Deceased Organ Donation Experiments.kessler Roth

8/13/2019 Deceased Organ Donation Experiments.kessler Roth

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DeceasedOrganDonationand

3ExperimentsinMarketDesign

JuddKessler (Wharton)AlRoth(Stanford)


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InSept.2012theNYTimescarriedtwostories

Anew(compromise)proposalabouthowtoallocatedeceaseddonorkidneyshasbeenputoutfor

scuss on

Theissueofcourseisthattherearentenough

Therearelotsofinterestingandimportantquestionsabouthowtomostefficientlyallocate

t escarcesupp y seee.g. en oseta . Butorganallocationhasanunusualaspect:how

supply,bychangingdonationbehavior. 2


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ofdeceaseddonororganallocationand

Describerelevantbackgroundonorgandonation

considertheoptionsweconsider,andnotothers)

Discusswhatex eriments sofar2abstract 1

involvingactualorgandonordecisionscan

contributetothedesign/policydebate.

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Waitin listcandidates: 115 508 9 19 12

Activewaitinglistcandidates: 73,532

22,518 fromdeceaseddonors

,

Donors(2011):14,145

, 6,019 livingdonors(almostallkidneys)Downloaded9/19/12fromhttp://optn.transplant.hrsa.gov/data/ and

http://unos.org/

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Kidneytransplantsareabigpart LastWednesdaywhenIlecturedtoyou

aboutkidneyexchangetherewerexx,xxx

donorkidneys.

smorn ng erewereyy,yyy

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Deceased

Table1:U.S.KidneyTransplants

Year

Deceased

Donors

Donor

Transplants

Living

Donors

All Wait-list

Patients

New Wait-list

Additions

1999 5,386 8,044 4,725 41,176 21,845

2000 5,489 8,126 5,499 44,568 22,356

2001 5,528 8,233 6,042 47,576 22,502

2002 5,638 8,539 6,240 50,301 23,631

2003 5,753 8,667 6,473 53,530 24,683

2004 6,325 9,358 6,647 57,168 27,280

2005 6,700 9,913 6,571 61,562 29,145

2006 7,178 10,661 6,435 66,352 32,361

2007 7,240 10,591 6,043 71,862 32,424

2008 7,188 10,552 5,968 78,366 32,584

, , , , ,The data for years 19992009 are provided by OPTN as of May 21, 2010. New Wait-list

Additions counts patients (rather than registrants) to eliminate the problems of counting

. -

patients rather than registratants. All Wait-list Patients data from 1999-2007 are from the

2008 OPTN/SRTR Annual Report; All Wait-list Patients data from 2008-2009 are extrapolatedfrom Wait-list Additions and Waitlist Removals provided by OPTN as of May 21, 2010.

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Wheredodonorscomefrom? Livedonors:Mostl ersonall connectedtoa atient

Growingnumberofwebrecruiteddonors

donors

Kidne exchan eisthefastest(butstillver small)growingsourceoflivedonortransplants.

But,despitethegrowthinlivedonation,werefallingbehindtheneedfortransplantable

.

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Deceaseddonors Donor

registration,

Optin,mostlyatDepartmentsofMotorVehicles(attimeofdriverslicense)

Donations romunregistere onorscana so ema e yt e

survivingnextofkin InNewEngland,abouthalfoftheeligibleunregisteredcadavers

Otherproposals

Optout(manycountries)

Organallocation bywaitinglist,byregionandorgan

eren organs ave eren wa ng s ru es e.g. ver s yhealthstatus,kidneysareprimarilybywaitingtime)

Otherproposals ngapore: rstpr or tytoreg stere onors

Israel:similarproposaladopted,justrecentlyimplemented 8


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TheconsentratefororgandonationinIsrael,definedastheproportion

ofactualdonorsoftotalnumberofmedicallyeligiblebraindeaddonors,,

mostwesterncountries Intwoformalsurveysofpublicattitudestowardsorgandonation,whichweredonebytheIsraelNationalTransplantCentrein1999(n=758)and

= ,willingnesstodonateorgansinexchangeforprioritisation inorganallocation.Inbothsurveys,theproportionofindividualswhochosethis

optionwasmuchgreaterthantheproportionschoosingthesecondand,

compensation(25%),respectively,fororgandonation.Thebasisofthispublicreactionismainlyaperceivedneedtorectifytheunfairnessoffreeriderspeoplewhoarewillingtoacceptanorganbutrefuseto

Israelipublic.

