaring it to be 'a social construct', it can't be valid. By that standard you couldn't use sex, either, since the left declares it to be unconnected to any biological reality.

There is an underlying biological reality to race. It's messy, and it's not perfectly correlated to what people report on a questionnaire, but it's there.

[Michael P]

"Not settled" means there is disagreement in the literature. It doesn't mean "disadvantages Black patients" or that "the old formula is bunk". And in particular, the "not settled" bit is whether the 2009 CKD-EPI formula is good for non-American populations.

As I pointed out in Somin's "rejoinder" thread, the old formula did not use self-identified race. It used race, period. You cited a source that misled you.

I left out the "racial" qualifier to "phenotypes" because my statement is true regardless of whether phenotypes are racial or not. A phenotype is an "observable physical or biochemical characteristics of an organism, as determined by both genetic makeup and environmental influences". Estimating GFR or describing someone's condition does not "perpetuate" phenotypes, whether racial or otherwise. Keeping a patient stable perpetuates their phenotypes, at least in the not-actually-perpetual sense of perpetuate.

I also disagree with your characterization of the Ladenheim et al (UC Davis) piece as a non-study article. They have a summary of their new findings in the section of "Review of UC Davis Health Data". Which other studies that Ladenheim et al cite do you think are relevant to US clinical practice? The ones about Africans? The ones that cite less-direct risk factors as evidence of actual disease?

Ladenheim et al do identify a significant drawback of the new formula: It will identify about 16% more people as having kidney disease. They acknowledge that these may represent false positives.

[NOVA Lawyer]

“Not settled” means there is disagreement in the literature

Goldfarb claims the old formula "were verified in multiple clinical studies with hundreds of patients." But you admit that there is disagreement in the literature as to the utility of the old formulas. Thanks for confirming Goldfarb was wrong.

"As I pointed out in Somin’s “rejoinder” thread, the old formula did not use self-identified race. It used race, period. You cited a source that misled you."

You continue to be wrong.

The old formula was based on self-identified race.

Your whole argument is that the formula says "race" rather than "self-identified race" but I have cited multiple articles and studies that confirm that the way it was developed and the way it is implemented is to fill in that factor using self-identified race (except, as I have consistently pointed out, when physicians use their own idiosyncratic, subjective categorization). You cite nothing but your own flawed understanding of "race" as different than "self-identified race". The point is there is no rigorous definition of "race" in the studies underlying the old formula or in the use of the formula. And in the studies and in practice it's just self-identification. Your continued denial of that does not speak well of your objectivity. You pretty clearly just refuse to admit you're wrong. This is a strange hill for your credibility to die on.

[Michael P]

Learn to read, you witless fucking moron. The 2009 formula was validated for American patients. The "not settled" part is whether it works for Africans. If you want to take up its utility for African patients, do it with Africans. We're talking about US recommendations here.

[NOVA Lawyer]

Why did you quote what you now claim is an irrelevant section of the article? Speaking of witless morons.....

I've already cited the UC Davis article which cites studies calling into question whether the 2009 formula with the race-based adjustment is accurate for Black Americans. The fact that you cited a separate sentence in a separate section which questions the validity of it for yet other populations of Black people says things about you, not me or the article.

And how, again, did the sentence about the validity of the 2009 formula being "unsettled" contradict what I said? At best, it was an irrelevance, but it wasn't the part I quoted and there are relevant studies that were quoted. That's on you.

Maybe try to make sense before you dig your hole too deeply.

[NOVA Lawyer]

Update: In a thread on the more recent post, Michael P helpfully supplied citation to an article which cites a study which found:

“the currently used 2009 CKD-EPI eGFRcr equation that includes age, sex, and race overestimated measured GFR in Black participants by a median of 3.7 ml per minute per 1.73 m2 of body-surface area (95% confidence interval, 1.8 to 5.4)” (https://www.nejm.org/doi/full/10.1056/NEJMe2114918)

Michael P,

I’m assuming you now admit it isn’t “validated” for Black American patients.

Or did you mean that it’s validated that it’s biased against Black Americans? In which case, we agree!

