Episode 518: Your Organs, Please : Planet Money How do you get someone to sign up as an organ donor? Today on the show: The story of one woman who found a way by partnering with one of the more hated American institutions.

Episode 518: Your Organs, Please

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Hey, everybody. It's David. We are replaying one of our favorite episodes today. This originally aired last year. This story is about - I'm not going to spoil it. Here it is.


CHANA JOFFE-WALT, BYLINE: Kelly was in the Swiss Alps when her heart started racing. When she made it to the hospital, the doctors told her she had a viral infection that was attacking her heart and would kill her. She was 30 years old. She waited four years, but eventually, Kelly got a heart transplant. And she recovered well. Within a month, Kelly climbed up Half Dome in Yosemite with her new heart. Then she summited Mount Fuji, Mount Kilimanjaro. She became the first person to do that with another person's heart beating inside of her. Now if I told you that story, which, by the way, is the completely true story of Kelly Perkins, if I had told you that story and then said, please sign up to be an organ donor...

KIM ZASA: Yeah, I think that sounds really cool (laughter). I've never summited a mountain. I don't know if you have. I mean, it sounds great, but...

JOFFE-WALT: This is Kim Zasa. It's her job to determine if stories like Kelly's will actually get you to become an organ donor. And she says the answer is no.

ZOE CHACE, BYLINE: Kim works for an organization called Gift of Life. It's a nonprofit that tries to increase the number of registered organ donors, tries to get people like you and me to say, when we die, we are willing to donate our organs. And initially, Kim's colleagues figured stories like Kelly's were their best tool. But they've tried stories about people like Kelly who got organs and have gone on to do amazing things, and they don't work. We don't sign up.

JOFFE-WALT: So they're trying other stories. Here is one Kim's colleague tried on a group of women recently. It's a true story about a woman named Cassandra, a single mother in Michigan. She's got two kids, a full-time job, and a condition called Fuchs dystrophy. Cassandra was going blind in both eyes until she got a cornea transplant.

UNIDENTIFIED WOMAN #1: And not only was she able to go on and support her family but one of the things she noticed after her cornea transplant was her son had freckles. She didn't know her son had freckles.

JOFFE-WALT: Kim says we like stories like this, stories about people who get organs or tissue donations and then go on to do not great things but normal things.

ZASA: You know, seeing your child's freckles or those everyday things that we can totally relate to.

JOFFE-WALT: Ads that feature fathers walking daughters down the aisle, that works, moms bringing in groceries from the car.

ZASA: Yeah, those kind of normal life occurrences that we all want to have.

CHACE: Most Americans support organ donation according to polls. But less than half are actually registered as organ donors. So, Kim and her colleagues tried to figure out what it is that will get people to sign up, to register.

JOFFE-WALT: And they've learned a lot about what works, mountain climbers, no.

CHACE: Freckles, yes.

JOFFE-WALT: A Midwestern mom talking about the gift of an organ, that's almost always effective.

CHACE: Although even that can get tricky, Kim tried another story out on the same audience who liked the freckles.

JOFFE-WALT: Yeah, this one was about another mother in Michigan, a woman who lost her son tragically. The son was an organ donor, and years later, the mom needed surgery herself on her neck.

ZASA: And she was able to actually receive some of her own son's bone tissue in her neck, which is just so cool. And his name was Tim, and now she calls it her Tim bit (laughter), which is so cool, yeah, absolutely.

JOFFE-WALT: There are some polite chuckles, but a couple women scrunch up their faces at this story. A few become extremely interested in their hands.

CHACE: It's a tricky thing trying to locate a person's empathy and then to hope that feelings will change a person's behavior. Changing behavior's really hard. Things you think would work don't, and then small things can get big unexpected results. Hello, and welcome to PLANET MONEY. I'm Zoe Chace.

JOFFE-WALT: And I'm Chana Joffe-Walt. And the problem that Kim has been trying to solve, how do you convince people to donate their organs, this is a problem that governments all over the world have struggled with, that transplant surgeons wonder about and public health people have worked on for years. On today's show, we have the story of one woman who believes she is close to an answer.

CHACE: And it is not a feel-good answer. It is not an inspirational tale. It involves partnering with one of the most hated, the most reviled institutions in American life.


JON LEMMON: (Singing) Mystery wonder and ecstasy...

UNIDENTIFIED WOMAN #2: PLANET MONEY and the following message are made possible by Squarespace, helping savvy entrepreneurs set their ideas apart online. Squarespace gives you 24/7 customer support and all the tools you need to easily transform one of their award-winning templates into a beautiful website or e-commerce store. Visit squarespace.com/planetmoney for a free trial and 10 percent off. Squarespace, build it beautiful.

