The Ethics of Organ Donor Registration Policies: Nudges and Respect for Autonomy

Thinking about default enrollment lowers vaccination intentions and public support in G7 countries

Policymakers often face a conundrum between being transparent about policies and ensuring that those policies are effective. This challenge is particularly relevant for behavioral nudges, which are not usually disclosed. Rather than avoiding transparency, we suggest that policymakers encourage citizens to reflect on nudges to help them understand their own views and align those views with their behaviors. Using data from an online survey experiment with 24,303 respondents in G7 countries, we examine the impact of reflection on a hypothetical default nudge policy for COVID-19 booster appointments. Contrary to expectations, participants say they would be less likely to get the booster when automatically enrolled compared with a control condition. Similarly, encouraging citizens to think about the status quo (baseline) policy also reduces intentions for boosters. These interventions have no effect on approval of the policy. Further, encouraging people to think about automatic enrollment decreases approval of the policy and further decreases their intentions to get vaccinated. These findings suggest that reflection on a nudge can increase backlash from a nudge and also elicit policy disapproval, thereby aligning policy support with behavioral intentions.

How clinicians discuss patients' donor registrations of consent and presumed consent in donor conversations in an opt-out system: a qualitative embedded multiple-case study

BACKGROUND

The Netherlands introduced an opt-out donor system in 2020. While the default in (presumed) consent cases is donation, family involvement adds a crucial layer of influence when applying this default in clinical practice. We explored how clinicians discuss patients' donor registrations of (presumed) consent in donor conversations in the first years of the opt-out system.

METHODS

A qualitative embedded multiple-case study in eight Dutch hospitals. We performed a thematic analysis based on audio recordings and direct observations of donor conversations (n = 15, 7 consent and 8 presumed consent) and interviews with the clinicians involved (n = 16).

RESULTS

Clinicians' personal considerations, their prior experiences with the family and contextual factors in the clinicians' profession defined their points of departure for the conversations. Four routes to discuss patients' donor registrations were constructed. In the Consent route (A), clinicians followed patients' explicit donation wishes. With presumed consent, increased uncertainty in interpreting the donation wish appeared and prompted clinicians to refer to "the law" as a conversation starter and verify patients' wishes multiple times with the family. In the Presumed consent route (B), clinicians followed the law intending to effectuate donation, which was more easily achieved when families recognised and agreed with the registration. In the Consensus route (C), clinicians provided families some participation in decision-making, while in the Family consent route (D), families were given full decisional capacity to pursue optimal grief processing.

CONCLUSION

Donor conversations in an opt-out system are a complex interplay between seemingly straightforward donor registrations and clinician-family interactions. When clinicians are left with concerns regarding patients' consent or families' coping, families are given a larger role in the decision. A strict uniform application of the opt-out system is unfeasible. We suggest incorporating the four previously described routes in clinical training, stimulating discussions across cases, and encouraging public conversations about donation.

Let the Chips Fall! Public Nudging Arrangements, Coercion, and the Role of Independent Shopkeepers

Nudging, according to its inventors and defenders, is supposed to provide a non-coercive way of changing human behavior for the better-a freedom-respecting form of "libertarian paternalism." Its original point was to complement coercive modes of influence without any need of justification in liberal frameworks. This article shows, using the example of food-product placement in grocery stores, how this image is deceptive. Although nudging practices may not restrict the freedom of consumers, nudging arrangements by public health authorities do restrict the freedom of shopkeepers in standard liberal senses. Libertarianism cannot justify this coercion, and the creed is best left out of the equation as the ideological ruse that it, in this discussion, is. Other liberal theories can justify the coercion, but on grounds that can also be applied to other methods of public health promotion by subsidies and regulation. This result reaffirms that nudging should be seen to complement, not to replace, those other methods.

