ArticlePDF Available

Medicine. Do defaults save lives?



The article discusses how should policy-makers choose defaults regarding organ donors. First, consider that every policy must have a no-action default, and defaults impose physical, cognitive, and, in the case of donation, emotional costs on those who must change their status. Second, note that defaults can lead to two kinds of misclassification, willing donors who are not identified or people who become donors against their wishes. Changes in defaults could increase donations in the United States of additional thousands of donors a year. Because each donor can be used for about three transplants, the consequences are substantial in lives saved.
Since 1995, more than 45,000 people in
the United States have died waiting
for a suitable donor organ. Although
an oft-cited poll (1) showed that 85% of
Americans approve of organ donation, less
than half had made a decision about donat-
ing, and fewer still (28%) had granted per-
mission by signing a donor card, a pattern
also observed in Germany, Spain, and
Sweden (24). Given the shortage of
donors, the gap between approval and ac-
tion is a matter of life and death.
What drives the decision to become a
potential donor? Within the European
Union, donation rates vary by nearly an or-
der of magnitude across countries and these
differences are stable from year to year.
Even when controlling for variables such as
transplant infrastructure, economic and ed-
ucational status, and religion (5), large dif-
ferences in donation rates persist. Why?
Most public policy choices have a no-
action default, that is, a condition is im-
posed when an individual fails to make a
decision (6,7). In the case of organ dona-
tion, European countries have one of two
default policies. In presumed-consent
states, people are organ donors unless they
register not to be, and in explicit-consent
countries, 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 little
value in organ donation. This view has led
to calls for the establishment of a regulated
market for the organs of the deceased (8,9),
for the payment of donors or donors’ fami-
lies (10,11), and even for suggestions that
organs should become public property upon
death (12). Calls for campaigns to change
public attitudes (13) are widespread. In clas-
sical economics, defaults should have a lim-
ited effect: when defaults are not consistent
with preferences, people would choose an
appropriate alternative.
A different hypothesis arises from re-
search depicting preferences as constructed,
that is, not yet articulated in the minds of
those who have not been asked (14–16). If
preferences for being an organ donor are
constructed, defaults can influence choices
in three ways: First, decision-makers might
believe that defaults are suggestions by the
policy-maker, which imply a recommended
action. Second, making a decision often in-
volves effort, whereas accepting the default
is effortless. Many people would rather
avoid making an active decision about dona-
tion, because it can be unpleasant and stress-
ful (17). Physical effort such as filling out a
form may also increase acceptance of the de-
fault (18). Finally, defaults often represent
the existing state or status quo, and change
usually involves a trade-off. Psychologists
have shown that losses loom larger than the
equivalent gains, a phenomenon known as
loss aversion (19). Thus, changes in the de-
fault may result in a change of choice.
Governments, companies, and public
agencies inadvertently run “natural experi-
ments” testing the power of defaults.
Studies of insurance choice (20), selection
of Internet privacy policies (21, 22), and
the level of pension savings (23) all show
large effects, often with substantial finan-
cial consequences.
Defaults and Organ Donations
We investigated the effect of defaults on
donation agreement rates in three studies.
The first used an online experiment (24):
161 respondents were asked whether they
would be donors on the basis of one of
three questions with varying defaults. In
the opt-in condition, participants were told
to assume that they had just moved to a
new state where the default was not to be
an organ donor, and they were given a
choice to confirm or change that status.
The opt-out condition was identical, except
the default was to be a donor. The third,
neutral condition simply required them to
choose with no prior default. Respondents
could 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 when
opting-out as when opting-in. The opt-out
condition did not differ significantly from
the neutral condition (without a default op-
tion). Only the opt-in condition, the current
practice in the United States, was signifi-
cantly lower.
In the last two decades, a number of
European 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 affected
by governmental educational programs, the
Do Defaults Save Lives?
Eric J. Johnson* and Daniel Goldstein
The authors are at the Center for Decision Sciences,
Columbia University, New York, NY 10027, USA.
