To Nudge or Not to Nudge: Ethics of Nudge Theory in Organ Donation in Ghana

Abstract

Introduction Globally, there is a rising prevalence of end-organ failures. This has resulted in the need for organ replacement therapies, including organ transplants. In Ghana, there is no established organ transplant system, and there are no working organ donor recruitment strategies in place. There is a wide gap between viable organ demand and supply. Different organ donor recruitment strategies exist in different parts of the world. Voluntary organ donation has not been able to narrow the demand and supply gap. The organ market, on the other hand, is characterized by exploitation of the poor, and questionable consent processes. Nudge theory based approach has been found to increase organ donation; however, it has also been criticized for being manipulative and coercive. There is paucity of data on nudge theory and organ donor recruitment in Ghana. This work seeks to explore whether Nudge theory (libertarian paternalism) sits well with African moral thought, and whether there is space for nudging in organ donor recruitment in Ghana. Methodology Adopting a comparative analysis approach, I aimed to explore and evaluate ongoing debate surrounding ethical basis of organ donor recruitment strategies in Europe, America, and Middle East. In addition to other literature, Nudge: The Final Edition, a book by Richard H. Thaler and Cass R. Sunstein, was purposefully selected as it was the current edition of the original work where Nudge theory was first proposed. Various organ donor recruitment strategies were evaluated using Caesar Atuire’s African Normative Framework, and Jennifer Ruger’s framework that combines Aristotle’s political theory, Amartya Sen’s Capability Approach, and Cass R. Sunstein’s Incompletely Theorized Agreements (ITA). Results Nudge theory (Libertarian paternalism) was developed from the concept of bounded rationality, and heuristics and bias. It is in sync with African moral thought, using African normative framework–ontological communitarianism, empathetic humanism, and virtuous character–and Ruger’s framework that combines Sen’s capability approach, and Sunstein’s incompletely theorizing agreements. African moral thought supports voluntary organ donation, but not organ markets. Voluntary organ donation and Nudge theory-based organ donation are ethically justifiable organ donor recruitment strategies in Ghana, and they are both supported by African moral thought. Soft presumed consent is a commonly used nudge in donor recruitment. Voluntary organ donation can be complemented by other nudge elements to enhance the outcome. Organ market is not an ethically justifiable organ donor recruitment strategy, and it is also not supported by African moral thought, especially considering how it commodifies personhood. Conclusion Nudge theory-based approach to organ donor recruitment sits well with African moral thought. Soft presumed consent is a recommended nudge for organ donor recruitment in Ghana. It also benefits from other nudges to enhance outcome. Voluntary organ donation is ethically justifiable in Ghanaian socio-cultural context, and it can be complemented by other nudge elements to enhance outcome. Nudge theory-based approach, and voluntary organ donation can coexist in Ghanaian sociocultural context.