Altruism as an Organizational Problem: The Case of Organ

18 Pages·2004·0.42 MB·English

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AAllttrruuiissmm aass aann OOrrggaanniizzaattiioonnaall PPrroobblleemm::
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Kieran Healy
University of Arizona and Australian National University, RSSS
This article presents a social-organizational approach to explaining empirical variation
in rates of altruism. The efforts of organizations are mostly responsible for much of the
altruism seen today, and the substance of these efforts varies. Although research from
social psychology and organizational studies suggests that altruistic action is sensitive to
social context, the link between individual and organizational aspects of altruism has not
been clearly articulated. In particular, our knowledge of “one-shot,” organizationally
managed altruism is limited. I suggest that the factors of organizational resources,
scope, and persistence are likely to generate higher rates of individual altruism in the
absence of long-term relationships that encourage giving behavior. The approach is
applied to the case of cadaveric organ procurement in the United States. The analysis
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highlights the central role of organ procurement organizations (OPOs). Quantitative
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explains a substantial amount of variation in rates of one-shot altruism.
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Altruism is a long-standing problem in soci- A social-organizational approach to altruism
ology. However, surprisingly little attention was set out by Titmuss (1971), but his pioneer-
has been paid to two important facts: First, that ing effort has seen little subsequent develop-
the incidence of altruism varies greatly; and ment. Instead, theoretical interest in altruism
second, that altruism is structured, promoted, and has mainly centered either on its robustness as
made logistically possible by organizations and a heritable trait or on its reality as a psycho-
institutions with a strong interest in producing logical motive. In the former case, research
it. These facts are not unrelated. Helping, giv- focuses on whether altruistic behavior can
ing, or caring is systematically elicited from evolve and survive across generations as altru-
people by organizations that are usually the ists compete with selfish agents. In the latter
immediate recipients of individual goodwill or, case, research focuses on whether individuals
at least, the necessary brokers for it. Without have altruistic motives or identities and, if so,
these organizations, much of the altruism we how they acquire them. Evidence from both
observe would not happen. Altruism, in short, fields suggests that altruism is a real, and com-
mon, phenomenon. The question of why rates
is highly institutionalized.
of altruism should vary across different orga-
nizational and institutional settings has not been
well addressed. Either the problem is not imme-
Direct correspondence to Kieran Healy, diately relevant to the research program (in
Department of Sociology, Social Sciences 404,
studies of evolution) or it must be posed in
University of Arizona, Tucson, AZ 85721
terms of identifying the real intentions of indi-
([email protected]). The author thanks Paul
vidual agents (in studies of motivation).
DiMaggio, Bruce Western, Viviana Zelizer, Mark
This article reframes the question by con-
Chaves, Ron Breiger, Marion Fourcade-Gourinchas,
Joe Galaskiewicz, Ted Gerber, audiences at sidering the literature on motivation together
Northwestern and Arizona, and the ASR reviewers for with that on voluntary and nonprofit organiza-
comments on earlier versions of this article. tions. I consider altruistic practices in terms of
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their frequency of occurrence for individuals on and Wilson (1998) note that “evolutionary biol-
the one hand, and their degree of social organ- ogists define altruism entirely in terms of sur-
ization on the other. Cases where altruism is a vival and reproduction. A behavior is altruistic
rare or “one-shot” event from the individual when it increases the fitness of others and
point of view yet also possess a substantial decreases the fitness of the actor” (p. 17). From
degree of social organization are an important a social-psychological perspective, altruism is
but undertheorized type in both literatures. I a disposition or identity. The problem is whether
identify organizational features that ought to people truly are altruistic or whether their
be associated with higher rates of altruism in actions are covertly selfish in some way—a
such cases and apply them to the case of cadav- question of purity of motive.
eric organ procurement in the United States. These contrasting approaches are not neces-
Organ procurement has not previously been sarily in conflict with each another—rather,
examined in detail from this perspective. As they are concerned with quite different prob-
with research on altruism more generally, the lems. In the evolutionary approach, altruism is
emphasis has been on the motives and experi- treated as (or as if it were) a heritable trait.
ences of individual donors. My general goal is Research formally analyzes or numerically sim-
to develop a middle-range approach to deter- ulates the reproductive fitness of agents who
mining why rates of altruism vary, highlighting behave altruistically towards other agents.
