Expectations of a new opt-out system of consent for deceased organ donation in England: A qualitative interview study

Introduction

In 2020 England moved to an opt‐out deceased donation law. We aimed to investigate the views of a mixed stakeholder group comprising people with kidney disease, family members and healthcare practitioners towards the change in legislation. We investigated the expected impacts of the new legislation on deceased‐donor and living‐donor transplantation, and views on media campaigns regarding the law change.

Methods

We undertook in‐depth qualitative interviews with people with kidney disease (n = 13), their family members (n = 4) and healthcare practitioners (n = 15). Purposive sampling was used to ensure diversity for patients and healthcare practitioners. Family members were recruited through snowball sampling and posters. Interviews were audio‐recorded and transcribed verbatim. Transcripts were analysed using thematic analysis.

Results

Three themes with six subthemes were identified: (i) Expectations of impact (Hopeful patients; Cautious healthcare professionals), (ii) Living‐donor transplantation (Divergent views; Unchanged clinical recommendations), (iii) Media campaigns (Single message; Highlighting recipient benefits). Patients expected the law change would result in more deceased‐donor transplant opportunities.

Conclusions

Clinicians should ensure patients and families are aware of the current evidence regarding the impact of opt‐out consent: expectations of an increased likelihood of receiving a deceased‐donor transplant are not currently supported by the evidence. This may help to prevent a decline in living‐donor transplantation seen in other countries with similar legislation. Media campaigns should include a focus on the impact of organ receipt.

Patient or Public Contribution

Two patient representatives from the Kidney Disease Health Integration Team, Primrose Granville and Soumeya Bouacida, contributed to the content and design of the study documents.

What blood and organ donation can tell us about cooperation?

High-cost cooperation directed towards strangers is difficult to explain from an evolutionary perspective. Here, it is argued that by studying the behaviours, motivations, and preferences of real-world high-cost cooperators - blood and organ donors - insights can be uncovered into the mechanisms supporting cooperation. In this respect, this article details two novel mechanisms to enhance cooperation in the face of free-riding, (1) 'reactive reluctant altruism' whereby people help because they do not trust others to help and (2) the 'Good Shepherd' effect whereby cooperation is enhanced when people observed others cooperate although the social norm is to free-ride. Finally, it is argued that repeated acts of high-cost cooperation are sustained by a self-selection process based on the reinforcing effect of warm-glow.

Effects of message framing on recruiting Rh-D-negative blood donors in an emergency situation: Two randomized trials

OBJECTIVES

Prospect theory categorizes message framing according to whether it emphasizes a possible loss or a possible gain. Promotions of blood donation worldwide mainly focus on gain-framed appeal. The objective of the current study is to examine the effects of message framing on recruiting Rh-D-negative blood donors (RDNBDs) in an emergency situation.

DESIGN

Two randomized trials.

METHODS

In Study 1, 813 group O and 500 group B RDNBDs were randomly assigned to three groups receiving three different recruitment text messages: (1) gain-framed, (2) loss-framed, and (3) information messages. In addition, 613 group A and 148 group AB RDNBDs were marked as (4) no message group. In Study 2, 758 RDNBDs were randomly provided one of two versions of materials focusing on either the possible survival (gain-framed) or the death (loss-framed) of a Rh-D-negative patient needed a blood transfusion. These participants then completed a questionnaire to examine the possible mechanisms underlying the observed effects.

RESULTS

Compared to not receiving any message, significantly more RDNBDs re-donated within 14 days after they received a loss-framed message. Study 2 found that RDNBDs who read the loss-framed material expressed more willingness to donate immediately than those who read the gain-framed material. RDNBDs with high-risk perception expressed a greater blood donation intention in the loss-framed group. The loss-framed message made participants perceive others' needs more strongly, which generated more empathy, and thus increased blood donation intention.

CONCLUSIONS

The results suggested that recruiting RDNBDs using a loss-framed message is suitable under an emergency.

Investigating the Effects of Threatening Language, Message Framing, and Reactance in Opt-Out Organ Donation Campaigns

Background

Under opt-out organ donation policies, individuals are automatically considered to have agreed to donate their organs in the absence of a recorded opt-out decision. Growing evidence suggests that the language used within organ donation campaigns influences donor intentions and decision-making.

Purpose

As awareness campaigns to promote opt-out consent in the UK are ongoing, the objectives of this study were to investigate the effect of language and message framing used in opt-out organ donation campaigns on donor intentions and psychological reactance.

