Public Affairs | Small Change

Organ donation has long been considered an important and cost-effective treatment for a variety of conditions which lead to organ failure. For many patients suffering from such conditions, transplantation is the only chance for survival. Since 2010, approximately a million organs have been donated worldwide. Despite both the effectiveness of the treatment and the general public support for organ donation, there is a persistent global shortage of transplantable organs. In recent years, governments and regulatory bodies have been exploring a variety of ways to decrease this shortage, potentially saving hundreds of thousands of lives.

This article summarises the most significant regulatory and technological developments around the world and evaluates their effectiveness in increasing the availability of transplantable organs, focussing on the move from an ‘opt-in’ to an ‘opt-out’ system. The importance of informing the public on how states can legislate to increase the efficiency of their donation system cannot be underestimated in the fight to improve a system which saves countless lives but is capable of saving many more.

In an opt-in, or ‘informed consent’ system, organs cannot be harvested unless the donor has given explicit consent during their life. The presumption is that nobody has consented until we know otherwise. Countries which use this system include Ireland, America, the UK, Germany and Australia. Last year Ireland announced that it will join the long, and ever-growing, list of countries which use an opt-out system. By contrast, in an opt-out, or ‘presumed consent’ system, the presumption is that everyone has consented unless they have explicitly refused. Countries which use this system include Spain, Belgium, Finland, France, Greece, Hungary, Israel, Italy, Sweden and Turkey.

A highly regarded 2006 study in the Journal of Health Economics showed that countries with opt-out systems have donation rates 25-30% higher than those which require explicit consent. This makes perfect sense, especially considering evidence from the same study, which states that while 85% of US adults support organ donation, only 28% are registered donors. An opt-out system could bring those numbers much closer together.

The same pattern of widespread support for donation but low numbers of registered donors seen in the US appears around the globe. Busy lives and lack of motivation mean that many people who would consent if formally asked simply do not specify that they would like to donate, and this contributes to the shortage of transplantable organs. Would it not be better if inertia and busy lives resulted in more organs for transplantation rather than fewer?

Given that far more people support donation than not, an opt-out system also means that the presumption of the law is in line with the majority wish. A simple legislative shift has the power both to save lives and make the law more representative of how people actually feel about organ donation. Spain has been the world’s leader in organ donation for 25 years running by a significant margin. The most cited reason for this is their efficient opt-out system. Spain’s success can also be linked to better hospital protocols and the fact that they do not cap the age at which donor organs will be considered. High public awareness may also contribute to Spain’s edge over other opt-out countries.

Governments have also tried to increase the availability of organs by applying the ‘priority rule’, where people who are on the donation register are given priority when organs are being allocated. If there are two potential recipients who are in the same stage of organ failure, but only one of them is on the register, then that person will receive the organ first. The idea is that people will consent to donation on the basis that it will increase their chance of survival if they are ever in need of a transplant themselves.

While on the surface this tactic seems to appeal to self-interest, it can also be seen as a reminder of the hypocrisy of benefitting from a system to which you do not contribute. You cannot expect others to donate their organs to you if you refuse to donate your organs to others. This tactic for decreasing the shortage of transplantable organs has also proved, usually alongside an opt-out system, to be an effective tool for saving lives.

The final policy I address is controversial; in almost all organ donation systems worldwide, the family of the deceased has the power to veto the consent given by the deceased during their life. Even Spain gives families the power of veto, though high public awareness means that very few families actually do so. There is no reason, in my view, that families should be given this power. It is a violation of the donor’s autonomy and yet another obstacle between a potential recipient and the organs that could save their life. If my family has a problem with organ donation, they can choose not to donate their own organs, but what happens to my body is my call and mine alone.

According to UNOS, around 20 people die every day in the US alone due to a lack of transplantable organs. By making simple legislative changes like removing the family’s power to veto and introducing opt-out donation and the priority rule, they could in theory cut that number in half. This is not some elevated ethical debate to be discussed in classrooms. What legislators decide with respect to this issue has incalculable effects on normal people.

None of us know if and when we may require an organ transplant. We are all vulnerable to the dangers of disease, age and injury. By doing everything in our power to increase the number of organs available, not only do we save the lives of others, but we also ensure that if the time comes when we are in need ourselves, we can rest assured that there is an efficient and sensible system in place to save us.

First Published in UCD College Tribune

We’ve all heard Bernie Sanders talk about how the top 1% of earners in the world own more than half of all global wealth. Unfortunately for most, Bernie is not wrong. In recent years, income inequality has been growing globally at an alarming and ever-increasing rate.

