Preview
FILED: WESTCHESTER COUNTY CLERK 07/14/2018 08:37 PM INDEX NO. 60767/2018
NYSCEF DOC. NO. 65 RECEIVED NYSCEF: 07/14/2018
EXHIBIT 5S
FILED: WESTCHESTER COUNTY CLERK 07/14/2018 08:37 PM INDEX NO. 60767/2018
NYSCEF DOC. NO. 65 RECEIVED NYSCEF: 07/14/2018
POL CY FORUM
M ED I C I N E Governments, companies, and public
agencies run "naturalexperi-
inadvertently
• ments"
testing the power of defaults.
Do Defaults Save Lives? studies ofinsurance choice (20),selection
of Internetprivacy policies (21, 22),and
EricJ. Johnson* and Daniel Goldstein the levelof pension savings (23) allshow
large often
effects, with substantialfinan-
~
Since 1995, more than 45,000 people in cialconsequences.
~ 100
the United States have died waiting --
~ 90 - --
fora suitable donor organ. Although Defaults and Organ Donations
~ cn 80
an oft-citedpoll (1) showed that85% of . a We investigatedthe effect of defaultson
70 82
Americans approve of organ donation,less 79 donation agreement ratesin three studies.
than halfhad made a decisionabout donat- The first
used an online experiment (24):
per- 50 -
ing,and fewer still(28%) had granted 8
tdm 161 respondents were asked whether they
mission by signing a donor card,a pattern c 'tt> would be donors on the basis of one of
< 30 - 42
also observed in Germany, Spain, and ~ three questions with varying defaults.In
— 20 -
Sweden (2-4). Given the shortage of the opt-incondition,participantswere told
¹° -
donors, the between approval and ac- to assume that had justmoved to a
gap they
tionis a matterof lifeand death. o
Opt-In Opt-Out Neutral
new he
State Ne Mad was not tobe
CV
What drives the decision tobecome a an organ donor, and they were given a
potential donor. Within the European Effectiveconsent rates,online experiment, choice to confirm or change that status.
Union, donation ratesvary by nearlyan or- as a functionofdefault. The opt-out conditionwas identical,except
der of magnitude acrosscountriesand these the default was to be a donor. The third, P
differences are stablefrom year to year. preferences forbeing an organ donor are neutral conditionsimply requiredthem to
Even when controllingforvariablessuch as constructed,defaultscan influence choices choose with no prior default.Respondents
transplant economic
infrastructure, and ed- in threeways: First,decision-makersmight could at a mouse clickchange theirchoice,
ucationalstatus,and religion(5),largedif- believethat defaultsaresuggestions the effortexplanations. 5
by largelyeliminating
ferences indonation ratespersist.
Why? policy-maker,which imply a recommended The form ofthe question had a dramat-
Most public choices have a no- action.Second, a decisionoftenin- icimpact (see figure,left):
Revealed dona-
policy making E
action default,that is,a condition is im- volves whereas
effort, thedefault tion rateswere about twice as high when
accepting
posed when an individualfailsto make a is effortless.Many people would rather opting-out as when opting-in.The opt-out
decision (6,7).In the case oforgan dona- avoid an activedecisionabout dona- condition did notdiffer from 5
making significantly
European countries have one of two tion,because it
can be unpleasantand stress- theneutral condition(without a defaultop-
tion,
default policies. In presumed-consent ful(17).Physical such
effort out
as filling a tion).Only theopt-in condition,thecurrent
people areorgan donors unless form also increaseacceptanceof the de- practicein the United States,was signifi-
states, they may
registernot to be, and in explicit-consent fault(18). defaults
Finally, oftenrepresent lower. E
cantly
countries, isan organ donor with- the stateorstatusquo, and change In the last two decades, a number of
nobody existing
out to be one. involvesa trade-off.