the logistical efforts of organizations in foster- Classic results from Hamilton (1964) and Smith
ing altruism. Results from the motivational lit- (1964) showed that altruism is a successful
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Princetoner Uatunriev earres pituyt Linibtor aa rcyo m(cpiadr a7ti5v0e 0co0n1t4ex6t,) and strategy if organisms maximize their inclusive
Princetonth Ueonryiv oenr sviotylu (nctaidry 3 o5rg0a0n5iz1a3tio3n)s is extended fitness. More ambitiously, Sober and Wilson
Princetonto U cansievse wrshietyre L oirbgraanriizeasti o(ncsid c a1n7n6ot2 h)ave had (1998) argue that multilevel or group-selection
PRINCETesOtaNbl iUshNedI VreElaRtioSnIsThYip s( cwidit h1 d9o5n0o0rs3.) mechanisms may favor the evolution of altru-
IP: 128.112.69.22 ism in populations to a greater degree than has
2004..07II.NN.2DD6II..VV1II1DD.UU.5AA8LL.. AALLTTRRUUIISSMM AANNDD SSOOCCIIAALL generally been accepted by biologists. Trivers
OORRGGAANNIIZZAATTIIOONN (1971) defined the concept of reciprocal altru-
ism, later developed in Axelrod and Hamilton
DDEEFFIINNIITTIIOONNAALLQQUUEESSTTIIOONNSS (1981), Smith (1982), and Axelrod (1984).1
In everyday usage, an altruistic act is one moti- Other studies show how altruistic behavior can
vated by concern or regard for others rather be transmitted culturally, in ways analogous to
than oneself. Simmons (1991) gives a useful the biological mechanisms of kin- and group-
definition: “Although scholars’definitions dif- selection (Allison 1992; Boyd and Richerson
fer, most would agree that altruism (1) seeks to 1985; Macy and Skvoretz 1998; Mark 2002).
increase another’s welfare, not one’s own; (2) is These sociological applications of the evolu-
voluntary; (3) is intentional, meant to help some- tionary approach examine problems of social
one else; and (4) expects no external reward” (p. order in a general way, with the focus on iden-
3). According to Sober and Wilson (1998), “The tifying the survival chances of prosocial behav-
altruism hypothesis maintains that people some- ior. The present article is not directly concerned
times care about the welfare of others as an end with these questions; instead, I examine varia-
in itself. Altruists have irreducible other-direct- tion in a kind of altruistic practice and take the
ed ends” (p. 228). existence of altruism per se as given.
Operational definitions of altruism are the- A direct conflict between the evolutionary
ory-laden, in that different research programs and motivational approaches arises only where
place varying degrees of constraint on what
acts should count as truly altruistic. This means
there can be reasonable disagreement over how
1 The “tit-for-tat” (cooperate first) strategy
to classify some actions or practices. For exam-
described in Axelrod (1984) is often thought not to
ple, from an evolutionary perspective, altruism
be altruistic, because the cooperator benefits in the
is a behavioral trait. The problem is to say how
long run. There is some disagreement about this:
a behavior that helps others at a cost to oneself Sober and Wilson (1998: 84) argue that the distinc-
could have evolved. This is a question of the tion is not built into a formal model of these process-
reproductive fitness of altruistic agents. Sober es, but lies instead in their interpretation.
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theory demands that ostensibly well-intentioned altruistic actions from the point of view of indi-
actions must be selfishness in disguise. For viduals. Practices range from rare, one-shot
example, homo economicusis both rational and exchanges to common or routine occurrences.
wholly self-regarding, so costly altruism is The second dimension captures variability in
impossible ex hypothesi.Apparently altruistic social organization. Practices here range from
acts must confer some kind of benefit, either those that are diffusely or informally regulated
directly or simply in the form of a “warm glow.” to those that are strongly institutionalized and
This view of altruism, it should be noted, aris- formally managed. We can place acts of altru-
es out of the constraints of a particular model ism within this framework.
of action and not simple facts about the world. Some acts of altruism are neither routine for
More sophisticated rational-choice models need individuals nor well institutionalized. Much
not force this point, and have room for a more experimental work on motivated altruism is
recognizable concept of altruism. As Schmidtz concerned with situations like this, where peo-
(1993) argues, reflectively rational agents (that ple have a sudden opportunity to act in one-shot
is, agents who think about the effects of their events detached from any strong organization-
choices on their preferences) may have reasons al context. “Bystander intervention” experi-
to cultivate an altruistic regard for others in the ments test how subjects react to an unexpected
ordinary sense. Having a reason for doing some- chance to help a stranger who has had an acci-
thing for someone—even a reason from one’s dent, been the victim of a crime, or is otherwise
Delivered byo wInng peonintta o ft oview—does not disqualify the act in need of immediate assistance (Latane and
Princeton Ufnriovme rbseiitnyg L ailbtrruaisrtyic (.cid 75000146) Darley 1970; Austin 1979; Krebs and Miller
Princeton UnivRearthseitry t h(acnid e x3a5m0in0e5 t1he3 3al)truistic authentic- 1985). Studies of help in the context of a rela-
Princeton Uintyiv oefr spiatyrt iLciublarar raicetsio (ncsi,d I 1p7re6s2en)t a middle- tionship are largely absent from this type of
PRINCETONran UgeN fIrVamEeRwSoIrTk Yfo (rc uidnd 1er9s5ta0n0di3n)g empirical study (Simmons 1991). Also absent is a stable
IP: 128.112.v6a9ri.a2ti2on in kinds of altruistic practices in a organizational context for action; the aim is to
2004..07..26w.a.1y 1th..a5t 8a.v.oids strong assumptions about the test people’s reactions when they must make a
motives of individual actors. I begin from the quick decision whether to help someone.
