Opt-out organ donation

(Mostly interested in this for two reasons: (1) the research in cognitive science about default effects and other unintuitive cognitive biases and (2) the adequacy implications of the lack of implementation of this policy)

In the United States, around 95% of the population approves of organ donation, while only 54% have granted permission for their organs to be used after death. Surveys in the UK indicate that the percentage that approve organ donation is around 90%, but only 25% of the population is registered on the Organ Donation Registry. Many other countries have similar patterns.

When polled, the reasons given for not explicitly registering for organ donation are things like laziness, confusion about the process and unwillingness to think about death.

And it’s actually worse than this – many countries have ‘soft’ organ-donation policies, meaning that family members can override the wishes of the deceased. Families are more likely to veto the decision to donate than the decision to not donate, further decreasing the number of organs available for transplant.

And this number really really matters. There are over 100,000 people in need of a life saving organ transplant in the United States, and over seven thousand people died last year while waiting. This amounts to 20 people every day. And in the UK and the US, the gap between available organs and patients awaiting transplantation is only growing.

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Psychologists have studied the effects of default options on expressed preferences. One experiment told subjects to imagine that they had just moved to a new state, and that they had to decide whether or not to be organ donors. Some subjects were told that the default was to be an organ donor, and their choice was to confirm or change that status. Others were told the opposite – that the default was to not be an organ donor. The results were dramatic: about two times more people became donors when this was the default than when it was not. The simple framing effect of “confirm the default or change?” had the power to cut organ donations in half.

The real-world equivalent of this is whether a country has an opt-in or opt-out organ donation system. The UK and the US have an opt-in system, which means that the default choice is to not be an organ donor. Other countries, like Austria, Belgium, Spain and Sweden, have an opt-out system.

This difference in policy has huge differences in the percentage of the population that consents to organ donation. When Austria and Belgium changed from an opt-in to an opt-out system, donation rates more than doubled. When Singapore changed to opt-out, their donation rates more than sextupled. And comparisons between countries that have different policies are similarly impressive. Germany and Austria, similar countries in many ways except for their donation policy showed an almost 88% difference in effective consent rates.

Consider for a moment how strange this is. In the United States, all it requires to become an organ donor is to check a box when registering for a driver’s license at the DMV. Can it really be that a simple difference in whether the box means “become an organ donor” or “stop being an organ donor” is preventing millions of people from becoming organ donors? Classical economics would certainly not predict this – it is presumed that if somebody has a preference about whether or not to be an organ donor, a tiny difference in framing should not have such huge effects on their behavior.

But apparently the answer is that yes, these tiny differences do matter. And our strange little human quirks can be hugely important in deciding on how to make effective policy.

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Ultimately, we are left with an adequacy question. Opt-out organ donation policies seem to me like low-hanging policy fruit. If policy-makers care to eliminate thousands of needless deaths, and are aware of these policies, then why aren’t they already implemented in the US and the UK?

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