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.


Education is Changing

By AJ Kelton
Education is changing. The days filled with students facing front, teachers doing all the talking, and books and pencils the only tools of the educational process are not just now starting to decline, they are well into decline. Find the most talented teacher, K-12 or higher education, and ask if s/he only lectures to students or tries to engage them. Certainly issues of crumbling buildings and poor infrastructure need to be addressed, but we cannot overlook technology, existing and emerging, as an equal player at the table.

Many of us did not have computers when we were in high school, let alone 1st grade. The world is a dramatically different place now and we make note of this all the time. When was the last time you turned to another adult and said, “These kids are so much smarter than we were”? They are. And they want to learn. But they do not want to learn the way you and I did; they want, and need, to learn differently.

Our students today are going to be the ones who have to figure out how to get us all out of the messes we have created. In order to help them we need to invest in technology infrastructure for our educational facilities, libraries, and homes. We need to find and encourage use of the hands-on technology that will let these brilliant minds develop and grow.

New construction must be designed with a technology infrastructure that is given equal and important consideration at the earliest stages of planning. All too often, technology is tossed in at the end, once all the plans are already in motion. Everything, from network traffic to electrical supply and jack availability to standard computer hardware, needs to be planned and budgeted for at the onset and with the same maintenance considerations as other essential infrastructure.

What applications our students will be using on our networks is a completely different animal. The world of technology changes quickly. Who would have thought a few short years ago that we would be looking at mobile technology and virtual worlds as a raising tide that lifts all technology boats?

From the days of Flash Gordon, Dick Tracy, and Star Trek, future inhabitants have been walking around with access to technology at their fingertips. One only need look at Apple’s iPhone to see a modern-day Communicator and Tricorder wrapped up in one. The idea that mobile technology would drive the marketplace so heavily was a distant thought not all that long ago. In the meantime, today we all iPhone and Blackberry our way through our workday, while students begin to do the same through their school workday.

So when you hear that virtual worlds are a growing market in the educational industry and have begun to provide exceptional learning experiences for students from many age ranges and from around the world, don’t wonder where your flying car is. We were all promised flying cars by the 21st-century, right?

Well, in virtual worlds, such as the very popular Second Life, we can have flying cars. But virtual environments are so much more than a frivolous place where “games” are played. Educators from all over the globe are finding amazing ways to engage students using a combination of the virtual and non-virtual worlds. Whether it’s a replica of a working heart one can walk through, a recreation of the Sistine Chapel, or a tour through a psychiatric ward hearing and seeing what a schizophrenic patient experiences, virtual worlds seem to be limited only by one’s imagination.

Although not the only virtual world being used for educational purposes, Second Life is currently the most widely used by a large margin. According to its main web page,, “Second Life is an online, 3D virtual world imagined and created by its Residents.” After signing up for a free membership (paid memberships with a few benefits are available but not required), and downloading the application to a computer, one creates an “avatar”, or 3D representation of oneself. The ability to customize the avatar in more ways than one can imagine is something that has attracted so many people to this virtual world.

Aside from flying cars, or even flying without cars, avatars can communicate with others, visit virtual places all designed and created by other “residents”, hold meetings, go to musical and artists performances, and even engage in micro transactions between individuals.

Second Life first became available to the public in 2003. On average, ten to fifteen thousand new avatars (accounts) are created each day and fifty thousand unique individuals are signed in to the Second Life grid at any given time, with a peak number recently exceeding seventy thousand. Over one million U.S. dollars are transacted each day in the Second Life economy. Although educational use makes up a small but growing percentage of the Second Life user base, there are well over three hundred self-identified educational institutions internationally with some kind of involvement in Second Life.

Second Life is designed specifically for adults, defined as those eighteen years old and older. This does not mean that those under eighteen are left out in the cold by the folks at Linden Lab, creators of Second Life. A few years back Linden Lab created Teen Second Life, a very carefully controlled and protected environment for those between the ages of thirteen and seventeen. A small number of middle and high schools in the U.S. have invested in creating a secure, school-only location for their students. An example of one assignment comes from the Suffern Middle School in the Ramapo School District. Students were asked to change their avatar’s appearance to reflect first on how they see themselves and then how they think society sees the idealized appearance of the gender they selected. This allowed for a rich and exciting discussion on how advertising and society impact not just what we do but even how we choose to look.

Aside from the educational uses of virtual worlds, there are practical design and architectural uses as well. Virtual environments have become an exceptional place to create, in advance, a planned non-virtual world space and allow users to experience it beyond the single dimension of drawings and blueprints. Imagine being able to build a technology-rich classroom, an innovatively designed library, a planned renovation of a current space or even a new construction, and then letting visitors, via an avatar experience that space. This is not the stuff that wild imaginations are dreaming of. This is happening in real time, right now.

At this point you may be scratching your head and thinking “Is this for real?” or “Where did this come from and how did I miss it?” The fact is that these types of environments have been around for decades. Educators, geeks, and kids have been using multi-user environments for as long as networks have allowed text to flow back and forth. More recently, while some have gotten into the fantasy role-playing environment of World of Warcraft, others have sat with their children and marveled as they engaged with their non-virtual and virtual Webkinz companion. If you are not sure what Webkinz is, ask almost anyone who has a young child or grandchild.

Whether its Webkinz by Ganz, Club Barbie by Mattel, or any of the many Disney virtual worlds our children are playing in these days, those same children are going to eventually bring this expectation for interactive and engaging learning environments to our schools. Trends in virtual worlds, as charted by companies like Virtual Worlds Management, show clear evidence that this is not a passing fad. Some folks at Princeton, Rutgers, Seton Hall, Kean, and Montclair State have also seen the handwriting on the virtual wall and have begun to experiment with learning and teaching in the virtual environment of Second Life. At Montclair State University, for example, a wide variety of subjects have used Second Life as a learning and teaching tool, including: Composition, Counseling, History, Law, Literacy, Literature, Media, and the New Student Experience. Even the Residence Life division has begun to experiment with using Second Life to reach a variety of students.

From a few visits to experience something not possible in the non-virtual world, to using the virtual environment to enhance distance and online learning, we are looking at the beginnings of a whole new world; a virtual one at the very least. The question becomes, who will be left wondering why or how some other college, school, library, or organization got the jump on this?

AJ Kelton is the Director of Emerging Instructional Technology for the College of Humanities and Social Sciences, as well as the Second Life Project Coordinator for the College of Education and Human Services, both at Montclair State University. Mr. Kelton is the author of the recent article “Virtual Worlds? ‘Outlook Good’”, published by the EDUCAUSE Review and he is the owner of AFK Consulting, a company dedicated to providing services in support of virtual worlds, social media and networking, and Web 2.0 initiatives.

Hall Institute New To Weblog!

Hello Weblog, this is the Hall Institute’s inaugural blog post. Following this first post, we will be posting critical articles regarding public policy-pertinent-issues in New Jersey. On Weblog, we hope to draw the attention and perspectives of a wide range of people who are interested in public policy issues like education, the environment, poverty studies, or just New Jersey.   

The Hall Institute is a not-for-profit public policy think tank based in Trenton, New Jersey right across from the statehouse. We are interested in advocacy, public policy, independent analysis, and original research. Most of all, we are interested in what people in New Jersey think about a political, cultural, and environmental New Jersey.  Hello Weblog, we hope to hear from you!