Nudging people for Organ donation

Nudging people for Organ donation

In the last few days, I am impressed with the campaign launched by Times of India to motivate people for Organ Donation. It is indeed a public cause with more than 200,000 people on the wait list for a kidney transplant and almost 100,000 for a liver transplant. These numbers may go up drastically if there was more awareness about the number of lives that could be saved with a timely transplant

The law presently allows organ donations from blood relatives. The real challenge is in getting consent of the next of the kin for brain dead patients who cannot be revived but their organs could save lives. Several issues are involved here which range from superstitions, religious, awareness as also having the medical facilities and surgeons capable of doing transplants.

One way many countries have addressed this issue is by using the Opt-In and Opt-Out options for giving consent to Organ donation. Opt In and Opt Out are the two main methods of determining voluntary consent for donors. Countries like Germany use the opt-in option, where you need to explicitly give your consent to be an organ donor, have low rates of organ donation consent. As against this, countries like Sweden, Austria and Spain, where the default option is to be an organ donor unless you explicitly opt out, have almost 100% consent rates of donation. Thus there is a simple way in which we can nudge people into being an organ donor. In most countries, this option is exercised when people fill in their forms for issue or renewal of driving licenses.

Richard Thaler, the celebrated author of the book Nudge, also concludes that Opt-In and Opt-Out options have a major impact on Organ donation consent rates. Another option to boost consent rates is mandating exercising choice. In United States, State of Illinois requires that people must indicate their choice. It’s not surprising that Illinois has a consent rate of 60% against the national average of 38%.

Given the high number of people on organ donation waitlist and the high rate of road accident fatalities we have in India, a simple nudge can make more people aware that they can save someone else’s life by getting an opportunity to give their consent. This can be done when people get their driving licenses or renew them. The default option can be that everyone is deemed to have given their consent to be an organ donor and in case they want to opt out, they would be required to fill another form. The same can be done while registering people under NPR of Aadhaar. This would help create a system that could create chances for saving lives by having organ donors amongst victims of road accidents.

However, such a policy is easier said that implemented. In our cultural context, there might be individuals and organizations who would claim that consent should imply informed consent. Just because people were lazy enough to fill another form or tick a box that said ‘I do not want to be an organ donor’, we must not presume their consent. Then there would be cases that would ultimately require consent of the kin also as in our country people still do not accept that brain dead people are dead as they have hopes of reviving anyone who is not completely dead. In order to overcome these issues, we will need an awareness drive by making people aware of the policy as the value it will have for saving lives. Once this message reaches more people, and more people are enrolled automatically on organ donor lists, everyone will have a greater chance of getting an organ, in case they ever needed. 

One can also follow the Singapore model where the Human Organ Transplant Act enrolls almost everyone above 21 years of age to be organ donors and those who don’t opt out also get a higher priority in receiving a deceased person’s organ if they ever needed such a transplant in future.

In United Kingdom too, the Nudge unit set up in the Prime Minister’s office is using insights from behavioral science to prompt more people in giving their consent for organ donation. This also seems logical as studies have shown that though more than 90% people desire to be organ donors, only about 29% people actually sign up to be a donor.

Thus there is an opportunity to be tapped. Nudge and behavioral sciences can help increase organ donation rates in India too and save precious lives.

Abhishek Singh

Hand Sanitizers or Soap & Water?

Hand Sanitizers or Soap & Water?

Hand Sanitizers are one of those products that have been created to make money where none should exist. By 2015, the Hand Sanitizer market is expected to be almost worth 400 million USD. I have always felt that soap and water is a better and cheaper alternative to hand sanitizers for hygiene and  germ free environment. I wonder why health care professionals keep on pushing alcohol based sanitizers as a panacea for all infections and germs. This policy is flawed and needs to be junked.

My belief that no one actually needs a hand sanitizer was confirmed during my visits to two of the top hospitals in Boston. The reception of both the hospitals, like almost everywhere else in the hospitals, had prominently displayed hand sanitizers of a popular brand. The first hospital had the world ‘COMPLIMENTARY’ written above the sanitizer stations and the second one had messages that said something about ‘Clean hands and a Germ Free world’. During my short stay at both the places, I observed that more people were using the ‘Complimentary’ sanitizer and less at the second hospital. This implied that people don’t use a sanitizer for its hygiene related qualities but they do so as they feel they are getting something free.

So, what affects the behavior of people who use a sanitizer at a public place. The core issue is attitudes of people towards hand washing – either with a sanitizer or with soap and water. Behavioral Scientists will call it the Want-Should conflict. Most people feel that they should wash hands but when it comes to actually washing, they avoid doing so as they are in a hurry or think that they will use it at the next available opportunity.

Part of this problem is psychological. Most people suffer from cognitive biases that skew their judgment from risk. In the case of health care workers, research has shown that they maintain an ‘illusion of vulnerability’. Many of them are so confident of their immunity to infection that they ignore the fact that they are most vulnerable to come in contact with germs. Even memories are biased. They are able to recall instances when they didn’t wash and didn’t get sick. The actual instances when they were sick and had not washed are easily forgotten as other direct reasons are ascribed to the sickness.

Researchers at Michigan University have studied the variables affecting hand sanitizer use in public facilities. Loukas and Dixon in their experiment found that the psycho educational approach is a more effective means to promote behavior change with regard to use of hand sanitizers.  In the study they compared two sets of data, one of people using free sanitizers next to the revolving gate with posting of information relating to Swine Flu incidence in US. In the second instance, next to the sanitizer station there was a student volunteer with a manually operated sanitizer in hand, who would ask people to use the sanitizer and thank them profusely when they did. It was found that in the second instance, with a verbal cue and social praise by the student volunteer, the percentage of people using the hand sanitizers goes upto almost 52% as against less than 1 % when there is a sanitizer station with just messages pasted regarding the benefits of the use. Thus the reason for the use of a hand sanitizer is externally influenced.

In another interesting experiment, Adam Grant of the Wharton School and David Hofmann, of the Kenan-Flagler Business School, found that doctors and nurses are more motivated by messages that emphasize patients’ welfare rather than their own. Messages like “Hand hygiene prevents patients from catching diseases” were found to yield better results than the ones like “Hand hygiene prevents you from catching diseases.”

These behavioral and cognitive psychology insights are used by hand sanitizer manufacturers to drive their demand by make people paranoid about personal health care as also making issues like Swine Flu a major concern, worldwide.

Studies have also shown that that hand sanitizers are no more effective than soap and water in preventing infection and spread of cold and flu. Dr Ron Cutler of Queen Mary University of London and an expert in infection control says that, "People think they're more effective than water because you don't see advertisements for soap and water saying the percentage of germs they kill."  Thus the ease of recall and vividness of a sanitizer with regard to hygiene is forced upon through advertisements. The use of sanitizers is so much like the use of bottled water, preferable from the point of view of choice and convenience, but not necessarily essential for a country which has safe tap drinking water and where chances of infections are minimal.

So it is clear, Soap and Water is a better alternate to hand sanitizers.