*To whom all correspondence should be addressed:
82 79
Opt-In Opt-Out Neutral
Percent consenting
to being donors
Effective consent rates, online experiment,
as a function of default.
17.17 12
99.98 98 99.91 99.97 99.5 99.64
Effective consent percentage
United Kingdom
Effective consent rates, by country.Explicit consent (opt-in, gold) and presumed consent (opt-
out, blue).
efforts of public health organizations, and
cultural and infrastructural factors. We ex-
amined the rate of agreement to become a
donor across European countries with ex-
plicit and presumed consent laws. We sup-
plemented the data reported in Gäbel (25)
by contacting the central registries for sever-
al countries, which allowed us to estimate
the effective consent rate, that is, the number
of people who had opted in (in explicit-con-
sent countries) or the number who had not
opted out (in presumed-consent countries).
If preferences concerning organ donation
are strong, we would expect defaults to have
little or no effect. However, as can be seen in
the figure (page 1338, bottom), defaults ap-
pear to make a large difference: the four opt-
in countries (gold) had lower rates than the
six opt-out countries (blue). The two distri-
butions have no overlap, and nearly 60 per-
centage points separate the two groups. One
reason these results appear to be greater than
those in our laboratory study is that the cost
of changing from the default is higher; it in-
volves filling out forms, making phone
calls, and sending mail. These low rates of
agreement to become a donor come, in
some cases, despite
marked efforts to in-
crease donation rates. In
the Netherlands, for ex-
ample, the 1998 cre-
ation of a national donor
registry was accompa-
nied by an extensive ed-
ucational campaign and
a mass mailing (of more
than 12 million letters in
a country of 15.8 mil-
lion) asking citizens to
register, which failed to
change the effective
consent rate (26).
Do increases in
agreement rates result
in increased rates of do-
nation? There are many reasons preventing
registered potential donors from actually
donating. 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 as
differences in religion, culture, and infra-
To examine this, we analyzed the actual
number of cadaveric donations made per
million on a slightly larger list of countries,
with data from 1991 to 2001 (27). We ana-
lyzed these data using a multiple regression
analysis with the actual donation rates as de-
pendent measures and the default as a pre-
dictor variable. To control for other differ-
ences in countries’ propensity to donate,
transplant infrastructure, educational level,
and religion, we included variables known to
serve as proxies for these constructs (5) and
an indicator variable representing each year.
This analysis presents a strong conclu-
sion. Although there are no differences
across years, there is a strong effect of the de-
fault: When donation is the default, there is a
16.3% (P< 0.02) increase in donation, in-
creasing the donor rate from 14.1 to 16.4
million (see figure, this page, blue line).
Using similar techniques, but looking only at
1999 for a broader set of European countries,
including many more from Eastern Europe,
Gimbel et al. (5) report an increase in the
rate from 10.8 to 16.9, a 56.5% increase (see
figure, this page, red line). Differences in the
estimates of size may be due to differences in
the countries included in the analysis: Many
of the countries examined by Gimbel et al.
had much lower rates of donation.
How should policy-makers choose defaults?
First, consider that every policy must have a
no-action default, and defaults impose physi-
cal, cognitive, and, in the case of donation,
emotional costs on those who must change
their status. As noted earlier, both national
surveys and the no-de-
fault condition in our ex-
periment suggest that
most Americans favor
organ donation. This im-
plies that explicit con-
sent policies impose the
costs of switching on the
apparent majority (28).
Second, note that de-
faults can lead to two
kinds of misclassifica-
tion: willing donors
who are not identified
or people who become
donors against their
wishes. Balancing these
errors with the good
done by the lives saved
through organ transplantation leads to deli-
cate ethical and psychological questions.
These decisions should be informed by fur-
ther research examining the role of the three
causes of default effects. For example, one
might draw different conclusions if the ef-
fect of defaults on donation rates is due pri-
marily to the physical costs of responding,
than if they were due to loss aversion.
The tradeoff between errors of classifi-
cation and physical, cognitive, and emo-
tional costs must be made with the knowl-
edge that defaults make a large difference
in lives saved through transplantation.
