Organ Donor
Incentives and
Preferences
Adrienne Janney
April 15, 2005
SI 646: Information Economics
Outline
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Why organ donation
Organ allocation
Addressing organ scarcity
Cadaveric donation
Incentive-minded policies
To opt in or to opt out?
Recommendation
Questions
Organ donation: ‘The Gift of Life’
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Organs are scarce goods
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Waitlisted as of last night: 88,212
Transplants YTD as of last week: 2,271 from 1,164 donors, living
or dead
In 2003, 7,147 people died of 114,442 waiting for organs
In 2000, the MTT was 1,199 days (3.28 years)
Organs are indivisible goods (houses)
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Kidneys come in pairs
Livers and pancreases can be split
Everyone comes with one set of organs (there’s no ‘organ
manufacturing plant’)
Organs are not cakes
Source: United Network for Organ
Sharing
Organ donation: Allocation methods
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Markets
Standing in line (queue)
Rationing
Lottery
Auction
(Thanks, Jeff)
Organ donation: Allocation methods
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Markets
Standing in line (queue)
Rationing
Lottery
Auction
(Thanks, Jeff)
Organ donation: Allocation methods
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Markets
Standing in line (queue)
Rationing
Lottery
Auction
(Thanks, Jeff)
Organ allocation: UNOS
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Rationing + queue + lottery (at the top)
Waiting list
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Numerical medical score based on laboratory findings
Time on list counts in a tie
Divided up by region (for efficiency—organ viability)
Requires blood type and possibly histologic tissue match
Compliance matters
‘Pull’ doesn’t matter (rich & famous)
Note: requires insurance—private or
Medicare or Medicaid
Addressing the scarcity: Ideas
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Increase cadaver pool
Increase living donor pool
Stem cell research (growing transplant
organs)
Artificial organs/organ ‘replacement’
technology (e.g., hemodialysis)
Addressing the scarcity: Problems
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Cadaver pool increasing at slow rate
Living donation only addresses certain
organs (kidneys and sometimes liver or
pancreas)
Stem cell research funding support
decreasing—and it’s a long way off
Not yet developed, and so far less quality of
life with external mechanisms
Deceased and Living Donors
1994-2003
Number of Donors
7,000
6,000
5,000
4,000
3,000
2,000
Deceased Donor
1,000
Living Donor
0
93
9
1
94
9
1
95
9
1
96
9
1
97
9
1
98
9
1
99
9
1
00
0
2
01
0
2
02
0
2
03
0
2
Year
Source: United Network for Organ
Sharing
Addressing the scarcity: Live
donors
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Live donors on increase
Innovation
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Kidney exchange ‘housing’ problem
Only addresses some organs (worth saying
again)
Less chance of rejection/graft failure
for organ recipient
Addressing the scarcity: Live
donors
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Donor incurs risk and costs
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Death
Pain
Temporary but dramatic illness
Less organs to spare
Unsuccessful donation (transplant outcome=death)
Time off work/downtime
(Interlude: Pareto efficiency)
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Recipients benefit from any donor
Live donors incur risk/costs
Ex-post donors lose and gain nothing
Cadaver donation as Pareto efficient?
But: Live donors gain utility via altruism
Jeff says: Dead men don’t have a utility
distribution.
Cadaveric donation: Barriers
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People don’t want to think about death
You have to opt in (more on this later)
Family ability to override (in some states)
Family asked at a time of newly inflicted grief
(fear of regret, high emotional state)
Cadaveric donation: Ex-ante costs
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Taking an action (phone, mail, e-mail, forms)
Psychic costs (upsetting)
Cognitive costs
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Cost of processing new information
Cost of changing viewpoint
Social costs (explaining/convincing family)
Cadaveric donation: Education
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(Advertising)
Education campaigns have not pushed
donation rates to critical mass
Possible reasons?
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Lack of quality?
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Lack of quantity?
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Not ‘values’ driven
Not reaching enough people
Futile venue for offsetting associated costs?
Incentive-minded policies
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Tax incentives
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Donor must be able to realize benefit ex-ante
Enforcement issues dictate ex-post payoff
Money to family or burial
Not in use in the United States
‘Donor will’
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Family cannot override donor-stated preference
Emphasizes individual choice (an American value)
# of states currently implementing
E.g.: Indiana transplants livers at a lower MELD score (better
chances of translant), but still a significant shortage
To opt in, or to opt out?
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We have opt in (‘explicit consent’)
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You have to volunteer your preference to be an organ donor
And in many states your family has to agree
Misclassification potential: underutilization
Several countries have tried opt out
(‘presumed consent’)
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Everyone presumed to be a donor
Individuals may opt out at any time by own initiative
Usual exclusions: minors, prisoners, mentally ill
Misclassification potential: unwilling donors donate
To opt in, or to opt out?
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Classical economics: policy defaults have
limited effects
However, ‘constructed’ preference research
implies otherwise
For unexpressed preferences, defaults do
matter
Source: Johnson and Golsdtein (2003)
To opt in, or to opt out?
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Defaults influences decisions
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Decision-makers believe defaults are suggestions
Making a decision involves effort (accepting default is effortless)
Defaults often represent status quo; change usually involves
tradeoff
‘Loss aversion’
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“Loss looms larger than equivalent gains”
Source: Johnson and Golsdtein (2003)
To opt in, or to opt out?
Opt out countries &
rates of consent (%)
Austria
99.99
Belgium
98
France
99.1
Hungary
99.997
Poland
99.95
Portugal
99.65
Sweden
91.73
Source: Johnson and Golsdtein (2003)
To opt in, or to opt out?
Denmark
4.25
Netherlands
28.79
United Kingdom
16.9
Opt in countries
and rates of
consent (%)
Source: Johnson and Golsdtein (2003)
To opt in, or to opt out?
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‘Natural experiments’ with organ donation
and opt in/opt out
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Revealed donation rates twice as high when opting out as in
Neutral condition (reveals true preferences?)
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Not far off from opt-out rate, implying true
preferences may be closer to opt-out result
Source: Johnson and Golsdtein (2003)
Policy recommendation
Adopting presumed consent in United States
will increase cadaver pool, take pressure off
waiting list and live donor supply, and install a
policy default that provides incentive to
donate by reducing costs association with
making and affirming decisions.
Questions?
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Does this system reveal true preferences?
Problems?
Better systems?
Ethical considerations?
Missed information issues?
Botched economics?
Your questions.