social-psychological conception of altruism as Other practices, such as simple acts of kind-
intentional, voluntary, and unrewarded action ness or consideration, may be habitual for many
oriented toward the welfare of others. But my individuals or a common part of their lives, but
argument here is not in conflict with the general they are not managed by formal organizations.
concerns of evolutionary approaches to proso- Social theorists have pointed to a general norm
cial behavior, and—apart from suggesting that of reciprocity that grounds actions of this sort
a narrowly rational-choice view may confuse the (Gouldner 1960; Granovetter 1985: 489–90).
issue—it is agnostic on the question of the prop- Research has examined the possibility that
er model of individual agency. empathy is a general human trait underlying
these sorts of actions (Davis 1996; Batson 1987;
Hoffman 1981). A related line of research doc-
KKIINNDDSSOOFFAALLTTRRUUIISSTTIICCPPRRAACCTTIICCEE
uments actions that cannot reasonably be called
To provide a framework for the subject, it may self-interested (Oliner and Oliner 1988; Monroe
be helpful to juxtapose findings from the social 1998). This approach emphasizes extraordinary
psychology of altruism on the one hand, and cases of altruism rather than the everyday vari-
research on voluntary organizations on the other. ety. (These studies have come about partly in
The two areas of study are related, but they response to the rational-choice critique men-
have generally progressed without much regard tioned earlier: the researchers are interested in
for each other. Bringing them together allows us finding cases of altruism that cannot reasonably
to think about variation in altruism in a new way. be construed as selfishly motivated.)
Consider the two-dimensional space shown in Social organization is minimal in both of
Figure 1, defined on one axis by the degree to these forms of altruism, extending at most to the
which practices are routine for individuals, and conventional or routine activities of individuals.
on the other by the degree to which they are But most of the altruism we observe in modern
institutionalized by formal organizations. The societies is more likely than not to have a strong-
first dimension represents the frequency of ly institutionalized aspect, with staffed organi-
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PRINCETON UNIVERSITY (cid 195003)
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Figure 1. Kinds of Altruistic Practice, by Individual Frequency and Degree of Social Organization.
zations working to produce contexts in which it 2002). Although studies at the organizational
can happen. level have tended to focus on questions of sur-
Research on voluntary organizations exam- vival and competition (usually for grant money),
ines part of this social-organizational dimension. some have examined how routine altruistic prac-
In the United States, many nonprofits operate tices are managed by organizations. This is the
in environments subject to considerable uncer- third case shown in Figure 1, where both the
tainty over sources of funding, whether gov- degree of social organization and the frequen-
ernmental or private (DiMaggio and Anheier cy of individual practice are relatively high.
1990; Grønbjerg 1993). Much recent research Studies of rates of charitable giving find that
has analyzed the structuration of organization- having effective “communities of participation”
al populations in light of these constraints. is the best way to channel social norms, prior
Organizations have reacted strategically in var- dispositions, or available resources into actual
ious ways to these circumstances (Clarke and donations (Schervish and Havens 1997).
Estes 1992; Oliver 1991); they may, for exam- Similarly, ethnographic evidence shows that
ple, co-opt competitors (Galaskiewicz and charitable acts and volunteering are common
Bielefeld 1998), diversify into less competitive when they are embedded in the social structure
areas (Alexander 1998) and attempt to differ- of a community (Eckstein 2001), but at the
entiate themselves from competitors (Barman same time effective organizations efficiently
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OORRGGAANN PPRROOCCUURREEMMEENNTT——––339911
recruit and carefully manage donors (Ostrander tify the particular features of the social context
1995). Frumkin (2002) notes that “[w]hile vol- or organizational environment that might
unteers remain an important engine driving explain variation in such altruistic acts.