Our data and those of Gimbel et al. sug-
gest changes in defaults could increase do-
nations in the United States of additional
thousands of donors a year. Because each
donor can be used for about three trans-
plants, the consequences are substantial in
lives saved. Our results stand in contrast
with the suggestion that defaults do not
matter (29). Policy-makers performing
analysis in this and other domains should
consider that defaults make a difference.
References and Notes
1. The Gallup Organization, “The American Public’s
Attitude Toward Organ Donation and Trans-
plantation” (Gallup Organization,Princeton, NJ,1993).
2. S. M. Gold, K. Shulz, U. Koch,
The Organ Donation
Process: Causes of the Organ Shortage and
Approaches to a Solution
(Federal Center for Health
Education, Cologne, 2001),
3. H. Gäbel, H. N. Rehnqvist,
Transplant. Proc.
4. C. Conesa
et al
., ,
Transplant. Proc.
35,1276 (2003).
5. R. W. Gimbel, M. A. Strosberg, S. E. Lehrman, E.
Gefenas, F. Taft,
Progr. Transplant.
13,17 (2003).
6. R. H. Thaler, C. Sunstein,
Univ. Chicago Law Rev.
7. C. Camerer, S. Issacharoff, G. Loewenstein, T.
O’Donoghue, M. Rabin,
Univ. Penn. Law Rev.
2111 (2003).
8. M. Clay, W. Block,
J. Soc. Polit. Econ. Stud.
9. J. Harris, C. Erin,
325,114 (2002).
10. C. E. Harris, S. P. Alcorn,
Issues Law Med.
3,213 (2001).
11. D. Josefson,
324,1541 (2002).
12. J. Harris,
J. Med. Ethics
29,303 (2003).
13. J. S.Wolf, E. M. Servino, H. N. Nathan,
Transplant. Proc.
29,1477 (1997).
14. J. W. Payne, J. R. Bettman, E. J. Johnson,
Annu. Rev.
43,87 (1992).
15. P. Slovic,
Am. Psychol.
50,364 (1995).
16. D. Kahneman, A. Tversky, Eds.,
Choices, Values, and
(Cambridge Univ. Press, Cambridge, 2000).
17. J. Baron, I. Ritov,
Org. Behav. Hum. Decision Processes
59,475 (1994).
18. W. Samuelson, R. Zeckhauser,
J. Risk Uncertainty
19. A. Tversky, D. Kahneman,
Q. J. Econ.
106(4), 1039
20. E. J. Johnson, J. Hershey, J. Meszaros, H. Kunreuther,
Risk Uncertainty
7,35 (1993).
21. S. Bellman, E. J. Johnson, G. L. Lohse,
Commun. ACM
Assoc. Comput. Machin.
) 44,25 (February 2001).
22. E. J. Johnson, S. Bellman, G. L. Lohse,
Marketing Lett.
13,5 (February 2002).
23. B. C. Madrian, D. Shea,
Q. J. Econ.
116(1), 1149 (2001).
24. Methods and details of analysis are available as sup-
porting material on
25. H. Gäbel,“Donor and Non-Donor Registries in Europe”
(on behalf of the committee of experts on the
Organizational Aspects of Co-operation in Organ
Transplantation of the Council of Europe, Brussels,
26. M. C. Oz
et al.
J. Heart Lung Transplant.
27. We used a times series analysis to account for possi-
ble changes in transplant technology and infrastruc-
ture, as well as the effects of continuing public edu-
cation campaigns.
28. An alternative advocated by the American Medical
Association (
) is mandated choice, which imposes
the cost of making an active decision on all.This prac-
tice is currently employed in the state of Virginia, but,
consistent with the constructive preferences perspec-
tive, about 24% of the first million Virginians asked
said they were undecided (
29. A. L. Caplan,
272,1708 (1994).
30. American Medical Association, “Strategies for cadav-
eric organ procurement: Mandated choice and pre-
sumed consent” (American Medical Association,
Chicago, 1993).
31. A. C. Klassen, D. K. Klassen,
Ann. Intern. Med.