Psychologists European countrieshave had opt-inor opt-
registering usually -
individuals'deci-
According to a classical
economics view, have shown thatlossesloom largerthan the out default options for individuals
preferencesexist to the de-
and are available equivalentgains, a phenomenon known as sionsto become organ donors.Actual deci- _O
cision-maker-people find too little lossaversion (19).Thus, changes inthe de- sions aboutorgan donation beaffected
simply may
value inorgan donation. This view has led faultmay resultina change of choice. by governmental educationalprograms, the
to callsfortheestablishment ofa regulated
market forthe organsof thedeceased (8, 9),. .
donors' 99.98 98 99.91 99.97 99.5 99.64
forthe payment ofdonors or fami- m 100 -
lies and even for suggestionsthat cego90 - 85.9
(10, 11),
"
organs shouldbecome public propertyupon 80 -
death (12).Calls for campaigns to change 0- 70 -
publicattitudes(13)are widespread.Inclas-
e 60 -
sicaleconomics, defaultsshouldhave a lim- ~ 50 -
itedeffect:when defaultsare not consistent 8
u 40 -
with people would choose an p 30 - 27.5
preferences,
appropriatealternative. 20 - 17·17
A differenthypothesis arises from re- 10 - 4.25
~~
search depictingpreferencesas constructed, 0
E E (g C
thatis,not yet articulatedinthe minds of o cn -8
— CD
those who have notbeen asked (14-16).If
EQ z K
The authors are at the Center for Decision Sciences,
Columbia University, New York, NY 10027, USA.
Effectiveconsent (opt-
*To whom all correspondenceshould be addressed: rates,by country.Explicit
consent(opt-in,
gold)and presumed consent
ejj3@columbia.edu out,blue).
1338 21 NOVEMBER 2003 VOL 302 SCIENCE www.sciencemag.org
Electronic copy available at: http:
//ssrn.corn/abstract=1324774
effect
FILED: WESTCHESTER COUNTY CLERK 07/14/2018 08:37 PM INDEX NO. 60767/2018
NYSCEF DOC. NO. 65 RECEIVED NYSCEF: 07/14/2018
P O LIC Y F O RU M
effortsof public health organizations,and serve as proxiesfortheseconstructs(5) and plants,the consequences aresubstantialin
culturaland infrastructural
factors.We ex- an indicatorvariable each year. lives saved. Our results stand incontrast
representing
amined therate of agreement to become a This analysis presentsa conclu- with the suggestion that defaultsdo not
strong
donor acrossEuropean countries with ex- sion. Although there are no differences matter (29). Policy-makers performing
plicitand presumed consent laws.We sup- across years,
thereis a strong of the de-
effect analysis in thisand other domains should
plemented thedata reported in Gäbel (25) When
fault: donation is the default,
thereis a consider thatdefaults make a difference.
the central for
registries sever- 16.3% (P < increasein donation,in-
by contacting 0.02)
al countries,which allowed us to estimate creasing the donor rate from 14.1 to 16.4 Referencesand Notes
the effective
consent that the number million (see this blue line). 1. The Gallup Organization, "The American Public's
rate, .is, figure, page, AttitudeToward Organ Donationand Trans-
of peoplewho had opted in(inexplicit-con- similartechniques,but at jjjznzgzjrjij"
Using looking only plantation"(GallupOrganization,Princeton,NJ,1993).
sent countries)orthe number who had not 1999 fora broaderset of Europeancountries, 2. S. M. cold, K. Shulz,U. Koch, The Organ Donation
°*³
opted out (inpresumed-consent countries). includingmany more from Eastern Europe, "tosoÎutionFe e a Centerfo
Heal h
If preferences concerning organ donation Gimbel etal. (5)report an increasein the Education,Cologne,2001),
are strong,
we would expectdefaultsto have ratefrom 10.8 to a 56.5% increase(see 3. H. Gäbel,H. N. Rehnqvist,Transplant.Proc.29, .30~3
3093
16.9,
(1997).
or no effect.
little However, as can be seen in figure,thispage,red line).
Differencesin the 4. C.9con sa et ai , Transplant.Proc.351275 (2003).
the figure(page 1338,bottom), defaultsap- estimatesof size may in
be due to differences 5. R. W. Gimbel, M. A. Strosberg, S. E. Lehrman, E.
pear to makea large the four
difference: opt- the countriesincludedin theanalysis: Gefenas,F.Taft, Progr.Transplant.13, 17 (2003).
. Many 6. R.H. Thaler,C. Sunstein,Univ. ChicagoLaw Rev.,in
in countries(gold)had lower ratesthan the of thecountries examined by Gimbel et al. press.
six opt-outcountries(blue).The two distri- had much lowerratesof donation. 7. c.camerer,s.Issacharoff, G.
