The Organ Donor Crisis, Essay Example

Introduction

The below review of public policies will cover the background and development of the Organ Donor Register of the U.S. Department of Health & Human Services. The author of the current study is also going to attempt to critique the Behavioral Public Policy from the perspective of effectiveness, costs, and suitability to fight the problem it is designed to address. The main issue to be tackled by the policy is to promote organ donation and increase public awareness. The main thesis of the below research is that the government takes a “nudge” behavioral public policy approach, trying to provide people with options, instead of applying command control or financial incentives. The author of the below essay will critically evaluate the effectiveness of the program, and the legislative background of organ donation.

Overview Of The Initiative

In 1984, the U.S. government approved the National Organ Transplant Act, which was designed to prohibit the private buying and sale of human organs. At the same time, the Congress realized that there is a great demand in health care for organ donation. The website of organdonor.com was created in order to put donation of organs into the Federal Government’s hands. The national statistics, published on the U.S. Department of Health & Human Services’ website for 2012 shows that “an average of 79 people receive organ transplants. However, an average of 21 people die each day waiting for transplants that can’t take place because of the shortage of donated organs”. The graph published on the Organ Donor website also shows that the waiting list for organs has been increasing sharply since 1991. Therefore, there was a need for a policy change and government intervention in order to increase the number of donated organs from living and deceased donors. While charities work on promoting organ donation and creating awareness about the changes people can make to others’ lives, the government has also created several campaigns to provide people with a choice. The “Made Possible by an Organ Donor” campaign is a good example for an awareness campaign, and the “nudge approach”. The creation of the Organ Procurement and Transplantation Network has made it possible for matching demand with offered organs more effectively, and cheaper. The network is currently operated by a non-profit organization under a government contract. In 1986, a system was introduced in U.S. hospitals under the The Omnibus Budget Reconciliation Act, to offer patients’ loved ones to donate the organs of the deceased. In 1996, the organ and tissue donation information booklet was sent out to 70 million households in the United States along with income tax refund documentation. Further promoting organ donation, in 1999, the Congress passed the Organ Donor Leave Act, providing paid time off for federal employees for donating organs. However, statistics show that the number of donors has been declining since 2009, while the demand continues rising. This calls for a thorough review of the current “nudge” approach of the policies related to public behavior modification, and the assessment of implemented policies.

Stakeholder Consideration

Before reviewing the above mentioned “nudge” approach of the Federal Government related to organ donation, it is important to examine the interest of different stakeholders represented by the federal agency. The main stakeholders identified are: health care facilities, patients currently on the waiting list for organ donation, the public, and the government. By signing a declaration of intent to donate organs, people commit to allow hospitals and health care facilities use their body to save others’ lives. However, it is also important to note that the decision of the family and the individual is influenced by their belief systems and cultural background. As organ donation is a relatively new area of health care, and transplantation success rates have just started increasing, it is necessary to communicate the potential benefits towards the public in order to achieve behavior change. Reviewing the number of donations received in recent years, it is evident that there is a need for improvement. At the same time, the number of hospitals being ready to receive and transplant donated organs is increasing, and doctors are more willing to perform challenging operations than ever before. From the government’s perspective, it is important to note that the main goal is to achieve the highest possible participation rate at the lowest cost. Families of the deceased, and individuals make decisions related to donation mainly on emotional basis, therefore, campaigns should focus on this area.

Efficiacy Analysis

According to the United Network of Organ Sharing’s statistics, in 2000 more than 70.000 American citizens were waiting for organs, but just above a quarter received one. According to Guadagnoli et al. (101), the current organ procurement system is ineffective in matching demand with donations. However, the problem is more complex than that. Even if an effective allocation system is in place, there is a gap between the demand and donations that needs to be filled. The United States chose to regulate organ donation and have full control over it, however, it did not manage to significantly increase the number of people opting in to donating their organs. Guadagnoli et al. (107) found that “Considering that 5,793 donors provided organs for transplantation in 1998 (35 percent overall donor efficiency), room for improvement exists”.

The main question the current review is examining is whether or not the improvement is possible through the current government approach of “nudge”, or is there a need for changing public policies using a different method?

The main questions related to the effectiveness of the nudge approach in the presentation of Weeek 8 are: does the nudge address causes, does it influence decisions, and does it impact different people in a different way? Based on the above review of the policies and initiatives, awareness campaigns, and interventions, it is evident that in order to change public attitudes related to organ donation, the most common barriers to sign up for a donor network need to be addressed. This requires extensive research, consultation, and understanding cultural diversity of potential donors. Further, without fully understanding the beliefs of potential donors and families, it is not possible to address the causes of organ shortage. While the controlling mechanisms built in the National Organ Transplant Act and The Omnibus Budget Reconciliation Act make the process straightforward for donors, they are not suitable for influencing families’ decisions. On the other hand, the messages of donation awareness campaigns do not address individual beliefs and behaviors.

