Organ donations – Changing the default option vs active choice

When making a decision, what happens if you do nothing: i.e. take no action? The answer is the default option. There is evidence that changing the default option for the same decision can sometimes have a big impact on the final choices people make. For example, when a person starts a new job, they often have to decide whether to contribute to the company’s pension scheme. The default option is typically for employees not to contribute. They have to do something actively (e.g. fill in an online form) to opt in to the scheme. An alternative is to change the default option so that employees are contributing to the pension. They now have to do something to opt out of the scheme.

Changing the default should have no impact on people who behave in ways that are consistent with the rational choice model in economics. However, research by Madrian and Shea (2001) found that it had a big effect. When employees had to opt-in, 49 per cent enrolled in a company pension. When they had to opt out, the figure increased to 86 per cent.

Other research suggests that defaults can influence the likelihood of getting a flu jab, making healthier food choices, receiving e-mail marketing and choosing certain types of car insurance.

Organ donation

One policy area where the choice of default has become a topical issue is organ donation. In 2017, over 400 people died in the UK because it was impossible to find an appropriate donor. Could changing the default increase the number of donors?

The scheme that operates in England requires people to sign-up to the organ donor register: i.e. they have to opt in. Although 80 per cent of the public support organ donation less than 50 per cent ever get around to signing this register.

Parliament recently approved the Organ Donation Bill and the new law will come into effect in 2020. The default position will change so that people are automatically signed-up for organ donation. If they do not want to donate their organs, they will have to opt out of the register.

In December 2015, the devolved Welsh government introduced a similar scheme. Although it is quite early to give a full assessment of the policy, its impact has been smaller than many people had hoped.

Why have the initial results been disappointing? One potential downside with an opt-out scheme is that it may create greater uncertainty about someone’s true wishes. With an opt-in scheme, a relative takes a deliberate action to indicate their preference to be an organ donor. In England, approximately 10 per cent of families overrule the wishes of a relative who has actively signed the register.

With an opt-out scheme, family members may worry that their relative did not want to donate their organs but never found the time to take their name off the register. In 2017/18, families in Wales overruled the presumed consent of their relatives in 33 per cent of cases.

Some countries, such as Singapore and Austria, operate a ‘hard opt-out’ policy. In these schemes, families cannot overrule and this leads to high organ donor rates. However, this type of policy is unpopular with large sections of the electorate who feel it is over paternalistic.

Forcing people to make a choice

Is it possible to force people to make a choice and so reveal their preferences to others? This is a policy of active choice. For example, the government could make the issuing of a driving licence conditional on a people making a choice about whether or not to sign the organ donor register.

This type of policy has been trialled in the USA with the take up of home delivered prescriptions. For the majority of people, there are clear advantages of choosing to have home delivered prescriptions rather than visiting a pharmacy – it is both cheaper and involves less time/hassle. However, the default option is to visit a pharmacy and one study found that only 6 per cent of people chose home delivered options. With the introduction of active choice, this figure increased to 42 per cent.

Some have argued that it is socially undesirable to force people to make a choice. An alternative is simplified active choice – people can either make a choice or accept the default option.

Articles

• Changing the defaults in organ donation: Moving the goalposts or pitch invasion

Journal of Medical Ethics Blog, David Shaw (5/3/19)

• Wales’ organ donation opt-out law has not increased donors

BBC News (4/12/17)

• Organ donor law change named after Max and Keira

BBC News, Fergus Walsh (26/2/19)

• Organ donation: Does an opt-out system increase transplants?

BBC News (10/9/17)

• Opt-out donation plan will not increase donors

BBC News (16/8/17)

• Opt-out organ donation ‘in place by 2020’ for England

BBC News (5/8/18)

Questions