Does default organ donation registration compromise autonomous choice? Public responses to a new donor registration system

Defaults have been shown to increase the number of organ donor registrations but it is unclear whether they violate personal autonomy of the people being registered. The implementation of a new Donor Act in the Netherlands, providing people with the opportunity for active registration before being defaulted, allowed for examining to what extent default registration affects personal autonomy and associated concepts. In an online survey among a representative sample (N = 1259), four groups were compared regarding autonomy, decision-making competence, decision satisfaction, and being pressured to register as a donor: people (1) who had registered their status prior to the Donor Act, (2) who had not yet received an invitation for default registration, (3) who had received an invitation and then registered their choice, and (4) who had received an invitation but took no action and were defaulted into donor registration. We found that among the three groups who were the target population of the new arrangement, people who registered their status reported relatively high levels of autonomy and related concepts. However, people who were invited to register but passed the opportunity to respond reported lower scores on these outcomes. We conclude that default organ donation registration may bear negative consequences for a minority of people who feel unable to take action after having been invited to make a choice for registration.

Survey Results on Using Nudges for Choice of Green-Energy Supplier

One of the most important climate change mitigation strategies is to exploit the potential of individual behavioral changes in order to reduce greenhouse gas (GHG) emissions, and the insights of behavioral economics are proving helpful in this regard. This contributes to improving traditional instruments, developing new ones related to choice architecture (nudges), and combining them within behavioral decarbonization intervention strategies. It is important, in terms of their effectiveness and efficiency, whether the instruments of such interventions are supported by citizens. This paper presents the results of a survey of Polish respondents’ (n = 1064) reactions to hypothetical nudges regarding the choice of a “green energy” supplier. The main research questions of the study are: how much civic support do these behavioral intervention tools have, and what is the importance of selected factors for their acceptance? The aim of the study is to present nudges as one of the strategies of pro-environmental behavioral change and to analyze selected factors of acceptance of these instruments by the Polish society. There are two main conclusions of the research: (1) Poles’ support for the green nudges analyzed is comparatively high, like in other European countries; (2) statistically significant differences in support for one of them are age and individual political party preferences.

Transitions in decision-making authority at the end of life: a problem of law, ethics and practice in deceased donation

Where a person is unable to make medical decisions for themselves, law and practice allows others to make decisions on their behalf. This is common at the end of a person's life where decision-making capacity is often lost. A further, and separate, decision that is often considered at the time of death (and often preceding death) is whether the person wanted to act as an organ or tissue donor. However, in some jurisdictions, the lawful decision-maker for the donation decision (the 'donation decision-maker') is different from the person who was granted decision-making authority for medical decisions during the person's life. To date, little attention has been given in the literature to the ethical concerns and practical problems that arise where this shift in legal authority occurs. Such a change in decision-making authority is particularly problematic where premortem measures are suggested to maximise the chances of a successful organ donation. This paper examines this shift in decision-making authority and discusses the legal, ethical and practical implications of such frameworks.

Presumed post-mortem donors: the degree of information among university students

BACKGROUND

Organ transplantation represents the most effective and acceptable therapy for end-stage organ failure. However, its frequent practice often leads to a shortage of organs worldwide. To solve this dilemma, some countries, such as Portugal, have switched from an opt-in to an opt-out system, which has raised concerns about respect for individual autonomy. We aimed to evaluate whether young university students are aware of this opt-out system so that they can make informed, autonomous and conscious decisions, as well as to identify the factors that determine a positive attitude toward post-mortem organ donation.

METHODS

An observational, cross-sectional study was developed and a questionnaire was administered to first-year students from six faculties of the University of Porto.

RESULTS

Of the 841 participants, 60% were unaware that Portugal had adopted an opt-out system. Among the informed individuals, their main sources of information included social media, internet, and family. Furthermore, only 48% of all participants agreed with the current opt-out system. Female sex (p = 0.049; OR 1.393), knowledge of the law (p < 0.001; OR 4.749) and family being the primary source of information (p < 0.001; OR 2.855) were independent factors associated with a positive attitude toward post-mortem organ donation law.

CONCLUSIONS

There is a significant lack of knowledge among young university students regarding the presumed post-mortem organ donation law and how it works. Female sex, having family as a primary source of information and being aware of the presumed post-mortem organ donation law are the strongest independent factors that determine a positive attitude toward the opt-out system.

Nudging to donate organs: do what you like or like what we do?