[Michael P]

In a number of comments in the more recent post, NOVA Lawyer ignores a pile of studies that find that, yes, the 2021 CKD-EPI formula is significantly biased against non-Black patients, and biased for Black patients. (In terms of absolute error against “gold standard” measurements of GFR, which the CKD-EPI formulas estimate.)

But he sure is focused on misunderstanding tense and lying about what multiple studies say and “confirmation of the results”. I assume he still refuses to admit that science has validated Goldfarb’s position rather than Somin and NOVA Liar.

[NOVA Lawyer]

You just keep saying things that are demonstrably false.

You claimed the 2009 CKD-EPI had been verified. But then you cited the study that said the 2009 CKD-EPI formula with the race-based adjustment was biased against Black patients. Right?

(And what is the tense argument? Are you hoping to save yourself by arguing that they were verified, but now they’re not. LOL. I'll chalk that up as an admission.)

You said the the old MDRD and 2009 CKD-EPI did not use self-identified race. Right? But they do.

And those are basically the only two points you’ve been arguing and you’re demonstrably wrong on both. Proven by your own cite.

Deal with it.

[Michael P]

You just haven't been paying attention. The latest studies show that the 2009 CKD-EPI formula is superior to the 2021 for non-Black patients, and has similar magnitude of bias for Black patients.

There's a reason that people say the 2021 equation has "acceptable" accurate rather than better accuracy than the older equation, and why they generally do not spell out their criteria for "acceptable" accuracy.

From the NEJM article proposing the new equations, with emphases added:

We present new eGFRcr equations without race that would be considered sufficiently accurate for clinical practice in many circumstances but may lead to systematic differences in accuracy of eGFRcr between race groups, with implications for individual patients and public health.

[NOVA Lawyer]

You keep ignoring the points I made and you chose to argue about.

Now you’re hell bent on changing the argument to whether the 2021 CKD-EPI is more accurate and/or more fair than the 2009 version. I never made a claim about that.

But that bolded language: As you know, because you cited a study which confirms it, the 2009 version has systematic biases against Black patients that disadvantage them. Therefore, using the 2009 version with race adjustment “has implications for individual patients and public health", specifically, it unfairly disadvantages Black patients with respect to treatment options and the transplant list. And that’s the argument.

You cited the study that proved I was right in my beef with Goldfarb. Thank you.

All the rest is your noise trying to create a new debate that you think you can win.

[Michael P]

How very lawyerly of you, to waste your time and mine arguing over a point that is ultimately futile.

No need to remind us that you think only Black Lives Matter.

[NOVA Lawyer]

a point that is ultimately futile.

Arguing against use of a formula that unfairly disadvantages Black kidney patients is futile? So Black lives don't matter to you?

[Michael P]

To home back in on your original lies:

citing multiple studies which essentially show there is, at minimum, no confirmation of the results; also explaining self-identified race is an unscientific factor to use

That's a total misrepresentation of the study's claim, which is:

Several studies suggest that the equations used to calculate eGFR may overestimate GFR in black Americans, potentially leading to underdiagnosis of CKD. Data from the USRDS annual report and several recent studies show that black Americans have a higher prevalence of risk factors for CKD, such as hypertension, diabetes, and abnormal adjunct laboratory markers for renal disease despite a lower prevalence of CKD (eGFR < 60 mL/min) in this population as currently calculated.

Emphasis added on the part that NOVA Lawyer misunderstood. The statement here does not claim actually higher rates of kidney disease.

[NOVA Lawyer]

"The statement here does not claim actually higher rates of kidney disease."

LOL. What does that have to do with anything we've been discussing? The question was whether the older formulas were "confirmed" and, obviously, there is much scholarly debate about their accuracy. Never mind this study, you cited a more recent one that explicitly stated there was bias against Black patients in that the 2009 formula significantly overestimated GFR for them.

Your weak attempt to say the article I quoted and the studies it cited are inconclusive (which I assume is your not well made point) does nothing for you as inconclusive is kind of the opposite of confirmed or verified. And, in any case, you cited even better evidence against your own claim. Thanks for that!

You cite studies that make my point (but then ignore that) and you now completely ignore that you were completely wrong about whether the MDRD and 2009 CKD-EPI used self-identified race.