Loewenstein, T.
M. Rabin, Univ. Penn.Law Rev. 151,
h9u9e,
butions have no overlap,and nearly60 per- 2111 (2003).
centage pointsseparatethe two groups.One ConclusionS 8. M. Clay,W. Block,J. Soc.Polit. Econ.Stud. 27, 227
reason appear
these results to be greater
than How should policy-makers choose defaults? (2002). o
. . 9. J. Harris,C. Erin,BMJ325, 114 (2002). CN
those inour laboratorystudy is that
thecost consider
First, thateverypolicy must have a 10. c. E.Harris,S.P.Alcorn,IssuesLawMed.3, 213 (2001).
of from thedefaultishigher; in-
it no-actiondefault,and defaults
impose physi- 11. D.Josefson,BMJ324, 1541 (2002).
changing
ofdonation 12. J. Harris,J. Med.Ethics29, 303 (2003).
volves fillingout forms, making phone cal,cognitive,and,in the case '
. 13. J.S.Wolf,E.M. Servino,H.N. Nathan,Transplant.Proc.
-3
calls,and sending mail.These low ratesof emotional costson thosewho must change 29, 1477 (1997). C
agreement to become a donor come, in theirstatus.As noted earlier,both national 14· J.w. Payne,J. R. Bettman, E.J. Johnson,Annu. Rev.
no-de- h 43, 87 (1992).
some cases, despite surveys and the s cho. 50, 364 (1995).
33 P.Slovic,4Am.
A
49 ~O
marked efforts to in- faultconditionin our ex- 16. D. Kahneman,A. Tversky,Eds.,Choices,Values,and
creasedonation rates.In o periment suggest that Frames(CambridgeUniv.Press,Cambridge,2000).
= T
ex- 17 - 17. J. Baron,I. Ritov,
' Org.Behav.Hum.DecisionProcesses
V)
the Netherlands,for most Americans favor 59, 475 (1994).
E I
ample, the 1998 cre- organ donation.Thisim- J. RiskUncertainty 1, 7
18. w. Samuelson,R.Zeckhauser, E
ationof a national
donor 8 15 - plies thatexplicitcon
(1988). ø
O
19. A. Tversky,D. Kahneman,Q. J. Econ. 106(4), 1039
accompa- I
registry was sent policies
impose the (1991).
nied an extensiveed- 13 - costs of switching
on the 20. E.J.Johnson,J. Hershey,J. Meszaros,H. Kunreuther,J.
·by ~ RiskUncertainty7, 35 (1993). 0
ucationalcampaign and o apparent (28).
.;-; majority 21. 2 Bellman,2 J. Johnson,G. L. Lohse,Commun.ACM
a maSS mailing (ofmore 11 - Second, notethatde- (Assoc.Comput.Machin.)44, 25 (February2001).
than 12 million in
letters Ê faultscan lead to two 22. E.J. Johnson,S. Bellman,G. L. Lohse,Marketing Lett.
a
mil-
. .
misclassifica- 13, 5 (February2002). E
a country of 15.8 9 kinds of 23. B.C. Madrian,D.Shea,Q.J.Econ.116(1), 1149(2001).
O
d-
lion) asking citizensto Opt-in Opt-out tion: willing donors 24. Methodsand detailsof analysisare availableas sup-
which failedto Default who are not identified Porting materialon Scienceonline.
Europe" -cy
register, G
25. H.Gäbel, DonorandNon-DonorRegistriesin Europe
change the effective Estimated donation opt-inversus or people who become the
(on behalf of committee of
experts on the
rate,
consent rate donors against their OrganizationalAspects of
Co-operation in
Organ O
. (261 . o Pt-out
, as a function of default, Transplantationof the Council of Europe,Brussels,
c
Do mereases in 1991-2001. yeans ± SEM; thispaper, wishes. Balancing these 2002). 3:
agreement rates result blue; Gimbelet al. ( 5), red. errors with the good 26. M. C. Oz et al., J. Heart Lung Transplant.22, 389
in ofdo- the livessaved (2°°3)· .