JOFFE-WALT: When Kim Zasa became the volunteer coordinator for Gift of Life in Michigan, about 11 percent of the population was on the organ donor registry. Her job was to increase that number, increase the supply of organs.

CHACE: There are currently 120,000 people waiting for organs in the United States. So basically, Kim's job was to solve a scarcity problem but without one of the main tools that you'd usually ease to do that, money. In the United States, it's illegal to pay people for their organs or to pay the family for their organs after death. You have to find other ways to get people to give up the organs for free.

JOFFE-WALT: But to Kim, this didn't seem like a problem. Kim's an energetic person. People like people is a thing she likes to say a lot and a thing that's easier for Kim to believe because people like her, even when she's not seven months pregnant as she is now, Kim can learn a stranger's place of birth, family configuration, and most anxious thought fairly soon after the first handshake. So, Kim was naturally optimistic about her ability to sell organ donation to the people of Michigan just by talking to them.

ZASA: We just went out and, like, signed up for every art fair, church event, yeah, every little podunk little thing that we could possibly think of just to try to get our information out there.

JOFFE-WALT: And Kim wouldn't travel alone. She'd bring volunteers like Marge Delgreco, a woman who has received not one but two donated livers.

MARGE DELGRECO: There I would, you know, drive there, set up my table, have little snicky snacks for the people to get them to come to the table. And six hours later, I could walk out of there and sign up two people. So, OK, is that really worth my time to do that?

JOFFE-WALT: Kim would hear from lots of volunteers like Marge who were driving out to things like the Romeo Peach Fest where they'd only manage to register a couple people.

ZASA: And that would be frustrating because they would go sit in maybe a hot art fair out in a street for six or eight hours, and these are recipients who were on medications, you know. They have to eat every two hours. Like, we knew we were doing a touchy-feely good thing. We were telling stories. We were, you know, trying to impact the public.

JOFFE-WALT: But she wasn't sure it was increasing the number of registered organ donors. And every month when her boss, Tim, would share the numbers with her, Kim would find out she was right. There would be a bump but not a big one. So they launched a Donate Life Day on the state capitol. They tried radio and TV ads, billboards with an endless cycle of new campaign slogans. And still, only 19, 20 percent of the population was registered as organ donors, very low numbers compared with other states. Michigan was consistently near the bottom of the list, a fact Kim was constantly reminded of at the National Donate Life conference every year. When all the other state organizations that managed donor registries would get together, Kim would always sit in the back of the room.

ZASA: We would see states like Colorado, Utah and others that had, you know, 60 percent of their population or more signed up on their donor registry. It was kind of embarrassing for us to sit in some of those meetings. Yeah, we'd be like, oh, look, we're in the bottom of the barrel again (laughter).

JOFFE-WALT: Kim was spending her time talking to as many people as she possibly could about organ donation, and she had 800 volunteers doing the same thing. But she noticed that the states that were the most successful, they had outsourced a lot of that work. They had enlisted the help of an enormous workforce, a workforce that was already coming into contact with people every day, all day, clerks at the DMV.

UNIDENTIFIED WOMAN #1: I think I see at least...

UNIDENTIFIED WOMAN #2: I'd say I'd see about 80 or 90 people a day.

JOFFE-WALT: 80 or 90?

UNIDENTIFIED WOMAN #2: I mean, she see more than I do (laughter) because she move faster than me.

JOFFE-WALT: How many do you see?


UNIDENTIFIED WOMAN #1: Probably about the same.

JOFFE-WALT: There was no way Kim was going to be able to talk to 80 or 90 people at the Romeo Peach Fest. In 2010, Kim and her colleagues convinced the state of Michigan to allow DMV clerks to ask every person they helped, would you like to be an organ donor. And pretty soon, Kim's boss, Tim, was coming to tell her about the numbers.

TIM: And it was almost like, well, that can't be right. I don't know how we could've had that many.

ZASA: And then he calls me in, and I'm like, you must have done it wrong (laughter). I'm like, do it again, boss.

JOFFE-WALT: 2010 was a record year for new registered organ donors in Michigan. Thanks to Kim's schlepping donor recipients all across the state, 320,000 people signed up. But in 2012, after the first full year where DMV clerks were asking people to become organ donors, there were 520,000 new organ donors. Kim and her 800 volunteers, they were emotionally invested, willing to offer whatever time and energy was necessary to get people to become donors. But the clerks at the DMV in a very short time were so much better. In the back of the office in the DMV break room in Ann Arbor, Mich., the clerks are talking about a new Geico ad. In it, a pig with a Geico insurance card is getting his picture taken by a surly, dismissive DMV clerk.


