Prompted Choice

Prompted Choice

How can we induce more of the people who wish to be organ donors to register those preferences? Defaulting them into that status is one way, for sure, but doing so has drawbacks. Fortunately, default rules are not the only tools available to choice architects. We call our preferred design prompted choice because it enhances explicit consent with a concerted effort to nudge willing donors into becoming registered donors. A primary function of prompted choice is overcoming procrastination, inertia, and limited attention.

Step 1: Make It Easy

The U.S. example described in Nudge: The Final Edition includes simple online registration through Donate Life (donatelife.net). It had once been common practice to require people to sign the back of their driver’s license or a special donor card and in some cases to get two witnesses to sign as well. These were barriers to joining the registry that modernity and sensible laws have usefully erased. Sludge reduction at work!

Step 2: Get Their Attention

We cannot count on everyone to go through the bother of signing up even if it is easy, so why not ask them to sign up when we have their attention? In the book’s account, U.S. states do so when people renew their driver’s license, though in some places that does not happen very often. After getting a picture taken and paying the fee, people are asked whether they are willing to be an organ donor. If they are, their name is added to the registry and their driver’s license is marked “Donor.” The authors describe increasing use of online renewals and report about 170 million registered donors in the United States, nearly all registered through the driver’s license process.

Step 3: Honor Wishes

The authors describe a “first-person consent law” under which donor registration establishes legal permission for donation after death. Their account includes good faith immunity for teams acting on that authority and emphasizes the value of a recorded decision when families face uncertainty and grief. They report a U.S. “conversion” rate close to 100 percent among registered donors who have died and are medically suitable for donation.

Potential Improvements

Still, we think it is possible to improve on the choice architecture here. We understand the approach of asking people whether they want to be donors every time they have to renew their license; we applaud that approach with respect to people who once said no but might have changed their minds. Still, we wonder whether the authorities should be asking people who have said yes to donation the last time they renewed their license. Maybe it makes sense to presume that yes once still means yes? And it is possible that if people who once said yes are asked again, they are getting an unintended signal, such as that their organs might no longer be usable or that officials think they are making a mistake. We agree that people who once said yes should be able to change their minds, but we are not sure how regularly they ought to be prompted again.

In addition, the Department of Motor Vehicles may not be the best place to make an organ donation decision. Since it is possible to add one’s name to the donor list online, recruitment could be done anywhere. One approach along these lines comes from Israel, where voters were prompted to become donors when they cast their ballots. The authors present this as another way to reach potential donors. In some U.S. states (for example, New York), you can also sign up when you register to vote, providing another opportunity to make the choice. Tax filing could provide a further opportunity.

Media campaigns can also prompt registration. The Brazilian football team Sport Club do Recife ran one such campaign. At home matches, the team showed a video encouraging fans to sign up for a donor card with the team’s logo. You can find the video online by searching for “Immortal fans.” A woman who has received a new heart promises that her new heart will be beating only for Recife! Those behind the promotion report that it yielded more than fifty thousand sign-ups. We hope that other sports teams or, even better, leagues follow this example.

Belgium, and Flanders in particular, has been a pioneer in this sort of recruitment. In 2018, the TV show Make Belgium Great Again dedicated an episode to organ donation, combining emotional appeal with a clear call to action. The show also coordinated with 240 municipalities across Flanders to open their offices on the following Sunday and allow people to come in and complete an organ donor form. The initiative resulted in more than 26,000 new registrations, compared with a previous average in Flanders of between 7,000 and 8,000 registrations per year.

The show also aired a special episode in 2020 to raise awareness of a new online registration function, and accompanied the episode with a special campaign in the Flemish city of Kortrijk. Overnight, bicycle paths were sprayed with the message “Call 0491 75 71 63 for the deal of a lifetime.” Once people called the number, they received a message from the town’s mayor and the show’s presenter encouraging people to register via the online function. Belgium also allowed citizens to register as organ donors during municipal elections, and the government introduced the Federal Truck, which toured the country between 2015 and 2019 to educate schoolchildren about transplantation and initiate discussions within families about organ donation. The authors report that registrations more than tripled in the years since 2009, while opt-outs remained stagnant.

The book also describes Apple’s registration prompt; its founder Steve Jobs received a liver transplant. The initiative invited Americans setting up a new iPhone or the health app to register through Donate Life. Launched in 2016, it had produced more than six million registrations by the authors’ account.