increased rates done by . 27. We useda times seriesanalysisto accountfor possi-
nation? There are many reasons through organ transplantationleadsto deh- ble changesin transplant technology and infrastruc-
preventing
registered potentialdonors from actually cate ethical and psychological questions. ture, aswell as the effects of continuing public edu-
families'objec- fur- d'
donating. These include: These decisions shouldbe informed by 28. An tern t aŠvocatedby the American Medical
doctors'hes-
tionsto a lovedone'sconsent, therresearch examining theroleof thethree Association(30) is mandatedchoice,which imposes
touse a default and a mis- causes of default For
effects. one the costof makingan activedecisionon all.Thisprac-
itancy option, example, tice is currently employedin the state of Virginia,but,
match with potential as well
recipients, as might draw differentconclusionsif theef- consistentwith the constructivepreferencesperspec-
differencesin culture,and infra- feetof defaultson donationratesis due pri- tive, about 24% of the first million Virginiansasked
religion, ~ said they were undecided(37).
structure. manly to thephysical costsof responding, 29. A L.Capa A 72, 1708 (1994).
To examine we
this, analyzed theactual than iftheywere due to lossaversion. 30. AmericanMedicalAssociation,"Strategiesfor cadav-
number of cadaveric donations made per The tradeoff between errors ofclassifi- eric organ procurement:Mandatedchoice and pre-
consent" (American Medical
. sumed Association,
millionon a slightlylarger of
list cation and cognitive, and emo-
countries, physical, Chicago,1993).
with data from 1991 to 2001 (27).We ana- tionalcosts must be made with theknowl- 31. A. C. Klassen,D.K. Klassen,Ann. intern Med. 125, 70
lyzed thesedata usinga multiple regression edge that defaultsmake a largedifference Th'
32. s r searchhas been supported by the Columbia
analysiswith theactualdonation ratesas de- inlives savedthrough transplantation. University Center for
Decision Science and the
pendent measures and thedefault as a pre- Our data and thoseof Gimbeletal. sug- ColumbiaBusinessSchoolCenterfor Excellencein E-
We thank L.Roelsfor providingthe data on
Business.
dictorvariable.To control for otherdiffer- gestchanges indefaultscould increase do- actualdonation rates.
countries'
ences in propensity to donate, nations in theUnited States of additional
su r
transplant educational
infrastructure, level, thousands of donors a year.Because each nnEcem or /cgi/content/full/302/5649/1338/
www sciencema
and religion,
we included known
variables to donor can be used forabout three trans- Dc1
www.sciencemag.org SCIENCE VOL 302 21 NOVEMBER 2003 1339
Electronic copy available at: http:
//ssrn.corn/abstract=1324774
Preview
FILED: WESTCHESTER COUNTY CLERK 07/14/2018 08:37 PM INDEX NO. 60767/2018 NYSCEF DOC. NO. 65 RECEIVED NYSCEF: 07/14/2018 EXHIBIT 5S FILED: WESTCHESTER COUNTY CLERK 07/14/2018 08:37 PM INDEX NO. 60767/2018 NYSCEF DOC. NO. 65 RECEIVED NYSCEF: 07/14/2018 POL CY FORUM M ED I C I N E Governments, companies, and public agencies run "naturalexperi- inadvertently • ments" testing the power of defaults. Do Defaults Save Lives? studies ofinsurance choice (20),selection of Internetprivacy policies (21, 22),and EricJ. Johnson* and Daniel Goldstein the levelof pension savings (23) allshow large often effects, with substantialfinan- ~ Since 1995, more than 45,000 people in cialconsequences. ~ 100 the United States have died waiting -- ~ 90 - -- fora suitable donor organ. Although Defaults and Organ Donations ~ cn 80 an oft-citedpoll (1) showed that85% of . a We investigatedthe effect of defaultson 70 82 Americans approve of organ donation,less 79 donation agreement ratesin three studies. than halfhad made a decisionabout donat- The first used an online experiment (24): per- 50 - ing,and fewer still(28%) had granted 8 tdm 161 respondents were asked whether they mission by signing a donor card,a pattern c 'tt> would be donors on the basis of one of < 30 - 42 also observed in Germany, Spain, and ~ three questions with varying defaults.In — 20 - Sweden (2-4). Given the shortage of the opt-incondition,participantswere told ¹° - donors, the