Commentary
Using Behavioral Economics to Increase
Transplantation Through Commitments to Donate
E. Glenn Dutcher, PhD,1 Ellen P. Green, PhD,2 and Bruce Kaplan, MD3
L
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ike many countries, Japan is facing a shortage of
deceased kidney donations. In Japan, this is exacerbated by certain cultural and religious objections to the use
of deceased donors. Despite efforts to mitigate these objections and increase deceased donor utilization, only 111
deceased donors were performed in Japan in 2017 (while
14 002 patients remained on the waiting list). To increase
the number of donors, Hirai et al1 leverage behavioral
economics and test 5 interventions and their impact on
commitments to donate in Japan. Using these simple and
inexpensive interventions, the authors are able to increase
the commitment to donation, which will potentially lead
to saving more lives through transplantation. In this commentary, we explore the economic principles that explain
the behavior observed in their study and provide further
considerations for using behavioral economics to increase
deceased kidney donations in light of their findings.
When faced with a choice, the standard Economics textbook lays out a convincing case that an individual will
choose the option that generates the most satisfaction or
utility. If an orange and an apple cost the same amount,
and the individual can afford only one, the individual
chooses the apple if she likes the taste of apples more
than oranges. If the apple is put into a red bin, and the
orange a blue bin, the individual should not change her
choice relative to when the color of the bins was reversed
because, regardless of the bin color, she still likes the taste
of apples more than oranges. However, as is evident from a
long line of studies (many nicely summarized in Thaler and
Sunstein2—Nudge), the context around the choice matters.
In their study, Hirai et al1 use nudge techniques to examine if different contexts lead to higher instances of individuals recording their decision to donate their organs on
health insurance cards and driver’s licenses.2 Specifically,
the authors explore how varying framing and increased
salience influence their decision to record their decision to
donate.
Received 5 February 2020.
Accepted 7 February 2020.
1
Department of Economics, Ohio University, Athens, OH.
2
College of Health Solutions, Arizona State University, Tempe, AZ.
3
Baylor Scott & White Health, Central Division, Temple, TX.
The authors declare no funding or conflicts of interest.
Correspondence: Bruce Kaplan, MD, Baylor Scott & White Health, Central
Division, 2401 S 31st St, Temple, TX 76508. (bruce.kaplan@bswhealth.org).
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0041-1337/20/10412-2467
DOI: 10.1097/TP.0000000000003182
Transplantation
Framed choices keep the outcome the same but alter
how the outcome is discussed. In line with the traditional
use of framing, Hirai et al1 utilize a positive frame for some
leaflets and a negative one for others. Hirai et al1 name
these gain-framed and loss-framed messages. The positive
frame highlights how many lives will be saved through
their organ donation, while the negative frame highlights
how many people may die because of too few donors. The
choices under these frames are compared against a control
that has a neutral frame. Their finding, that the negative
frame is more effective than the positive or neutral frame,
is consistent with prospect theory which finds individuals
dislike losses more than equivalent gains.3 Of course, a
gain or loss can be relative—an individual could possess
$1000 by starting with $900 and gaining $100 or starting
with $10 000 and losing $9000. Most would agree that the
first individual is happier with her $1000 given the reference point of $900 versus $10 000. Thus, framing works
to alter the reference point where a negative frame leads
individuals to wish to avoid a loss. The typical descriptive
model used to explain this behavior is aptly dubbed the
reference-dependent utility model.4
Though referenced as framing in their study, the reciprocity-framed and peer-framed interventions do not follow the traditional definition of framing in behavioral
economics. These interventions are more aptly described
by their ability to draw an individual’s attention to one of
the many aspects of their choice to increase the saliency,
which in turn may increase the weight an individual places
on this aspect when making a decision. If an individual is
hungry, they are likely to pay more attention to restaurant
signs and ignore clothing-store signs because their hunger
is more salient than their desire to buy a new sweater. To
successfully increase the salience of an aspect of a choice,
the researcher must know which aspects individuals may
care about and then make certain that the message sufficiently draws the subject’s attention to this aspect. The
reciprocity-framed messages point out that the individual
may, in the future, need an organ from others. This message likely makes salient some guilt-aversion preference
the individual has.5 That is, if the individuals wish to avoid
guilt from free-riding off a system that would benefit them,
this message would increase the rate of consent. Similarly,
the study’s peer-framed message conveys that many people have volunteered to be a deceased organ donor. Given
that individuals can be averse to violating social norms,6
this message, which makes the social norm of registering salient, should lead to an increase in the likelihood of
registering.
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These are just a few ways in which some aspects can
be highlighted and made salient to alter decision-making.
This general methodology can be extraordinarily useful
in achieving some policy objective, though caveats apply.
First, as is evident from the null results for 3 of the 5 messages presented in Hirai et al,1 determining which aspect
to focus on and coming up with the most effective message to highlight that aspect is tricky. Are the null results in
the current article due to the message construction (ie, the
aspect is not salient enough) or are the highlighted aspects
irrelevant for this population in this setting? Second, concerns exist over the long-term effectiveness of these interventions. It would be great to see a follow-up study that
examines if the messages lead to long-term change (if they
are, in fact, adopted). Finally, in response to Thaler and
Sunstein,2 Sugden7 brings up a more philosophical point.
Such interventions are based on normative viewpoints,
which implies that it is the nudger who defines socially
beneficial outcomes which may be at odds with normative
views held by others, including the nudged.
REFERENCES
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on readiness to indicate willingness to register for organ donation during driver’s license renewal in Japan. Transplantation. [Epub ahead of
print. February 13, 2020]. doi: 10.1097/TP.0000000000003181.
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Wealth, and Happiness. New Haven, CT: Yale University Press; 2008.
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Sunstein. Int J Econ Business. 2009;16:365–373.
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.