How default settings doubled organ donation rates in the U.S.

Intervention Healthcare

Abstract

Lack of organs available for donation is a significant problem in the United States, where the default option – defined as the condition present when someone fails to make a decision – is not to be a donor. This shortage is confusing, as approval rates of organ donations in the U.S. are significantly high, hovering around 95%.1 

To investigate this discrepancy between attitudes and action, researchers created a survey in which respondents were asked whether or not they would be donors in one of three conditions: opt-in (default is not to be a donor), opt out (default is to be a donor), or a neutral condition where they chose with no prior default. They found that the donation rates under the opt-out condition were twice as high than in the opt-in condition. These findings reflect the power of the default option and suggest this could be a way to increase donation rates, thus saving lives.

Rating: 5/5 (easy to implement, significant results)

How a default option increased organ donation rates
Condition Results
Default is not a donor 42% consent to be a donor
Default is a donor 82% consent to be a donor
Neutral condition with no prior default 79% consent to be a donor

Key Concepts

Defaults: The option we get when we make no choice.

Opt-in condition: When a person has to take action to confirm that they consent to something, otherwise it’s assumed they don’t consent and the change will not occur.

Opt-out condition: When someone’s consent is assumed with no action taken on their part; to withdraw consent they will need to take action.

Homo economicus: A term used to describe rational human behavior, which vastly differs from the behaviors humans naturally exhibit.

The Problem

Waiting on organ donations

Lack of viable organs for donation has contributed to countless preventable deaths. In the United States, where the default option is not to be an organ donor, there are currently over 100,000 people on the organ transplant waiting list. Unfortunately, 17 people die each day due to a lack of  available organs.2 While there is clearly a lack of donors, approval of organ donation in the United States is high at almost 95%, according to a 2012 Gallup survey.1 What can be done to bridge this gap between need and availability? 

Previous approaches

Many people have also observed this discrepancy and have come up with solutions that follow the classical economic perspective, which suggests that people have a low appraisal of organ donations. They have suggested a public service announcement campaign, an organ market, or even for organs to become public property after death. What they’re missing, though, is a critical look at why donation rates are high in some European countries, where the default option is to be an organ donor. Since we do not behave like Homo economicus, Johnson and Goldstein used a behavioral perspective to find out just how impactful default options can be.

Design

In the lab: surveys

The research duo created a survey in which participants were asked to pretend that they were moving to a new state where the default options varied on three organ donation forms. The first condition was an opt-in condition, where the default option was not to be an organ donor. To change that status, the respondent would have to manually select to be an organ donor. The second condition, the opt-out condition, was identically formed, except the default condition was to be a donor. The third was a neutral condition, in which there was no default and participants could choose freely whether or not to be a donor.

Real-world findings: European organ donation rates

To contextualize these findings, the researchers reached out to several European countries’ central registries in order to approximate the effective consent rate on a broader scale. The effective consent rate is the number of people who opted in in explicit-consent countries, and opted out in presumed consent countries.

Lastly, they broadened their scope further and looked at a larger list of countries’ donation rates between 1991 and 2001. They also controlled for variables that could negatively impact rates, such as religious beliefs and hospital infrastructure.

The MINDSPACE framework

A MINDSPACE Framework guided their practices as they searched for these answers. The MINDSPACE Framework is driven by nine components:

  1. Messenger – We are heavily influenced by who is communicating information.
  2. IncentivesOur responses to incentives are shaped by predictable mental shortcuts, such as the strong desire to avoid losses.
  3. Norms – We are heavily influenced by what others do.
  4. Defaults – We “go with the flow” of pre-set options.
  5. Salience – Our attention is drawn to novel things that seem relevant to us.
  6. Priming – Our actions are often influenced by subconscious cues.
  7. Affect – Our actions can be powerfully shaped by our emotional associations.
  8. Commitments – We seek to be consistent with our public promises and to reciprocate actions.
  9. Ego – We act in ways that make us feel better about ourselves. 3

Results and Application

Opt-out forms led to double the sign-ups

Results from the survey showed that participants in the opt-out condition had nearly double the donation rate than those in the opt-in condition. They also showed that there wasn’t a significant difference between the neutral condition (79% donation consent rate) versus the opt-out condition (82% donation consent rate). There were, however, significant differences between these two conditions and the opt-in condition (42% donation consent rate). 