nonprofits, most nonprofits use professionals Learning more about one-shot, socially man-
to manage volunteers, rather than using vol- aged exchanges is important. Recent studies of
unteers to manage their organizations” (p. altruistic practices such as blood donation
102). (Healy 2000), together with those on cognate
Theory and research from the social-psy- activities such as voluntary association
chological and organizational literature, then, (Salamon and Anheier 1994) and civic partic-
has focused on these three kinds of altruistic ipation (Skocpol, Ganz, and Munson 2000),
practice: one-shot opportunities with no orga- develop the general view that “involvement in
nizational context; conventional or routine volunteer activities does not simply spring
actions, also with little in the way of formal from already constituted social groups or from
social organization; and repeated giving man- aggregated individual characteristics” but is
aged by organizations. The fourth variety sug- structured by institutions (Schofer and
gested by our typology—one-shot Fourcade-Gourinchas 2001, 807). This argu-
opportunities for altruism in socially organized ment is counter to the view that such prac-
contexts—has received comparatively little tices are to be explained by individual-level
attention. This is not to say that the logistical characteristics or value orientations (Almond
Delivered bya sIpnegcetsn otaf atoltruism have gone wholly unno- and Verba 1963; Inglehart 1997; Knoke 1986).
Princeton Utniciveed:r sreitsye aLrcibhr daoreys (fcinidd t7h5a0t s0o0c1ia4l-6o)rganiza- One-shot exchanges would seem to be the most
Princeton Utnioivnealr scoitnyt e(xcti dd i3re5c0tly0 5af1fe3c3ts) the likelihood of likely case where this argument would not
Princeton Uanlitvrueirssmit. yIn L pibarrtaicruielasr, (tcheid i m1p7o6r2ta)nce of direct apply—where either the distinctive character-
PRINCETONre qUueNstIsV tEo RpoSteITntYia l( cdiodn o1r9s 5o0r 0he3l)pers is well istics of individual altruists or the motivating
IP: 128.112.e6s9ta.b2li2shed. Oliner and Oliner (1988) found force of generalized norms would be most
2004..07..26th..a1t 1re.s.5cu8e.r.s of Jews were more likely to have important. But this need be true only if one-
been directly asked for help than nonrescuers. shot exchanges must by definition lack an
Drake, Finkelstein, and Sapolsky (1982) found institutional context. This is a plausible
that people were more likely to give blood if assumption, as the degree of repeated or rou-
they were asked directly (see also Piliavin and tine action is usually thought of as the mech-
Callero 1991). The same is true for donations anism of institutionalization rather than as
of money to charity (Clotfelter 1993; potentially orthogonal to it. By separating the
Hodgkinson and Weitzman 1992; Jencks 1992; frequency of altruistic practice at the individ-
Schervish and Havens 1997). ual level from the degree to which contexts for
Despite the recognition that direct requests giving are socially organized, however, we gain
increase the likelihood of altruism, however, leverage on the question of why rates of dif-
the relationship between organizationally pro- ferent kinds of altruism vary. Empirically
duced contexts for giving and variation in rates establishing the organizational basis of one-
of individual altruism remains underexplored, shot altruistic exchanges thus serves two pur-
particularly in the case of one-shot events. The poses. First, it extends theory on the
link between the logistical effort of organiza- organizational and institutional sources of vol-
tions and the action of individuals is general- unteering and participation to a challenging
ly missing in studies of bystander intervention case. Second, it connects the problem of
(where there is no organization) as well as in explaining individual altruism, which has been
the literature on voluntary organizations (where dominated by social-psychological explana-
the focus is on establishing patterns of giving, tions, to wider debates in economic and polit-
or more often on field-level processes of orga- ical sociology about the institutional sources
nizational competition). Thus we find an of individual actions and identities.
empirical and a theoretical gap in the literature.
Empirically, we know little about altruistic
LLOOGGIISSTTIICCAALLAASSPPEECCTTSSOOFFAALLTTRRUUIISSMM
practices that are one-shot experiences for
individuals and are also socially managed by From a social-organizational perspective, one-
organizations. Theoretically, we should iden- shot altruistic acts are distinguished by the logis-
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tical problems that organizations must solve in stock example in social theory. A social-orga-
order to create a viable context in which giv- nizational treatment of organ donation extends
ing can happen. Variation in these efforts ought our general understanding of the sources of
to generate variation in rates of altruism, inde- variation in altruism and contributes to our
pendent of the characteristics of the individual knowledge of an increasingly common med-
donors. Just as a sale made by someone in a ical therapy.
market is necessarily also a purchase made by
someone else, donation is also necessarily pro-
TTHHEE CCAASSEE OOFF OORRGGAANN PPRROOCCUURREEMMEENNTT
curement. Organizations attempt to routinize
and maximize the production of procurement Most organs transplanted in the United States
opportunities. Even though these may be one- come from cadavericdonors.2A report from the
shot experiences from the individual point of General Accounting Office (1993) describes
view, they can be well institutionalized from the process:
the procuring organization’s perspective.