What even are you attempting anymore? You refuted your own position on the very points you chose to make the object of debate.

[Michael P]

You claimed the first part of that quote meant the old test was wrong. In context, the study you quoted avoids saying that. That's why what it says is important.

I've pointed you to at least five studies that say the old formula is much less biased than the new one for non-Black patients (US, European, Asian in different studies) and equally wrong -- but in the opposite direction -- for Black patients. You've focused on the one single result about

You don't even address those points, even when I bring them up again -- you just ignore the parts of my comments that point out your errors.

[NOVA Lawyer]

You claimed the first part of that quote meant the old test was wrong.

No, I claimed that it showed there was scholarly debate about it was accurate, particularly for Black patients. You helpfully cited a study that didn't just suggest that, but showed it. (Of course, it's one study, but it's a recent, rigorous study that contradicts Goldfarb's assertion that the old formula is verified as accurate and/or not biased or whatever he meant by verified if he meant anything relevant at all.)

This point is won in my favor. I don't have to show anything is proven, my point is that Goldfarb's claim that, essentially, it was proven, is false. You and I (thank you) have shown that.

You don’t even address those points

Yes, I did. I pointed out that I never asserted the new formula was unbiased. Goldfarb didn't make that claim and I was responding to Goldfarb. Goldfarb merely said the new study "was not more accurate." I never disagreed with that, I merely pointed out that probably meant it was about as accurate.

No, you haven't pointed to five studies that show that. List them. You pointed to one study that showed that and one study that was done in Europe comparing the 2009 CKD-EPI (presumably w/o the race coefficient), the 2021 CKD-EPI, and the EKFC (that latter two of which don't have a race coefficient). It's not clear that study included any Black patients and, at any rate, it didn't show anything about bias in Black patients.

But, again, I never claimed the new formula was more accurate. I just said they are right to ditch the old formulas with the plus factor based on self-identified race (or physician categorization based on whatever subjective, idiosyncratic method each physician uses). The old formula disadvantages individuals because they identify as Black. And you cited a study which confirms that it disadvantages Black patients generally as, on average, it overestimates GFR for Black patients.

Why would anyone want to support using an equation that we know unfairly disadvantages Black patients? Seriously. Why?

And just for fun, one of your studies: "we found that in participants who identified as Black". Why you keep pretending self-identification isn't a thing in these equations and studies is a mystery?

[Michael P]

1. Tufts Medical Center: "Compared to the 2009 CKD-EPI Creatinine equation, the 2021 equation is less accurate but acceptable for clinical use in many circumstances."

2. Delanaye et al, "The New 2021 CKD-EPI Equation Without Race in a European Cohort of Renal Transplanted Patients".

3. Betzler et al, "Impact of Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) GFR Estimating Equations on CKD Prevalence and Classification Among Asians".

4. Williams et al, "Time to Eliminate Health Care Disparities in the Estimation of Kidney Function"

5. Inker et al, "New Creatinine- and Cystatin C–Based Equations to Estimate GFR without Race"

Incidentally, #5 is the paper that introduced the 2021 CKD-EPI equations. It is up-front that it is worse for non-Blacks -- even worse than the old formula was for non-Blacks -- and just as wrong (but in the opposite direction) for Blacks:

In the validation data set, the current creatinine equation that uses age, sex, and race overestimated measured GFR in Blacks (median, 3.7 ml per minute per 1.73 m2 of body-surface area; 95% confidence interval [CI], 1.8 to 5.4) and to a lesser degree in non-Blacks (median, 0.5 ml per minute per 1.73 m2; 95% CI, 0.0 to 0.9). [...] A new equation using age and sex and omitting race underestimated measured GFR in Blacks (median, 3.6 ml per minute per 1.73 m2; 95% CI, 1.8 to 5.5) and overestimated measured GFR in non-Blacks (median, 3.9 ml per minute per 1.73 m2; 95% CI, 3.4 to 4.4).

Even worse, they knew that before they ran the validation:

In the development data sets, the current eGFRcr(ASR) and eGFRcr-cys(ASR) equations were unbiased in both race groups (Fig. S4 and Table S11). The new ASR-NB equations underestimated measured GFR in Black participants. The new AS equations underestimated measured GFR in Black participants less than the ASR-NB equations but overestimated measured GFR in non-Black participants.