32. This research has been supported by the Columbia
University Center for Decision Science and the
Columbia Business School Center for Excellence in E-
Business. We thank L. Roels for providing the data on
actual donation rates.
Supporting Online Material
Opt-in Opt-out
Donation rate per million
Estimated donation rate,opt-in versus
opt-out, as a function of default,
1991–2001. Means ± SEM; this paper,
blue; Gimbel
et al
), red.
... Hence, the assumptions of how heuristics and biases are triggered have been applied in nudging. As a result, nudging has been applied in real-life contexts and was successful; for instance, companies utilize status quo bias (a preference for no change) to ensure that employees sign up for pension plans [34,60,61]. Other examples are when governments use a default effect (a pre-set course of action) for organ donation or shops display first the healthy products in the cafeteria to increase their consumption [34,60,61]. ...
... As a result, nudging has been applied in real-life contexts and was successful; for instance, companies utilize status quo bias (a preference for no change) to ensure that employees sign up for pension plans [34,60,61]. Other examples are when governments use a default effect (a pre-set course of action) for organ donation or shops display first the healthy products in the cafeteria to increase their consumption [34,60,61]. The applicability of Type 1 thinking also expands to the digital environment, particularly to UI and choice architecture design, often in the form of dark patterns. ...
Full-text available
When people interact with digital technologies, their choices are often driven in a specific direction, mainly through user interface designs—e.g., specific layout or content. Such guiding practices might be useful. They may help find desired information quicker or proceed with a given task more efficiently. Ultimately, they may contribute to improved usability and satisfaction that users experience during the interaction. However, some of such designs can mislead, manipulate, or trick users into choices that are beneficial to service providers but not necessarily to users. These designs are known as dark patterns, and their success relies on psychological characteristics, particularly exploiting decision-making processes’ weaknesses. The applicability of dark patterns is traditionally associated with e-commerce or marketing strategies aiming to increase sales. However, research shows that dark patterns also extend to online privacy, resulting in harms reaching beyond economic loss and exploiting the vulnerabilities of individuals. This chapter reviews research on dark patterns and explains some of the psychological bases that dark patterns rely on. The chapter focuses on privacy issues and discusses possible ways of preventing the detrimental effects of dark patterns, including their effects on business.
... Choice architecture and nudging have successfully been utilised to improve people's decisions in various domains, such as health (Johnson and Goldstein, 2003) and finance (Thaler and Benartzi, 2004). 1 At the same time, growing evidence has documented a widespread use of 'sludges' or 'dark patterns', especially in the online choice environment (Mathur, Acar, Friedman, Lucherini, Mayer, Chetty, and Narayanan, 2019;Kozyreva, Lewandowsky, and Hertwig, 2020). 2 These refer to the phenomena whereby a choice architect, such as an online firm, designs the choice environment with the objective of exploiting the consumers' cognitive biases at its advantage, by manipulating the way information is presented, steering, using decoys, suitably selecting the default option, etc. 3 Policy-makers, such as the UK Competition and Markets Authority (CMA), have acknowledged the benefits of online choice architecture, such as that of simplifying the overwhelming amount of information available, but -at the same time -expressed concerns about its potentially harmful effects and, in multiple occasions, taken actions (Competition and Markets Authority, 2020). 4 Despite its importance, relatively little attention has been devoted to the study of the effects of exposing consumers to different online choice interfaces. ...
Full-text available
Despite its importance, relatively little attention has been devoted to studying the effects of exposing individuals to digital choice interfaces. In two pre-registered lottery-choice experiments, we administer three information-search technologies that are based on well-known heuristics: in the ABS (alternative-based search) treatment, subjects explore outcomes and corresponding probabilities within lotteries; in the CBS (characteristic-based search) treatment, subjects explore outcomes and corresponding probabilities across lotteries; in the Baseline treatment, subjects view outcomes and corresponding probabilities all at once. We find that (i) when lottery outcomes comprise gains and losses (experiment 1), exposing subjects to the CBS technology systematically makes them choose safer lotteries, compared to the subjects that are exposed to the other technologies, and (ii) when lottery outcomes comprise gains only (experiment 2), the above results are reversed: exposing subjects to the CBS technology systematically makes them choose riskier lotteries. By combining the information-search and choice analysis, we offer an interpretation of our results that is based on prospect theory, whereby the information-search technology subjects are exposed to contributes to determine the level of attention that the lottery attributes receive, which in turn has an effect on the reference point.