Organ donation is dependent on voluntarism and
Although the literature on charitable giving generosity as well as solicitation and decision-
suggests that asking directly makes it more making at a time when family members are under
likely that individuals will donate, it offers lit- the stress of bereavement. Typically this process
tle guidance as to what organizational features begins at a hospital when a patient is identified as
will matter in this regard. I suggest three kinds a potential organ donor. .|.|. Once a potential organ
of logistical effectiveness: resources, scope, donor has been identified, the patient’s family is
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contacted by a staff member of either the hospital
and persistence. Resources should be posi-
Princeton University Library (cid 75000146)
or the OPO [organ procurement organization] and
Princetonti vUelnyi vasesrosciitayt e(dc iwdi t3h5 h0ig0h5e1r 3ra3t)es of procure- the family is given the opportunity to donate the
Princetonm Uennti vbeercsaituys Le iblarargrieers, b(ceitdt e1r7-f6u2n)ded, or deceased’s organs. If the family consents to dona-
PRINCETbeOttNer -UstaNffIeVdE oRrgSaInTizYat i(ocnids w1i9ll5 f0in0d3 )it easier tion, OPO staff coordinate the remainder of the
IP: 128.1t1o 2g.e6n9er.a2t2e opportunities to give. Scopecan be procurement activities, including recovering and
2004..07t.h.2o6ug..h1t 1o.f. 5as8 t.h.e reach, or spread, of a procur- preserving the organs and arranging for their trans-
ing organization across the range of potential port. (pp. 17–18)
sites where donors present themselves.
Note that it is the next of kin who makes the
Organizations with broader scope will be pres-
decision whether to donate the person’s organs.
ent in more places where potential donors are
Cadaveric organ donors have usually died sud-
likely to be found. Resources and scope are
denly, either from a serious nonaccidental
related but distinct metrics, as an organiza-
injury (such as a brain hemorrhage or stroke)
tion may be large or well funded but narrow in
or from injuries sustained in a violent accident
focus, or vice versa. Finally, persistencemeas-
(such as a motor vehicle accident or gunshot
ures the degree to which an organization will
wound). Whether the deceased carried an organ
pursue a potential donor once the opportunity
donor card may affect the family’s decision to
is discovered. More persistent organizations
donate. But in general OPO staff defer to the
should be more successful at procuring donors.
choice of the next of kin, who decides whether
I test these hypotheses using the case of
to give.3
cadaveric organ procurement in the United
Donating the organs of a recently deceased
States. This case is useful and important for a
relative is a difficult choice. The decision is not
number of reasons. The decision to donate is
a one-shot exchange from the individual’s point
of view. The organizations that manage the
process are not in direct competition with one 2Kidneys are the main exception. An increasing
another for funds or donors, so complicating number is obtained from living, related donors. Note
that I do not address the question of commercial
field-level forces are not directly relevant. The
trafficking in organs here. On this topic see, for
logistical forces at work are thus clearer than
example, Scheper-Hughes and Waquant (2002),
in cases where giving is bound up with well-
Scheper-Hughes (2000), and Cohen (1999).
established social relations. In addition, organ
3The extent to which OPOs actively draw atten-
donation is a canonical example of individual tion to the wishes of the deceased is an empirical
altruism: the idealized individual organ donor question, discussed below with respect to variation
is a strong trope in public discourse and a in OPO procurement policies.
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straightforward. Donor families do not know TTHHEESSOOCCIIAALLOORRGGAANNIIZZAATTIIOONNOOFFOORRGGAANN
who will benefit from their choice; the vast PPRROOCCUURREEMMEENNTT
majority never learn more than the gender,
Some background on the procurement system
age, and approximate geographical location
is necessary. Through the 1960s and 1970s, it
of the recipient. In addition, those deciding to
was taken for granted that human organs
donate receive no reward. In short, the decision
belonged to the surgeons who had removed
to donate satisfies our definition of altruism in
them from donors, and these surgeons decided
that it is an intentional, voluntary, unreward-
who received organs for transplant on the basis
ed action that seeks to increase the welfare of
of whatever ethical and clinical criteria they
others (strangers, in this case).
saw fit to apply (Prottas 1994). The federal gov-
Most research on organ donation, like the lit-
ernment overhauled the system in 1984 when it
erature on altruism generally, has focused on
passed the National Organ Transplant Act.
questions of individual motivation and cost.
