Introduction
Organ donations are essential for the developed society; the unconditional benefits of the possibility of organ donations help save significant amounts of lives every year. However, there is an ethical question regarding organ donation policies used in various countries regarding organ donor registrations. In some countries, the government deliberately nudges the people by asking them a question of great value in a yes or no way in inappropriate conditions to manipulate the number of potential organ donors. The matter results in reducing people’s autonomy and influences the people’s outlook on the seriousness of organ donations. To further analyze the process of nudging in organ donor registration, this essay will explore the definition of nudging and four types of organ donor registration processes. Then the essay will provide an evaluation of which types of organ donor registration processes are more affected by nudging and which is more ethically suitable for broad application.
Main body
To analyze the process of nudging in organ donor registration, one should thoroughly understand the concept of nudging, the ethical means behind nudging, and the importance of nudging for public policy. The idea of nudging implies manipulating people’s decisions by changing the presentation of options given to people. Thaler and Sunstein defined a nudge as “any aspect of the choice architecture that alters people’s behavior in a predictable way without forbidding any options” (qt. in Schmidt and Engelen 2). Nudges are not necessarily directed to pressure people, as some are directed towards pushing the residents to a healthier lifestyle or more ecologically correct way of living.
In caring for the population’s health and environmental footprint, the use of nudges could be justified and perceived as ethically correct. Noggle expresses that patients should be ready to experience manipulation in healthcare settings as manipulation is used to make patients do what their physicians recommend which is justified in the healthcare context (169). However, nudges in the organ donation registration process put people in a position where they are forced to resort to the status quo interferes with the population’s level of autonomy. Moreover, the nudges in this situation are targeted directly to increasing the proportion of potential donors, which is ethically questionable.
To discuss the influence the nudges make on people’s autonomy, one should examine the definition of autonomy up close. Schmidt and Engelen propose to separate autonomy into four dimensions: freedom of choice, volitional autonomy, rational agency, and absence of domination (4). The freedom of choice dimension speaks to the external options presented to individuals and is not significantly affected by nudging. Volitional autonomy, however, stands for the idea of an individual’s actions reflecting his preferences and views and is directly affected by nudging. Schmidt and Engelen emphasized the importance of volitional autonomy, stating that an individual might not be “an author of his own choice” under the effect of nudging (4). Nudges also bypass humans’ sense of rationality and speak to people’s biases instead. Finally, the government could use the nudges to control the population, which is the main concern of the last dimension.
The first type of organ donor registration process, called opt-in, is generally made through residents’ active registrations as donors by signing an organ donor registration card or checking a box when renewing a driver’s license. The opt-in method of registration is widely used in Canada, some U.S. states, and Germany (MacKay and Robinson, 3). People are given a choice of actively checking the box to register as a donor. However, the matter is deficient in terms of ethics as unless people are actively registered as a donor; they are classified as non-donors. In addition to driver’s license renewal being a situation not suitable for forming an argumentative decision regarding the question of organ donor registration, the situation is also influenced by the individual’s status quo (MacKay and Robinson, 4). The status quo bias affects an individual’s decision in terms that the individual is more likely to express inertia and choose the default option than take time to make an active decision.
The nudging mechanism, in this case, works in stating the default option of not registering as an organ donor. The case touches on the third dimension of an individual’s autonomy, the sense of rationality. It could be that changing the default option from non-registering as an organ donor to the need to actively check the box not to register as an organ donor would impact the situation significantly. Although registering everyone as organ donors by default is not ethically correct, if the choice was presented as a default option for the people, the majority of the population would stick with the default (MacKay and Robinson, 5). The status quo aspect affects the individual’s perception of the topic and leaves the individual no time for thinking.
The policy could potentially be improved by taking away the default option to reduce opportunities for nudging. However, when presented with a yes or no question with no meaning and absence of consequences, individuals tend to choose the absence of consequences. The individual’s status quo would undoubtedly influence the decision, but at least the individuals would be allowed to think on the matter and refer to their own opinions. Although reducing the default option would not change the registration rates significantly, the problem of nudging in the opt-in method would be solved, and individuals would have more autonomy.
In fact, the improved version of the opt-in policy with a reduction of default option is similar to the Voluntary active choice policy, or VAC. VAC asks the individual to actively check one of two boxes regarding their will to be registered as an organ donor in the process of ID card or driver’s license application or renewal. Although the policy implies the default option that unless the individuals actively register as organ donors, they are classified as non-donors, the policy hides the default option in the right way (MacKay and Robinson, 5). Asking the people a yes or no question helps minimize nudging and gives a significant amount of autonomy to the population.
However, the actual design of the questions in the VAC policy needs to be corrected to be ethically right. According to MacKay and Robinson, the policy designs the questions not in a yes or no way but rather implying that the individual does not want to register at this time (5). Although the design is supposed to reduce individuals giving the complete rejection, the option could be regarded as a default option and be chosen frequently as a passive option.
