Behavioral Science Strategies to Boost Organ Donor Consent.

Abstract

Webb and colleagues1 present a fascinating insight into the array of factors that affect decision making to grant consent (or authorisation) for organ donation in England. Interpretation of their data suggests 2 important strategies to improve organ donor rates: encourage more individuals to categorically declare their willingness to donate organs during life, and improve consent rates from family to support organ donation after death. Guidance from the National Institute for Health and Care Excellence to improve donor identification/consent was published in 2011, highlighting very poor level of evidence to make any firm evidence-based recommendations.2 Research data also conflict with registry statistics. For example, collaborative requesting for organ donor consent (by clinical team and dedicated transplant coordinator) did not increase consent rates compared with routine requesting by the clinical team alone in a randomized controlled trial.3 However, data from the latest Organ Donation and Transplantation Activity Report suggest family consent is much higher with specialist nurses in organ donation supporting the clinical team (67.2% compared to 33.9% with no specialist nurses in organ donation).4 In addition, consent rates of 88.9% are obtained when an individual has made a clear wish to be a donor (eg, signed up to organ donor register) compared to 44.9% in the absence of any explicit affirmation to donate.4 Although signing up to the organ donor register is considered a legally valid recognition of an individual's intention to be a donor, standard practice in the United Kingdom remains to seek consent from the family to proceed. With a refusal rate of 43% (the second highest in Europe), this is perhaps the single biggest obstacle to maximize potential utilization of organs. Getting more individuals to declare their willingness to donate in life is clearly important and must be encouraged, but this is meaningless without tackling family consent to proceed. We could override families who refuse consent (especially if it contradicts the explicit wish of the deceased), but the negative image of such a hard approach may have a detrimental impact on overall organ procurement (eg, Singapore experience). Such an approach is also unlikely to rouse significant enthusiasm from transplant professionals. A different approach may be to better understand and target organ donor consent using skills from the field of cognitive psychology. For example, nudge theory is a concept from behavioral science that positive reinforcement and indirect suggestion can influence consent by influencing decision-making processes (perhaps more effectively than direct instruction, legislation, or enforcement). Another option is motivational interviewing, defined as “a collaborative conversation style for strengthening a person's own motivation and commitment to change” and advocated as a potential tool to increase family consent for organ donation.5 The ability to affect behavior, while preserving freedom of choice, is the hallmark of libertarian paternalism and should be explored by transplant professionals to reduce organ donor refusal. The report from Webb and colleagues is a timely reminder that tackling the psychology of organ donor consent remains a significant challenge and requires collaborative research to overcome (Tables 1 and 2).TABLE 1: Survey demographics and individual desire to donateTABLE 2: Hypothetical consent rates depending on prior discussion and Organ Donor Register registration