Using Behavioral Economics to Increase Transplantation Through Commitments to Donate.

L many countries, Japan is facing a shortage of deceased kidney donations. In Japan, this is exacerbated by certain cultural and religious objections to the use of deceased donors. Despite efforts to mitigate these objections and increase deceased donor utilization, only 111 deceased donors were performed in Japan in 2017 (while 14 002 patients remained on the waiting list). To increase the number of donors, Hirai et al leverage behavioral economics and test 5 interventions and their impact on commitments to donate in Japan. Using these simple and inexpensive interventions, the authors are able to increase the commitment to donation, which will potentially lead to saving more lives through transplantation. In this commentary, we explore the economic principles that explain the behavior observed in their study and provide further considerations for using behavioral economics to increase deceased kidney donations in light of their findings. When faced with a choice, the standard Economics textbook lays out a convincing case that an individual will choose the option that generates the most satisfaction or utility. If an orange and an apple cost the same amount, and the individual can afford only one, the individual chooses the apple if she likes the taste of apples more than oranges. If the apple is put into a red bin, and the orange a blue bin, the individual should not change her choice relative to when the color of the bins was reversed because, regardless of the bin color, she still likes the taste of apples more than oranges. However, as is evident from a long line of studies (many nicely summarized in Thaler and Sunstein—Nudge), the context around the choice matters. In their study, Hirai et al use nudge techniques to examine if different contexts lead to higher instances of individuals recording their decision to donate their organs on health insurance cards and driver’s licenses. Specifically, the authors explore how varying framing and increased salience influence their decision to record their decision to donate. Framed choices keep the outcome the same but alter how the outcome is discussed. In line with the traditional use of framing, Hirai et al utilize a positive frame for some leaflets and a negative one for others. Hirai et al name these gain-framed and loss-framed messages. The positive frame highlights how many lives will be saved through their organ donation, while the negative frame highlights how many people may die because of too few donors. The choices under these frames are compared against a control that has a neutral frame. Their finding, that the negative frame is more effective than the positive or neutral frame, is consistent with prospect theory which finds individuals dislike losses more than equivalent gains. Of course, a gain or loss can be relative—an individual could possess $1000 by starting with $900 and gaining $100 or starting with $10 000 and losing $9000. Most would agree that the first individual is happier with her $1000 given the reference point of $900 versus $10 000. Thus, framing works to alter the reference point where a negative frame leads individuals to wish to avoid a loss. The typical descriptive model used to explain this behavior is aptly dubbed the reference-dependent utility model. Though referenced as framing in their study, the reciprocity-framed and peer-framed interventions do not follow the traditional definition of framing in behavioral economics. These interventions are more aptly described by their ability to draw an individual’s attention to one of the many aspects of their choice to increase the saliency, which in turn may increase the weight an individual places on this aspect when making a decision. If an individual is hungry, they are likely to pay more attention to restaurant signs and ignore clothing-store signs because their hunger is more salient than their desire to buy a new sweater. To successfully increase the salience of an aspect of a choice, the researcher must know which aspects individuals may care about and then make certain that the message sufficiently draws the subject’s attention to this aspect. The reciprocity-framed messages point out that the individual may, in the future, need an organ from others. This message likely makes salient some guilt-aversion preference the individual has. That is, if the individuals wish to avoid guilt from free-riding off a system that would benefit them, this message would increase the rate of consent. Similarly, the study’s peer-framed message conveys that many people have volunteered to be a deceased organ donor. Given that individuals can be averse to violating social norms, this message, which makes the social norm of registering salient, should lead to an increase in the likelihood of registering. Commentary