Limitations of Defaults in Organ Donation
Thaler and Sunstein argue that organ-donation systems depend on organizational practices and communication with families as well as consent defaults. Their examples include Spain and high-performing U.S. organ procurement organizations.
THE IDEA
The Bottom Line
We have emphasized that although defaults can be a powerful tool, changing the default is not the answer to every problem. The topic of organ donation is a good illustration of that point. The crucial factor is that Potential Donors are not the only relevant actors. The challenge is that Families are part of the process, which makes presumed consent a much weaker tool than it may seem. As we have seen, the other aspects of the organizational processes are the secret ingredients to success. These procedures are what Spain is managing so well. They are a combination of organizational choice architecture and well-designed communication strategies used when approaching Families—factors that have proved to be more important than the choice of a default.
The book describes these duties in the United States as being carried out regionally by fifty-eight organ procurement organizations (OPOs) that are responsible for handling deceased organ donations in their territory.30 For example, the Gift of Life Donor Program, an OPO based in Philadelphia and responsible for eastern Pennsylvania and Delaware, is well recognized as a top performer, and unsurprisingly Pennsylvania and Delaware consistently have high organ donation rates. Unfortunately, the underlying pool of potential donors varies by region, and the procedures used by OPOs are rather opaque (at least to us), which makes it difficult to identify which specific OPO practices lead to higher donation rates.
In this context, the goals should be to save the lives of Patients, to respect the rights of Potential Donors, and to do whatever can be done to protect the interests of Families. With those goals in mind, we think that states and countries should concentrate on two priorities in dealing with this problem. First, learn the best practices from Spain and elsewhere, and second, experiment with alternative ways of prompting more sign-ups to the willing donor list, in terms of locations for prompting, incentives for joining the list, and media campaigns. Changing the default rule can be a distraction from these more promising paths.
When to use it
Designing organ donation registration systems
Improving participation in retirement savings plans
Implementing public health policies like vaccination uptake
Ethical considerations in policy design.
FROM THEORY TO EVERYDAY LIFE
In practice
Spain's Organ Donation System
Thaler and Sunstein attribute Spain’s high donation rates chiefly to organizational practices and communication with families. They use the example to argue for examining how a system operates alongside its consent default.
Gift of Life Donor Program
The book describes Philadelphia’s Gift of Life Donor Program as a high-performing OPO and notes high donation rates in Pennsylvania and Delaware. The authors also explain why regional differences make it difficult to isolate the contribution of particular OPO practices.
A MOMENT TO REFLECT
Put it to work.
Why might changing the default rule be a distraction from more effective interventions?
What other factors, besides defaults, influence the success of organ donation systems?
How can the principles from Spain be applied to other areas of public policy?
Often confused with
CONTINUE THE CONVERSATION
Source texts
- Nudge The Final Edition (Richard H. Thaler Cass R. Sunstein)