I particularly draw your attention to the first sentence. (ASR denotes the old formulas, which consider age, sex and race. ASR-NB denotes the old formulas without the "if black" scaling factor. AS means the 2021 formula.)

Contrary to your implication, it is not always true that underestimating GFR is advantageous. Dosing for -- or even use of -- certain medicines to treat other conditions is affected by eGFR and suspected presence of kidney disease. Underestimation of GFR can be just as bad as overestimation.

[NOVA Lawyer]

"Underestimation of GFR can be just as bad as overestimation."

Not for placement on the transplant list which is the use we're talking about.

[Michael P]

That's not the only thing this formula is used for, ignoramus.

[Michael P]

P.S. If you take that kind of very narrow view of the discussion, I would also remind you that this whole discussion started with the replacement of the mostly-unbiased 2009 CKD-EPI formula with the universally biased 2021 version. Focusing on the flaws of one while ignoring the flaws of the other is not good-faith behavior, especially given that you keep implying the other is better.

[Michael P]

It is funny that you keep harping on EKFC.

https://academic.oup.com/ndt/article/38/1/1/6693717?login=false

EKFC is recommended to use Q factors that not only consider race, but distinguish European vs African and male vs female Black patients. Otherwise it underperforms competing equations in Black patients. See also https://orbi.uliege.be/handle/2268/300146 .

Also from the first link: "The new 2021 CKD-EPI equation that has no race coefficient performs slightly worse on a population level [....] At a population level, however, these changes in bias can lead to important differences in CKD prevalence and risk prediction, with different results for Black and non-Black race groups."

The later summaries of two studies included in that issue emphasize how bad the 2021 formula is for non-Black patients with the highest rates of CKD. And there's a dig at the American cowboys who adopted a more biased measure "without consulting their counterparts in other parts of the world".

[NOVA Lawyer]

"It is funny that you keep harping on EKFC."

You're just dishonest. I summarized a study you quoted, which involved the EKFC. I don't see anyway that can honestly be phrased as me harping on it.

Not unlike how you cite a study that proves the very point we are arguing, that the 2009 formula overestimates GFR for Black patients, which means they are disadvantaged in getting on the kidney transplant list.

At least in these walls of irrelevant text, you have allowed that that inequity should be fixed.

That's the argument. You now agree with me. Thanks.

[Michael P]

You keep pointing to the EKFC formula as one that doesn't use race as a factor. It's less accurate as a result. You won't admit that you keep criticizing a formula that is more accurate and more available over the entire population, because you're on a woke crusade.

[Michael P]

Finally, why would someone want to use the 2009 equation rather than the alternatives? Because it’s more accurate and more available for most people. Like you, I would like a way to know patients’ GFR with high precision, zero bias, and universal availability. But we don’t know how to do that. We should continue to research the correlations and indicators that will get us closer to that. Maybe using cystatin C will get us there without an explicit racial factor, but so far it doesn’t seem to. And cystatin C labs are not commonly available, I think because of cost, but maybe establishing it as part of the gold standard would bring cost down.

I think I would be happy if doctors subtract 3 to 4 from the 2009 equation’s eGFR for Black patients (assuming that the validation data from the 2021 CKD-EPI paper holds up). It would reduce overall bias for those patients, and I don’t know of subgroups where it would increase bias. But that’s too trivial a tweak to get published, and it thwarts the woke project of pretending that race is purely a social construct, so it would never be adopted.

[NOVA Lawyer]

“I think I would be happy if doctors subtract 3 to 4 from the 2009 equation’s eGFR for Black patients (assuming that the validation data from the 2021 CKD-EPI paper holds up).”

I’ll take that as acknowledgement that the 2009 CKD-EPI is biased against Black patients and that should be fixed. You agree with me.

That only took three days and about 200,000 words of debate.

But we agree that it should be fixed. Given how hard it was to get to that obviously correct position, I’m not going to debate the best way to fix it.

The 2009 formula is biased against Black patients, it needs to be fixed. That’s the point I originally made. We agree. Good. Have a nice weekend.

