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

2. Setting the Context Short movie clip: http://watch.thecomedynetwork.ca/south- park/season-4/south-park-407-cherokee- hair-tampons/#clip11305

3. Organ Donation Facts 90,000 Americans are on waiting lists for organ transplants as of January 2006 Waiting lists grow by 12% each year 60% of those on waiting lists will die before a donor is found 80% of organs come from deceased donors If every person who dies and has organs viable for transplantation were to consent to donation, twice as many organs would be available

4. Article Review “Presumed Consent To Organ Donation: Its Rise and Fall in the United States” by David Orentlicher Presumed consent (opt-out) has had limited success since 1960s Since 2006, trend has moved to explicit consent (opt-in) Opt-out: onus is on individuals and their family to document their objections Opt-in: onus is on health-care professionals to obtain consent

5. Problems With Presumed Consent People don’t always think about organ donation while they are alive Physicians may fail to ask family of the deceased for consent when a decision hasn’t been documented When asked, family often chooses not to donate, sometimes even when the deceased documented that they wanted to donate Presumed consent failed because it didn’t address why family members say no to donation

6. Negative Externalities Lack 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 oversight If people with rights opt out of organ donation, people without rights are forced to opt in.

7. It’s All About the Default! Rules surrounding organ donation play a large role in determining the number of transplants Even if donor consents before death, family can overrule their decisions in several states How regulations are structured can greatly influence the number of organs that are given

8. Some Problems/Concerns Successful 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 matter Complications from opposing views of donors and their families How 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

9. Nudges to Improve Choice Architecture and Donor Rates Choice 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 wishes Greater PR campaigns to raise awareness and nudge people to want to donate Give Donors Priority: If you do not opt to donate, you fall to the bottom of the waiting list for organ/tissue donations Give Minors a Voice: Allow minors to choose the fate of their organs without parental interference Change the Choice Documentation: Make organ donor choices part of essential documents, not driver’s licenses (mandated choice on applications for health cards, SS/SIN cards, etc.)

10. Beyond Explicit and Presumed Consent: Mandated Choice Problem with explicit consent (opt-in): the need to gain consent from family members ◦ ↑ autonomy but ↓ organ donation Problem 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 don’t 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

11. Creating the Perfect Nudge Remember 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:  Yes  No  Let my family decide ◦ AND impose the act of choosing in the most easily accessible ways (tax submissions, voting, driver’s license, health insurance, doctor’s 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.

12. Public Policy Questions 1. Which is the higher role for the state: ◦ Ensuring higher rates of health for the community, or ◦ Ensuring that individual autonomy isn’t violated? 2. Who owns the property rights on deceased bodies – individuals, their families, or the state? 3. Which default option do you perceive as the most effective? Discuss.