Behavioural Economics and Nudges:Organ Donation

Rae Bourassa and Alec Jenkin

12 March 2009

Setting the ContextSetting the Context

Short movie clip: http://watch.thecomedynetwork.ca/south-park/season-4/south-park-407-cherokee-hair-tampons/#clip11305

Organ Donation FactsOrgan Donation Facts

90,000 Americans are on waiting lists for organ transplants as of January 2006

Waiting lists grow by 12% each year60% of those on waiting lists will die before

a donor is found80% of organs come from deceased donorsIf every person who dies and has organs

viable for transplantation were to consent to donation, twice as many organs would be available

Article ReviewArticle Review“Presumed Consent To Organ Donation: Its Rise and Fall “Presumed Consent To Organ Donation: Its Rise and Fall in the United States” by David Orentlicherin the United States” by David Orentlicher

Presumed consent (opt-out) has had limited success since 1960s

Since 2006, trend has moved to explicit consent (opt-in)

Opt-out: onus is on individuals and their family to document their objections

Opt-in: onus is on health-care professionals to obtain consent

Problems With Presumed ConsentProblems With Presumed Consent

People don’t always think about organ donation while they are alive

Physicians may fail to ask family of the deceased for consent when a decision hasn’t been documented

When asked, family often chooses not to donate, sometimes even when the deceased documented that they wanted to donate

Presumed consent failed because it didn’t address why family members say no to donation

Negative ExternalitiesNegative Externalities

Lack of availability of organs creates excess demand, and potential for markets in barter trade.

With the growth in the gap between organ supply and demand, people begin to seek alternative methods to acquire desired organs.

Leads to Organ Tourism and the rise of organ harvesting in countries with little oversight

If people with rights opt out of organ donation, people without rights are forced to opt in.

It’s All About the Default!It’s All About the Default!

Rules surrounding organ donation play a large role in determining the number of transplants

Even if donor consents before death, family can overrule their decisions in several states

How regulations are structured can greatly influence the number of organs that are given

Some Problems/ConcernsSome Problems/Concerns

Successful organ transplants need the infrastructure to operate effectively and efficiently (donation rate is higher in US than many presumed consent countries)

Differences in implementation of laws matterComplications from opposing views of donors and

their familiesHow organ donor lists are organized and promoted

plays a role (ex: Illinois FPC Registry)Thaler and Sunstein opt for presumed

consent/mandated choice as they best preserve individual freedom

Nudges to Improve Choice Nudges to Improve Choice Architecture and Donor RatesArchitecture and Donor Rates Choice of recipient: Mandate donors to choose where they

would like their organs to go REAL libertarianism: Use mandated choice and remove the

ability of families to overrule donor wishes Greater PR campaigns to raise awareness and nudge people

to want to donate Give Donors Priority: If you do not opt to donate, you fall to

the bottom of the waiting list for organ/tissue donations Give Minors a Voice: Allow minors to choose the fate of their

organs without parental interference Change the Choice Documentation: Make organ donor

choices part of essential documents, not driver’s licenses (mandated choice on applications for health cards, SS/SIN cards, etc.)

Beyond Explicit and Presumed Beyond Explicit and Presumed Consent: Mandated ChoiceConsent: Mandated ChoiceProblem with explicit consent (opt-in): the need to

gain consent from family members◦ ↑ autonomy but ↓ organ donation

Problem with presumed consent (opt-out): fear that organs will be taken against individual or family wishes◦ ↓ autonomy but ↑ organ donation

Thaler and Sunstein promote nudges that impose low to no costs for those who don’t want to be nudged. Both explicit and presumed consent impose relatively high costs to not participate.

Mandated Choice: People are forced to disclose their preferences before receiving other benefits

Creating the Perfect NudgeCreating the Perfect NudgeRemember that nudges must impose low to no

costs for non-participation

What if we were to rewrite Mandated Choice to ask:◦ In the event of unexpected death, do you wish to donate

your tissues and/or organs: Yes No Let my family decide

◦ AND impose the act of choosing in the most easily accessible ways (tax submissions, voting, driver’s license, health insurance, doctor’s visits and hospital stays).

◦ A national electronic registry would be needed that stores this information so that individuals need only answer once. However, they may change their decision at any time and as often as they want.

Public Policy QuestionsPublic Policy Questions

1. Which is the higher role for the state: ◦ Ensuring higher rates of health for the community,

or◦ Ensuring that individual autonomy isn’t violated?

2. Who owns the property rights on deceased bodies – individuals, their families, or the state?

3. Which default option do you perceive as the most effective? Discuss.