How default settings doubled organ donation rates in the U.S.

Defaults: The option we get when we make no choice.

Opt-in condition: When a person has to take action to confirm that they consent to something, otherwise it’s assumed they don’t consent and the change will not occur.

Opt-out condition: When someone’s consent is assumed with no action taken on their part; to withdraw consent they will need to take action.

Homo economicus: A term used to describe rational human behavior, which vastly differs from the behaviors humans naturally exhibit.

Waiting on organ donations

Lack of viable organs for donation has contributed to countless preventable deaths. In the United States, where the default option is not to be an organ donor, there are currently over 100,000 people on the organ transplant waiting list. Unfortunately, 17 people die each day due to a lack of  available organs.² While there is clearly a lack of donors, approval of organ donation in the United States is high at almost 95%, according to a 2012 Gallup survey.¹ What can be done to bridge this gap between need and availability? 

Previous approaches

Many people have also observed this discrepancy and have come up with solutions that follow the classical economic perspective, which suggests that people have a low appraisal of organ donations. They have suggested a public service announcement campaign, an organ market, or even for organs to become public property after death. What they’re missing, though, is a critical look at why donation rates are high in some European countries, where the default option is to be an organ donor. Since we do not behave like Homo economicus, Johnson and Goldstein used a behavioral perspective to find out just how impactful default options can be.

In the lab: surveys

The research duo created a survey in which participants were asked to pretend that they were moving to a new state where the default options varied on three organ donation forms. The first condition was an opt-in condition, where the default option was not to be an organ donor. To change that status, the respondent would have to manually select to be an organ donor. The second condition, the opt-out condition, was identically formed, except the default condition was to be a donor. The third was a neutral condition, in which there was no default and participants could choose freely whether or not to be a donor.

Real-world findings: European organ donation rates

To contextualize these findings, the researchers reached out to several European countries’ central registries in order to approximate the effective consent rate on a broader scale. The effective consent rate is the number of people who opted in explicit-consent countries, and opted out in presumed consent countries.

Lastly, they broadened their scope further and looked at a larger list of countries’ donation rates between 1991 and 2001. They also controlled for variables that could negatively impact rates, such as religious beliefs and hospital infrastructure.

The MINDSPACE framework

A MINDSPACE Framework guided their practices as they searched for these answers. The MINDSPACE Framework is driven by nine components:

1. Messenger - We are heavily influenced by who is communicating information.
2. Incentives - Our responses to incentives are shaped by predictable mental shortcuts, such as the strong desire to avoid losses.
3. Norms - We are heavily influenced by what others do.
4. Defaults - We “go with the flow” of pre-set options.
5. Salience - Our attention is drawn to novel things that seem relevant to us.
6. Priming - Our actions are often influenced by subconscious cues.
7. Affect - Our actions can be powerfully shaped by our emotional associations.
8. Commitments - We seek to be consistent with our public promises and to reciprocate actions.
9. Ego - We act in ways that make us feel better about ourselves. ³

Opt-out forms led to double the sign-ups

Results from the survey showed that participants in the opt-out condition had nearly double the donation rate than those in the opt-in condition. They also showed that there wasn’t a significant difference between the neutral condition (79% donation consent rate) versus the opt-out condition (82% donation consent rate). There were, however, significant differences between these two conditions and the opt-in condition (42% donation consent rate). 

Similar findings in the real world

Johnson and Goldstein’s two secondary research initiatives, looking at European countries’ effective consent rate and the number of cadaveric donations of a larger number of countries, further support the claim that default settings influence donation rates. This data, in addition to the survey data, suggest that switching the United States’ default to opt-out could increase the number of donors by 1,000 every year. Given that every donor can save up to 8 lives, policy makers should consider switching the default option as it could be an effective way to save up to 8,000 lives annually.²

• The difficulty of avoiding the nudge was negligible.
• The intervention could significantly increase organ donation rates and save thousands of lives.

Bridging The Divide Between Decision Science And Policy - What does it look like to try to increase organ donation rates in real-life? How do behavioral scientists encourage policymakers to take on their point of view? This article tackles some of these vital issues with more updated research built upon Johnson and Goldstein’s influential 2003 paper.

A Nudge A Day Keeps The Doctor Away - In addition to organ donation, nudges can drive significant changes in the world of public health. In this perspective piece, the author incorporates behavioral science into her observations and recommendations.

Behavioral Economics - Reference Guide - Amos Tversky and Daniel Kahneman, pioneers in the field of Behavioral Economics, were two of the first people to coin the term Homo Economicus. This article will take you through the history of behavioral economics and provide you with insights on how we got to where we are today.