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Behavioural Economics and Nudges: Organ Donation Rae Bourassa and Alec Jenkin 12 March 2009

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  • Behavioural Economics and Nudges:Organ Donation

    Rae Bourassa and Alec Jenkin12 March 2009

  • Setting the ContextShort movie clip:

  • Organ Donation Facts90,000 Americans are on waiting lists for organ transplants as of January 2006Waiting 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 ReviewPresumed Consent To Organ Donation: Its Rise and Fall in the United States by David Orentlicher

    Presumed consent (opt-out) has had limited success since 1960sSince 2006, trend has moved to explicit consent (opt-in)Opt-out: onus is on individuals and their family to document their objectionsOpt-in: onus is on health-care professionals to obtain consent

  • Problems With Presumed ConsentPeople dont always think about organ donation while they are alivePhysicians may fail to ask family of the deceased for consent when a decision hasnt been documented When asked, family often chooses not to donate, sometimes even when the deceased documented that they wanted to donatePresumed consent failed because it didnt address why family members say no to donation

  • Negative ExternalitiesLack 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 oversightIf people with rights opt out of organ donation, people without rights are forced to opt in.

  • Its All About the Default!Rules surrounding organ donation play a large role in determining the number of transplantsEven if donor consents before death, family can overrule their decisions in several statesHow regulations are structured can greatly influence the number of organs that are given

  • Some Problems/ConcernsSuccessful 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 Architecture and Donor RatesChoice 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 wishesGreater PR campaigns to raise awareness and nudge people to want to donateGive Donors Priority: If you do not opt to donate, you fall to the bottom of the waiting list for organ/tissue donationsGive Minors a Voice: Allow minors to choose the fate of their organs without parental interferenceChange the Choice Documentation: Make organ donor choices part of essential documents, not drivers licenses (mandated choice on applications for health cards, SS/SIN cards, etc.)

  • Beyond Explicit and Presumed Consent: Mandated ChoiceProblem with explicit consent (opt-in): the need to gain consent from family members autonomy but organ donationProblem 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 dont 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 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:YesNoLet my family decideAND impose the act of choosing in the most easily accessible ways (tax submissions, voting, drivers license, health insurance, doctors 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 Questions

    Which is the higher role for the state: Ensuring higher rates of health for the community, orEnsuring that individual autonomy isnt violated?

    Who owns the property rights on deceased bodies individuals, their families, or the state?Which default option do you perceive as the most effective? Discuss.

    **The other 20% of organ donations come from the living, from whom consent has been gained consent issues only relate to deceased donors*Article reviews history of presumed consent in U.S.

    Presumed consent means that the state presumes that a deceased individual would have wanted to donate their organs but didnt get around to saying so during their lifetime

    Since 1960s, individual states have authorized retrieval of corneas, pituitary glands, other tissues and organs from dead persons who came under the custody of coroners or medical examiners. Since they were to be autopsied anyway to determine the cause of death, it was decided that organ and other tissue retrieval would not be an additional major intrusion

    This was permitted as long as coroners or examiners were not aware of an objection by the person or family

    In 2006, a revised Act (Revised Uniform Anatomical Gift Act) recommended that organ/tissue retrieval only be done when actual consent is providedProblem: if implemented in a socially-acceptable way, organ shortage is not addressed. But if implemented in a way that the organ shortage is addressed, it becomes unacceptable to the public

    Presumed consent did not go far enough because it allowed family members to reject donation, even though the state presumes that the individual would have wanted donation, and even when the individual indicated that they wanted donation

    But, presumed consent also went too far because some public officials intentionally bypassed family members, not allowing them the opportunity to voice their objection in order to ensure donation

    Fear that organs may be taken from dead persons who would not have wanted organs removed validated

    Case of David Kilgour and David Mattas.*In the 1970s when the states of Georgia, Florida, Texas and Alabama enacted presumed consent for corneas, organ donations increased anywhere from 500% to 1000%. In Alabama, it actually resulted in a surplus of needed corneas.*-Without the rapid transit and storage capacity, organ donation registries are meaningless-Case of France (presumed consent) where doctors still consult with families.*Would probably create more willing donors and a sense of security against organs being used the way their owners prefer (science, transplant, etc.)Allows the views of people to be fulfilledSimilar to Dont Mess With Texas or Illinois First Person Consent registryKarmic BalanceGive Minors a Voice: Insures true libertarianism in that even those under age will have a voice in the fate of their body parts.*-Mandated choice would be useful in preserving freedom and avoid legal complications after death, while also ensuring public input.*For presumed consent to work, the following assumptions must be true:

    People generally want to donate their organs, and Peoples wishes to donate are frustrated because they didnt document their wishes while alive and family members are not reachable to give consent in time

    However, this is untrue.

    A key reason why organs are not donated is the unwillingness of family to consent.