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Nudges and Incentives for Transplant Organ Donation

 Clark Wolf, Director of Bioethics, Iowa State University 

Organ transplants save lives.  The supply of transplant organs is far too meager to support the huge demand.  As I discussed in an earlier edition of Bioethics in Brief, this predicament costs many lives every day.  These are people whose lives could have been saved if we could have found some way to increase the supply.

There have been several different proposals for increasing the supply of organs for transplant.   One proposal would open up a market in transplant organs so that people could freely buy and sell them.  Such a market might be arranged to cover in vivo (living donor) transplants of kidneys, for example, but might also be set up as post mortem transplants, with the benefit going to the donor's heirs.  A market for transplant organs would need to be carefully regulated to protect people from exploitation.  In spite of predictions that such a market would dramatically increase the supply, such proposals are unpopular in the US and elsewhere.

There are several reasons to believe that the potential supply of transplant organs is significantly larger than the actual supply.  For example, there are many people who would be willing to sign up as organ donors but have not done so.  Perhaps the supply could be increased if we could persuade these people to sign up as donors in a program they already support but have not yet taken steps to join.

Nudges
Recent work in behavioral economics indicates that there are alternative means to increase the supply of transplant organs without developing such a market.  A book by Richard H. Thaler and Cass R. Sunstein titled Nudge: Improving Decisions about Health, Wealth, and Happiness makes several different suggestions.  Their book investigates different ways to make it more likely that people will make socially beneficial choices without imposing restrictive regulations.  As they put it, "A nudge is any aspect of the choice architecture that alters people's behavior in a predictable way without forbidding any options or significantly changing their economic incentives."  Such a policy-based encouragement, in Thaler and Sunstein's terms, is a "nudge." According to the authors, there are several different ways to nudge people who would be willing to donate their organs for transplant so that they are more likely to sign up to do so.  For example, patients predictably make different choices about whether to undergo a medical procedure depending on whether the outcome is described as having a "30% failure rate" or a "70% success rate." People are more likely to choose a procedure when it is framed in terms of the likelihood of success instead of the likelihood of failure.

Nudging Organ Donors
There are several ways that people might be nudged to make it more likely that they would sign up to be organ donors and that their organs will be available for transplant at death.  Under existing regulations, most states require family consent in addition to donor consent before transplant organs can be harvested.  If donors were given the opportunity to give full consent in advance, relieving family members of making a decision about organ donation at a time of personal tragedy, this could increase the likelihood that a donor's organs will be available.

Other simple institutional changes could have a similar effect.  In Iowa, as in most other states in the US, people are invited to sign up as organ donors when they apply for a driver's license.  If one wishes to be a donor, one must check the "organ donor" box on the application.  But Thaler and Sunstein note that donor participation can be increased simply by giving people a more neutral choice, either to tick the box that says "organ donor" or another box that indicates "I do not wish to participate in the organ donor program."

A more aggressive nudge would include only the second of the two alternatives, in which people would need to check a box to indicate that they do not wish to participate as donors, with a presumption that people have chosen to be donors unless they indicate otherwise.  Such a system could include easy and public methods to insure that people who prefer not to participate can easily insure that they will be identified as non-donors.  In this proposal, the institutional "default" includes a presumption that people are donors unless they expressly indicate otherwise.   Changing the default rule can have a dramatic influence on participation rates.  Thaler and Sunstein note that in Germany, which has an "opt in" system like our own, only 12 percent of citizens chose to participate as donors.  In Austria, which adopted an "opt out" system, the participation rate rose to 99 percent.

Costs and Benefits
Some people are concerned about the proposal to change the organ donation default to include such a presumption in favor of donation. One major concern is the risk that people who would have preferred not to participate may mistakenly have their organs removed in spite of their wishes.  But the present system also includes serious risks.  In particular, people who strongly wish that their organs should be available for transplant may be concerned that institutional barriers will prevent their organs from being used.  The most important cost of the present system, of course, is the cost to those whose lives could be saved if transplant organs were available, but who will die waiting.

Political Controversy
Sunstein and Thaler's proposals became politically controversial when Sunstein was nominated by President Obama to serve as Administrator for the Office of Information and Regulatory Affairs (OIRA).  One Web site reported that news commentator Glenn Beck claimed that Sunstein favored mandatory organ donation  and another site reported that Sunstein holds the view that "the state owns the rights to body parts of people who are dead or in certain hopeless conditions, and it can remove their organs without asking anyone's permission."  These claims, of course, are quite different from those discussed in Nudge.  Certainly there is little evidence of abuse or disadvantage in Austria or other places that have adopted a presumption in favor of donation.

As public discussion of this issue continues, people on the waiting list will continue to die.  Under the circumstances, we must be willing to discuss the full range of policy alternatives that might effectively increase participation in donor programs.

Sources:
Colb, Sherry F.  2009.  "Cass Sunstein's Views about Organ Donation: When is a 'Nudge' Illegitimate?"  Findlaw Writ.
Thaler, Richard H. and Cass Sunstein. 2008. Nudge: Improving Decisions about Health, Wealth, and Happiness.  New Haven: Yale University Press.
Wolf, Clark. 2006.  "A Market for Transplant Organs?"  Bioethics in Brief.

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