UNIDENTIFIED ACTOR #1: (As DMV Clerk) Turn to the camera.

UNIDENTIFIED ACTOR #2: (As Maxwell) Actually, I think my eyes might...


JOFFE-WALT: Audrea Agee and Janine Shepherd, DMV clerks themselves, do not like this depiction. And other clerks in and out of the break room have clearly been waiting for the chance to walk into a conversation about this ad. They tell me it's got the dynamic completely backwards. Clerks are not the ones who are rude or mean. DMV clerks, they tell me, are shy.

JANINE SHEPHERD: When I first got here, oh my goodness. I didn't think I could do this. But...


SHEPHERD: I have no - just, well, I was afraid and scared. At first, I was afraid to even call a number because you have to call a number really loud, you know. I just did not. And then when people come up and, you know, some people can be intimidating about the way they come up.

JOFFE-WALT: In her first few weeks, Janine would sit behind the counter and whisper, 22, 22. And no one would come. The lady in the ad who screams, next - Janine says you have to learn to yell like that because customers get angry with you if you don't. It takes practice. And similarly, asking a person if they'd like to donate their body parts when they die - the clerks say that took practice, too.

AUDREA AGEE: As Janine, said it was uncomfortable when the first - it did come out. Like, I don't really want to ask. But I know I should. And it just - I guess I got into a habit. But it is uncomfortable at first.

JOFFE-WALT: It took Janine years to learn to do this with ease.

SHEPHERD: Twenty-eight?

JOFFE-WALT: And it only took a couple months to get used to doing this.

SHEPHERD: Would you like to be on our organ donor registry today?

UNIDENTIFIED MAN #1: What's that for?

SHEPHERD: If something happens to you, your organs go to help someone else live.


SHEPHERD: I have you - let's see. And how will you be paying today? It's going to be cash, check that we take, Discover.

JOFFE-WALT: Most of the interactions go like this. People don't say, yes, I'd love to sign up to save someone else's life. And they also don't say, no, I'd like to get new plates for my car without imagining myself brain-dead in a hospital, thank you very much. Most people just say, ah, what? Yeah, sure. Can I pay with a credit card for this?

SHEPHERD: Would you like to be an organ donor?


UNIDENTIFIED WOMAN #2: OK, I need your ID. OK. Did you want to be an organ donor while you're here today?

UNIDENTIFIED MAN #2: Yeah, I thought I was.

JOFFE-WALT: There are some noes.

UNIDENTIFIED WOMAN #2: What we doing for you today?

UNIDENTIFIED MAN #3: I just need to renew my driver's license.

UNIDENTIFIED WOMAN #2: OK, so I'll need your license. Do we have a correct address and everything else on there for you? OK. And did you want to be an organ donor?

UNIDENTIFIED MAN #3: No, that's all right. I don't think anybody wants my organs.

UNIDENTIFIED WOMAN #2: Well that's not true.


UNIDENTIFIED WOMAN #2: No (laughter).

UNIDENTIFIED MAN #3: ...I'm a heavy smoker and drinker. Nobody wants my organs.


JOFFE-WALT: OK. Kim Zasa would want me to jump in here and tell you that smoking and drinking do not disqualify you from becoming an organ donor. But anyway, many, many people offer ambivalent or distracted yeses.

Can I ask you - were you an organ donor before?


JOFFE-WALT: How come you weren't one before?

UNIDENTIFIED WOMAN #3: I haven't - probably somebody didn't even ask me.

JOFFE-WALT: Michigan's organ registry was created in 1994. More than 3 million people are now on it. And it took 16 years to register 2 million of those people. The DMV clerks - they did the rest of the job in just the last couple years. Michigan isn't the only state that has clerks directly asking people to become organ donors. Although Michigan's jump in the registry numbers - that was really notable, notable enough that last year at the national Donate Life conference, Kim Zasa wasn't sitting in the back of the room at all the panels. She was asked for the first time to present.

ZASA: I was like, wow, people actually showed up (laughter). And then, you know, I had people call me afterwards and say, oh, how did you do that? And, you know, how did it work? And suddenly it felt like, oh, we're on the map (laughter). And we didn't feel like the laughingstock of the whole nation, yeah - because we kind of were, for a while. And, you know, it's been nice to be able to share our successes and say, oh, OK, Michigan is really - you know, has something to offer (laughter). It sounds awful (laughter). Yeah, it's honest.

