POLICY FORUM - Dan Goldstein

1 1338 Since 1995, more than 45,000 people inthe United States have died waitingfor a suitable donor organ. Althoughan oft-cited poll (1) showed that 85% ofAmericans approve of organ donation, lessthan half had made a decision about donat-ing, and fewer still (28%) had granted per-mission by signing a donor card, a patternalso observed in Germany, Spain, andSweden (2 4). Given the shortage ofdonors, the gap between approval and ac-tion is a matter of life and drives the decision to become apotential donor? Within the EuropeanUnion, donation rates vary by nearly an or-der of magnitude across countries and thesedifferences are stable from year to when controlling for variables such astransplant infrastructure, economic and ed-ucational status, and religion (5), large dif-ferences in donation rates persist.

2 Why?Most public POLICY choices have a no-action default, that is, a condition is im-posed when an individual fails to make adecision (6,7). In the case of organ dona-tion, European countries have one of twodefault policies. In presumed-consentstates, people are organ donors unless theyregister not to be, and in explicit-consentcountries, nobody is an organ donor with-out registering to be one. According to a classical economics view,preferences exist and are available to the de-cision-maker people simply find too littlevalue in organ donation. This view has ledto calls for the establishment of a regulatedmarket for the organs of the deceased (8,9),for the payment of donors or donors fami-lies (10,11), and even for suggestions thatorgans should become public property upondeath (12).

3 Calls for campaigns to changepublic attitudes (13) are widespread. In clas-sical economics, defaults should have a lim-ited effect: when defaults are not consistentwith preferences, people would choose anappropriate different hypothesis arises from re-search depicting preferences as constructed,that is, not yet articulated in the minds ofthose who have not been asked (14 16). Ifpreferences for being an organ donor areconstructed, defaults can influence choicesin three ways: First, decision-makers mightbelieve that defaults are suggestions by thepolicy-maker, which imply a recommendedaction. Second, making a decision often in-volves effort, whereas accepting the defaultis effortless.

4 Many people would ratheravoid making an active decision about dona-tion, because it can be unpleasant and stress-ful (17). Physical effort such as filling out aform may also increase acceptance of the de-fault (18). Finally, defaults often representthe existing state or status quo, and changeusually involves a trade-off. Psychologistshave shown that losses loom larger than theequivalent gains, a phenomenon known asloss aversion (19). Thus, changes in the de-fault may result in a change of , companies, and publicagencies inadvertently run natural experi-ments testing the power of of insurance choice (20), selectionof Internet privacy policies (21, 22), andthe level of pension savings (23) all showlarge effects, often with substantial finan-cial and Organ DonationsWe investigated the effect of defaults ondonation agreement rates in three first used an online experiment (24):161 respondents were asked whether theywould be donors on the basis of one ofthree questions with varying defaults.

5 Inthe opt-in condition, participants were toldto assume that they had just moved to anew state where the default was not to bean organ donor, and they were given achoice to confirm or change that opt-out condition was identical, exceptthe default was to be a donor. The third,neutral condition simply required them tochoose with no prior default. Respondentscould at a mouse click change their choice,largely eliminating effort explanations. The form of the question had a dramat-ic impact (see figure, left): Revealed dona-tion rates were about twice as high whenopting-out as when opting-in. The opt-outcondition did not differ significantly fromthe neutral condition (without a default op-tion).

6 Only the opt-in condition, the currentpractice in the United States, was signifi-cantly the last two decades, a number ofEuropean countries have had opt-in or opt-out default options for individuals deci-sions to become organ donors. Actual deci-sions about organ donation may be affectedby governmental educational programs, theMEDICINEDo Defaults Save Lives?Eric J. Johnson* and Daniel GoldsteinPOLICYFORUMThe authors are at the Center for Decision Sciences,Columbia University, New York, NY 10027, USA.*To whom all correspondence should be consentingto being donors0102030405060708090100 Effective consent rates, online experiment,as a function of consent percentageUnited KingdomGermanyAustriaBelgiumFranceHungar yPolandPortugalSwedenEffective consent rates, by consent (opt-in, gold) and presumed consent (opt-out, blue).

7 21 NOVEMBER 2003 VOL of public health organizations, andcultural and infrastructural factors. We ex-amined the rate of agreement to become adonor across European countries with ex-plicit and presumed consent laws. We sup-plemented the data reported in G bel (25)by contacting the central registries for sever-al countries, which allowed us to estimatethe effective consent rate, that is, the numberof people who had opted in (in explicit-con-sent countries) or the number who had notopted out (in presumed-consent countries).If preferences concerning organ donationare strong, we would expect defaults to havelittle or no effect. However, as can be seen inthe figure (page 1338, bottom), defaults ap-pear to make a large difference: the four opt-in countries (gold) had lower rates than thesix opt-out countries (blue).

8 The two distri-butions have no overlap, and nearly 60 per-centage points separate the two groups. Onereason these results appear to be greater thanthose in our laboratory study is that the costof changing from the default is higher; it in-volves filling out forms, making phonecalls, and sending mail. These low rates ofagreement to become a donor come, insome cases, despitemarked efforts to in-crease donation rates. Inthe Netherlands, for ex-ample, the 1998 cre-ation of a national donorregistry was accompa-nied by an extensive ed-ucational campaign anda mass mailing (of morethan 12 million letters ina country of mil-lion) asking citizens toregister, which failed tochange the effectiveconsent rate (26).

9 Do increases inagreement rates resultin increased rates of do-nation? There are many reasons preventingregistered potential donors from actuallydonating. These include: families objec-tions to a loved one s consent, doctors hes-itancy to use a default option, and a mis-match with potential recipients, as well asdifferences in religion, culture, and infra-structure. To examine this, we analyzed the actualnumber of cadaveric donations made permillion on a slightly larger list of countries,with data from 1991 to 2001 (27). We ana-lyzed these data using a multiple regressionanalysis with the actual donation rates as de-pendent measures and the default as a pre-dictor variable.

10 To control for other differ-ences in countries propensity to donate,transplant infrastructure, educational level,and religion, we included variables known toserve as proxies for these constructs (5) andan indicator variable representing each year. This analysis presents a strong conclu-sion. Although there are no differencesacross years, there is a strong effect of the de-fault: When donation is the default, there is (P< ) increase in donation, in-creasing the donor rate from to (see figure, this page, blue line).Using similar techniques, but looking only at1999 for a broader set of European countries,including many more from Eastern Europe,Gimbel et al. (5) report an increase in therate from to , a increase (seefigure, this page, red line).