These

individuals

are

opposed

to

the

idea

of

brain

death

andorgandonation,yettheydonotabstainfrombecomingcandidatesfortransplantationwhentheyneedanorganforthemselves.

LaveeJ,As enaziT,Gurman G,Stein ergD.Anew aw ora ocationodonororgansinIsrael.Lancet2010;375:11311133.

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heavilyregulated,andmakingchangesisan

regulatory/politicalprocesswithlotsof

.

Oneofthemostimportantregulationsisthat

.

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The National Organ Transplant Act of 1984Pub. L. 98-507, Section 301

It shall be unlaw ul or an erson to knowin l ac uire,

receive, or otherwise transfer any human organ for

valuable consideration . . .

(b) Penalties

Any person who violates subsection (a) of this section

shall be ined not more than 50 000 or im risoned not

more than five years, or both11


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whatkindsofhypothesesrelevanttoorgandonation

doesntinvolveactualorgandonationdecisions? caremustalwa sbetakeninextra olatin

experimentalresultstocomplexenvironmentsoutside

thelab,andcautionisparticularlycalledforwhenthe

intangibleissues.Howeverthedifficultyofperformingcomparableexperimentsorcomparisonsoutsideofthe

a ma es tsens eto oo tos mp eexper mentstogeneratehypothesesaboutorgandonationpolicies.

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Kessler,JuddB.andAlvinE.Roth,

OrganAllocationPolicyandthe

EconomicReview,August2012 Experimentinanabstractsetting

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Sub ectsstarteachroundwithoneAunit

andtwoBunits

activeAunitandatleastoneactiveBunit

,

probabilityoffailingandtheBunitshasa20%

Likekidneys,bothBunitsoperateorfailtogether

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Sub ectstartwith$2andliveforanumberof

periods Wheneverasub ectsAunitfails heloses 1and

theroundendsforhim

periodstoreceiveaBunitfromsomeoneelse

durin whichhedoesnotearnan mone

IfhedoesnotreceiveaBunitinthosefive

eriods heloses 1andtheroundendsforhim

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Asub ectwithfailedBunitscouldreceiveaB

unitfromanotherplayerinagivenperiodif

Bunitswerestillactive

Andifthat la erhada reedtodonatehisBunitsatthestartofthatround

Donationhadacost,either40centsor80cents

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Subjectsplayed31roundsinafixedgroupof

12subjects

Eachgrouphad6lowcostdonors($0.40)and

6highcostdonors($0.80)andsubjectswereonlyinformedoftheirowncostofdonation

Justbeforeround31,Ssweretolditwouldbethelastround

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Experimentalconditions:

1. Control(U.S.):transplantcandidatesreceivedorgansinorderofwaitingtime

intermsofmonetarypayoffs,donatingisadominatedstrategyinthiscondition;costly,withno ene ose ,a oug ene s oo ers

2.

Priority(Israel):thosewhoagreedtobe

priority

,withsomebenefittoselfaswellasbenefittoothers,primarilyotherdonors(dependson#donors)

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Experimentalconditions:

3.Rebate(cashequivalentofPriority):Bunitswereassignedasinthecontrolcondition,butdonors

basedonthenumberofothersubjectsintheirgroupwhoagreedtobedonors.Donationhasreducedcosttoself,andprovidesan

expectedbenefittoallothersandacashbenefitto

otherdonors4.Discount(cashequivalentofPrioritywith56donors):Bunitswereassignedasinthecontrol

, . thaninthecontrolcondition.

