Nudging organ donation

Nudging organ donation

Steven had been a driver for over twenty years. In his country, as in many other, Steven had to renew his driver’s licence every ten years. Recently, the driving licence authority in his country changed their licence renewal process to an online system. After Steven filled out his licence number, confirmed his home address and clicked through to the next page he was prompted with a message about organ donation. Following the message, he was asked if he’d like to register to be an organ donor, he wondered for a while as to why this was included in the driving licence renewal process, clicked yes and continued.

Organ donation rates vary dramatically from country-to-country, despite the universal need for organ donors. In 2012, some countries such as The United Kingdom had about 13 people per a million signed up to the organ donors register, whilst other countries such as Belgium had over double this with 27 people per million signed up (see Table 1). Even within individual countries the numbers of people signed up to organ donors registers very a lot (see Table 2). There are many reasons for the differences in the rate of organ donors across countries including how to sign-up (opt-in or opt-out method), religious beliefs and cultural norms (Morgan et al., 2015).


Country Opt-in or opt-out Donors per million population Population
Belgium Opt-out 27.1 10,827,519
Denmark Opt-in 11.5 5,547,088
France Opt-out 23.2 64,709,480
Germany Opt-in 15.3 81,757,595
United Kingdom Opt-in (Opt-out in Wales) 12.9 63,230,000
United States Opt-in 25.97 305,529,237

Table 1. Data from EU Directorate General for Health & Consumers, March 2012


US State % Donors (18+) Population






Montana 82 782,161
New York 20 15,307,107
Texas 17 19,073,315
Vermont 5 502,060

Table 2. Data from National Donor Designation Report Card, April 2013

The modification of choice architecture (i.e., nudging) is one way in which donor numbers can be increased by making it easier for individuals to sign-up to be an organ donor (Rodriguez-Arias et al., 2016). The two ways for individuals to join the donors register are through an ‘opt-in’ or ‘opt-out’ registration system. In the ‘opt-in’ system individuals have to acquire an organ donor’s application form and make the effort to sign-up. In the ’opt-out’ system everyone is by default an organ donor if a person does not want to be an organ donor then they need to unregister from the organ donors register. As we can see in Table 1 the system of registration for organ donors vary from country-to-county.

In an effort to improve donor numbers the government of Belgium changed their system of organ donor’s registration in 2002. Initially Belgium employed the opt-in system were individuals had to put in an effort to sign-up to donate (Rodriguez-Arias et al., 2016). The change to an opt-out system doubled the number of organ donations in the first 3 years of implementing this change.


Another nudge that has been applied with the aim of increasing organ donor rates other than changing the default opt-in / opt-out system include increasing awareness of the need for organ donors. In New Zealand, individuals who register for a driving licence are made aware that they can sign-up to be an organ donor (Rosenblum et al., 2012). From 2011, British citizens applying for a driver’s licence, or to renew their licence online, are required to answer a question about organ donation (British Medical Association, 2012). Whilst in The United States, in Texas new drivers in the 1990s were asked to state their views on organ donation before acquiring their licence, unfortunately this has now been abandoned in Texas (Klassen & Klassen, 1996). The states of Illinois, trialled a similar system to Texas (Thaler et al., 2010).

Two demographics that are underrepresented among organ donors are Black and South Asian people (Morgan et al. 2015). Morgan and colleagues (2015) suggested tailoring nudges to individuals to improve organ donor rates among Black and South Asian people. In 22 focus groups across London Morgan’s group investigated the views of Nigerian Christians, Indian Hindus, Indian Sikhs, Pakistani Muslims and Bangladeshi Muslims. Most of the interviewees stated that they regard organ donation as allowable regardless of their faith, they simply had not signed-up to the organ donor register because it is something that is not done in their immediate social groups. Tailoring nudges (i.e., messages) to these social groups can be one way improving donor rates among Black and South Asian people.


One large survey of the public’s view of organ donation in The United Kingdom found that 90% of people support organ donation whilst less than a third are registered (James, 2015). The UK’s Behavioural Insight Team (BIT) tailored nudge messages to investigate their effect on organ donation rates (BIT paper: Applying Behavioural Insights to Organ Donation, Cabinet Office and Department of Health, 2013). On a government website BIT ran a randomised study for 5 weeks where over a million people saw one of eight messages (see Table 3). Both presenting a message as a social norm with an image and asking the reader about the fairness of donating and organ with reciprocation increased registration rates. This large study clearly shows that tailoring a message can make a nudge more or less effective depending on the target audience.


Message variant Attribute Message
1 Control Please join the NHS Organ Donor Register
2 Social norm + basic message Every day thousands of people who see this page decide to register
3 Variant 2 + images  
4 Variant 2 + images  
5 Loss frame + basic message Three people die every day because there are not enough organ donors…
6 Gain frame + basic message You could save or transform up to 9 lives as an organ donor
7 Fairness + reciprocity If you need an organ transplant would you have one? If so please help others
8   If you support organ donation please turn your support into action

Table 3. Tailored nudge messages employed in BIT study.

Therefore, like Steven if you sign-up to renew your driving licence and you are asked about organ donation it may be that you are seeing a message that is aimed at increasing organ donation rates. Depending on whether you would like someone to donate an organ to you if needed you may want to opt-in to donate. As we have seen nudges can be used in a variety of ways to increase donation rates. The default organ registration system (i.e., opt-in / opt-out) and public awareness of the need for donations through messages can all dramatically improve donations rates. More work needs to be done on nudging for organ donation to investigate all of the factors involved.