Theoretical Analysis

Altman (2) summarizes behavioral policies as an approach to deal with the phenomenon that “individuals are said to be persistently irrational in their decision-making”. The theory is extremely relevant to the current issue examined, as it highlights the fact that human behavior is usually influenced by emotions and culture. Therefore, messages that build on the logical approach might not be suitable for changing the public’s behavior related to organ donation.

Dolan et al. (9) describes the Mindspace approach to policy-making, which is more suitable for changing human behavior than the traditional “nudge” approach. The three different ways of improving policies are: enhance, introduce, and reassess. According to the authors, policymakers need to focus on three different areas: the stakeholders (who is affected by the policy), the behavior itself, and the methods to be used when implementing policies.

According to Dolan et al. (11), there are several factors influencing individuals’ decisions and perception of social or economic issues. Some of these are listed in the article, and could provide an insight into what needs to be changed in the United States’ policies and promotion campaigns to change public behavior. Social influence and norms is listed as one of the main influencers of behavior and decisions. Therefore, the more commonly accepted organ donation in the society is, the more likely individuals are going to be to sign up for the register. Commitment and reciprocity is another factor listed, and it brings up the questions whether or not financial or non-fiscal benefits would increase the number of people willing to donate their organs to those who need it. While incentives might be able to increase participation rates, it is important to note that before offering any type of benefit as an exchange for organs, a cost-benefit assessment would need to be created. Further, in order to provide the benefit for donors, a pre-assessment of qualifying organs need to be completed, and this would increase the cost associated with running the program.

Whyte et al. (32) state that “people often make bad decisions as a consequence of predictable biases guiding their behavior”. Therefore, the right approach towards changing public behavior would be to tackle the common misconceptions and biases related to organ donation.

Phelps (40) states that there are two main areas emotions can impact decisions: loss aversion and temporal discounting. Temporal discounting could be affecting the decisions related to organ donation: the reward of one’s actions (saving somebody’s life) might be delayed if they opt for donation after their death, and they would not enjoy the satisfaction of doing good. Therefore, individuals’ motivations are low, and need to be increased through relevant emotional messages.

Critique

Comparing the messages of UK and United States government initiatives related to changing public attitudes about organ donation, some differences are extremely visible. In the United Kingdom, policymakers are motivated by the cost-saving impact of increasing the number of organ donations. Indeed, having a government-funded national health system increases policy-makers’ motivation to implement changes that improve the overall efficiency of the health system. One of the main statements of the NHS Blood & Transplant document released last year is that “work in 2010 found the transplant programme delivered a cost saving to the NHS of £316 million per annum”. Other statements and findings are related to the impact of increased donation on the overall health of the nation, cost-effectiveness of hospitals, and the public’s interest. Based on the 2014 report’s findings (NHS, 5),  in the past five years, the number of deceased donor donations grew by 50 percent.

The main difference found between the policy approach of the U.S. and UK government’s policymakers is that the United Kingdom has a clearly outlined, well developed goal for making changes to the system that would increase participation rate in organ donation programs. The “Taking Organ Transplantation to 2020” strategy (NHS) sets clear, measurable targets for consent rates, transplantation numbers, and number of donors. As a contrast, the United States lacks a strategy that has clearly identified goals that guide strategies.

Whyte et al. (32) state that in the United States one of the main barriers to donate organs is the 2006 amendment of the Uniform Anatomical Gift Act, which means that even if an individual notes on their drivers’ license that they are willing to donate their organs, the decision of the deceased’s family members can still overwrite this choice (Burgess and Ratto). There is sufficient relevant research available that focuses on reasons why individuals do not opt for becoming a donor. As an example, Thaler and Sunstein confirm, low awareness of the default choices, and the impact of organ donation is mainly responsible for the low participation rate. The low rate of signing an organ donor card also indicates that there are some serious issues related to the administration of donors, as well. Mandated choice would – according to Thaler and Sunstein – increase participation rate in the programs.

Some of the disadvantages of the “nudge” approach, according to Thaler and Sustein are the ease of opting out, the “infantilisation” of the nudge, and the question of whose decision it is to select and adjust preferences. Indeed, some of the legislation surrounding organ donation in the United States is problematic, and the rights of patients, individuals, as well as family members need to be clearly defined in order to eliminate legislative and legal issues.

