(credit: Engin_Aykurt)

Organ donation in da nation

Enough with the nudging already — why not simply pay people to donate their organs?

One of my earliest childhood memories is hearing on the radio about an operation performed by Dr Christiaan Barnard at the Groote Schuur hospital in Cape Town. The quirky name of the hospital was one thing that caught my youthful attention (it means “great barn” in Afrikaans as well as in my native Dutch). But what really struck me then (as it does now), is that it was possible to remove the heart from a dead person and transplant it into another person, who then goes on to live with it.

His patient, Louis Washkansky (I even remember his name too, today) only survived for 18 days, but in the following decades the intervention has become much more successful. People with a donor heart can now expect to live a normal life. Transplantations, not just of hearts but of just about any organs, remain complex operations, but have in many ways become routine.

The thing is, you need donor organs. As dead people don’t need a pancreas or a set of lungs, you might think there is an abundance of transplant organs. Unfortunately this is not the case. There are long waiting lists — in the UK 6,300 are actively waiting for a transplant; in the US 75,000, in Belgium nearly 1300 and in the Netherlands nearly 1100. Many of these people will die (20 per day in the US alone) before a suitable donor organ is found. This is because not everyone is a donor.

Last month, two European countries took a first step on the path to new legislation to boost the number of potential organ donors. Both the UK and the Netherlands new organ donation laws will implement an ‘opt-out’ system. This means that citizens who don’t want their organs being used after they die must register that objection. Everyone else will be considered as a willing donor.

This default is a key factor in the number of organ donors. In some countries their proportion is closer to 100% than a dictator’s share of the vote, while in others it is barely in double digits. In 2003, psychologists Eric Johnson and Daniel Goldstein published a very popular (1250 citations so far) short article, “Do Defaults Save Lives?” In it they described the differences in the proportion of donors between countries operating an ‘opt-in’ approach, where only people who have actively register their willingness are donors, and those with an ‘opt-out’ approach. The figure below shows the stark difference between countries according to the prevailing default. It is easy to see why two laggard countries want to change their legislation.

The default bias is a well-known cognitive tendency, and a prime example of where the choice architecture can influence decision making — the home turf of nudging. We know it well from web forms: the pre-checked box we need to uncheck if we don’t want to be contacted, that kind of thing.

The default effect can be very powerful, as the organ donation statistics show. The logic for the opt-out system is that, as long as it is easy to register as a non-donor, anyone who really wants to hang on to their organs can ensure that their bodily integrity will be preserved to their grave. But nudging a customer into receiving marketing spam from “selected third parties” through inaction is quite different from nudging a person, through similar inaction, to agree to have their organs removed after they die.

Quite understandably the professionals who need to decide whether they can remove a deceased person’s organs do not consider inaction as a firm expression of preference. So they consult the relatives, who then effectively have the final say. This is exactly what happens in practice (for example in Belgium, which has had opt-out legislation since 1986). The end result has no real advantages over a situation where there is no donation register at all.

It is disappointing therefore to see the UK and the Netherlands adopt this line, rather than go for a far superior option. One of the originators of the Nudge theory, 2017 Nobel winner Richard Thaler, is not a fan of the opt-out approach, and advocates a ‘mandated choice’ instead. Ask people the question, for example as part of the application for a driving licence, and make answering the question mandatory. This will make either choice, whether to be a donor or not, a deliberate one, giving clear instructions to the surgeons.

The passing on of vital organs from one person to another is not just a popular theme in behavioural economics. Ordinary economists too are interested in the problem of supply and demand of organs. Why isn’t there a market to ensure supply meets demand?

People whose kidneys are failing are doomed to a life with frequent dialysis, unless they can get a transplant. Since a perfectly normal life is possible with a single kidney, family or close friends are often prepared to act as a living donor, but that doesn’t work if their organs are not compatible. A market for buying and selling kidneys would make economic sense, but the idea is generally considered immoral — economists speak of a repugnant market.

Al Roth, an economist at Stanford and Harvard, has been studying such exchanges for many years (see his 2007 paper “Repugnance as a constraint on markets”). He received the Economics Nobel Memorial prize in 2012 for his work on designing markets, notably a ‘market’ for the live donation of kidneys. In order to circumvent the legal prohibition of the sale of organs, he came up with an ingenious idea: an exchange where donors and recipients can be matched.

Last Christmas, I gave you my kidney (image: Dade Freeman)

Imagine my brother needs a kidney transplant. I would give him one of my kidneys, but our different blood types means we are not a match. At the same time, you would donate a kidney to your spouse, but you have the same problem. However, it turns out that my kidney would suit your spouse, and your kidney would suit my brother. All four of us go under the knife together, and you and I come out with one fewer kidney, having saved both your spouse and my brother through a transplant. Roth extended this idea so that it could work with more than two pairs (eg Alice donates a kidney to Bill’s brother, Bill donates a kidney to Carole’s daughter, and Carole donates a kidney to Alice’s husband.)

This approach, put into practice in the New England Program for Kidney Exchange has undoubtedly saved many lives. But it is still cumbersome, leaving many people waiting for a transplant, at risk of dying before a suitable donor is found. A real market where organs can be bought and sold would save many more people’s lives, as economist Scott Sumner argues. But others disagree: people should not become ‘vendors’ rather than ‘donors’, as Francis Delmonico, a transplant surgeon and Alexander Capron, an ethicist say. And as long as the idea of a market for organs remains repugnant, it will remain mostly an idea (with exceptions few and far between, as in Iran).

What about selling our organs after we’re dead? Imagine a system in which, by registering as a donor, you enter a binding contract: in return for a sum of money, you permit the removal of your organs after you die. The compensation could come from the individuals on the waiting list (or the scheme could be funded by insurers or the state). Such an incentive is likely to do much more to boost the supply of transplant organs to match the demand, than any behavioural nudge ever could.

The arguments against repugnant transactions lose most (if not all) of their power when it concerns taking organs from a corpse. Individual donors would not be adversely affected while they’re alive, on the contrary.

In last week’s edition, the Economist carried an article about repugnant markets. It rightly pointed out that economists cannot avoid morals, ethics and making value judgements. But isn’t there an equivalent situation faced by ordinary citizens? It is hard to see any material harm in a market for organs of dead people. It is easy to see the benefit: thousands of people who now die waiting for a transplant would live years longer.

Does the indulgence of a vague moral objection against the commercialization of human tissue justify the societal harm of the premature death of thousands of people every year, for whom a compatible transplant organ is not found in time?

This is the question us ordinary citizens cannot dodge: where economists must face up to the morality of their economic choices, we have to consider the stark material consequences of our moral choices.

Originally published at koenfucius.wordpress.com on March 2, 2018.

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Accidental behavioural economist in search of wisdom. Uses insights from (behavioural) economics in organization development. On Twitter as @koenfucius

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