An effective method to increase the number of potential cadaveric organ donors is to make people donors by default with the option to opt out. This non-coercive public policy tool to influence people's choices is often justified on the basis of the as-judged-by-themselves principle: people are nudged into choosing what they themselves truly want. We review three often hypothesized reasons for why defaults work and argue that the as-judged-by-themselves principle may hold only in two of these cases. We specify further conditions for when the principle can hold in these cases and show that whether those conditions are met is often unclear. We recommend ways to expand nationwide surveys to identify the actual reasons for why defaults work and discuss mandated choice policy as a viable solution to many arising conundrums.

Why a Virtual Assistant for Moral Enhancement When We Could have a Socrates?

Can Artificial Intelligence (AI) be more effective than human instruction for the moral enhancement of people? The author argues that it only would be if the use of this technology were aimed at increasing the individual's capacity to reflectively decide for themselves, rather than at directly influencing behaviour. To support this, it is shown how a disregard for personal autonomy, in particular, invalidates the main proposals for applying new technologies, both biomedical and AI-based, to moral enhancement. As an alternative to these proposals, this article proposes a virtual assistant that, through dialogue, neutrality and virtual reality technologies, can teach users to make better moral decisions on their own. The author concludes that, as long as certain precautions are taken in its design, such an assistant could do this better than a human instructor adopting the same educational methodology.

Governance quality indicators for organ procurement policies

Background

Consent policies for post-mortem organ procurement (OP) vary throughout Europe, and yet no studies have empirically evaluated the ethical implications of contrasting consent models. To fill this gap, we introduce a novel indicator of governance quality based on the ideal of informed support, and examine national differences on this measure through a quantitative survey of OP policy informedness and preferences in seven European countries.

Methods

Between 2017–2019, we conducted a convenience sample survey of students (n = 2006) in Austria (AT), Belgium (BE), Denmark (DK), Germany (DE), Greece (GR), Slovenia (SI) and Spain (ES), asking participants about their donation preferences, as well as their beliefs and views about the policy in place. From these measures, we computed indices of informedness, policy support, and fulfilment of unexpressed preferences, which we compared across countries and consent systems.

Results

Our study introduces a tool for analyzing policy governance in the context of OP. Wide variation in policy awareness was observed: Most respondents in DK, DE, AT and BE correctly identified the policy in place, while those in SI, GR and ES did not. Respondents in opt-out countries (AT, BE, ES and GR) tended to support the policy in place (with one exception, i.e., SI), whereas those in opt-in countries (DE and DK) overwhelmingly opposed it. These results reveal stark differences in governance quality across countries and consent policies: We found a preponderance of informed opposition in opt-in countries and a general tendency towards support–either informed or uninformed–in opt-out countries. We also found informed divergence in opt-in countries and a tendency for convergence–either informed or uninformed–among opt-out countries.

Conclusion

Our study offers a novel tool for analyzing governance quality and illustrates, in the context of OP, how the strengths and weaknesses of different policy implementations can be estimated and compared using quantitative survey data.

Opt-Out to the Rescue: Organ Donation and Samaritan Duties

Deceased organ donation is widely considered as a case of easy rescue―that is, a case in which A may bestow considerable benefits on B while incurring negligent costs herself. Yet, the policy implications of this observation remain unclear. Drawing on Christopher H. Wellman’s samaritan account of political obligations, the paper develops a case for a so-called opt-out system, i.e., a scheme in which people are defaulted into being donors. The proposal’s key idea is that we may arrange people’s options in specific ways for the sake of others.

Opt-out policy and the organ shortage problem: Critical insights and practical considerations

