How to increase organ donation

When is a nudge better than an incentive?

Eighteen people will die in this country today because the organs needed to save their lives weren’t available. No, not all of them would have survived otherwise, but those are needless deaths, and we should be ashamed of the policies that lead to them.

Sally Satel, a transplant recipient herself*, proposes getting rid of the federal law that bars paying for organs. I’m for it; I’m for just about anything that will provide more organs, barring the Chinese approach of encouraging executions and “harvesting” the victims’ organs.

But the simplest and most effective measure would be to switch from the current opt-in system to an opt-out system: that is, make donation the default option. Most (all?) states now have an organ-donor box on the driver’s license application form, but the result of not filling it out is that you aren’t a donor. (Even if you are, there are still problems with next of kin.) Why not reverse the presumption? If you have a religious or other objection to having your organs used to save other people’s lives once you no longer have any use for them, just say so when you get your driver’s license and you’ll be on the “do not harvest” list. Otherwise, the presumption is that you want to do the right thing, at no cost to yourself.

This strikes me as a case where a “nudge” is more effective than an incentive.

* Virginia Postrel heroically provided the needed kidney. Live-donor organs are better than cadaveric organs. If we want to increase the number of live donors, opt-out is irrelevant, so incentives seem like the way to go.

Update A reader with serious expertise in the matter writes:

It’s not as simple as changing the law.

Comparison of countries with different approaches suggest that soft variables are much more important: public attitudes, hospital staff attitudes, dissenting relatives ability to get publicity or court access, support of opinion leaders. A well designed and funded PR campaign would have to accompany any change to opt-out or donation rates would remain essentially the same. It could maybe even replace payment for organs).

Unlimited payment size raises complex ethical issues about rich and poor. It’s not just that the rich would have more options (see Wikipedia on organ donation), but at the legal edges.

1. Should the government pay for free organs for paupers? Who actually pays taxes and their opportunity cost is complex. My own analysis is that it ultimately comes out of K-12 education, a bad tradeoff for keeping the chronically ill at the public tough longer (few can ever

resume employment).

2. Will it increase pressure on doctors to certify the dying prematurely or on legislatures to alter the definition of death?

3. Will the politically influential benefit more than the rich? The Singapore cases all involved important politicians (although they were also rich). If being rich is merely one precondition to receiving a transplant, then I’m probably against it.

4. Need is nonrandom by demography. Closer immunological matching produces greater success rates. In the US, because of the distribution of disease; Black (females) have a higher rate or need for kidney transplants. For historical and cultural reasons, Black Americans have

lower donation rates. Hence, a worse mismatch of supply and demand. It’s unclear that paying for donations would be more efficient than paying selected clergy to preach that organ donation is a Christian duty and paying for a support network to provide a chorus.

5. What are the implications of economic cycles? Do organs become easier to obtain in a recession, or merely cheaper? The ethical implications are entirely different. E.g., the army attributes its current ability to meet enlistment quotas to improved advertising, pressuring its recruiters to make quota, opportunities for promotion during wartime (versus the economy having something to do with it).

Xenotransplantation probably looks more promising in the long run. Humanized mice are quite advanced and rapidly becoming less antigenic. Very little work is done in pigs because of cost, but they’re the best candidate. A few million $/year for a decade has a decent probability

of paying off better than paying for organs.

Another reader points to Kieran Healy’s work suggesting the limited (but non-zero) value of opt-in, as embodied in (at increasing length) a Crooked Timber post, this paper, and a book, Last Best Gifts: Altruism and the Market for Human Blood and

Organs .

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: Markarkleiman-at-gmail.com