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The European Journal of Health Economics
Published in: The European Journal of Health Economics 1/2012

01-02-2012 | Original Paper

The impact of presumed consent laws and institutions on deceased organ donation

Author: Fırat Bilgel

Published in: The European Journal of Health Economics | Issue 1/2012

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Abstract

This article purports to advance the literature on the impact of presumed consent laws on deceased donation rates by examining the interactions between a presumed consent legal regime and other customs and institutions, using data on health expenditure, death rates caused by cerebro vascular diseases, motor vehicle accidents and homicides, legislation, legal systems, family consent, civil rights and liberties and donor registry systems, for 24 countries over a 14-year period. Countries in which presumed consent is enacted exhibit significantly higher donation rates only if family consent is routinely sought and a combined registry is maintained or neither practice is administered. Otherwise, presumed consent legislation does not have a sizeable impact on deceased donation rates.
Footnotes
1
As of April 2010, the first person consent system has been ratified in all states in the US except Kansas and Wisconsin [23].
 
2
This strategy, known as “the Spanish model of organ procurement”, has been introduced in 1989 by the efforts of Dr. Rafael Matesanz and has been successfully implemented in Spain, followed by Italy and later by South Australia. The Spanish model adopts the principle of decentralization of the donor coordination through regional coordination and aims to cope with the obstacles faced by physicians and staff [5]. These include under-trained doctors, unidentified donors and the reluctance and incompetence to approach families to request donation. Therefore, Spanish model endorses continuous education and training of transplant coordinators to improve management and communication skills.
 
3
A remarkable exception to this case is Austria and recently Czech Republic where presumed consent legislation is strictly enforced, that is families are ruled out of the decision-making process. Therefore, the organs of the donor can be procured unless the donor opposed the removal of her organs.
 
4
If a country always seeks family consent, this means that the consent of the family is asked every time irrespective of the preferences of the donor (i.e. a deceased could have premortem allowed the removal of her organs but the hospital still asks the family or a deceased could have premortem opposed the removal of her organs but the hospital still asks the family).
 
5
A combined registry indicates that the country allows both organ donors and organ retainers the right to express their wishes regarding organ donation by registering. On the other hand, a single registry indicates that the country allows either organ donors or organ retainers to express their wishes by registering, depending on the default rule (i.e. presumed or informed consent).
 
6
The cause of extremely low deceased donations in Israel is the reservation on the definition of death and the belief that the Jewish Law forbidding desecration of the human body outlaws donation [25].
 
7
In the first stage, the country-specific effects are estimated via FE excluding time-invariant and almost time-invariant variables. In the second stage, the country-specific effects are decomposed into an unexplained and an explained part by the regression on the time-invariant or almost time-invariant variables. In the third stage, a (standard error corrected) pooled OLS is performed by including all the time-variant and invariant variables in the model and the unexplained part (residuals) from the second stage. The third stage allows for computing the correct standard errors of the parameters of (almost) time-invariant variables.
 
8
In the absence of country-specific effects and other explanatory factors, Abadie and Gay [1] found that the impact of presumed consent on deceased donation rates is much higher, around 15 percent on average once the year fixed effects have been accounted for. The reason is that without country-specific effects, the consent legislation variable soaks up most of the explanatory power of the unobserved heterogeneity and shows a higher-than-otherwise impact of presumed consent laws.
 
9
The control of supply measures for donation policy purposes creates a paradox in organ collection because the promotion of deceased donation through continuous education and awareness programs contradicts policies that aim to reduce the prevalence of motor vehicle accidents and hand-gun crimes by raising awareness [2]. Recently, Dickert-Conlin et al. [7] found that organ donations due to motor vehicle accidents increase by 10 percent following helmet law repeals and that a nationwide elimination of helmet laws in the US would increase the annual supply of organ donors by less than 1 percent.
 
10
In the preliminary analysis, a binary variable representing religious belief that takes the value of 1 for countries in which the majority of the population is catholic and 0 otherwise has been considered as a potential factor that might affect deceased donation rates. However, such a measurement will not represent the effect of religious beliefs on deceased donation because it does not take into account the practice of religion but merely represents a group of the population who consider themselves as Catholics.
 
11
The author would like to thank an anonymous referee for pointing this out.
 
12
In the specification analysis, a family veto dummy variable compiled from various sources has been considered as a potential explanatory factor. However, it has not been considered in the regressions for two reasons. First, family veto variable is highly correlated with consent legislation and registry variables, whose inclusion in the regressions rendered significant estimates but a lower than otherwise R-squared, confirming collinearity. Second, even if countries allow the right to veto donor's wishes, families do not use this right either because they do not want to oppose their loved one's wishes or do not actually aware whether such a right has been granted.
 
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Metadata
Title
The impact of presumed consent laws and institutions on deceased organ donation
Author
Fırat Bilgel
Publication date
01-02-2012
Publisher
Springer-Verlag
Published in
The European Journal of Health Economics / Issue 1/2012
Print ISSN: 1618-7598
Electronic ISSN: 1618-7601
DOI
https://doi.org/10.1007/s10198-010-0277-8

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