Similar findings in the real world

Johnson and Goldstein’s two secondary research initiatives, looking at European countries’ effective consent rate and the number of cadaveric donations of a larger number of countries, further support the claim that default settings influence donation rates. This data, in addition to the survey data, suggest that switching the United States’ default to opt-out could increase the number of donors by 1,000 every year. Given that every donor can save up to 8 lives, policy makers should consider switching the default option as it could be an effective way to save up to 8,000 lives annually.2

Industry Application
Philanthropy Grocery stores and drug stores could use the default method by adding a donation to one’s total, where the consumer would have to take action to remove the donation.
Financial Services Banks could set their default so that $1 is sent to the consumer’s savings account after every transaction, whereas that is only an opt-in method currently.
Climate & Energy Energy companies could have sustainable energy sources be the default, and it’s likely that this would influence higher sustainability practices for the consumer as they’d be less likely to go through the hassle of changing it.

Ethics

  • The difficulty of avoiding the nudge was negligible.
  • The intervention could significantly increase organ donation rates and save thousands of lives.
Yes Room for improvement Insufficient information/Not applicable
Welfare
Does the intervention demonstrably improve the lives of those affected by it? Increasing donation rates using  defaults could save an estimated 8,000 lives per year in the United States.
Does the intervention respect the privacy (including the privacy of identity) of those it affects? Yes, as none of the survey respondents were identified. It also doesn’t identify any of the organ recipients.
Does the intervention have a plan to monitor the safety, effectiveness, and validity of the intervention? The investigators identified gaps related to defaults research and encouraged future researchers to measure the effectiveness and validity of default interventions. It didn’t mention safety.
Autonomy
Does the intervention abide by a reasonable degree of consent? Survey respondents were free to leave at any time without fear of retribution.
Does the intervention respect the ability of those it affects to make their own decisions? Even if the default option in the U.S. were switched, individuals would still have the freedom to opt-out of organ donation if they desired.
Does the intervention increase the number of choices available to those it affects? The intervention provides the same number of choices to potential donors. 
Equity
Does the intervention acknowledge the perspectives, interests, and preferences of everyone it affects, including traditionally marginalized groups? This intervention does a great job at acknowledging the multidimensional issue of organ donation and addresses the many reasons why someone may or may not want to donate.
Are the participants diverse? No data is given on the survey respondents’ diversity, nor names of the specific countries whose donation rates were analyzed. The survey only had 161 respondents.
Does the intervention help ensure a just, equitable distribution of welfare? It encourages policy makers to change the default setting so that more organs are donated and more lives are saved.

Related TDL Content

Bridging The Divide Between Decision Science And Policy – What does it look like to try to increase organ donation rates in real-life? How do behavioral scientists encourage policymakers to take on their point of view? This article tackles some of these vital issues with more updated research built upon Johnson and Goldstein’s influential 2003 paper.

A Nudge A Day Keeps The Doctor Away – In addition to organ donation, nudges can drive significant changes in the world of public health. In this perspective piece, the author incorporates behavioral science into her observations and recommendations.

Behavioral Economics – Reference Guide – Amos Tversky and Daniel Kahneman, pioneers in the field of Behavioral Economics, were two of the first people to coin the term Homo Economicus. This article will take you through the history of behavioral economics and provide you with insights on how we got to where we are today.

Sources

  1. U.S. Department of Health and Human Services. (2013, September). 2012 National Survey of Organ Donation Attitudes and Behaviors. https://www.organdonor.gov/sites/default/files/organ-donor/professional/grants-research/national-survey-organ-donation-2012.pdf.
  2. Health Resources & Services Administration. (2021, May). Organ Donation Statistics. https://www.organdonor.gov/learn/organ-donation-statistics
  3. MINDSPACE Framework. The Decision Lab. (n.d.). https://thedecisionlab.com/reference-guide/neuroscience/mindspace-framework/
  4. Johnson, E. J., & Goldstein, D. (2003). Do defaults save lives? Science, 302(5649), 1338–1339. https://doi.org/10.1126/science.1091721.