Donationhasreducedcosttoselfandprovidesanexpecte ene ittoa ot ers notjustot er onors

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Groups(withinandbetween

experimentaldesign

forthefirst15roundsandthenswitchedtooneofthetreatmentconditions(17groups)orstayedinthecontrolcondition(3groups)

Theothertwelvegroupsplayedoneofthethreetreatmentconditionsforthefirst15

roundsandthenswitchedtothecontrolcondition forthelast16rounds

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1

Figure 1: Share Donating by Round

0.8

0.9

0.6

0.7

ating

0.4

0.5

S

hareDo

0.2

0.3

0

0.1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Roun

Control Priority Discount Rebate 21


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.

thepriorityconditionthaninthecontrol

An ,pr or tycou e mp emente outs eo

thelabinthecurrentlegalenvironment,while

cas ac s ustsomet ngwecan nvest gateinthelab

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thecoststructure,thecashbackconditions,

mayjustreducethecostofgiving

BeforeSshaveexperience,priorityproduces

t emost onat on,so tmay es mp ertounderstand

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Ifawaitinglist,yougetabenefitfrompriorityIfnowaitin list ouma refernottoincurthe

costofdonation

Withourexperimentalparametersthereisnoequilibriumatwhichanyonedonates(wheneveryoneisentirelycashmotivated)

Thisdependsoncosts,rateoforgandemand(Bfailure),andrateoforgansupply(Afailure)

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0.5

RebateProfiles(10millionsimulationseach)

0.4

0.45

0.3

0.35

A=0.1;B=0.2;n=12

0.2

0.25

A=0.1;B=0.1;n=12A=0.2;B=0.2;n=12A=0.1;B=0.05;n=12

0.1

0.15

A=0.2;B=0.1;n=12A=0.3;B=0.1;n=12

0.05

25

0 1 2 3 4 5 6 7 8 9 10 11

#otherregistereddonorsingroupof12


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Period1a entschoosetore isterasadonor

Period2payoffsrealizedProbabilit a entshavekidne failure

Probabilityagentshavebraindeath

Numberofkidneysis (=2?) Call/ theproductionneedratio(kidneysa

donorgenerates/needsinexpectation)

Agentswhohavekidneyfailureearnutility0unlesstheyreceiveakidneyandearnutility1

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c~F(c)whereccanbenegative

Sosomeagentsdonateevenwithoutpriority

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Onlyagentswhohavenegativecostsdonate

So,shareofdonorsinequilibriumisF(0)

NotethatF(0)doesntseemtobenegligible,eitherintheexperimentorintheU.S.population.

, .

needoneisindependentofdonorstatusand= *

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>

GetshareofdonorsAlldonors etakidne ifthe needone

Nondonorsgetakidneywithprobability1F(c*)

/


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Notetheimportanceofaltruisticdonors

inc u ing onations ynexto in

.

Andunderaprioritysystem,priorityaccessto

foradditionaldonationdecisions.

T s sw atma esanat ona pr or tysystema

morefeasiblesystemthanaprivatemembers

on yc u .

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Q.HowmanyLifeSharers membershavediedanddonated

32

organs?

A.Wehavenotyethadamemberdieincircumstancesthatwould

havepermittedrecoveryofhisorherorgans.(accessed9/24/12)


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Anewexperimentmotivatedbythe

Israeliexperience

,

andtheimplementationoftheIsraelilaw

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IsraelTransplantLawORGAN

TRANSPLANTACT,2008 Section3,clause9(b)(4)(ac)

(b) TheSteeringCommitteesdutiesshallbeasfollows:

(4)Todrawupdirectivesinthematteroftheallocationoforgansremoved

Section6ofthisAct,providedthatatthetimeofsaidallocationthefollowingconsiderations,interalia,betakenintoaccount:

(a)Theconsentofapersonduringhislifetotheremovalofanorganafter, , relativeneedatransplant;

(b)AnorgandonationundertheAnatomyandPathologyAct,shouldafirstdegreerelativeneedatransplant;

(c)Thelivedonationofanorgantoanunspecifiedrecipient,shouldthedonororafirstdegreerelativeneedatransplant;

recipient.