Methods

Individuals from Scotland and England (N = 1,350) completed this online experiment. Participants were randomized to view one of four messages, designed in the format of a newspaper article, which described the upcoming opt-out system. This followed a 2 × 2 design whereby the degree of threatening language (high threat vs. low threat) and message framing (loss vs. gain) of the newspaper article was experimentally manipulated. Measures of intention (pre-exposure and postexposure) and postmessage reactance (threat to freedom and anger and counter-arguing) were obtained.

Results

A mixed analysis of variance revealed a significant Group × Time interaction on donor intentions; post hoc analysis revealed that intentions significantly decreased for individuals exposed to the High threat × Loss frame article but significantly increased for those exposed to the High threat × Gain frame article.

Conclusions

In campaigns to promote opt-out legislation, high-threat language combined with loss-frame messages should be avoided. If high-threat language is used, gain-frame messaging that highlights the benefits of organ donation should also be incorporated.

Education and Message Framing Increase Willingness to Undergo Research Lumbar Puncture: A Randomized Controlled Trial

Reluctance to undergo lumbar puncture (LP) is a barrier to neurological disease biomarker research. We assessed whether an educational intervention increased willingness to consider research LP and whether message framing modified intervention effectiveness. We randomly assigned 851 recruitment registry enrollees who had previously indicated they were unwilling to be contacted about studies requiring LP to gain or loss framed video educational interventions describing the procedure and the probability of experiencing adverse events. The gain framed intervention emphasized the proportion of individuals free of adverse events; the loss frame emphasized the proportion experiencing adverse events. The primary outcome for the study was the participant's post-intervention agreement to be contacted about studies requiring LP. Participants were mean (SD) age 60.1 years (15.7), 69% female (n = 591), and mostly college educated and white. Among the 699 participants who completed the study, 43% (95% CI: 0.39, 0.47; n = 301) changed their response to agree to be contacted about studies requiring LP. We estimated that participants randomized to the gain framed intervention had 67% higher odds of changing their response compared to those randomized to the loss frame (Odds Ratio = 1.67; 95% CI: 1.24, 2.26; p < 0.001). A classification and regression tree model identified participants' pre-intervention willingness as the strongest predictor of changing response. Education, in particular education that alerts participants to the probability of not experiencing adverse events, may be an effective tool to increase participation rates in research requiring LP.

Effect of Different Types of Messages on Readiness to Indicate Willingness to Register for Organ Donation During Driver's License Renewal in Japan

BACKGROUND

In Japan, a recent opinion poll in 2017 showed that 41.9% of the respondents wished to donate their organs, but only 12.7% declared their intention to donate or not do so. Therefore, it is important to explore measures to prompt more individuals to register their intention about organ donation.

METHODS

A field experimental questionnaire survey was conducted to confirm the effect of a prompt message for registering intentions for organ donation, which was communicated at a driver's license center. The study employed a prospective randomized control design. Seven thousand six hundred fifteen individuals visited the Tokyo Fuchu License Examination Center to update their driver's license and received leaflets including a message prompting organ donation registration and the questionnaire. Of the participants who received leaflets, 3224 respondents provided complete responses to the questionnaire (valid response rate: 42.3%). Subsequently, a questionnaire survey was conducted to assess the participants' willingness to register for organ donation. A control condition and the following types of messages were used: peer-framed, gain-framed, loss-framed, reciprocity-framed, and peer + reciprocity-framed.

RESULTS

The reciprocity message emerged as a significant predictor of increase in immediate decision response. The loss-framed message was a significant predictor of decrease in no intention to register.

CONCLUSIONS

This study found that reciprocity and loss-framed messages promoted the readiness to register for organ donation among individuals from a Japanese urban area. Mandatory distribution of prompt messages at every driver's license centers in Japan would be recommended.

Circumventing the "Ick" Factor: A Randomized Trial of the Effects of Omitting Affective Attitudes Questions to Increase Intention to Become an Organ Donor

Objectives: Including or excluding certain questions about organ donation may influence peoples’ intention to donate. We investigated the effect of omitting certain affective attitudinal items on potential donors’ intention and behavior for donation.

Design: A cross-sectional survey with a subgroup nested randomized trial.

Methods: A total of 578 members of the public in four shopping centers were surveyed on their attitudes to organ donation. Non-donors (n = 349) were randomly assigned to one of three groups: Group 1 completed items on affective and cognitive attitudes, anticipated regret, intention, subjective norm and perceived behavioral control. Group 2 completed all items above but excluded affective attitudes. Group 3 completed all items but omitted negatively worded affective attitudes. The primary outcome was intention to donate, taking a donor card after the interview was a secondary behavioral outcome, and both were predicted using linear and logistic regression with group 1 as the reference.

