Comparing the effects of defaults in organ donation systems

Highlights

• Survey results for the Netherlands reveal that defaults matter in organ donation systems.

• Alternative default settings are confronted with the existing system of explicit consent.

• Mandated choice and presumed consent are more effective in generating donors than explicit consent.

Abstract

The ability of patients in many parts of the world to benefit from transplantation is limited by growing shortages of transplantable organs. The choice architecture of donation systems is said to play a pivotal role in explaining this gap. In this paper we examine the question how different defaults affect the decision to register as organ donor. Three defaults in organ donation systems are compared: mandated choice, presumed consent and explicit consent. Hypothetical choices from a national survey of 2069 respondents in May 2011 in the Netherlands – a country with an explicit consent system – suggests that mandated choice and presumed consent are more effective at generating registered donors than explicit consent.

Introduction

Throughout the developed world one of the most pressing health problems is a persistent shortage for transplantable organs. The discrepancy between demand and supply results in long waiting times for patients who are in need of an organ (British Medical Association (BMA), 2012, Howard, 2007, Johnson and Goldstein, 2003). The policy debate in many countries revolves around solving this shortage. To shed light and inform this debate this paper exams how different systems of organ donation registration affect individual choice. The main debate seems to focus on the two most dominant systems: the explicit consent versus the presumed consent system. In the explicit consent system, the default is that nobody is a donor, and in order to become one they have to officially register (‘opt in’) their status as organ donor. The drawback of relying on such a spontaneous form of altruism is that due to procrastination or inertia the donation rate can be quite low and less than the willingness to donate. Some of these drawbacks are resolved in a presumed consent system. In such a system every adult citizen is by default a donor, unless they choose to opt out of this system. Johnson and Goldstein (2003) used a US sample to show how a presumed consent system in which people may ‘opt out’ generates a substantially higher percentage of registered donors than a system which explicitly makes people state their consent to donate their organs in case they die.

One of the drawbacks of the presumed consent system is that families of a deceased relative may object and withdraw the presumed consent. Furthermore, government can be seen as taking advantage of the inertia or inattention of citizens in giving consent. Spital, 1995, Spital, 1996 was one of the first to suggest a way out of this dilemma: mandated choice. By forcing people to make a choice one can mitigate the ethical drawbacks of the presumed consent system, but it remains uncertain whether this will lead to substantial higher donation rates. Even clearly framed questions cannot prevent the possibility that people are uncertain and leave room for revoking an earlier made decision. In this paper we provide a replication and extension of the widely cited study of Johnson and Goldstein (2003) and measure whether there are substantial differences across three alternative donation systems. We use a survey among the Dutch population of which 48 percent of the respondents say they are registered organ donors. The Netherlands is a country which has an explicit consent system and like many other countries has to solve the problem of too few organ donors (Coppen et al. 2008).