CHACE: It almost sounds like what happened is that the clerks appealed to a completely different part of the brain. And that's what made it work. Like, instead of telling a compelling story about a mom or a mountain climber and using empathy to try to get people to sign up, the clerks at the DMV hit the annoyed, distracted part of us. Instead of getting people to think about whether they wanted to donate their organs, they got people to say yes because they weren't necessarily thinking about it at all. They weren't thinking about death. They weren't thinking about organs or helping people. They were thinking about getting the hell out of the DMV.

AL ROTH: I agree. That sounds good and is great.

CHACE: Al Roth is a Stanford economist. He studies organ markets. And he says there could be a problem with this approach.

ROTH: We don't want to simply increase the number of people who sign up on the registry. We want to increase the number of organs that become available for transplant. And those aren't quite the same thing.

CHACE: Organ donation is a two-step process. First, you get someone to sign up. Then, after the person dies, the family has to go along with it. And you want the family to be convinced that organ donation is something their loved one actually wanted. Someone will come to the family and say, OK, your mom is on the organ donor registry list. Do you want to donate her organs? And if the family's not sure that's what she actually wanted and you say, well, one time she said yes to a clerk at the DMV, that doesn't necessarily convince the family that that's what the mom wanted. Maybe their mom was just trying to be nice.

JOFFE-WALT: And Al Roth's concern is actually based on something that we've seen happen in other countries, especially countries that have something called an opt-out system. So this is a system where everyone is an organ donor unless they specifically say they don't want to be. So when the child is approached and told, your mom was a registered organ donor, would you like to donate her organs, the child is left wondering, did she want to donate her organs or did she just do nothing, and that's why she's on the list? And Al Roth says it is possible to make it too easy to be an organ donor. He prefers that instead of asking people directly, where you have social pressure or the question of whether or not there was social pressure, ask people on paper. Give them the question on paper, and if they say yes, the family will know that that person actively wanted to donate their organs.

CHACE: Either way, if you ask people on paper or in person, we wind up with an opt-in system, this large public health initiative that thousands of people hope will deliver them health and survival that's being run through our DMVs, which is kind of weird. It's being run by women - they are mostly women in Michigan - who spend their time asking, what's your address, eye color, weight, did you bring proof of insurance - and oh, when you die, can we take your heart?

JOFFE-WALT: Kim Zasa, who has spent years training volunteers, driving them to distant churches and fairs - now she spends almost all her time traveling between the state's 131 DMV branches with chocolates for the DMV clerks. These are her soldiers now. And she wants them to be pampered.

ZASA: OK so we've got candies, of course, 'cause nothing makes a girl feel better than chocolate (laughter).

JOFFE-WALT: Kim tells the clerks she couldn't do it without them. She's here for them. They're saving lives. She gives them green folders full of information about just how many lives. She brings a liver recipient to deliver a heartfelt thank-you to the clerks. She asks them what their greatest challenges are, how she can help. But it's not until the end of Kim's three-hour visit with the Ann Arbor clerks that I can tell they are totally bought in.

ZASA: I do want to share with you, too, in your folder - your branch is doing awesome, OK (laughter). But we just put together our annual data for 2013. And you, in 2013, signed up almost 42 percent of your transactions on the donor registry. So ooh, ooh, ooh (ph).

UNIDENTIFIED WOMAN #4: Yay, yay, yay (ph).

JOFFE-WALT: Audrea Agee opens up her folder for the first time since Kim arrived and started talking. She starts looking at the data. The Temperance DMV in Monroe County is ahead of them. Audrea grabs the elbow of another clerk and pretty soon no one is listening to Kim. They're all hunched over Audrea's folder.

UNIDENTIFIED WOMAN #5: I was showing her the rates here. And someone else beat us. It was Temperance.


UNIDENTIFIED WOMAN #6: Temperance, though, they don't have - we have a lot of foreign customers that won't do it.

UNIDENTIFIED WOMAN #5: OK. So that's the reason that our numbers are low.


UNIDENTIFIED WOMAN #5: The clientele is different, so that makes a difference.

JOFFE-WALT: The clerks found some of the personal stories Kim told moving. The organ recipient showing up in person to offer her heartfelt gratitude - that was nice to hear. And the chocolate was tasty. But in the end, what worked best on the clerks was competition.


LEMMON: (Singing) Mystery, wonder and ecstasy, wonder and ecstasy, wonder and ecstasy.

CHACE: As always, you can let us know what you think. Send us a note - planetmoney@npr.org. Or find us on Facebook or Twitter. I'm Zoe Chace.

JOFFE-WALT: And I'm Chana Joffe-Walt. Thanks for listening.


LEMMON: (Singing) Into the depths beyond the gravity, your heart is beating and your mind is free. You're moving faster than you were before.

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