... First, changing the default option is a powerful way to affect individuals' choices. For example, Johnson and Goldstein (2003) point out that, in countries where citizens were added to an organ donor list by default and had to actively opt out, the donor rate increases substantially. Second, the desirability of a choice seems to be directly affected by the effort an individual has to undergo when choosing this specific option. ...
Full-text available
This paper discusses current developments in tax compliance research, with a focus on three aspects. First, we summarize empirical evidence on the traditional deterrence or enforcement approach, suggesting that tax audits and fines for noncompliance are critical in taxpayers’ compliance decisions. However, recent research indicates that the effects of deterrence are more nuanced than initially thought, suggesting that other interventions are needed to improve tax compliance. Second, therefore, we discuss research on behavioral approaches to increase tax compliance, starting with research that analyzes the effects of “nudges”, or interventions that use behavioral economics to alter the ways in which the choice architecture facing individuals is communicated to them by the tax administration. As applied to tax compliance, we conclude that nudges have had mixed effects on increasing tax compliance, suggesting that the specific design and implementation of these interventions determine their effectiveness. Third, we extend our discussion to other behavioral economics interventions that have not yet been studied widely in tax compliance research. These include “sludge”, or institutional features that complicate compliance, and “boosts”, or initiatives that target individuals’ competencies and thereby help them to make better decisions. Our central argument is that all three of these behavioral interventions should be utilized in the design of tax policies. However, for these methods to effectively complement traditional deterrence approaches, tax administrations should evaluate them before implementing them in the field. Closer cooperation between administrators and academics should thus be facilitated and encouraged.
Nudges are interventions promoting healthy behavior without forbidding options or substantial incentives; the Apple Watch, for example, encourages users to stand by delivering a notification if they have been sitting for the first 50 minutes of an hour. On the basis of 76 billion minutes of observational standing data from 160,000 subjects in the public Apple Heart and Movement Study, we estimate the causal effect of this notification using a regression discontinuity design for time series data with time-varying treatment. We show that the nudge increases the probability of standing by up to 43.9% and remains effective with time. The nudge’s effectiveness increases with age and is independent of gender. Closing Apple Watch Activity Rings, a visualization of participants’ daily progress in Move, Exercise, and Stand, further increases the nudge’s impact. This work demonstrates the effectiveness of behavioral health interventions and introduces tools for investigating their causal effect from large-scale observations.
In three studies, with samples from different countries (the United States and Israel) and religions (Christians and Jews), we found that individual levels of fear of death significantly predicted lower willingness to register as organ donors (Studies 1 and 2). Moreover, after being asked about their organ donation status (i.e., whether they are registered as donors), fear of death significantly increased among unregistered people. This did not occur among registered people, who had already faced the decision to become donors in the past (Study 2). Finally, providing non-registered (non-religious) people with a defense strategy to manage their fear of death increased their willingness to sign an organ donation commitment, partially by increasing their feelings of hopefulness. The implications of these findings for increasing organ donation registration are discussed.
People prefer active decision-making and induce greater emotional feelings than computer-based passive mode, yet the modulation of decision-making mode on outcome evaluation remains unknown. The present study adopted event-related potentials to investigate the discrepancies in active and computer-based passive mode on outcome evaluation using a card gambling task. The subjective rating results showed that active mode elicited more cognitive effort and stronger emotional feelings than passive mode. For received outcomes, we observed no significant Feedback-Related Negativity (FRN) effect on difference waveshapes (d-FRN) between the 2 modes, but active decision-making elicited larger P300 amplitudes than the passive mode. For unchosen card outcomes, the results revealed larger d-FRN amplitudes of relative valences (Superior - Inferior) in responses to negative feedback in active mode than in passive mode. The averaged P300 results revealed an interplay among outcome feedback, decision-making mode, and relative valence, and the average P300 amplitude elicited by the received loss outcome in the active mode partially mediated the relationship between subjective cognitive effort and negative emotion ratings on loss. Our findings indicate discrepancies between active and computer-based passive modes, and cognitive effort and emotional experience involved in outcome evaluation.
