The concepts of policy bubbles has received considerable attention in recent years, but more empirical applications are needed (Jones et al. 2014; Maor 2012, 2013, 2014a,b,c). This paper applies the concept of policy underreaction (Maor 2013) to organ donation policy – a typical morality issue - to link specific policy tools (Maor 2012) with emotional aspects (Maor 2014a). The paper underscores the importance of values and emotions for policy underinvestment in morality policies (Maor 2014a), and adds the dimension of explicitness to the existing taxonomy of policy instruments.
The underlying policy problem is a burning one worldwide: how to meet the ever-increasing demand for deceased donor organs – that is, how to lower relatives’ refusal rates to organ donation? Based on observational and interview data and an extensive literature review, I compare the two contrasting cases of Switzerland and Spain (Manatschal and Thomann 2011). In German-speaking Switzerland, organ donation policies are characterized by “too little policy” (Jones et al. 2014: 147), i.e. a systematic underinvestment in personnel, resources and adequate tools (“family approach”) to lower relatives’ refusal rates – despite a vast amount of scientific evidence on “what works” (Matesanz and Dominguez-Gil 2007; Simpkin et al. 2009). In light of fast-growing waiting list in transplantation centers, the Swiss Transplantation Act was revised in 2007 to introduce the organizational elements of the “Spanish model”. However, underinvestment continued, as expressed in continuously low donation rates. This could be seen as a case of directed underreaction (Maor 2013). In fact, policy makers at the national level were well aware of the need to address the problem. Yet in the light of the fundamental clash of values within the constituency, the government chose a procedural design which did not redistribute values (Engeli and Varone 2011). At the organizational level strong resistance by hospital staff (the “policy makers” at the frontline, Lipksy 1980/2010) prevented policy change. None of the conventional explanations for this resistance work (Maor 2014: 1). What does explain resistance, however, is that the issue is deeply value-laden. Policy instruments at the national, regional and hospital level avoid an explicit position regarding the morally contested issue. The intense emotions of hospital staff toward organ donation, fed by negative media presence and traumatic situations in operating rooms, demonstrably influence how they perform the family approach (Morgan and Miller 2001). Results reveal a strong link between the policy instruments’ explicitness, the value distribution in the population, and the policy outcome.