Results: Mean (SD) 1–7 intention scores for groups 1, 2 and 3 were, respectively: 4.43 (SD 1.89), 4.95 (SD 1.64) and 4.88 (SD 1.81), with group 2 significantly higher than group 1 (β = 0.518, 95% confidence interval [CI] 0.18 to 0.86).At the end of the interview, people in group 2 (66.7%; OR = 1.40, 95% CI 0.94 to 2.07, p = 0.096) but not those in group 3 (61.7%; OR = 1.10, 95% CI 0.69 to 1.75, p = 0.685), were marginally more likely to accept a donor card from the interviewer than people in group 1 (59.7%).

Conclusion: Omitting affective attitudinal items results in higher intention to donate organs and marginally higher rates of acceptance of donor cards, which has important implications for future organ donation public health campaigns.

Development of a Donor-Centered Approach to Risk Assessment: Rebalancing Nonmaleficence and Autonomy

Living kidney donors are often excluded from the shared decision making and patient-centered models that are advocated in medical practice. Thresholds for acceptable risk vary between transplant centers, and between clinicians and donors. Although donor selection committees commonly focus on medical risks, potential donors also consider nonmedical risks and burdens, which may alter their assessment of an acceptable level of medical risk. Thus, transplant centers may encounter ethical tensions between nonmaleficence and respect for donor autonomy. A donor-centered model of risk assessment and risk reconciliation would integrate the donor's values and preferences in a shared decision about their eligibility to donate. This paper argues for shifting to a donor-centered model of risk assessment, and presents a research agenda to facilitate the greater participation of donors in their own evaluation and approval processes.

A study on the development of public campaign messages for organ donation promotion in Korea

This study aims to find an effective method of expressing a message in public service ads by investigating whether or not a message framing type affects the outcome. Specifically, the study looks into the effects of messaging on organ donation by identifying how the type of message framing (positive vs. negative) and appeal type (rational vs. emotional) affect the attitude and behavioural intention of the consumer. The individual characteristics of each subject such as altruistic mind, level of self-monitoring and issue involvement were selected as intermediate variables that may affect the impact of a message. The study therefore tries to establish a proposition that can be used to generate an effective promotional message on organ donation in a systematic way.

Does perceived risk influence the effects of message framing? A new investigation of a widely held notion

Health-promoting messages can be framed in terms of the beneficial consequences of healthy behaviour (gain-framed messages) or the detrimental consequences of unhealthy behaviour (loss-framed messages). An influential notion holds that the perceived risk associated with the recommended behaviour determines the relative persuasiveness of gain- and loss-framed messages. This 'risk-framing hypothesis', as we call it, was derived from prospect theory, has been central to health message framing research for the last two decades, and does not cease to appeal to researchers. The present paper examines the validity of the risk-framing hypothesis. We performed six empirical studies on the interaction between perceived risk and message framing. These studies were conducted in two different countries and employed framed messages targeting skin cancer prevention and detection, physical activity, breast self-examination and vaccination behaviour. Behavioural intention served as the outcome measure. None of these studies found evidence in support of the risk-framing hypothesis. We conclude that the empirical evidence in favour of the hypothesis is weak and discuss the ramifications of this for future message framing research.

When do next-of-kin opt-in? Anticipated regret, affective attitudes and donating deceased family member's organs

This research assessed whether affective factors promote and prevent family members from donating their loved one's organs. Participants (N = 191) imagined that a family member had died and that they had to decide whether or not to donate their organs and body parts for transplantation purposes. The least organs and body parts were donated when the deceased opposed donation. Moreover, participants who were not registered organ donors donated fewer organs than registered donors. This effect was mediated by anticipated regret, disgust and the perceived benefits of donation. Organ donation campaigns should target such factors to increase donor rates.

Message framing, it does a body good: Effects of message framing and motivational orientation on young women’s calcium consumption

We investigated the effects of gain-framed versus loss-framed messages and motivational orientation on calcium consumption. After completing a motivational orientation scale (behavioral inhibition system/behavioral activation system), undergraduate women ( N = 141) were randomly assigned to read a gain-framed or loss-framed pamphlet promoting calcium consumption. Calcium consumption was assessed 1 month later. For calcium supplement behavior, a gain-framed advantage was observed for behavioral activation system–oriented individuals, whereas a loss-framed advantage was observed for behavioral inhibition system–oriented individuals. For dietary calcium intake, a gain-framed advantage was observed among behavioral activation system–oriented individuals; however, no framing effect emerged for behavioral inhibition system–oriented individuals. The success of framed messages depends on the message recipient’s motivational orientation.