Full-text available
Dark patterns are user interface design elements which harm users but benefit vendors. These harms have led to growing interest from several stakeholders, including policymakers. We develop a high-level analytical framework – the dark patterns auditing framework (DPAF) – to support policymaker efforts concerning dark patterns. There are growing links between dark patterns and the behavioural science concept of sludge. We examine both literatures, noting several worthwhile similarities and important conceptual differences. Using two ‘sludge audits,’ and the DPAF, we examine 14 large online services to provide a high-level review of the user experience of these services. Our approach allows policymakers to identify areas of the user ‘journey’ ( dark paths ) where sludge/dark patterns persist. For regulators with constrained resources, such an approach more be advantageous when planning more granular analyses. Our approach also reveals several important limitations, notably, within some of the tools for sludge auditing which we develop, such as the ‘equal clicks principle.’ We discuss these limitations and directions for future research.
The effects of adding choice architecture to a theory-based (Health Action Process Approach; HAPA) sedentary intervention remain unknown. To investigate whether choice architecture enhances a theory-based sedentary behaviour reduction intervention in home-based office workers. A 4-week HAPA-based intervention was conducted in London, Canada. Choice architecture was tested as an enhancement via a two (group: ‘Choice of Intervention’ vs. ‘No Choice Intervention’) by two (time: Baseline vs. Week 4) factorial repeated measure randomized comparison design. Sedentary behaviour reduction strategies focussed on obtaining a sedentary break frequency (BF) of every 30–45 min with break durations (BD) of 2–3 min. BF, BD, sitting, standing, and moving time were objectively measured (activPAL4™) at both time points. Participants (n = 148) were 44.9 ± 11.4 years old and 72.3% female. BF and total sitting time showed a time effect (P < .001), where both groups improved over the 4 weeks; there were no significant differences between groups across time. BD, standing, and moving time had a significant group by time effect where the ‘No Choice’ group showed significant increases in BD (P < .001), standing (P = .006), and moving time (P < .001) over the 4 weeks. Augmenting a theory-based intervention with choice architecture resulted in change in some sedentary behaviours in at home office workers. Specifically, while BF increased for all participants, the ‘No Choice’ group exhibited greater changes for BD, standing, and moving time compared with the ‘Choice’ group. Overall, these changes exceeded the intervention BF and BD goals.
Full-text available
A series of studies examines whether certain biases in probability assessments and perceptions of loss, previously found in experimental studies, affect consumers' decisions about insurance. Framing manipulations lead the consumers studied here to make hypothetical insurance-purchase choices that violate basic laws of probability and value. Subjects exhibit distortions in their perception of risk and framing effects in evaluating premiums and benefits. Illustrations from insurance markets suggest that the same effects occur when consumers make actual insurance purchases.
Full-text available
Differences in opt-in and opt-out responses are an important element of the current public debate concerning on-line privacy and more generally for permission marketing. We explored the issue empirically. Using two on-line experiments we show that the default has a major role in determining revealed preferences for further contact with a Web site. We then explore the origins of these differences showing that both framing and defaults have separate and additive effects in affecting the construction of preferences.
Full-text available
Permission marketing requires consumers' consent before a Web site can track them with cookies, or send them marketing email, or sell their data to another company. Yet a study conducted by Cyber Dialogue Inc. found that 69% of U.S. Internet users did not know they had given their consent to be included on email distribution lists. Using the right combination of question framing and default answer, an online organization can almost guarantee it will get the consent of nearly every visitor to its site. Although lists of people who have supposedly opted-in for permission marketing schemes are valuable sources of revenue for Web sites, high response rates alone do not mean these lists contain valuable customers. They systematically explored the influence of question framing and response defaults on consumers' apparent privacy preferences in two online experiments detailed. Participants in these experiments were members of the Wharton Virtual Test Market, an online panel of over 30,000 Internet users representative of the U.S. Internet population. Results of experiments highlight the need for all online consumers to pay close attention to what they agree to when they send responses to a Web site. If consumers had fixed policies about the privacy of their data, then asking them to opt-out or opt-in to a Web site's privacy policy would make no difference to their answer.
