Incentives for Organ Donation

In an important editorial the Washington Post advocates giving points in the current organ allocation system to people who have previously signed their organ donor cards.  I have long argued for such a system (see Entrepreneurial Economics and here) and am an advisor to Lifesharers an organization that is implementing a similar system privately.

The decision to pledge organs could be linked to the chance of
receiving one: People who check the box on the driver’s-license
application when they are healthy would, if they later fell sick, get
extra points in the system used to assign their position on the
transplant waiting list (other factors include how long you have waited
and how well an available organ would match your blood type and immune
system).

Thanks to Dave Undis for the pointer.

Comments

The Washington Post article mentions Georgia's $9 discount on a driver's license if you check the donate box. About 10 years ago when I got a Georgia license, they only told you about the discount AFTER you had chosen whether to be a donor!

I bet you'd get lots more donors with other simple incentives, like the option to submit your own photo for the drivers license, the ability to choose from 3 they take...or a modest reduction in the bad driver points on your driving record...

And if we were serious about it we'd make it more fun and socially reinforcing ... giving donors a completly free license AND the photo options if they allow a legally dependable donor bumper sticker to be put on their car.

I'm sure using an opt-out of donor status, versus our current opt-in to donor status, policy would greatly increase donors. I've seen several studies that show people willing to donate are less likely to opt in than people not willing to donate are to opt out. Thus, along with greater supply, you are able to line up preferences better. Further, I've heard from medical field friends that the opt-in policy causes significance deference to the wishes of family. So that when Dad is going and even though he has opted in to donor status, that the objections of family members will often prevent the hospital from carrying through with the donor's wishes for fear of litigation. An opt-out policy may help to deal this problem as well, though I have no evidence one way or the other on this latter point.

Unfortunately for kidney patients, who represent the plurality of those needing organs, cadaver organs are a sideshow. Even if every medically appropriate cadaver kidney were harvested (100% opting in), the vast majority of people waiting for kidneys would be out of luck. Only living donors can close this gap, and it is their incentives which should be enhanced. Large Pareto improvements are possible.

The sad thing is that all the publicity about cadaver harvesting freaks out the public and makes it harder to focus on this living-donor issue. People come to associate all organ donations with the discomfiting, death-reminding, grave-robber-evoking act of taking pieces out of a loved one's corpse for another's use. People perceive (to a greatly exaggerated extent) all sorts of potential agency problems in the relationship between doctors, donors, and their families. They then translate this generally negative feeling over to the far less problematic live donor process. It's irrational, but real.

It would be nice if the WaPo would editorialize in favor of incentives for live kidney donors, or maybe for donors to get paid for lost wages (legal now but rarely done), or at least for donors to be guaranteed follow-up medical care down the line. But somehow the cadaver issue just seems sexier, even though it is quantitatively less important (and emotionally poisons the well for living donor encouragement).

Kieran Healy's excellent "Last Best Gifts" talks about the kind of problem Tracy W. refers to. Basically, he says that whatever people sign or don't sign, the decision in most systems is up to the relatives (in practice if not legally) because it would not be done without their consent.

I wonder what would happen if you introduce a scheme like this. I think it would be more than "a bit of efficiency" - it could be major conflict between the law (which, once there are benefits to signing your card, becomes more of a factor) and the wishes of relatives.

Healy's book has much more on how the devil is in the details when it comes to incentive schemes for organs, and he is critical also of the other side of the debate. He suggests that the real issue (regardless of the incentive question) is that we are entering an age where organ donation/harvesting/exchange is becoming industrialized, and that there are inevitably many incentive problems that we are going to have to deal with.

Prof. AT,

People should never pay their way to receiving an organ.

Giving preferential treatment to organ donors on top of medical evaluations of need and best match has the potential of creating a confusing system of allocation and may disadvantage those who are not educated enough to opt in.

The opt-out system is reasonable. It does however have the potential to create a legal nightmare – a la Terri Schiavo.

The GA $9 DL discount is a great idea – practical and with immediate and tangible payoffs.

People would rather waste organs than save a life. This is bewildering. If the barrier to donation is religious, will any amount of money overrule God? What economic theory addresses this anomaly?

There are a lot of myths about organ donation. One of the main ones that I hear is that "the medical professionals won't work as hard to save someone's life if they know he/she is an organ donor." Utter nonsense, of course.

Hirohito,

The matching of organs to recipients is a very complicated process and the best that we can do is to ensure that rejection is kept to a minimum. Remember, transplants today are a last resort option. The donor’s organ has to be transplanted within a very short time of donor’s death to the recipient. Time is a critical factor (helicopters are often used to deliver the organ). Do you really believe that in such an atmosphere, anyone has the patience to investigate the economic status of recipients? If you abhor inefficiency, you would want your organs to go to the patient with the highest chance of survival.

Hirohito,

You can choose the recipient with respect to organs transplanted while you are living (i.e. kidney).

In the case of most organs though, there will inherently be a middleman/bureaucracy that will handle the transaction. That middleman must set priorities and not conflicting ones (otherwise you have an even larger bureaucracy). The argument is that those priorities must be focused on the probability of success of the transplant. Otherwise, the survival rate drops for a pricey procedure.

Can you say with certainty that a poor man on welfare or a 45-year old miner who needs a lung transplant will not be a more productive member of society post-op than a rich 60-year-old who simply wants to spend more time with his grandchildren?

If you are a person on welfare, choose to be an organ donor and expect to receive an organ when the best (genetic) match is found for you.

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