between approval and ac- to assume that had justmoved to a gap they tionis a matterof lifeand death. o Opt-In Opt-Out Neutral new he State Ne Mad was not tobe CV What drives the decision tobecome a an organ donor, and they were given a potential donor. Within the European Effectiveconsent rates,online experiment, choice to confirm or change that status. Union, donation ratesvary by nearlyan or- as a functionofdefault. The opt-out conditionwas identical,except der of magnitude acrosscountriesand these the default was to be a donor. The third, P differences are stablefrom year to year. preferences forbeing an organ donor are neutral conditionsimply requiredthem to Even when controllingforvariablessuch as constructed,defaultscan influence choices choose with no prior default.Respondents transplant economic infrastructure, and ed- in threeways: First,decision-makersmight could at a mouse clickchange theirchoice, ucationalstatus,and religion(5),largedif- believethat defaultsaresuggestions the effortexplanations. 5 by largelyeliminating ferences indonation ratespersist. Why? policy-maker,which imply a recommended The form ofthe question had a dramat- Most public choices have a no- action.Second, a decisionoftenin- icimpact (see figure,left): Revealed dona- policy making E action default,that is,a condition is im- volves whereas effort, thedefault tion rateswere about twice as high when accepting posed when an individualfailsto make a is effortless.Many people would rather opting-out as when opting-in.The opt-out decision (6,7).In the case oforgan dona- avoid an activedecisionabout dona- condition did notdiffer from 5 making significantly European countries have one of two tion,because it can be unpleasantand stress- theneutral condition(without a defaultop- tion, default policies. In presumed-consent ful(17).Physical such effort out as filling a tion).Only theopt-in condition,thecurrent people areorgan donors unless form also increaseacceptanceof the de- practicein the United States,was signifi- states, they may registernot to be, and in explicit-consent fault(18). defaults Finally, oftenrepresent lower. E cantly countries, isan organ donor with- the stateorstatusquo, and change In the last two decades, a number of nobody existing out to be one. involvesa trade-off. Psychologists European countrieshave had opt-inor opt- registering usually - individuals'deci- According to a classical economics view, have shown thatlossesloom largerthan the out default options for individuals preferencesexist to the de- and are available equivalentgains, a phenomenon known as sionsto become organ donors.Actual deci- _O cision-maker-people find too little lossaversion (19).Thus, changes inthe de- sions aboutorgan donation beaffected simply may value inorgan donation. This view has led faultmay resultina change of choice. by governmental educationalprograms, the to callsfortheestablishment ofa regulated market forthe organsof thedeceased (8, 9),. . donors' 99.98 98 99.91 99.97 99.5 99.64 forthe payment ofdonors or fami- m 100 - lies and even for suggestionsthat cego90 - 85.9 (10, 11), " organs shouldbecome public propertyupon 80 - death (12).Calls for campaigns to change 0- 70 - publicattitudes(13)are widespread.Inclas- e 60 - sicaleconomics, defaultsshouldhave a lim- ~ 50 - itedeffect:when defaultsare not consistent 8 u 40 - with people would choose an p 30 - 27.5 preferences, appropriatealternative. 20 - 17·17 A differenthypothesis arises from re- 10 - 4.25 ~~ search depictingpreferencesas constructed, 0 E E (g C thatis,not yet articulatedinthe minds of o cn -8 — CD those who have notbeen asked (14-16).If EQ z K The authors are at the Center for Decision Sciences, Columbia University, New York, NY 10027, USA. Effectiveconsent (opt- *To whom all correspondenceshould be addressed: rates,by country.Explicit consent(opt-in, gold)and presumed consent ejj3@columbia.edu out,blue). 