Don’t Take ‘No’ for an Answer: An Experiment with Actual Organ Donor Registrations

by Judd B. Kessler & Alvin E. Roth

Overview — More than 10,000 people in the United States die each year while waiting for an organ transplant. Policymakers and some economists who have tried to increase the rates of organ transplantation have focused on changing the registration question—usually asked when people renew their driver's license—from a simple opt-in to one in which potential donors have the opportunity to make an active "yes" or "no " choice. The authors provide the first concrete evidence of whether active choice affects registration decisions about organ donation. Somewhat surprisingly, the results suggest that not only does active choice not increase registration, it may decrease the transplantation rate by suggesting to next-of-kin that unregistered donors actively chose not to donate. At the same time, however, experimental results suggest other ways to increase the rates of organ donor registration. For example, people are 22 times more likely to add themselves to the registry than remove themselves from the registry, even though they had been asked previously about organ donor registration. This suggests the effectiveness of making a repeated appeal for organ donor registration. In addition, giving people more information about organ donation increases registration rates. Key concepts include:

Giving people the opportunity to make an active choice about donation rather than a simple opt-in does not increase, and may decrease, organ donor registration rates.
Asking more than once for organ donation increases the number of donors. We shouldn't assume that "no" is a final answer (i.e., don't take no for an answer).
People who are registered donors are unlikely to remove themselves from the registry when given the opportunity to do so
Giving people information about the benefits of donation, namely providing a list of organs that might be donated, increases the likelihood of registration.
Increasing the number of individuals who register as deceased donors is just one way of addressing the need for transplantable organs. Kidney exchange, in which incompatible patient-donor pairs are matched, has facilitated transplantation of kidneys from living donors.

Author Abstract

Over 10,000 people in the U.S. die each year while waiting for an organ. Attempts to increase organ transplantation have focused on changing the registration question from an opt-in frame to an active choice frame. We analyze this change in California and show it decreased registration rates. Similarly, a "field in the lab" experiment run on actual organ donor registration decisions finds no increase in registrations resulting from an active choice frame. In addition, individuals are more likely to support donating the organs of a deceased who did not opt-in than one who said "no" in an active choice frame.