In a week when the selection of Welsh rugby players ahead of Brian O’Driscoll for the final Lions test made all the headlines, the vote by the Welsh National Assembly to approve the Human Transplantation Bill caught my attention.
This Bill will introduce an opt-out system of “presumed consent” for donating organs, which would mean everyone is regarded as a willing donor when they die unless they state otherwise. The Human Tissue Bill currently being evaluated by the Irish government would contain somewhat similar provisions. At present, people in both Wales and Ireland must sign up to an organ donor register or their families must agree to allow organs be used after their death. Under the new law in Wales, there will be two forms of consent: (a) ‘consent’ by anybody who has not registered to opt-out and (b) ‘express consent’ by those who have registered to say they wish to be a donor.
The fundamental issue is an imbalance between demand and supply. In the United States alone, up to 4,000 people die each year waiting for kidney transplants. A few economists have argued that because people have two kidneys and need only one to live, a market-based system incorporating the buying and selling of organs could greatly increase supply. However, there is a real danger of poorer people having their kidneys ‘harvested’ for wealthy recipients. Furthermore, there are potentially ethical concerns around whether human organs should be bought and sold in this manner.
Instead of this market-based system, behavioural economists have focused more on the issue of ‘opting in’ versus ‘opting out’ for potential donors. In particular, the best-selling book ‘Nudge: Improving Decisions About Health, Wealth, and Happiness’ by White House advisor Cass Sunstein and leading behavioural economist Richard Thaler has brought attention to this issue. Indeed, while Ireland, the UK and most US states currently have an ‘opt in’ system, several EU countries (including Spain, Belgium, Austria, Croatia and Portugal) have implemented ‘opt out’ or ‘presumed consent’ systems in which citizens are presumed to be consenting donors unless they act to register their unwillingness.
In standard economic models, as long as the costs of registering as a donor or a non-donor are low, the results should be similar. But many findings of behavioural economics show that tiny disparities in such rules can make a big difference. Mr Thaler has highlighted the difference in consent rates between two similar countries, Austria and Germany. In Germany, which uses an opt-in system for organ donation, only 12 per cent give their consent; in Austria, which uses opt-out, nearly everyone (99 per cent) does.
Prof. Thaler has coined the term ‘nudges’ to describe these small changes in incentives. Indeed, the UK government’s Behavioural Insight Team has been nicknamed the ‘Nudge Unit’ and currently takes advice from Richard Thaler on issues ranging from pensions to obesity. To conclude, most Irish (and Welsh) people say they want to be organ donors, but they just don’t get around to acting on their intentions. If a piece of legislation can ‘nudge’ behaviour to increase donation rates, then it should be worthwhile.