1338 21 NOVEMBER 2003 VOL 302 SCIENCE www.sciencemag.org Electronic copy available at: http: //ssrn.corn/abstract=1324774 effect FILED: WESTCHESTER COUNTY CLERK 07/14/2018 08:37 PM INDEX NO. 60767/2018 NYSCEF DOC. NO. 65 RECEIVED NYSCEF: 07/14/2018 P O LIC Y F O RU M effortsof public health organizations,and serve as proxiesfortheseconstructs(5) and plants,the consequences aresubstantialin culturaland infrastructural factors.We ex- an indicatorvariable each year. lives saved. Our results stand incontrast representing amined therate of agreement to become a This analysis presentsa conclu- with the suggestion that defaultsdo not strong donor acrossEuropean countries with ex- sion. Although there are no differences matter (29). Policy-makers performing plicitand presumed consent laws.We sup- across years, thereis a strong of the de- effect analysis in thisand other domains should plemented thedata reported in Gäbel (25) When fault: donation is the default, thereis a consider thatdefaults make a difference. the central for registries sever- 16.3% (P < increasein donation,in- by contacting 0.02) al countries,which allowed us to estimate creasing the donor rate from 14.1 to 16.4 Referencesand Notes the effective consent that the number million (see this blue line). 1. The Gallup Organization, "The American Public's rate, .is, figure, page, AttitudeToward Organ Donationand Trans- of peoplewho had opted in(inexplicit-con- similartechniques,but at jjjznzgzjrjij" Using looking only plantation"(GallupOrganization,Princeton,NJ,1993). sent countries)orthe number who had not 1999 fora broaderset of Europeancountries, 2. S. M. cold, K. Shulz,U. Koch, The Organ Donation °*³ opted out (inpresumed-consent countries). includingmany more from Eastern Europe, "tosoÎutionFe e a Centerfo Heal h If preferences concerning organ donation Gimbel etal. (5)report an increasein the Education,Cologne,2001), are strong, we would expectdefaultsto have ratefrom 10.8 to a 56.5% increase(see 3. H. Gäbel,H. N. Rehnqvist,Transplant.Proc.29, .30~3 3093 16.9, (1997). or no effect. little However, as can be seen in figure,thispage,red line). Differencesin the 4. C.9con sa et ai , Transplant.Proc.351275 (2003). the figure(page 1338,bottom), defaultsap- estimatesof size may in be due to differences 5. R. W. Gimbel, M. A. Strosberg, S. E. Lehrman, E. pear to makea large the four difference: opt- the countriesincludedin theanalysis: Gefenas,F.Taft, Progr.Transplant.13, 17 (2003). . Many 6. R.H. Thaler,C. Sunstein,Univ. ChicagoLaw Rev.,in in countries(gold)had lower ratesthan the of thecountries examined by Gimbel et al. press. six opt-outcountries(blue).The two distri- had much lowerratesof donation. 7. c.camerer,s.Issacharoff, G. Loewenstein, T. M. Rabin, Univ. Penn.Law Rev. 151, h9u9e, butions have no overlap,and nearly60 per- 2111 (2003). centage pointsseparatethe two groups.One ConclusionS 8. M. Clay,W. Block,J. Soc.Polit. Econ.Stud. 27, 227 reason appear these results to be greater than How should policy-makers choose defaults? (2002). o . . 9. J. Harris,C. Erin,BMJ325, 114 (2002). CN those inour laboratorystudy is that thecost consider First, thateverypolicy must have a 10. c. E.Harris,S.P.Alcorn,IssuesLawMed.3, 213 (2001). of from thedefaultishigher; in- it no-actiondefault,and defaults impose physi- 11. D.Josefson,BMJ324, 1541 (2002). changing ofdonation 12. J. Harris,J. Med.Ethics29, 303 (2003). volves fillingout forms, making phone cal,cognitive,and,in the case ' . 13. J.S.Wolf,E.M. Servino,H.N. Nathan,Transplant.Proc. -3 calls,and sending mail.These low ratesof emotional costson thosewho must change 29, 1477 (1997). C agreement to become a donor come, in theirstatus.As noted earlier,both national 14· J.w. Payne,J. R. Bettman, E.J. Johnson,Annu. Rev. no-de- h 43, 87 (1992). some cases, despite surveys and the s cho. 50, 364 (1995). 33 P.Slovic,4Am. A 49 ~O marked efforts to in- faultconditionin our ex- 16. D. Kahneman,A. Tversky,Eds.,Choices,Values,and creasedonation rates.In o periment suggest that Frames(CambridgeUniv.Press,Cambridge,2000). = T ex- 17 - 17. J. Baron,I. Ritov, ' Org.Behav.Hum.DecisionProcesses V) the Netherlands,for most Americans favor 59, 475 (1994). E I ample, the 1998 cre- organ donation.Thisim- J. RiskUncertainty 1, 7 18. w. Samuelson,R.Zeckhauser, E ationof a national donor 8 15 - plies thatexplicitcon (1988). ø O 19. A. Tversky,D. Kahneman,Q. J. Econ. 106(4), 1039 accompa- I registry was sent policies impose the (1991). nied an extensiveed- 13 - costs of switching on the 20. E.J.Johnson,J. Hershey,J. Meszaros,H. Kunreuther,J. ·by ~ RiskUncertainty7, 35 (1993). 