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IsraeliOrganallocationprioritycategories*

Basedonclause9(4)(b)intheOrganTransplantLaw,candidatesfortransplantationwillbeprioritizedduringorgansallocationasfollows:

Toppriority

willbegrantedtocandidateswhosefirstdegree

relativedonatedorgansafterdeathorhavebeenthemselveslive

Second

prioritywillbegrantedtocandidateswhohaveregistered

Thirdprioritywillbegrantedtocandidateswhosefirstdegree

theirlisting;

*SlidesfromJa Lavee


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ADDITIONALSCORESFORALLOCATIONPRIORITYCATEGORIES

KIDNEY HEART LUNG(LAS)

LIVER(MELD)

Candidate's

first degreerelative

onate organ

after death or

candidate was

a live or an

3.5op o tatus

candidacy list15 3.5

donor

Candidate is a

re istered 2

Following previous

rioritization cate or 10 2

donor candidates in Status 2

Candidates

first-de ree Followin revious

relative is a

registered

donor

0.5 prioritization category

candidates in Status 2

2.5 0.5


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,

invalidcandidatesforthepurposeofsigninga,

prioritizationplanandwillretaintheirpriority

meritspriority.

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transplantationwillcontinuetobegivenpriorityfororganallocationasusual,irrespectiveoftheireligibilitystatusonthe

basisoftheirnewprioritizationcategory. However,iftwosuchcandidatesareequally

suitableforadonatedorgan,thentheone

w oqua es oroneo t epr or t zat oncategorieswillbegiventheorgan.

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organatanytimebeforetheorganisremovedandshallbearnocivilorcriminalliabilityforsuch

arevocation(section8,34)

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Thedonorcardasimplemented

WiththehopethatImaybeofhelptoanother,Iherebyorderanddonateaftermydeath:

Anyorgano my o yt atanot ermy in o usetosave is er i e.

Or:

()Kidney()Liver() Cornea()Heart()Skin()Lungs()Bones()Pancreas

[] s ongasac ergymanc osen ymy am yw approvethedonationaftermydeath.

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l d f d / ll l ( l)


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Empiricalstudyofdonation/allocationpatternsinIsrael(proposal),

WithTamarAshkenazy,JuddKessler,JayLavee,Avraham Stoler

Howmanyregistereddonorsarethereeachyear,andhowmanychecktheboxsayingthataclergymanmustbeconsulted?

Howmanytransplantsarethereeachyear,andhowmanygotopeoplewhohaveprioritybyvirtueofbeingregistereddonors?

Ofthese,howmanygotopeoplewhoareconditionaldonors? Ofthedeceasedregistereddonorswhoseorgansarerecoverable,how

,becomedonors?i.e.howoftendotheclergymenapprove?(Inwhatcircumstances,e.g.braindeathversusDCD?)

Arethereanyaccompanyingchangesinlivedonationofkidneys(orlungsor vers

Whathappenswithpediatriccandidatesandlivedonors?

Whatchangesifanyareobservedintheaggregatefiguresofwhoreceivesor ans e. .amon thesecularandreli iouscommunities ?

Whatchangesareobservedinpublicopinion(surveys) Itwillbealongtimebeforedataareavailableabouttransplantsfromnew

donors.