The legal shift to an opt-out system of consent for deceased organ donation is now official in England, Wales and Scotland. While it is commendable that national governments across the United Kingdom have publicly signalled their serious engagement with organ donation, it remains questionable that opt-out policy can in and of itself solve the public health issue of organ shortage. Opt-out policy risks becoming a futile solution if it fails to attend to key factors in clinical practice. Thus, this article provides critical insights and practical considerations in order to work towards increasing the availability of organs for transplantation: 1) organ donation specialists on their own are not enough, a collaborative hospital culture of donation is also needed; 2) investment in innovative perfusion technologies is fundamental to increase both the quantity and quality of organs utilised for transplants; and 3) opt-out does not solve the enduring problem of consent or authorization for donation, rather than hoping that opt-out will shift the societal culture of donation and make donation the default choice, it is necessary to acknowledge that families' authorization remains essential and their emotional experience can neither be minimized nor excluded altogether. Importantly, consent rates are not the only factor to account for overall deceased donation rates. The organ shortage cannot be solely attributed to a matter of negative public attitudes reversible by law. Doing that does a disservice to the public and diverts strategic attention and resources from fostering the organizational and technological enablers of organ donation in clinical practice.

Beyond the ticked box: organ donation decision-making under different registration systems

OBJECTIVE

To explore how people experience organ donation decision-making under the conditions of an opt-in, opt-out or no-objection registration system.

DESIGN

A between-subjects experimental 3 × 2 design (registration system x preselection). Participants (N = 1312) were presented with a description of one of the three registration systems and went through a mock donor registration process. In half of the conditions, the default option of the system was visualized by a ticked box. After, participants answered questions about their perceived autonomy and perceived effective decision-making.

MAIN OUTCOME MEASUREMENTS

Perceived autonomy, perceived decision effectiveness and registration choice.

RESULTS

The preselected box did not impact any of the outcomes. Participants had higher perceived autonomy under the conditions of an opt-in system. There were no differences in effective decision-making across conditions. Registration choices did differ across conditions and educational levels. In the opt-in system, participants more often made an active decision. Lower-educated participants were more likely to choose to do nothing, while higher-educated people more often made an active decision, especially in the no-objection system.

CONCLUSION

Where the opt-out system potentially leads to the highest number of donors, the opt-in system seems better in terms of preserving people's autonomy and motivating people to make an active decision.

On Nudging's Supposed Threat to Rational Decision-Making

Nudging is a tool of libertarian paternalism. It involves making use of certain psychological tendencies in order to help people make better decisions without restricting their freedom. However, some have argued that nudging is objectionable because it interferes with, or undermines, the rational decision-making of the nudged agents. Opinions differ on why this is objectionable, but the underlying concerns appear to begin with nudging's threat to rational decision-making. Those who discuss this issue do not make it clear to what this threat to rationality amounts. In this paper I evaluate what effect nudging has on our decision-making and I argue that it does not typically interfere with our rationality in a problematic way. Perhaps nudging is objectionable for other reasons, but we should not argue that nudging is objectionable based on concerns about rational decision-making.

A Systematic Review of Opt-out Versus Opt-in Consent on Deceased Organ Donation and Transplantation (2006-2016)

BACKGROUND

Significant numbers of patients in the USA and UK die while waiting for solid organ transplant. Only 1-2% of deaths are eligible as donors with a fraction of the deceased donating organs. The form of consent to donation may affect the organs available. Forms of consent include: opt-in, mandated choice, opt-out, and organ conscription. Opt-in and opt-out are commonly practiced. A systematic review was conducted to determine the effect of opt-in versus opt-out consent on the deceased donation rate (DDR) and deceased transplantation rate (DTR).

METHODS

Literature searches of PubMed and EMBASE between 2006 and 2016 were performed. Research studies were selected based on certain inclusion criteria which include USA, UK, and Spain; compare opt-in versus opt-out; primary data analysis; and reported DDR or DTR. Modeled effect on US transplant activity was conducted using public data from Organ Procurement and Transplantation Network and Centers for Disease Control WONDER from 2006 to 2015.

RESULTS

A total of 2400 studies were screened and six studies were included. Four studies reported opt-out consent increases DDR by 21-76% over 5-14 years. These studies compared 13-25 opt-out countries versus 9-23 opt-in countries. Three studies reported opt-out consent increases DTR by 38-83% over 11-13 years. These studies compared 22-25 opt-out versus 22-28 opt-in countries. Modeled opt-out activity on the USA resulted in 4753-17,201 additional transplants annually.

CONCLUSION

Opt-out consent increases DDR and DTR and may be useful in decreasing deaths on the waiting list in the USA and other countries.