0 ucationalcampaign and o apparent (28). .;-; majority 21. 2 Bellman,2 J. Johnson,G. L. Lohse,Commun.ACM a maSS mailing (ofmore 11 - Second, notethatde- (Assoc.Comput.Machin.)44, 25 (February2001). than 12 million in letters Ê faultscan lead to two 22. E.J. Johnson,S. Bellman,G. L. Lohse,Marketing Lett. a mil- . . misclassifica- 13, 5 (February2002). E a country of 15.8 9 kinds of 23. B.C. Madrian,D.Shea,Q.J.Econ.116(1), 1149(2001). O d- lion) asking citizensto Opt-in Opt-out tion: willing donors 24. Methodsand detailsof analysisare availableas sup- which failedto Default who are not identified Porting materialon Scienceonline. Europe" -cy register, G 25. H.Gäbel, DonorandNon-DonorRegistriesin Europe change the effective Estimated donation opt-inversus or people who become the (on behalf of committee of experts on the rate, consent rate donors against their OrganizationalAspects of Co-operation in Organ O . (261 . o Pt-out , as a function of default, Transplantationof the Council of Europe,Brussels, c Do mereases in 1991-2001. yeans ± SEM; thispaper, wishes. Balancing these 2002). 3: agreement rates result blue; Gimbelet al. ( 5), red. errors with the good 26. M. C. Oz et al., J. Heart Lung Transplant.22, 389 in ofdo- the livessaved (2°°3)· . increased rates done by . 27. We useda times seriesanalysisto accountfor possi- nation? There are many reasons through organ transplantationleadsto deh- ble changesin transplant technology and infrastruc- preventing registered potentialdonors from actually cate ethical and psychological questions. ture, aswell as the effects of continuing public edu- families'objec- fur- d' donating. These include: These decisions shouldbe informed by 28. An tern t aŠvocatedby the American Medical doctors'hes- tionsto a lovedone'sconsent, therresearch examining theroleof thethree Association(30) is mandatedchoice,which imposes touse a default and a mis- causes of default For effects. one the costof makingan activedecisionon all.Thisprac- itancy option, example, tice is currently employedin the state of Virginia,but, match with potential as well recipients, as might draw differentconclusionsif theef- consistentwith the constructivepreferencesperspec- differencesin culture,and infra- feetof defaultson donationratesis due pri- tive, about 24% of the first million Virginiansasked religion, ~ said they were undecided(37). structure. manly to thephysical costsof responding, 29. A L.Capa A 72, 1708 (1994). To examine we this, analyzed theactual than iftheywere due to lossaversion. 30. AmericanMedicalAssociation,"Strategiesfor cadav- number of cadaveric donations made per The tradeoff between errors ofclassifi- eric organ procurement:Mandatedchoice and pre- consent" (American Medical . sumed Association, millionon a slightlylarger of list cation and cognitive, and emo- countries, physical, Chicago,1993). with data from 1991 to 2001 (27).We ana- tionalcosts must be made with theknowl- 31. A. C. Klassen,D.K. Klassen,Ann. intern Med. 125, 70 lyzed thesedata usinga multiple regression edge that defaultsmake a largedifference Th' 32. s r searchhas been supported by the Columbia analysiswith theactualdonation ratesas de- inlives savedthrough transplantation. University Center for Decision Science and the pendent measures and thedefault as a pre- Our data and thoseof Gimbeletal. sug- ColumbiaBusinessSchoolCenterfor Excellencein E- We thank L.Roelsfor providingthe data on Business. dictorvariable.To control for otherdiffer- gestchanges indefaultscould increase do- actualdonation rates. countries' ences in propensity to donate, nations in theUnited States of additional su r transplant educational infrastructure, level, thousands of donors a year.Because each nnEcem or /cgi/content/full/302/5649/1338/ www sciencema and religion, we included known variables to donor can be used forabout three trans- Dc1 www.sciencemag.org SCIENCE VOL 302 21 NOVEMBER 2003 1339 Electronic copy available at: http: //ssrn.corn/abstract=1324774