Further improvement of VAC policies should touch on the aspect of the design of the questions as just like opt-in policy, the VAC is massively influenced by the status quo bias or people’s inertia. Although the nudging influence is minimized when individuals are given both options to choose from, the statement of default option connects to the use of the status quo bias. Perhaps in this situation, people’s predictable resort to the passive alternative could be perceived as nudging. However, the actual form of the given option of being not ready to register as an organ donor yet also nudges the people as it influences the volitional part of autonomy. The format of the questions supposes that eventually, someday, the individual would be ready to register as an organ donor, which could alter the individual’s outlook on the matter.
Similar to the VAC policy, the Mandated active choice policy or MAC asks the individual to choose one of two options. However, in terms of the design of the question, MAC policy resembles an upgraded version of VAC. As the policy also requires the individual to actively choose one of two options, with leaving the question unanswered not being an option, the policy has no default option. The convenient design of the question “would you be willing to donate organs in the event of your death” developed in New Zealand speaks to the individual’s mind directly, bypassing the status quo bias (MacKay and Robinson, 5). However, Kirby pointed out that there is a possibility that the respondent is more likely to choose the no option due to it being a less active choice (31). Although forcing the residents to answer the question reduces the voluntary aspect of the policy, the people are given a maximum amount of autonomy without the possibility of nudging.
However, there are cases when the positive point of MAC being specific with active choice of yes or no question is reduced by the ill design of the question. According to MacKay and Robinson, New York State, for example, asks the individual if he would like to be added to the Donate Life Registry and gives the option to skip the question (5). Obviously, in this case, due to status quo bias, the individual would stick with the provided default option of skipping the question. Although the MAC policy seems like the most ethically correct policy in terms of the absence of nudging, the improper use of the policy could potentially result in a decrease in people’s level of autonomy.
As all the previously discussed policies use or imply the default option of individuals being classified as non-donors, the opt-out policy uses an opposing method. The opt-out policy implies that all residents are classified as organ donors but have an option to opt out. According to MacKay and Robinson, the option to opt-out could be fulfilled by completing a form or via mail (6). Although classifying all residents as organ donors is not ethically correct, the given option of changing the status anytime through a simple process in conditions determined by the individual makes the policy work.
As government classifies the residents as organ donors by default, there is no nudging involved rather than direct pressure, but the organization of the policy makes up for the pressure by simplifying the opt-out process. In addition, as there is no default option, the status quo bias does not interfere in the situation. Each individual is presented with a chance to make an argumentative decision for himself without nudges or pressure, in conditions determined by the individual. The aspect of conditions being determined by the individual is often dismissed. However, it is obvious that such serious decisions require time and attention from the individual, and driver’s license renewal or id car applications are not suitable for the thought process. Although it seems that in this type of policy, the individuals are given less autonomy, in fact, there is more autonomy due to the absence of nudging and status quo bias.
Summing up, the analysis of the nudges in four types of policies used for organ donor registrations showed that MAC and opt-out policies are less affected by nudging and present more autonomy to the population. MAC policy asks the individuals to answer the question without giving default options, providing full autonomy to the individuals. Although the opt-out policy, on the other hand, classifies all residents as donors, residents are given full autonomy to opt out and time to formulate an argumentative opinion and come to a decision. The opt-out policy seemingly leaves only one option, which contradicts the opinion that the number of options increases the level of autonomy in terms of being able to say no as well as yes (Hurka, 376). However, the choice to keep the organ donor status and not opt out is also an option.
Conclusion
In conclusion, as nudging in the organ donor registration process is currently targeted to increase the number of potential donors, the most ethically suitable option for broad application would be the opt-out policy. Although the opt-out policy and classifying all residents as organ donors with the option to opt out at first seems ethically incorrect, the policy at least allows an individual to form his own decision. The default option in opt-out policy could be perceived as governmental promotion or measure to increase the number of potential organ donors and not nudging.
Works Cited
Hurka, Tomas. “Why Value Autonomy?” Social theory and Practice, vol. 13, no. 3, 1987, pp. 361-382.
Kirby, Jeffrey. “Beyond Influence and Autonomy: Expanding the Scope of Ethical Considerations in Organ Donation Registration.” The American Journal of Bioethics, vol. 16, no.11, 2016, pp. 31-33.
MacKay, Douglas & Alexandra Robinson. “The Ethics of Organ Donor Registration Policies: Nudges and Respect for Autonomy.” The American Journal of Bioethics, vol. 16, no. 11, 2016, pp. 3-12.
Noggle, Robert. “Manipulation, Salience, and Nudges.” Bioethics, vol. 32, no. 3, 2018, pp. 164– 170.
Schmidt, Andreas T. & Bart Engelen. “The ethics of nudging: An overview.” Philosophy Compass, vol. 15, no. 4, 2020. Wiley Online Library.