REGISTRATION NUMBER

PROSPERO CRD42019098759.

The Unfinished Business of Respect for Autonomy: Persons, Relationships, and Nonhuman Animals

This essay explores three issues in respect for autonomy that pose unfinished business for the concept. By this, I mean that the dialogue over them is ongoing and essentially unresolved. These are: (1) whether we ought to respect persons or their autonomous choices; (2) the role of relational autonomy; and (3) whether nonhuman animals can be autonomous. In attending to this particular set of unfinished business, I highlight some critical moral work left aside by the concept of respect for autonomy as understood in Beauchamp and Childress’ Principles of Biomedical Ethics. Specifically, while significant pragmatic traction is gained by the authors’ focus on autonomous choice, carving such a focus out from the broader questions of moral respect and the autonomy of the person leaves aside a number of questions that we might have thought a view about respect for autonomy in biomedicine ought to answer. These include: How should physicians respond when autonomous patients make decisions that appear nonautonomous? What is the impact of the view that autonomy is “relational” for cross-cultural differences in how autonomy is respected? If chimpanzees (and by extension young children) can be autonomous, what does that mean for how they should be treated?

When Lone Wolf Defectors Undermine the Power of the Opt-Out Default

High levels of cooperation are a central feature of human society, and conditional cooperation has been proposed as one proximal mechanism to support this. The counterforce of free-riding can, however, undermine cooperation and as such a number of external mechanisms have been proposed to ameliorate the effects of free-riding. One such mechanism is setting cooperation as the default (i.e., an opt-out default). We posit, however, that in dynamic settings where people can observe and condition their actions on others' behaviour, 'lone wolf' defectors undermine initial cooperation encouraged by an opt-out default, while 'good shepherds' defeat the free-riding encouraged by an opt-in default. Thus, we examine the dynamic emergence of conditional cooperation under different default settings. Specifically, we develop a game theoretical model to analyse cooperation under defaults for cooperation (opt-out) and defection (opt-in). The model predicts that the 'lone wolf' effect is stronger than the 'good shepherd' effect, which - if anticipated by players - should strategically deter free-riding under opt-out and cooperation under opt-in. Our experimental games confirm the existence of both 'lone wolf' defectors and 'good shepherd' cooperators, and that the 'lone wolf'effect is stronger in the context of organ donation registration behaviour. We thus show a potential 'dark side' to conditional cooperation ('lone wolf effect') and draw implications for the adoption of an opt-out organ donation policy.

Geographic Location and Moral Arbitrariness in the Allocation of Donated Livers

The federal system for allocating donated livers in the United States is often criticized for allowing geographic disparities in access to livers. Critics argue that such disparities are unfair on the grounds that where one lives is morally arbitrary and so should not influence one's access to donated livers. They argue instead that livers should be allocated in accordance with the equal opportunity principle, according to which US residents who are equally sick should have the same opportunity to receive a liver, regardless of where they live. In this paper, we examine a central premise of the argument for the equal opportunity principle, namely, that geographic location is a morally arbitrary basis for allocating livers. We raise some serious doubts regarding the truth of this premise, arguing that under certain conditions, factors closely associated with geographic location are relevant to the allocation of livers, and so that candidates' geographic location is sometimes a morally non-arbitrary basis for allocating livers. Geographic location is morally non-arbitrary, we suggest, since by taking it into account, the UNOS may better fulfill its central goals of facilitating the effective and efficient placement of organs for transplantation and increasing organ donation.

Nudges in a post-truth world

Nudges-policy proposals informed by work in behavioural economics and psychology that are designed to lead to better decision-making or better behaviour-are controversial. Critics allege that they bypass our deliberative capacities, thereby undermining autonomy and responsible agency. In this paper, I identify a kind of nudge I call a nudge to reason, which make us more responsive to genuine evidence. I argue that at least some nudges to reason do not bypass our deliberative capacities. Instead, use of these nudges should be seen as appeals to mechanisms partially constitutive of these capacities, and therefore as benign (so far as autonomy and responsible agency are concerned). I sketch some concrete proposals for nudges to reason which are especially important given the apparent widespread resistance to evidence seen in recent political events.