As transplant policy evolves and access remains uneven, the future of kidney care may depend not only on scientific advances but on the choices individual people make.
Lloyd Ratner, MD, Director of Renal and Pancreatic Transplantation at Columbia University Irving Medical Center/NewYork-Presbyterian, reflects on why donors come forward, how certain people go on to donate to strangers, and how individual decisions could redefine access to transplant in America.
The Science of Giving: Studying How Donors Decide
You are actively studying what motivates someone to become a living donor?
Yes. I work with a colleague in the business school, Eric Johnson, who studies choice. Marketing, psychology, behavioral economics—how people make decisions. Things like opting in versus opting out, how choices are presented, how information is framed. That’s what we’re looking at.
So this isn’t about persuading people to donate, it’s studying how people make the decision?
Right. We’re trying to understand the decision, not manipulate it. We’re not trying to convince someone to donate. We’re trying to understand what motivates non-directed donation and how to present the choice, so more people say yes if it’s right for them.
How is that research being conducted?
We’re trying to figure out how to set up an experiment. How to structure the choice. What the best pitch for these potential donors will be. Not to sell them on it, but to see how they respond when you present the choice in different ways. Nobody’s done this before. We have a really unique situation that allows us to study it.
Living Donation Today
How has the landscape of living kidney donation changed in recent years?
Well, for example, we had close to 2,000 people fill out a donor questionnaire after the recent sudden death of a celebrity from kidney failure. Five of those people have already come forward to donate to someone else. We call these “residual donors,” people who come forward for someone specific, but who can still donate to anyone.
What makes someone who steps forward for a specific person continue to donate to someone else?
That’s the whole point. They came forward because they were motivated by something personal. Even if they never meet the person they were trying to donate to, that original motivation doesn’t disappear. It’s still meaningful for them.
How many residual donors may be out there, realistically?
We looked at 479 living donor transplants. Out of those, 301 had residual donors.
Then from that 301, we removed all the people whose kidney failed or didn’t have great kidney function, because they’ll probably need another transplant, and we don’t want to take any of their donors away. From there, we narrowed it to 232.
And out of those 232 transplants, there were 1,441 individuals who had come forward wanting to be donors.
How many of those came in for type testing? 700.
And among those, how many were type O? 350.
Wow. And type O matters because they can donate to anyone?
Right. They’re universal donors. So, if you take even a fraction of those people and give them the opportunity to donate to someone else, that’s what changes the game. That’s where scalability is.
Do most donors make the decision quickly?
No. Most donors have thought about it for more than six months. It’s not impulsive.
What motivates someone to donate to a stranger?
Two things: hearing someone’s story and knowing someone who donated. Those are the biggest motivators. People don’t always donate because someone asked. They donate because they heard a story and they met someone who did it. That’s what gets them thinking about it.
How important is personal connection in that decision?
That’s what drives it. You see something that resonates with you. You hear someone’s story. And maybe you know someone who donated, or you saw someone who needed it. That’s enough to get someone thinking about it.
Not Courage, Just Doing It Anyway
Donors are often described as brave. Do you see it that way?
It’s not courage. Sometimes they just do it anyway. They aren’t doing it because they’re fearless. They may be afraid. But they still do it anyway.
What seems to move someone forward if they’re afraid?
They see meaning in it. That’s the difference. Not courage. Meaning. If you give people the opportunity to do something meaningful, some of them will do it even if they’re scared. For many, donating is the most meaningful thing they’ll ever do. It gives them the chance to do something great.
Absolutely. At the end of the day, we humans do want to help each other.
Why not give everyone an opportunity to be able to do something great and to be great? Greatness isn’t great people doing stuff. It’s ordinary people doing something great.
Right, greatness isn’t a character trait people already have.
Exactly. It’s a choice. It’s someone doing something meaningful, not because they were “great” already, but because the act itself is what makes them great.
Can ordinary donor decisions genuinely address the donor shortage?
In the last 25 years, the number of non-directed donors has increased like 90-fold. If it increased another 90-fold, we’d basically meet the current demand of all the patients currently on the list. It’s genuinely possible.
If you give people the chance to do something great, a lot of them will do it. You just have to give them the opportunity.