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Organ Donor Incentives and Preferences

Adrienne JanneyApril 15, 2005SI 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

Organ donation: ‘The Gift of Life’ Organs are scarce goods

Waitlisted as of last night: 88,212 Transplants YTD as of last week: 2,271 from 1,164

donors, living or dead In 2003, 7,147 people died of 114,442 waiting for organs In 2000, the MTT was 1,199 days (3.28 years)

Organs are indivisible goods (houses) Kidneys come in pairs Livers and pancreases can be split Everyone comes with one set of organs (there’s no

‘organ manufacturing plant’) Organs are not cakes

Source: United Network for Organ Sharing

Organ donation: Allocation methods Markets Standing in line (queue) Rationing Lottery Auction

(Thanks, Jeff)


(Thanks, Jeff)


(Thanks, Jeff)

Organ allocation: UNOS

Rationing + queue + lottery (at the top) Waiting list

Numerical medical score based on laboratory findings Time on list counts in a tie Divided up by region (for efficiency—organ viability) Requires blood type and possibly histologic tissue match Compliance matters

‘Pull’ doesn’t matter (rich & famous) Note: requires insurance—private or

Medicare or Medicaid

Addressing the scarcity: Ideas

Increase cadaver pool Increase living donor pool Stem cell research (growing transplant

organs) Artificial organs/organ ‘replacement’

technology (e.g., hemodialysis)

Addressing the scarcity: Problems Cadaver pool increasing at slow rate Living donation only addresses certain

organs (kidneys and sometimes liver or pancreas)

Stem cell research funding support decreasing—and it’s a long way off

Not yet developed, and so far less quality of life with external mechanisms

Deceased and Living Donors1994-2003

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

19931994199519961997199819992000200120022003

Year

Number of DonorsDeceased Donor

Living Donor

Source: United Network for Organ Sharing

Addressing the scarcity: Live donors Live donors on increase Innovation

Kidney exchange ‘housing’ problem

Only addresses some organs (worth saying again)

Less chance of rejection/graft failure for organ recipient

Addressing the scarcity: Live donors

Donor incurs risk and costs Death Pain Temporary but dramatic illness Less organs to spare Unsuccessful donation (transplant outcome=death) Time off work/downtime

(Interlude: Pareto efficiency)

Recipients benefit from any donor Live donors incur risk/costs Ex-post donors lose and gain nothing Cadaver donation as Pareto efficient? But: Live donors gain utility via altruism Jeff says: Dead men don’t have a utility

distribution.

Cadaveric donation: Barriers

People don’t want to think about death You 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 costs Taking an action (phone, mail, e-mail,

forms) Psychic costs (upsetting) Cognitive costs

Cost of processing new information Cost of changing viewpoint

Social costs (explaining/convincing family)

Cadaveric donation: Education

(Advertising) Education campaigns have not pushed

donation rates to critical mass Possible reasons?

Lack of quality? Not ‘values’ driven

Lack of quantity? Not reaching enough people

Futile venue for offsetting associated costs?

Incentive-minded policies

Tax incentives Donor must be able to realize benefit ex-ante Enforcement issues dictate ex-post payoff Money to family or burial Not in use in the United States

‘Donor will’ Family cannot override donor-stated preference Emphasizes individual choice (an American value) # of states currently implementing E.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

donor And in many states your family has to agree Misclassification potential: underutilization

Several countries have tried opt out (‘presumed consent’) Everyone presumed to be a donor Individuals may opt out at any time by own initiative Usual exclusions: minors, prisoners, mentally ill Misclassification potential: unwilling donors donate


Classical economics: policy defaults have limited effects

However, ‘constructed’ preference research implies otherwise

For unexpressed preferences, defaults do matter

Source: Johnson and Golsdtein (2003)


Defaults influences decisions Decision-makers believe defaults are suggestions Making a decision involves effort (accepting default is

effortless) Defaults often represent status quo; change usually

involves tradeoff

‘Loss aversion’ “Loss looms larger than equivalent gains”



Austria 99.99

Belgium 98

France 99.1

Hungary 99.997

Poland 99.95

Portugal 99.65

Sweden 91.73

Opt out countries & rates of consent (%)



Denmark 4.25

Netherlands 28.79

United Kingdom 16.9

Opt in countries and rates of consent (%)



‘Natural experiments’ with organ donation and opt in/opt out Revealed donation rates twice as high when opting out

as in Neutral condition (reveals true preferences?)

Not far off from opt-out rate, implying true preferences may be closer to opt-out result


Policy recommendation

Adopting 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.