Using Behavioral Economics to Inform the Integration of Human Services and Health Programs under the Affordable Care Act . Organ donation check-boxes and opt-outs


Different countries take different approaches to organ donation. Johnson and colleagues reported that, in six out of the seven European countries where organ donation takes place unless people object by mailing a form or making a telephone call, at least 98 percent of decedents effectively consented to have their organs donated. In three out of the four countries where such form submission or telephone calling is required for organ donation to take place, fewer than 20 percent of decedents have their organs donated, and in the fourth nation (the Netherlands), only 27.5 percent donate, a participation level that was unchanged by a major national education and mass mailing campaign.

To learn more about this disparity, these researchers conducted a randomized, controlled experiment to test the impact of implementing default arrangements through the simplest possible choice mechanism, without any need for mailings, form completion, or even telephone calls. Among all experimental subjects, 79 percent reported a preference for donating their organs after death. One experimental group was deemed to consent unless members checked a simple website box opting out of organ donation. This group had an 82 percent organ donation rate—nearly identical to the expressed preferences of all study participants. Members of a second group had to check a comparably simple website box to opt into organ donation. In the latter group, only 42 percent donated their organs.41 Put differently, in the group where the default was non-donation rather than donation for people who failed to check a simple on-line box:

  • the relative rate of organ donation was 49 percent lower (42 percent vs. 82 percent); and
  • the organ donation rate was substantially different than consumers’ actual preferences (47 percent lower) rather than almost identical to those preferences (just 4 percent higher).42

41 Johnson, E.J., and D.G. Goldstein. “Defaults and Donation Decisions.” Transplantation. 78 (12): 1713-1716. December 27, 2004.

42 As with 401(k) accounts, intermediate approaches are possible that represent neither pure opt-in or pure opt-out models. For example, the state of Illinois uses an “active decision” or “mandated choice” strategy. People renewing drivers’ licenses must decide whether or not to donate their organs after death; defaults are not permitted. According to agencies involved in organ donation, the donation rate in Illinois is 60 percent, compared to a national average of 38 percent. Richard H. Thaler. “Opting in vs. Opting Out.” New York Times. Sept. 26, 2009.

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