Full-text available
Regulation by the state can take a variety of forms. Some regulations are aimed entirely at redistribution, such as when we tax the rich and give to the poor. Other regulations seek to counteract externalities by restricting behavior in a way that imposes harm on an individual basis but yields net societal benefits. A good example is taxation to fund public goods such as roads. In such situations, an individual would be better off if she alone were exempt from the tax; she benefits when everyone (including herself) must pay the tax.
Context Few studies on presumed consent and environmental predictors of cadaveric organ donation in Europe have been published. Objective To determine if a presumed consent policy and other variables can be used to predict the cadaveric organ donation rate per million population. Design Secondary analysis of published data. Setting Europe. Participants The unit of analysis for this study is the individual country. Main Outcome Measure Cadaveric organ donation rate per million population. Results Original and transformed data were subjected to ordinary least-squares regression. All 4 independent variables were significant predictors of cadaveric donation rate, including (1) having a presumed consent (opting-out) policy in practice, (2) number of transplant centers per million population, (3) percentage of the population enrolled in third-tier education, and (4) percentage of population that is Roman Catholic. Conclusion Findings may be useful to academics and professionals responsible for organ procurement. Additional research is necessary for practical application of findings. Generalizing these findings beyond Europe may be problematic because of external validity constraints.
The American Medical Association has just voted to encourage studies that would determine whether financial incentives would increase the pool of donor organs from cadavers.1 The association is only eight years behind a proposal that we made, outlining probably the only circumstances in which a market in donor organs could be achieved ethically and in a way that minimised the dangers of such a scheme. This is how an ethical market in live organs would work. To meet legitimate ethical and regulatory concerns any such scheme must have built into it safeguards against wrongful exploitation and show concern for vulnerable people, as well as taking into account considerations of justice and equity. If all this can be done then a market in human body products will be shown to be, at the very least, not prima facie unethical.2 One way of attending to this need for prudent regulation would be to establish a monopsony, a situation where only one buyer exists for the products of several sellers.3 The one legitimate purchaser in the marketplace would be required to take on responsibility for ensuring equitable distribution of all organs and tissues purchased. This would prevent the rich using their purchasing power to exploit …
THE SCARCITY OF ORGANS FOR TRANSPLANTATION The shortage of organs for transplantation is becoming more critical every year. Because of improvements in transplantation procedures, beginning with the advent of immunosuppressive therapies in the early 1980s, more patients now benefit from organ transplantation. As a result of transplantation's success, waiting lists for donor organs are increasingly crowded. Between December 1987 and June 1991, for example, the total number of patients on organ transplant waiting lists increased 75.3%, from 13153 to 23 056 patients.1
Behavioral decision research: A constructive processing perspective
One of the main themes that has emerged from behavioral decision research during the past 2 decades is the view that people's preferences are often constructed in the process of elicitation. This concept is derived in part from studies demonstrating that normatively equivalent methods of elicitation often give rise to systematically different responses. These "preference reversals" violate the principle of procedure invariance that is fundamental to theories of rational choice and raise difficult questions about the nature of human values. If different elicitation procedures produce different orderings of options, how can preferences be defined and in what sense do they exist? Describing and explaining such failures of invariance will require choice models of far greater complexity than the traditional models. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Much experimental evidence indicates that choice depends on the status quo or reference level: changes of reference point often lead to reversals of preference. The authors present a reference-dependent theory of consumer choice, which explains such effects by a deformation of indifference curves about the reference point. The central assumption of the theory is that losses and disadvantages have greater impact on preferences than gains and advantages. Implications of loss aversion for economic behavior are considered. Copyright 1991, the President and Fellows of Harvard College and the Massachusetts Institute of Technology.