Inthemeantime

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Anewexperiment(withtheclergymanpriority

Conditions:

Control(allpotentialrecipientshaveequalchanceatreceivingavailabledonatedorgans)

Pr or ty t osew oc ooseto onatean payt ecostofdonationreceivepriority)

Ineachround,anydonatedBunitsthatbecome

availablewillbeprovidedfirsttothosemembersofthe

groupw opa t ecostto onatet e rBun ts nt atroundorwhodidnotpaythecosttodonatetheirBunitsbutaskedtoreceivepriorityinthatroundanyway.

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Instructionsforloopholeexpt SCREEN1

T isexperimentisastu yo in ivi ua ecisionma ingan e avior.Moneyearne wi epaidtoyouincashattheendofthisexperiment.

Youwillplayagameinagroupof8people.

Youwillplaythisgameforanumberofroundsinthesamegroup.

The rules of the ame ma chan e durin our course of la and ou will be informed if the do.

Youwillbepaidbasedononerandomlyselectedroundacrosstheentirestudy.

SCREEN2

Atthestartofeachround,youwillhave$6,oneAunitandtwoBunits.

Eachround,thereisa25%chancethatyourAunitwillfail.

IfyourAunitfails,youdonotearnanymoremoneyinthatround.

IfyourAunitdoesnotfail,bothyourBunitswillfail(yourBunitsoperateorfailtogether).

IfyourBunitsfail,youmayreceiveaBunitfromsomeoneelse. you ono rece vea un romsomeonee se,you ono earnanymoremoney n a roun .

IfyoudoreceiveaBunitfromsomeoneelse,youearnanadditional$4inthatround.

SCREEN3

, , ,

yourtwoBunitstootherplayers. IfyoudecidetodonateyourBunits,itwillcostyou{$0.50;$4},butifyourAunitfails,eachofyourtwoBunitswillgotoaplayerwithfailedBunits.AplayerwithfailedBunitscanreceiveoneBunit.

OPTIONAL:Ineachround,2playerswilleachhavetheirAunitfailand6playerswillhavetheirB.

[NOTE:EXPERIMENTERWILLBEINSTRUCTEDTOREADIfyoudecidetodonateyourBunits,ithasa

cost,shownonyourscreen,butifyouraunitfails] 43


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Instructions,continued:Screen5

Ineachround,youstartwith$6,anAunit,andtwoBunits

Ineachround,eitheryourAunitwillfailoryourBunitswillfail.Foracostof{$0.50;$4}youcandonateyourBunitssothatintheeventthatyourAunitfails,whichoccurswithprobability25%,eachofyourtwoBunitsgoes

toaplayerinyourgroupwhoneedsaBunit. IfyourBunitfailsandyoureceiveaBunitfromanotherplayerinyour, .

AnyavailableBunitswill[CONTROLbeassignedrandomlyamongthemembersofthegroupthatneedaBunit.][PRIORITYbeassignedfirstto

thosewhopaidthecosttodonatetheirBunitsandonlythenprovidedto.PRIORITYbeassignedfirsttothosewhoeitherpaidthecosttodonatetheirBunitsoraskedtoreceivepriority;onlyafterallthoseplayershavereceivedaBunitwillBunitsbeassignedtothosewhodidnotpaythecost

.

Oneoftheroundsofthestudywillberandomlychosenforcashpaymentandyoureceivewhateveramountofmoneyyouearnedinthatround.

45

DECISION SCREEN


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DECISIONSCREEN

Youcurrentlyhave$6.

IfyoudecidetodonateyourBunits,itwillcostyou{$0.50;$4},butifyourAunitfails,eachofyour

twoBunitswillgotoaplayerwithfailedBunits.AplayerwithfailedBunitscanreceiveoneBunit.

yagree ng o ona eyour un s,youare e p ngpeop ew oare nnee , us asyoumay ehelpedbypeoplewhoagreetodonatetheirBunits.

PleasedecidewhetheryouwouldliketodonateyourtwoBunitsatacostof{$0.50;$4}.