It has been growing, however, at vastly different speeds in different countries. It seems that the way in which a country legislates has a real and important effect on inequality. In this piece, I’ll examine the possible relationship between income inequality and happiness by looking at figures from, among others, the World Happiness Report (WHR) and the World Inequality Report (WIR)

It is definitely worth noting that happiness is a subjective and complex notion which surely depends on any number of factors outside of wealth. My aims here are simply to a) showcase some pieces of evidence (in the form of graphs from various sources) which suggest a link between inequality and happiness and b) to provide a largely theoretical discussion of the possible mechanisms for such a correlation and what the implications are if the correlation holds water.

Before I go any further, I’ll tell you a little about the measurements being used. For happiness (or more accurately ‘subjective wellbeing’), the figures come from so-called Cantril ladder answers. The Cantril ladder question is simply asking people to rate how happy they are on a scale of 1 to 10. On which rung of the ladder do you think you are? For inequality measurements, the Gini Coefficient is perhaps the most useful here. The Gini Index shows how much inequality there is in a country on a scale of 0 (perfect equality) to 1 (perfect inequality) by measuring the “average distance between the income or wealth of all the pairs of individuals” (WIR). Some graphs included in this report, however, use more tools than just the Gini.

Oishi and Kesebir. Link in sources.

Back in the seventies, the ‘father of happiness economics’ Richard Easterlin found that while people with a higher income in a given country were more likely to be happy, this relationship did not hold up on a national level. While the US is the wealthiest country on earth, for example, it ranks just eighteenth in the 2018 World Happiness Report. Though there is a correlation between absolute wealth and happiness in the short term, it is by no means guaranteed that a country with a higher GDP will be happier than one with a lower GDP, nor is it guaranteed that an increase in the wealth of a country will positively affect the country’s ranking in the world happiness report.

From World Happpiness Report – Link in Sources

The above graph from the WHR shows that while average US income more than doubled over the studied period, happiness was the same if not lower in 2016 than it was in the early seventies. This is the Easterlin Paradox in motion.

There could, of course, be any number of reasons for the findings shown in the above graph (WHR figure 7.1). A possible explanation is the idea of diminished returns. This is the concept that as we acquire more and more wealth, the happiness that a given quantity of money brings us diminishes. If most people won fifteen grand on the lottery, for example, the money would transform their lives for the better. If Bill Gates or Donald Trump won the same amount, it is debatable whether they would even notice.

This idea could help account for the theoretical reasons why inequality should affect happiness. If, as the data shows, the majority of global wealth is being accumulated by people who already have plenty to spare, there will not be a huge ‘return’ of happiness. In a perfectly equal world, everybody requires the same amount to be satisfied. In a perfectly unequal world, the majority of people require little to be satisfied but do not receive even that because all the money is tied up in the bank accounts of people who take their yachts for granted.

From World Inequality Report – Link in Sources

Easterlin’s hypothesis was that our happiness depends not on the absolute wealth of the country we live in, but rather where we rank in the social pecking order within the country. This is the concept of ‘keeping up with the Joneses’, which could also be a possible mechanism whereby inequality may affect happiness. In a perfectly equal world, people look around and see that everyone around them has the same amount of money they do. In a perfectly unequal world, the vast majority of people can look around and see some people who own more money than they could make in a hundred lifetimes at their salary. This is not to say that everyone would be unhappy because of petty jealousy but it is disheartening for someone who is starving to see someone else participating in an eating competition until they make themselves puke. Higher income inequality means more people starving and more people who have enough money to last a hundred lifetimes, lying dormant and useless in an offshore bank account.

From World Inequality Database – Link in Sources

Figures from the World Inequality Report show that while the income of the Russian population grew by a total of 34% between 1980 and 2016, the income of the top 0.001% over the same period in Russia grew by a gargantuan 25,269%. When we look at the global rankings, we see that, for the most part, the most equal countries are also the happiest and the least equal are the least happy. Some readers may question here whether correlation implies causation or if external factors may be influencing the data. Happiness, after all is a slippery and complicated thing to measure. In the US, for example, low happiness levels relative to wealth may be due to such factors as high rates of gun violence, racism and obesity or any number of other problems.

From the Guardian – Link in Sources

However, if we look at the trends over time on a global scale, there seems to be a link and it is important that we explain that link if we are to learn how best to organise society in terms of subjective wellbeing. Perhaps some countries have both high happiness and low inequality because they have effective governments with a knack for social policy. These governments may provide the infrastructure for happiness through effective legislation aimed at increasing public wellbeing. Might it not be their legislation in other areas which increases national happiness, thus making our apparent link redundant?

It makes sense to me to conclude, at least, that part of the effective policy required to increase national happiness is legislation designed to minimise income inequality. Raising the minimum wage. Raising taxes for the wealthy and using that money for social goods. This is what smart governments do. Legislation influences both the happiness of a country and its place in the Gini index. What is good for income equality may also be good for happiness.