The impact of presumed consent legislation on cadaveric organ donation: A cross-country study
Introduction
Chronic shortage of human organs for transplantation is one of the most pressing health policy issues in many developed countries, including the U.S. and Great Britain. In recent years, the persistent scarcity of organs for transplantation has invigorated the controversy about the determinants of organ donation rates and the magnitude of their effects. With a few exceptions, however, this debate has not been informed by systematic empirical studies.1
A particularly heated debate has arisen on the matter of legislative defaults on cadaveric organ donation. In many countries, including the U.S., Great Britain, Germany and Australia, cadaveric organ procurement is carried out under the informed consent principle. Under an informed consent law, cadaveric organ extraction requires the explicit consent of the donor before death, which is usually reflected on a donor registration card. In contrast, in most of continental Europe, cadaveric organ procurement is based on the principle of presumed consent. Under presumed consent legislation, a deceased individual is classified as a potential donor in absence of explicit opposition to donation before death. In practice, regardless of the type of legislation and of whether a deceased individual is registered as a donor (or as a non-donor), in most countries families are allowed to have the last word on whether organs will be donated. It has been argued, however, that legislative defaults affect the decisions of potential donors and families.2
This article uses a panel of 22 countries over a 10-year period to analyze the impact of presumed consent laws on donation rates. After controlling for other determinants of cadaveric organ donation, we find that countries with presumed consent legislation have higher organ donation rates. Moreover, we use the panel structure of our database to test and reject the hypothesis that unmeasured (additive) determinants of organ donation rates confound our empirical results.
The rest of the article is organized as follows. Section 2 summarizes the main facts highlighted in the previous literature on organ donation. Section 3 presents a simple model that illustrates a way in which legislative defaults may affect organ donation rates. The main empirical results of the article are given in Section 4. Section 5 concludes. Data sources and technical details are reported in Appendix A Technical details, A.1 Affiliated random variables, A.2 Solution of the model under normality, Appendix B Data sources and sample selection, Appendix C Legislative defaults on cadaveric organ donation.
Section snippets
The organ shortage problem
In 2002, 6679 patients died on the U.S. organ waiting lists before an organ became available, roughly 18 per day (OPTN, 2003). In spite of media campaigns and other attempts to promote donation, the supply of organs cannot keep up with the demand, and the number of patients on waiting lists has been growing steadily during the last decade (see Fig. 1). One of the most frequently quoted explanations of the gap between the supply and demand of organs is that the number of families that refuse to
A simple model of presumed consent
In this section, we outline a model of organ donation. Albeit simple, the model has two important implications: (1) even if families make the final decision on organ donation, presumed consent laws may result in notably higher consent and donation rates; (2) registration rates may be low even if registration costs are low (and even if preferences for donation are high in informed consent countries and low in presumed consent countries).
Let uD and uN be the utility levels realized in the
Empirical analysis
Despite the worldwide concern about organ shortage for transplantation, few empirical studies have aimed to identify and measure the factors that influence donation rates. The reason may be, in part, that the data required to conduct these studies are not readily available.21
Conclusions
With some notable exceptions (see, e.g., Johnson and Goldstein, 2003, Johnson and Goldstein, 2004), most previous studies have pointed out that, on average, presumed consent countries do not produce significantly higher organ donation rates. Moreover, several authors have hypothesized that this lack of correlation may be explained by the fact that presumed consent laws are rarely enforced and that, in practice, family consent is always required before organs are extracted.
In this article, we
Acknowledgements
We thank Josh Angrist, Susan Athey, Chris Avery, Adolfo de Motta, Mark Duggan, Michael Greenstone, Asim Khwaja, Jeff Liebman, Nolan Miller, Joseph Newhouse, Todd Olmstead, Balázs Szentes, Richard Zeckhauser, two referees, and seminar participants at Harvard Economics for helpful comments and discussions.
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