Organ donation....need a catchy title suggestions welcome

By James Wisson (being edited by Jagoda)

In the year that the NHS turns 60, Gordon Brown started a new policy debate over the issue of organ donation with an article in the Sunday Telegraph. He described the shortage of organ donations in the UK as “an avoidable human tragedy we can and must address.”[1] His proposed solution? To change from an ‘opt-in’ system, in which potential donors have to register their wishes to donate their organs, to an ‘opt-out’ system of presumed consent. Recent research from the likes of David Laibson that overlaps economics with psychology can help explain why this might increase the number of donors.

But first of all, how big is this shortage of organs? From the 1st April 2006 to 31st March 2007, 3,087 patients had transplants to save or improve their lives of which about 5 in 6 came from a deceased donor. However, 459 patients died during this period and by the end of it, 7,234 people remained on the active transplant waiting list (with a further 1,915 on the temporarily suspended transplant lists).[2] So for every one transplant that went ahead in the 2006-07 period a little over three more were demanded.

So there is a serious shortage of organs. More organs are needed because demand has increased, with medical advances allowing new transplants and an ageing population needing more of them, while supply has fallen – transplantation is only possible from the recently deceased, in practice, people who die in hospital, and as medical practice and road safety improve, less people are able to donate.

As of the 11th February, 15,006,985 people or 24% of the population[3] had signed up to the NHS Organ Donor Register. This will impress some (that over 15 million people have made the effort to sign up) and depress others (only one in four people are willing to help others live after they have died?) depending on individual points of view. But what is clear is that the number of organ donors is not sufficient. In the UK, the rate of 12.9 organ donors for every million people in the population is much lower than the rate of 35 donors per million in Spain[4], which has been held up as a model system by ‘opt-out’ supporters.

[1] http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2008/01/13/norgans213.xml
[2] All figures in this paragraph: http://www.uktransplant.org.uk/ukt/statistics/transplant_activity_report/current_activity_reports/ukt/transplant_activity_uk_2006-2007.pdf
[3] http://www.uktransplant.org.uk/ukt/default.jsp
[4] http://news.bbc.co.uk/1/hi/health/7183798.stm

So, is it the case that the type of donation system in place in a country will affect the number of people signed up for organ donation? In neoclassical economic theory, it shouldn’t make a difference: individuals should weigh up the costs and benefits of a decision and always come to the same outcome regardless of whether it’s an opt-in or opt-out system.

But, during the Lionel Robbins Memorial lecture series in the Old Theatre last term, David Laibson of Harvard University showed why this isn’t the case. Focussing upon employee decisions over how to save their pension contributions, Laibson showed that when an employer sets an automatic proportion of income to be saved and a default type of pension fund for it to be invested in, a huge proportion of employees stuck with these defaults even when the proportion of income saved was low (there is normally an incentive to save more, as often the employer will match the amount contributed) and the type of stock invested in was very conservative. Sure enough, when the same company removed these defaults and instead obligated employees to choose both a savings rate and where the money was being invested, the savings rate increased and there was a change in the type of funds receiving the investment.

So, how does this cross over to organ donation? Laibson identified four psychological factors to explain this behaviour: financial illiteracy, endorsement effects from an institution that people trust, complexity or the cost of decision making, and present biased preferences. The first three factors do not really apply to UK organ donation although the endorsement effects of the government would make an interesting tangent – do the British population trust/support the government on this or not?

But by far the biggest effects on organ donation will come from the last factor, present biased preferences. In laymen’s terms this is procrastination. Dr Laibson presented a simple model for procrastination in his lecture. For an employee about to enrol into a pension plan the benefits of doing so are huge. Suppose the costs of making the decision are £50 and every day that passes she loses £10 of the overall benefit (counted as a cost in the workings below). Finally there is a discount factor for costs and benefits in the future. So the cost of doing something is the cost today plus the future cost reduced by the discount factor. Supposing that the employee’s discount factor is a half:

Cost of making the decision today = £50
Cost of making the decision tomorrow = 0 + (50+10)/2 = £30
Cost of making the decision in two days time = 0 + (50+20)/2 = £35As the minimum cost occurs tomorrow that is when a rational individual should join the pension plan. But of course ‘tomorrow never comes’, and so this logic will continue on into the future (only stopping when the cost of making the decision or the discount factor decreases – possibly because the individual has more free time).

So if defaults in organ donation affect the number of people who are on the organ donor register, it will largely be down to procrastination. By the logic above, with the present opt-in system, there is a group within the population who haven’t got around to signing up. If the default changes as the PM has proposed, then the number on the register should increase and then there will be a group of people registered who haven’t got around to opting-out.
How much will it increase? Well, in a survey carried out in October, two thirds of people said that they would be “willing to donate their organs for transplantation after their death.”[1] But how far do we trust a survey when in reality only one in four people have signed up to the donors register?

While the opt-in or out register has made the headlines and will increase the ranks of potential organ donors, a more important aspect of our Spanish model may be the dialogue between specialised ‘transplant co-ordinators’ and families of potential donors after their death. The wishes of families still affect whether organs can be donated or not; in the UK there is a 40% family refusal rate compared to 15% in Spain (it was 30% in the 1990s)[2]. This has been attributed to the specially trained transplant co-ordinators in Spanish hospitals who attempt to persuade families to consider donation amidst their grief.

So perhaps the shortage of organs for transplantation will be more significantly addressed through specialised workers addressing the attitudes of families to donation instead of just attempting to increase the supply of people willing to donate (when their families in practice can make the final decision). But in practice we may have to accept that organ donations will never fully match the demand for transplants and so artificially created organs will probably provide the key to resolving this organ shortage.

[1] http://news.bbc.co.uk/1/hi/health/7051235.stm
[2] http://news.bbc.co.uk/1/hi/health/7183798.stm