[CONTROL

Yes,IwanttodonatemyBunits

No,IdonotwanttodonatemyBunits]

[PRIORITY

Yes,IwanttodonatemyBunitsandreceivepriorityforaBunitifIneedone


Yes,IwanttodonatemyBunitsandreceivepriorityforaBunitifIneedone No,IdonotwanttodonatemyBunits,butIdowanttoreceivepriorityforaBunitifIneedone


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0.8

0.9

0.6

0.7

oDonate

0.4

0.5

u

bjectsW

0.2

0.3

Percentof

0

0.1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

47

Round

Control Priority Loophole


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ThePrioritytreatmentgeneratesmoredonors

thantheothertwotreatments(p


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EarningsaresubstantiallyhigherinthePriority

treatment(p


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Inthelaboratory,wedidntuserealorgans,butweimposedrealcosts,whichwecouldmanipulate

Inthelabwecanlookatarchitectureofpriorityrules,

andcompareprioritychangestomonetarycostchan esthatwecouldntlookatinthefield. Wecanforexamplebegintoaddresshypothesesabout

crowdingoutofaltruisticmotivation,clubgoods,etc.

capturedinanabstractsetting Soweextrapolatewithcaution

ewou e oa sos u yac ua organ ona ondecisions

andwevefoundtwodifferentwa stodoso,oneconventionallyempirical(proposaldescribedearlier),

andoneexperimental. 50

A i t (i th U S ) ith t l


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Anexperiment(intheU.S.)withactual

onor ecisionst roug on ineregistry

51

Our login screen


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Ourloginscreen

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,

Optin,

Mandated

Choice

Lowcost, ig cost a ap rasea outcause

ofdeathcouldbee.g.autoaccident)

Cuthalfwaythroughduetolackofpower,made

remainderlowcost]

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Onthiswebsiteyoucanchoosetobean

death. enhancethelivesofasmanyas50peopleby

.registerasorgandonorsagreetodonatealltheiror ansandtissues.

Ifyoucontinuewithoutcheckingthebox,ouwillnotbere isteredasanor anand

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tissuedonor.


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,

closetotheMAaverage,theotherswere

WeknowbecausetheyhaveanMAstateid

Donttakenoforananswer

29%ofnondonorsbecomedonorswhenaskedonly1%ofdonorstakethemselvesofftheregistry

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Weseeatreatmenteffectofincludingthelistof,

Thoseshownthelistthinkmorelivesaresavedby

donationMandatedchoicehasadirectionallylower

donationratethanoptin(33%donatewithopt

in,

25%

with

mandated

choice) Theprobabilitythatmandatedchoiceisbetterthan

60

Mandated choice, registry entries and


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Mandatedchoice,registryentriesand

transplants RecallthatinNewEn land,we resentl et50%

oftheeligibleunregistereddonors.

Sowewerepreparedtosaythat,unlessmore

intoyesdecisionsundermandatedchoice,

mandatedchoicemightstillnotbebetter(becausethenextofkinwouldknowthatthedeceasedhadchosenno).

,

mandatedchoiceItappearsthatmakingnooneofthereadily

suggestedanswersleadsmorepeopletochooseit

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62

More deceased donors?


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Moredeceaseddonors?

Askdifferently:

Optout(manycountries)

USissecondonlytoSpaininorganrecoveryrate

(deceasedorganstransplantedper10,000people) Deffains andYthier (2010)arguethatSpains highrate

resultsfrommoreefficienttransplantproductionchain

Act,andoptoutdoesnotgenerateconsent Anumberofstudiesshowthatitdoes enerateman

moreregistrations

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Experimentsgiveawindowonsomeaspects

otherwise

Enormouscaut on snee e e ore

recommendingpolicy

Therecommendationofmandatedchoicemaybeprematureinthecaseoforgandonation

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Whydowehavelawsagainstsimply


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y g p y

uyingan se ing i neys

,

thinkitsasubjectthatsocialscientistsneed

Itisntjustaboutbodyparts

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Documents

Deceased Organ Donation Experiments.kessler Roth