Organ Donor Incentives and Preferences

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Organ Donor Incentives and Preferences. Adrienne Janney April 15, 2005 SI 646: Information Economics. Outline. Why organ donation Organ allocation Addressing organ scarcity Cadaveric donation Incentive-minded policies To opt in or to opt out? Recommendation Questions. - PowerPoint PPT Presentation

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  • Organ Donor Incentives and PreferencesAdrienne JanneyApril 15, 2005SI 646: Information Economics

  • OutlineWhy organ donationOrgan allocationAddressing organ scarcityCadaveric donationIncentive-minded policiesTo opt in or to opt out?RecommendationQuestions

  • Organ donation: The Gift of LifeOrgans are scarce goodsWaitlisted as of last night: 88,212Transplants YTD as of last week: 2,271 from 1,164 donors, living or deadIn 2003, 7,147 people died of 114,442 waiting for organsIn 2000, the MTT was 1,199 days (3.28 years)Organs are indivisible goods (houses)Kidneys come in pairsLivers and pancreases can be splitEveryone comes with one set of organs (theres no organ manufacturing plant)Organs are not cakesSource: United Network for Organ Sharing

  • Organ donation: Allocation methodsMarketsStanding in line (queue)RationingLotteryAuction

    (Thanks, Jeff)

  • Organ donation: Allocation methodsMarketsStanding in line (queue)RationingLotteryAuction

    (Thanks, Jeff)

  • Organ donation: Allocation methodsMarketsStanding in line (queue)RationingLotteryAuction

    (Thanks, Jeff)

  • Organ allocation: UNOSRationing + queue + lottery (at the top)Waiting listNumerical medical score based on laboratory findingsTime on list counts in a tieDivided up by region (for efficiencyorgan viability)Requires blood type and possibly histologic tissue matchCompliance mattersPull doesnt matter (rich & famous)Note: requires insuranceprivate or Medicare or Medicaid

  • Addressing the scarcity: IdeasIncrease cadaver poolIncrease living donor poolStem cell research (growing transplant organs)Artificial organs/organ replacement technology (e.g., hemodialysis)

  • Addressing the scarcity: ProblemsCadaver pool increasing at slow rateLiving donation only addresses certain organs (kidneys and sometimes liver or pancreas)Stem cell research funding support decreasingand its a long way offNot yet developed, and so far less quality of life with external mechanisms

  • Deceased and Living Donors1994-2003Source: United Network for Organ Sharing

  • Addressing the scarcity: Live donorsLive donors on increaseInnovationKidney exchange housing problemOnly addresses some organs (worth saying again)Less chance of rejection/graft failure for organ recipient

  • Addressing the scarcity: Live donorsDonor incurs risk and costsDeathPainTemporary but dramatic illnessLess organs to spareUnsuccessful donation (transplant outcome=death)Time off work/downtime

  • (Interlude: Pareto efficiency)Recipients benefit from any donorLive donors incur risk/costsEx-post donors lose and gain nothingCadaver donation as Pareto efficient?But: Live donors gain utility via altruismJeff says: Dead men dont have a utility distribution.

  • Cadaveric donation: BarriersPeople dont want to think about deathYou have to opt in (more on this later)Family ability to override (in some states)Family asked at a time of newly inflicted grief (fear of regret, high emotional state)

  • Cadaveric donation: Ex-ante costsTaking an action (phone, mail, e-mail, forms)Psychic costs (upsetting)Cognitive costsCost of processing new informationCost of changing viewpointSocial costs (explaining/convincing family)

  • Cadaveric donation: Education(Advertising)Education campaigns have not pushed donation rates to critical massPossible reasons?Lack of quality?Not values drivenLack of quantity?Not reaching enough peopleFutile venue for offsetting associated costs?

  • Incentive-minded policiesTax incentivesDonor must be able to realize benefit ex-anteEnforcement issues dictate ex-post payoffMoney to family or burialNot in use in the United StatesDonor willFamily cannot override donor-stated preferenceEmphasizes individual choice (an American value)# of states currently implementingE.g.: Indiana transplants livers at a lower MELD score (better chances of translant), but still a significant shortage

  • To opt in, or to opt out?We have opt in (explicit consent)You have to volunteer your preference to be an organ donorAnd in many states your family has to agreeMisclassification potential: underutilizationSeveral countries have tried opt out (presumed consent)Everyone presumed to be a donorIndividuals may opt out at any time by own initiativeUsual exclusions: minors, prisoners, mentally illMisclassification potential: unwilling donors donate

  • To opt in, or to opt out?Classical economics: policy defaults have limited effectsHowever, constructed preference research implies otherwiseFor unexpressed preferences, defaults do matterSource: Johnson and Golsdtein (2003)

  • To opt in, or to opt out?Defaults influences decisionsDecision-makers believe defaults are suggestionsMaking a decision involves effort (accepting default is effortless)Defaults often represent status quo; change usually involves tradeoffLoss aversionLoss looms larger than equivalent gainsSource: Johnson and Golsdtein (2003)

  • To opt in, or to opt out?Opt out countries & rates of consent (%)Source: Johnson and Golsdtein (2003)

    Austria99.99Belgium98France99.1Hungary99.997Poland99.95Portugal99.65Sweden91.73

  • To opt in, or to opt out?Opt in countries and rates of consent (%)Source: Johnson and Golsdtein (2003)

    Denmark4.25Netherlands28.79United Kingdom16.9

  • To opt in, or to opt out?Natural experiments with organ donation and opt in/opt outRevealed donation rates twice as high when opting out as inNeutral condition (reveals true preferences?)Not far off from opt-out rate, implying true preferences may be closer to opt-out resultSource: Johnson and Golsdtein (2003)

  • Policy recommendationAdopting presumed consent in United States will increase cadaver pool, take pressure off waiting list and live donor supply, and install a policy default that provides incentive to donate by reducing costs association with making and affirming decisions.

  • Questions?Does this system reveal true preferences?Problems?Better systems?Ethical considerations?Missed information issues?Botched economics?Your questions.

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