Potential Considerations

According to Spital, mandated choice would be the most suitable way of increasing organ donor program participation. Eliminating the emotional and cultural influences of family members and the society would allow individuals to correctly assess the situation and make the right choice.  Whyte et al. (33) also states that mandated choice would eliminate forced options and disputes. Presumed consent is likely to be disputed by several agencies, family members, and human rights organizations, however, providing people with the choice to opt in or out would save time and simplify the system.

Deedat et al.’s literature research included published articles related to intervention methods designed to increase organ donation. The research found that – in particular focus on minority groups – motivational and educational programs were found to be the most successful in increasing people’s willingness to participate in organ donation programs. The review or published research has concluded that changing behaviors and beliefs about organ donation is a more effective way of increasing participation rates than regulation. Therefore, based on the above research of literature, it is recommended that the U.S.  Department of Health & Human Services implements a long-term strategy that addresses the below issues:

• increasing the number of people making choice
• implementing meaningful messages in education system
• researching the most common barriers for signing up for organ donation programs
• emphasizing the importance of saving lives
• based on the U.K. system, creating a long term plan with measurable targets, based on the size of the gap between demand and donated organs
• working on a plan to introduce mandated choice within a large proportion of the population.

Conclusion

The above review and critique of the U.S. Government’s “nudge” approach has revealed that the policies and awareness programs focusing on increasing the number of organ donations were not clearly  effective. However, it has also been found that using financial incentives would be illegal, based on the National Organ Transplant Act, and would create legal issues. On the other hand, command and control would affect individuals’ free choices, and potentially raise human rights issues, as Burgess and Ratto  confirmed. Reviewing the policy  and initiatives created in the United Kingdom, also using the “nudge” approach has indicated that the main issue is not related to the behavioral policy approach, but the implementation of the program. In the UK, the government benefits from increased organ donation, as the health service is owned by the government. Therefore, policymakers are highly motivated to succeed in promoting organ donation, and have created some innovative programs, campaigns, and agendas to improve the effectiveness of public awareness campaigns and the administration of donors. In the United States, however, the number of donors has not been rising in recent years, and this indicates that there is a need for reviewing the related policies, target cultural and emotional barriers, creating measurable goals for long term. This way the U.S. Department of Health & Human Services could increase participation rates and make the most out of the “nudge” approach.

Works Cited

Altman, Morris. “Behavioral economics, economic theory and public policy.” Economic Theory and Public Policy (June 27, 2008) (2008).

Anderson, Joel. “Nudge: Improving Decisions about Health, Wealth, and Happiness, Richard H. Thaler and Cass R. Sunstein. Yale University Press, 2008. x+ 293 pages.[Paperback edition, Penguin, 2009, 320 pages.].”Economics and Philosophy 26.03 (2010): 369-376.

Aubrey, P., S. Arber, and M. Tyler. “The organ donor crisis: the missed organ donor potential from the accident and emergency departments.”Transplantation proceedings. Vol. 40. No. 4. Elsevier, 2008.

Burgess, Simon, and Marisa Ratto. “The role of incentives in the public sector: Issues and evidence.” Oxford review of economic policy 19.2 (2003): 285-300.

Deedat, Sarah, Charlotte Kenten, and Myfanwy Morgan. “What are effective approaches to increasing rates of organ donor registration among ethnic minority populations: a systematic review.”BMJ open 3.12 (2013): e003453.

Dolan, Paul, et al. “Mindplace: influencing behaviour through public policy.” (2014). Guadagnoli, Edward, Cindy L. Christiansen, and Carol L. Beasley. “Potential organ-donor supply and efficiency of organ procurement organizations.”Health care financing review 24.4 (2002): 101-110.

Levinson, Arik. Happiness, behavioral economics, and public policy. No. w19329. National Bureau of Economic Research, 2013.

Mayers, G. “Buying and Selling Organs for Transplantation in the US: National Organ Transplant Act of 1984 (NOTA) Bans Buying and Selling” Medscape.org

“National Organ Transplant Act of 1984” 1984.

NHS Blood & Transplant Office. “A strategy for delivering a revolution in public behaviour in relation to organ donation” 2004. Web.

Phelps, E. “Changing Emotions, Changing Decisions” Psychological Science and Behavioral Economics in the Service of Public Policy IN THE SERVICE OF PUBLIC POLICY. 2003.

United Network of Organ Sharing. “Organ Procurement and Transplantation Network” 2015. Web.

U.S. Department of Health & Human Services. “Made Possible by an Organ Donor” Campaign”. n.d. Web.

U.S. Department of Health & Human Services. “The Need Is Real: Data” n.d. Web.

Whyte, Kyle Powys, et al. “Nudge, nudge or shove, shove—The right way for nudges to increase the supply of donated cadaver organs.” The American Journal of Bioethics 12.2 (2012): 32-39.