[Michael P]

That's why I said you were arguing an irrelevant point. I never said we shouldn't fix the 2009 formula. But it IS more accurate and available than the others you keep pointing to, unless one modifies the EKFC formula to use race as a variable. My point over the last several days has been that you don't have a workable solution. And now we agree on that.

Have a nice weekend!

[NOVA Lawyer]

“Using the new formula prospectively will likely have a minimal impact but using it retrospectively will force a to-be-determined number of White and Asian patients to lose their place on the transplant wait list and be forced to wait longer for their transplants.”

This sentence is self-contradictory. If it will have minimal impact, then the number of White and Asian patients must also be minimal and, by definition, can’t be greater than the number of Black patients who gain a place. He doesn’t value White and Asian patients more than Black patients does he?

Unless he means some White and Asian patients will lose their place not to Black patients, but to other White and Asian patients. But then he says:

“As the formula was knowingly constructed to achieve this result” [referring to the prior sentence about White and Asian patients losing their place.]

His thesis is that it is to advantage Black patients, not to advantage some White and Asian patients relative to other White and Asian patients. He posits that the motivation was to change the mix, as it were. In that case, he can’t be referring to some White and Asian patients being replaced by other White and Asian patients. He’s upset White and Asian patients will lose their place to Black patients via a new formula which he coyly says is “not more accurate”. But is it less accurate? Doesn’t appear so.

So Stanley is upset that a new formula will result in some “to be determined number of White and Asian patients” losing their spots to a “minimal” number of Black patients (who he claims basically won’t take advantage of their spot on the list anyway).

See what he does there? The number of White and Asian patients adversely affected is the scary “to be determined” while the Black patients positively affected is “minimal.”

And the thrust of his argument isn’t citation to studies showing the new formula is flawed, just a the milquetoast complaint that, he alleges, it isn’t “more accurate.”

The old formula he likes is from 1999 and, contrary to his claims, hasn’t been confirmed as valid in its use of race-based adjustments. Moreover, there are rigorous studies, better studies with more patients based on actual biological factors for the new formula. The may or may not be “more accurate”, but it isn’t less accurate. And there’s plenty of evidence the old formula is quite inaccurate for Black patients.

Rather than establishing that the new formula is inferior to the old formula on a scientific / medical basis, he basically accepts they are equally effective then bemoans that the new formula may allow some Black patients onto the transplant list ahead of some White and Asian patients. He’s letting racial grievance do all his work for him.

Stanley, that is an ugly piece of writing you’ve put out there. Very ugly.

[Michael P]

Again, you just don't understand the simple English he used. The current transplant wait list was built using one formula. When you throw out a proxy variable in that formula, and then recalculate the wait list, then you impose lots of work to figure out who is willing and eligible among those who move up the wait list. If the new formula is only applied going forward, there is no rework needed to adjust the (current) wait list. He expects minimal impact going forward because he thinks most of the change in order for new wait list members will be ineffectual: the number of African Americans willing to get a transplant will be (he thinks) low, so their higher positions on the wait list will have be mostly declined. That's minimal impact going forward, but a lot of rework of applied retrospectively.

[NOVA Lawyer]

"then you impose lots of work to figure out who is willing and eligible among those who move up the wait list."

That's not his argument. At all. Though it is just as dumb as the argument that he makes. And equally motivated by white racial grievance.

Essentially, you are claiming if the new formula is just as good or better and also is more fair to Black patients, we shouldn't do all that work to be just to Black patients who were unjustly disadvantaged by the old formula. That's not a good look.

At least Stanley's just claiming, in a remarkably forthright way, that he simply doesn't want White and Asian patients to be replaced by Black patients. It's not about indifference to fairness to Black patients such that extra work to be fair is too much, as in your case, rather it's the fact of being fair to individuals who happen to be Black that sticks in his craw. It's a morally vile argument, but at least it's honest and doesn't hide behind the wimpy "it would be hard to be fair."

[Brett Bellmore]

"That’s not his argument. "

That is literally his argument, and you quoted him saying it.

People are in the point in the waiting list they're in due to a calculation. If you change the calculation prospectively, you only have to do the new calculation on new patients. If you change the calculation retrospectively, you have to recalculate for EVERYBODY. Clearly more work.