Under this law, human organs must be given as
The focus has been on discovering the sources
gifts in the United States. Organs are considered
of opposition to donation and ways of over- to be a public good belonging to the state; they
coming such opposition. Refusals have been cannot be sold. The United Network for Organ
found to be due to bad information or myths Sharing (UNOS) oversees the activities of
about the donation process (Gallup OPOs, who help make up its membership.
Organization 1993). Irrational beliefs and fears Besides the OPOs, the other two main compo-
Delivered byth Iant gmeanntya pteoople have about organ donation nents of the transplant system (and also mem-
Princeton Umniavye brsei trye sLpiobnrsaibryle (fcoird k7e5ep0i0ng0 1th4e6 p)rocure- bers of UNOS) are about 60 independent
Princeton Umnievnet rrsaittey d (ocwidn (3P5ro0t0ta5s 1139934)). Thus, for those histocompatibility laboratories and about 270
Princeton Uwniovrekirnsgit yw Litihb ara croiensce (pct idof 1 a7lt6ru2i)sm as moti- hospital transplant centers. The labs carry out
PRINCETON UNIVERSITY (cid 195003)
vated action, the issue is treated as an indi- the tests that allow compatible organs and
IP: 128.112.69.22
vidual-level problem whose solution lies in patients to be matched up; the transplant cen-
2004..07..26..11..58..
understanding (and perhaps adjusting) the ters, of course, are where the surgery actually
motives of potential donors. A further parallel takes place.
with research on motivated altruism in gener- Today, a national network of organizations
al is the discovery (and rediscovery) of the locates as many potential donors as possible,
importance of situational factors to donation. secures voluntary consent from the next of kin,
Simmons, Marine, and Simmons (1977) found and distributes the procured organs to patients
that kidney donors were more likely to have on waiting lists in eleven regions across the
been asked in person to give than nondonors. country. In 1997, there were sixty-one OPOs
Zimmerman et al. (2000) found that female rel- operating in the United States. Each one is able
to procure, store, and deliver organs to transplant
atives were more likely to donate a kidney
centers, where patients register on waiting lists.
than male relatives, possibly because women
Each one is responsible for procurement with-
were more likely than men to be asked to
in a particular area. OPO borders are drawn at
donate. In the case of cadaveric donors, the
the county level and may cross state lines. In
importance of the request process and the need
addition, a few OPOs administer noncontiguous
to take care in asking relatives to donate their
areas. Figure 2shows the OPO boundaries in the
next of kin’s organs have been recognized for
United States.
some time (Verble and Worth 2000; Ehrle,
Shafer, and Nelson 1999; Gortmaker 1998).
There are few studies, however, of the logisti- OOPPOO RREESSOOUURRCCEESS,, SSCCOOPPEE,, AANNDDPPEERRSSIISSTTEENNCCEE
cal role of OPOs in the process of organ pro-
How might variation in the donor procurement
curement, outside of research on the moment rate of OPOs be explained? Successful pro-
when consent is requested.4 curement depends in part on logistical effort—
that is, the process of locating potential donors,
creating opportunities to give, and securing
4But see Klassen et al. 1999, Siminoff and Nelson consent. I have argued that three organization-
1999, and Wendler and Dickert 2001 for important al features help determine the success of these
exceptions. efforts: resources, scope, and persistence. The
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339944——––AAMMEERRIICCAANN SSOOCCIIOOLLOOGGIICCAALL RREEVVIIEEWW
39 10
63 37
33
43
20 25
11
52
Delivered by Ingenta to
Princeton University Library (cid 75000146)
Princeton University (cid 35005133)
15
Princeton University Libraries (cid 1762)
12
PRINCETON UNIVERSITY (cid 195003) 16
IP: 128.112.69.22
13
2004..07..26..11..58..
Figure 2. OPO Boundaries in 1997.
Note:Shaded areas mark the catchment areas of different organ procurement organizations (OPOs), which are
identified by number.
first of these features for OPOs is suggested by that hospitals play a key role in the procurement
their administrative spending per annum. When process. In some cases, the OPO has a staff
measured relative to the number of potential member working at the hospital. More often, a
donors, OPO spending indexes the resources member of the hospital staff is responsible for
that the organization brings to the procurement contacting the OPO to let the organization know
process. Donor procurement is a resource-inten- that a potential donor has become available.
sive procedure requiring substantial coordina- OPOs may make referral agreements with hos-
tion. The OPO (or its agents) must identify pitals. The more hospitals an OPO has referral
potential donors, determine that brain death has agreements with, the greater its scope and the
occurred, contact and obtain consent from the more donors it is likely to procure.
