Organs for transplant: Improving the supply by shifting the policy (from opting in to opting out)

By Linda Stamato

Most people support organ donation and organ transplants but, as it turns out, they don’t donate. Given the former, how do we encourage the latter? How does (or can) society encourage positive behavior? Should government attempt to affect certain decision-making behaviors? Whether we’re talking about limiting climate change, for example, or promoting healthy living, or donating organs, one crucial question is whether (and, if yes, when) to use the techniques and tools of science, particularly cognitive science, to try to steer people toward better choices.

In “Why Isn’t the Brain Green?” (The New York Times Magazine) Jon Gertner explores this question. He is struck by the fact that Americans fail to place concerns about climate change, for example, high on the nation’s list of critical priorities and so individuals fail to make decisions and take actions that reflect that concern. Accordingly, policy experts are turning to the work of cognitive scientists, especially those who work in the area of decision science, to discern ways to encourage behavior changes to protect the environment and limit negative climate change.

An image from an organ donation website

This same research is remarkably useful in consumer psychology and may offer a critical insight into how to increase the availability of organs for transplant. Richard Thaler, a pioneer in the field, and author, with Cass Sunstein, of Nudge: Improving Decisions About Health, Wealth, and Happiness (Yale University Press, 2008), conducted research on consumer savings patterns that has direct relevance. Thaler found that many more people saved money in a 401(K) retirement plan if they did not have to take active steps to join the plan. In one study, only 45 percent of a company’s new employees participated in the 401(K) plan when doing so required them to take some kind of action, like filling out a form. However, 86 percent participated when doing so was the default option.

And, Max Bazerman, along with colleagues at the Harvard Business School, investigated how people make unwise tradeoffs. One finding is particularly relevant. It’s this: Most people agree that organ donation makes sense, but, as noted above, they don’t donate. Most people accept the default position, the status quo. It is not that people are deciding not to donate; rather, they are not thinking about it. In countries other than the United States, the default is that unless you specify that you do not want to donate your organs, you become a viable donor at death. In the U.S., unless you actively decide to donate, you are not likely to be a donor. Thus, the default approach that society imposes dramatically affects donor rates. As a result of the U.S system, according to Bazerman, 6,000 people die each year who might not have given a change in the default.

Organs in the body that can be donated and transplanted

There really is a difference in how a choice is presented.

In “Expand pool of blood donors” the The Star Ledger editorial on 15th of February, 2009, observed:

“When it comes to our blood, we’re selfish. Only 2.5 percent of eligible New Jerseyans donate blood, compared to the national average of 5 percent.
But, oh, when we need blood, when our life hangs in the balance, we want it.”

The same point can be made about all organ and tissue donations. The “Chain of Life” three-part multimedia series by The Star Ledger in June, makes the case urgently and passionately. As does a column that appeared in February, 2009, which featured the lives of the five recipients of the organs of a young man, Dennis Maloosseril, who was killed by a gunman inside a church in Clifton. His parents donated his heart, lungs, liver, kidneys and pancreas to donors. These stories, compelling as they are, help to heighten awareness of the need for organs for transplant. As do efforts, say, by employers to promote organ donation by their employees, such as Rutgers University, my employer, does. And, too, changes in the law such as the New Jersey Hero Act that was signed into law in October of 2008 that requires residents of New Jersey who are applying for a driver’s license to consider becoming organ donors. This consideration certainly does make people think.

But, as important as new law and education efforts are, organ donations will not keep pace with the need for them. (The New Jersey Organ and Tissue Sharing Network reports an increase in organ donations but, at the same time, thousands of state residents await organs to save their lives.

We have to think about this problem differently.

We could provide incentives such as life-long Medicare coverage or even tax credits or vouchers. Through greater educational efforts, too, we could hope for a surge in altruism. Fundamentally, though, while these efforts might increase the number of organ donations, the problem will remain unsolved because the need is so great.

In “Enlarging the Societal Pie through Wise Legislation: A Psychological Perspective,” Max Bazerman, this time with fellow authors Jonathan Baron and Katherine Shonk, looked into the psychology of decision-making and the impact on policy. They asked this question, “Why are organ-donor programs constrained to the point where thousands of Americans die needlessly each year?” They posed the following hypothetical:

a. If you die in an auto accident, your heart will be used to save another person’s life. In addition, if you are ever in need of a heart transplant, there will be a 90 percent chance that you will get the heart.

b. If you die in an auto accident, you will be buried with your heart in your body. In addition, if you are ever in need of a heart transplant, there will be a 45 percent chance that you will get the heart.

They asked the study participants which of these options they’d prefer. Most people choose “a” as the benefit of the trade-off is quite clear. Yet government policy, yielding to what psychologists term “omissions bias”– which is the “irrational preference for harms of omission over harms of action”–follows an organ donation program that favors “b.”

This is a striking result that clearly supports a change in policy: We need to switch to a ‘default’ system that functions as follows: Unless you specify that you do not want to donate your organs, you become a viable donor at death. By this simple shift in policy, organ donations would rise substantially.
A free collection of articles on transplants can be found at this website.

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