If the new calculation were much more accurate, that work might be worth putting in. But he doesn't think the new calculation IS more accurate. So it's not just extra work, it's pointless extra work, maybe even counter-productive extra work, extra work to degrade the system.

And his closing argument is that the new formula, and especially the proposal to stop prioritizing kidney donors, was deliberately adopted in order to disadvantage non-blacks. That it was chosen for racial impact, NOT accuracy.

There's no question about the racial impact part of that, it was explicit. If he's right about the accuracy part, then what you've got here is just outright racial animus motivating changes to the health care system.

[Michael P]

Most of the work involved in retrospective use of the new formula is not just calculating the formula and publishing a new list, of course. It is communicating with patients; evaluating whether the new front-of-line patients are good candidates and (still) willing to pursue transplants; re-evaluating potential donor matches; and all the other actual work derived from people's cases being unique.

[NOVA Lawyer]

All interesting hypothesizing, but Goldfarb makes no argument based on the onerousness of recalculating patients' eGFR, he just argues that the result of the recalculation would be unfair and not any more accurate.

If you and Brett disagree, quote where he makes any point about the difficulty of recalculation in the cited City Paper article. You won’t, because you can’t because there isn’t one.

[David Nieporent]

People are in the point in the waiting list they’re in due to a calculation. If you change the calculation prospectively, you only have to do the new calculation on new patients. If you change the calculation retrospectively, you have to recalculate for EVERYBODY. Clearly more work.

Really? Clicking a button on a mouse is "work"? The data already exists. I assume that it is stored on a hard drive, not on index cards. All you need to do is have the computer connected to that hard drive run the data through the new formula and then sort the results.

[NOVA Lawyer]

"That is literally his argument..."

It literally is not. His argument is about the fairness of it and whether it is justified based on accuracy. It has nothing to do with how much work will be involved. You may imagine that he doesn't like the extra work, but he doesn't make that argument at all (either in the excerpted portion quoted here or in the entire article at City Paper.

"...and you quoted him saying it."

Where in this quote (which is the quote I used) did he say it?

“Using the new formula prospectively will likely have a minimal impact but using it retrospectively will force a to-be-determined number of White and Asian patients to lose their place on the transplant wait list and be forced to wait longer for their transplants.”

Not a thing about extra work being a problem, but plenty about his perception of fairness.

[Krayt]

As with yesterday’s thread on this, any formula that reduces net lives saved, kills, to make someone not-dying feel better, which is to say, murders, so a slightly different set of chemicals can whoosh through your neurons, feel-better-about-yourself-junkies.

I do not know which is which, but that should be the only goal designing formulae in a scientific process of continuous improvement.

[NOVA Lawyer]

“any formula that reduces net lives saved, kills”

You’re just full tilt into the claim that utilitarianism (and a particular form of utilitarianism which only calculates based on people alive versus people dead or, alternatively, life years) conclusively solves the trolley car problem and all variations of it. Utilitarianism doesn’t manage that. Read some Robert Nozick for coherent arguments as to why not.

“the only goal [should be] designing formulae in a scientific process of continuous improvement”

Agreed. Wholeheartedly. Emphasis on “scientific”.

[Krayt]

If you wanna leave out drunks who wreck their kidneys, that's you. Happy increasing death count!

[Frank Drackman]

You study at the same Med School as "Dr" Jill Biden? Kidneys mostly fail due to uncontrolled hypertension, diabetes, with a small % being congenital conditions such as Polycystic Kidneys and other conditions only Fleas (Dr. Slang for Internists) care about,
it's the Liver that gets wrecked by Alcohol, and good luck getting a new one.

Frank

[NOVA Lawyer]

Are you drunk? That comment suggests so.

[Frank Drackman]

For realizing "Dr" Jill Biden is about as much a "Dr" as "Dr J", "Dr Who", "Dr. Doolittle", "Dr. No" "Dr Evil"
might want to check your own Breath Alcohol there "NOVA",

Frank

[Frank Drackman]

"First, Do No Harm?"
thought it was "Fists, Do Some Harm!"

makes more sense now