next of kin, and then recover and preserve OPOs also vary in their procurement policies
obtainable organs. Time is of the essence in this and consent practices. Donor families either
process. Resource-rich OPOs, on average, give or refuse consent for donation (Klassen
would be expected to be more successful in and Klassen 1996), and it may be assumed that
donor procurement than those with fewer successful organ procurement is related to strate-
resources. gies adopted by OPOs. Families rarely suggest
OPOs are not the only players in the pro- donation on their own; Powner and Darby
curement process. Almost all deaths that lead to (1999) found that “educational interventions
procurement occur in hospitals. The scope of the for health care professionals and a coordinated
organization across hospitals is therefore of requesting process that includes the organ pro-
some importance; Klassen et al. (1999) found curement organization and hospital personnel
#1471-ASR 69:2 filename:69304-healy
OORRGGAANN PPRROOCCUURREEMMEENNTT——––339955
result in a higher number of donations” (p. that the transplant system is unfair to minorities
1225). Requesting procedures may include the (Kasiske et al. 1991), a more general distrust of
presence of racial or ethnic minority staff to the medical system (Randall 1996), or ineffec-
discuss procurement with minority families, tive methods of request on the part of OPOs
the presence of training programs, and the (Gortmaker 1996). Recent studies have dis-
involvement of medical social workers and cler- covered evidence that African-Americans face
gy in the procurement process (Siminoff et al. institutionalized barriers to organ transplanta-
1995). The consent process is a delicate one, and tion. African-American patients are much less
OPOs differ in their policies about asking fam- likely than whites to express an interest in, be
ilies or next of kin to donate. If some OPOs are listed for, or receive a transplant (Alexander
more willing than others to, for instance, men- and Seghal 1998; Kasiske et al. 1991). This
tion the wishes of the deceased, this may affect suggests that lower rates of donation and trans-
the outcome. Wendler and Dickert (2001) found plantation among African-Americans are not
substantial variation in consent policies. Consent simply a matter of irrational individual belief,
policy may be taken as a measure of organiza- but may reflect a more structural exclusion from
tional persistence. The expectation is that the the medical system. The expectation is that the
stronger the stated willingness to procure under higher the black population within an OPO’s
adverse circumstances, the higher the procure- service area, the lower the procurement rate.
ment rate.
Delivered by Ingenta to POVERTY. The logistical demands of donor
Princeton UDDniEEvMMeOOrGGsRRitAAyPP HHLiYYbOOraFFrPPyRR (OOcCCiUUdRR 7EEMM5EE0NN0TT0146) procurement begin at the point when a person
Princeton University (cid 35005133) becomes a potential donor. Once the initial
Princeton USnuivcecersssiftuyl pLriobcruarreimesen (t cisid n o1t 7si6m2p)ly a function event happens—a car accident or a shooting, for
PRINCETONof UorNgaInViEzaRtioSnIaTl Yfa (cctoidrs ,1 o9f5 c0o0u3rs)e. Because example—the victim must be found, quickly
IP: 128.112.t6he9y. 2a2dminister geographical areas with wide- brought to a hospital, and placed on a ventila-
2004..07..26ly.. 1v1ar.y.5in8g. .populations, OPOs’ procurement tor. The longer the gap between initial injury and
rates are affected by features of their catchment
subsequent hospitalization, the less likely it is
area. Some populations are more likely than
that procurement will be successful. OPOs that
others to yield potential donors regardless of the
serve wealthier counties are more likely to have
social organization of the procurement system.
the necessary resources and facilities available
It is important to control for these background to them (and the hospitals they work with) to
forces. The research literature on organ dona- successfully manage this task. OPOs serving
tion and donor motivation points toward a num- poorer counties will tend to procure fewer of the
ber of important demographic variables. potential donors that become available to them.
Specifically, population density, racial compo-
sition, the poverty rate, and the degree of edu-
cational attainment within an OPO’s catchment EDUCATION. Survey data show a higher level
of support for organ donation among more edu-
area should all affect the number of potential
cated people (Gallup Organization 1993;
donors.
Southeastern Institute of Research 1994),
though there is no direct evidence that this trans-
POPULATIONDENSITY. Some OPOs adminis- lates into consent to procure when the occa-
ter relatively small, densely populated regions. sion arises. There could be a sizable gap between
Others service much larger, more sparsely pop- abstract support for organ donation and the
ulated areas. Because concentrated populations actual decision as next of kin to allow procure-
are easier to manage and are more likely to pro- ment to go ahead. But we should still expect that
vide opportunities for donation the procure- OPOs serving more educated populations to do
ment rate should rise with population density. better on average than others.
RACE. Support for organ donation is known UNMEASURED FACTORS. A number of other
to vary by race; African-Americans are less features of OPO catchment areas might have an
likely to donate than whites (Ehrle et al. 1999). effect on the procurement rate; their effect is not
It is unclear whether this is due mainly to beliefs estimated in my analysis.
#1600-ASR 69:3 filename:69304-healy
339966——––AAMMEERRIICCAANN SSOOCCIIOOLLOOGGIICCAALL RREEVVIIEEWW
First, the age distribution of the population death. These developments are generally agreed
might be a factor. In the early days of organ not to have increased donation rates (Norris
transplantation, surgeons were reluctant to use 1990), and a number of studies have shown that
the organs of older potential donors. An OPO about a quarter of the time, eligible families
with a disproportionately older population might are not offered the option to donate (Gortmaker
therefore be expected to procure fewer donors. 1996). Several states have passed “routine noti-
As surgical techniques improved and the organ fication” laws, which require that all deaths,
shortage worsened, however, transplant teams actual or imminent, be referred to the local
have drawn on as much of the available pool as OPO. There is evidence that this has increased
possible. In 1997, 19.7 percent of cadaver procurement rates in some areas (Nathan 1999;
donors were aged 17 years or less; 52.3 percent Shafer et al. 1998). Because their diffusion was
were aged 18–49; and 28 percent were aged 50 so rapid, the effects of these laws are not
or older. In exploratory analyses, the proportion assessed here.
of the population aged between 5 and 60 was not Few studies have analyzed variation in OPO
associated with the procurement rate (r= –0.14). procurement rates. None is entirely satisfacto-
Second, religious participation and affilia- ry. Prottas (1989) noted the importance of the
tion might also affect one’s likelihood of sup- organization of procurement and suggested a
porting donation. Existing research on religion number of different measures of OPO effec-
has focused on the theological or traditional tiveness. Evans, Orians, and Ascher (1992) tried
Deliveredo bbjeyc tIinognse snotmae t roeligions have or have had with to estimate the number of potential donors but
Princetono rUganni dvoenrastiitoyn L(Tibwrearsrkyy ,( Gciodl d7, a5n0d0 J0ac1o4b6 1)991; did not analyze procurement data. Siminoff and
PrincetonK eUllnyi vaenrds iWtyi e(csti d1 939510)0. 5T1he3r3e) has been no Nelson (1999) studied the efficiency of OPOs
Princetonre Usenaricvhe orsni twyh Letihberra trhiee gse (ocgirda p1h7y6 o2f )religious but confined themselves to a particular UNOS
PRINCETafOfilNia tUioNn IdVrEivResS vIaTrYia t(iocnid i n1 9d5on0a0ti3o)n rates. region. A study by Ozcan, Begun, and
IP: 128.1T1h2e. l6it9er.a2t2ure on religious attitudes toward organ McKinney (1999) focused on organizational
2004..07d..o2n6a.ti.o1n1 m..5ig8h.t. suggest that areas with Jewish, measures of efficiency but did not control for
Conservative Catholic, and some Protestant any structural variables. The analysis presented
denominations will have lower donation rates. here brings together measures of structural and
I used county-level data on religious affiliation organizational forces affecting organ procure-
and activity to examine whether there was a ment and tests their importance using a good
link between religion and procurement. The measure of the procurement rate across the
religion data were obtained from the American whole population of procurement organizations.
Religion Data Archive (Bradley et al. 1992).
Exploratory analyses did not show any strong
DDAATTAA AANNDD MMEETTHHOODDSS
effects. This is consistent with available opin-
ion data. A 1993 survey (Gallup Organization To make a sensible comparison between OPOs
1993, section 6) found that “[r]eligious barriers we must first estimate a standardized procure-
to organ donation do not appear to be wide- ment rate. To do so for any OPO in a given
spread.” Such religious objections as there were year, we need to know the number of donors it
came mainly from Black and Hispanic respon- actually procured and the number of cadavers
dents, who were “much more likely to report that that it could have procured—that is, the true
organ donation is against their religion (14 per- number of potential donors. The former figure
cent and 13 percent agree, respectively) than are is known with certainty, as UNOS tracks all
white respondents (4 percent agree).” the organ donors in the country. The latter fig-
Third, states have implemented several kinds ure must be estimated.
of laws that may affect organ procurement rates. Following a study by the General Accounting
Soon after the passing of the National Organ Office (1997), I have assumed that the best esti-
Transplantation Act, states began to provide the mate of the potential donor pool is the in-hos-
organ donor cards on the back of drivers’licens- pital death rate adjusted for circumstance or
es. In the late 1980s, “required request” laws cause of death. Because organs suitable for
were introduced in most states. This legislation transplantation must in general be undamaged
requires hospitals to consult with the potential and undiseased and quickly obtained after death,
donor’s next of kin should the patient be near many causes or circumstances of death rule out