DOI 10.55206/TUGE6545

Ivet Tileva

University of National and World Economy

E-mail: itileva@unwe.bg

Abstract: The article focuses on an analysis of effective communication approach in different groups of society considering a very important health issue that affects the economic system in Bulgaria – organ donation. The aim is to present economic effects for the state budget of the organ donation policy in Bulgaria and to propose solutions for improving the situation using appropriate public communication campaigns and rhetoric. The topics of research are related to the opportunities to obtain a kidney for the purposes of transplantation and how to articulate this socially sensitive theme. The hypothesis is that synchronized actions between institutions are necessary to implement a complex communication campaign in relation to this socially significant problem like organ donation. In order to reach different groups of society, adequate communication techniques and use of modern communication channels is required. The methodology includes desk research, presenting secondary statistical information from various administrative institutions and comparative analysis. The best performing European countries in terms of transplant policy are considered as an example for implementing good practices. Since public communication is a powerful means for influence, an alternative based on the framing effect is proposed as a rhetoric instrument for dealing with this economic and social problem.

 

Keywords: public communication, framing effect, donation policies, organ do­nation, kidney transplantation, economic aspects.

Introduction

One of the global problems facing humanity is the willingness to donate organs. The population is getting larger and more people are in need of an organ transplantation. However, some nations are more willing to donate than others. Scepticism is usually associated with national psychology, religious dogma, insufficient awareness, mistrust in institutions, superstition, fear of causing bad circumstances, etc.

This medical problem has its fiscal dimensions in national budgets of countries all over the world. In this regard in Bulgaria very few transplantations are performed in comparison with the number of people in need. Transplantation is not only the better option for patients, but also the much more beneficial alternative for the state budget. Despite having similar donation systems at first sight, individual countries in Europe achieve different annual results in terms of the realization of transplant surgeries.

Traditionally, it is believed that mainly different cultures and social PR campaigns are the main factor leading to the different level of willingness to donate organs. The factors are many, but it is worth analyzing the public and institutional communication as well as rhetoric as a tool that can change the results about this kind of donation. During the process of collecting answers of the survey, rhetoric can largely lead to change of nations’ attitudes, regardless of its culture, religion, etc. The technical way in which the surveys are carried out also affects the outcome of the campaign.

 

Research methodology

The methodology employed has 3 main stages. The first includes a comparative analysis of policies of the best performing countries in Europe regarding organ donation and transplantation. These policies are compared with the Bulgarian one. The second stage is an economic analysis of secondary information collected by administrative units in Bulgaria, such as: National Statistical Institute, Ministry of Health, National Health Insurance Fund and Executive Agency “Medical Supervision”. On this basis, economic conclusion are made. In the fourth stage of the study solutions for improving the situation with organ transplantations in Bulgaria mainly by using the tools of rhetoric are proposed.

The analysis covers the time period of 2015-2022 – 5 years before and 3 year after the outbreak of Covid-19.  An interdisciplinary approach is used due to the specificity of the study subject, which is characterized by complexity and social sensitivity. The methodology combines desk research, analysis of secondary statistical data and comparative analysis.

 

Literature review

For the purposes of the article, various sources of information are used such as: scientific articles, doctoral dissertations, official reports, public information upon request provided by administrative units in Bulgaria, information from official government websites and media sources. Among the most important scientific sources are Johnson and Goldstein’s article “Do Defaults Save Lives?” and its interpretation of Dan Ariely. Daniel Kahneman and Amos Tversky scientific works are also used as a rhetorical base, particularly their concept of the framing. Scientific sources of Bulgarian and foreign authors which affect the issues related to the transplant policy in Bulgaria and the European Union are also used.

 

State policies for organ donation in European countries

Each country in the EU sets its own policy regarding organ donation. There are two main options for determining citizens’ willingness to donate organs. This happens by filling out an official declaration. In some countries, the declaration states the citizen’s will to be a donor, and in others – the desire to refuse his organs to be taken after death. The process of declaring willingness or unwillingness is also different in the European countries and this largely determines the success rate of the implemented health policy.

Until 2011 Croatia was one of the leaders in the world regarding to organ transplantations. [1] Logically, more transplant surgical operations in Croatia ensure a decreasing trend of patients’ number on the waiting list. [2] Meanwhile, as of March 2023, the first place of transplantation per capita is already occupied by Spain. [3] The very successful methodology of Spain is related to the fact that in each intensive care unit there is a person who is responsible for organ donation and is in contact with the relatives. The role of such a specialist is to communicate potential donation of organs with families of the deceased. [4] In Bulgaria, doctors are relied on for this purpose – to properly communicate the possibility of donation.

The policy models of Croatia and Spain are similar. In each of them every citizen is automatically a donor, unless the potential donor declares a refusal through an official declaration. [6] In Croatia, the family could refuse to donate the organs of a deceased person. The will of the deceased is practically taken into account, but it is not written into the law. Also, in Croatia there is a donor card in which a person expresses their willingness to be a donor and usually the family complies with it. [6] It is not a coincidence that Spain and Croatia are among the world leaders in the context of organ transplantations. [7]

In 2015 Wales makes a decision to follow the example of Croatia and Spain by introducing a similar policy called “deemed consent”. As of this moment Wales is the only UK country to take this approach. The new introduced ‘opt-out’ system of Wales is so successful that the donor consent reaches 80.5%. For comparison the rest of UK is 66.2%. After 2020 and the Covid crisis in England it was also necessary to pass a law that every adult becomes a donor after death, unless they have expressly refused or fall into excluded groups. [8] [9]

According to an official report of the European Parliament, an ‘opt-out’ system has been implemented in Bulgaria. [10] In practice, however, this is not exactly the case. Bulgaria has one of the lowest donation rates in Europe. [11] Unlike in Spain and Croatia, in Bulgaria anyone who meets the requirements to be a donor after death does not automatically become one. It is written in the law that any person who meets the requirements for donation and has not expressed a written refusal could become a donor. Regardless, for this to happen, an agree­ment from the relatives is absolutely mandatory. In other words, the person becomes a donor if only their relatives did not express written objection to the deceased’s organs being transplanted. [12] In comparison, in Croatian law the express consent of the family does not appear, although it is taken into account because of ethical and moral reasons.

Meanwhile, another important point arises here. If a citizen in Bulgaria would like to become a donor after death, they could fill out a donor card to state their own will that his or her organs can be used for transplantation after proven brain death. [13] Nevertheless, this card has practically no legal value. It is simply a signal to the relatives that the person would like to be a donor. In reality, the relatives are the ones who make the final decision and are not obliged to comply with what is indicated in the donor card. From a legal point of view, this also has its ethical and moral aspects. This deprives the person of making their own decision regarding organ donation. [14] There is a similar card in Croatia and although the family traditionally complies with the will of the deceased, in case of relatives’ objection, in practice the refusal could be ignored, since there is no express paragraph in the law that a consent of the family is necessary unlike in the Bulgarian legislation.

 

Economic aspects for the Bulgarian health system

By law, the dialysis of health insured persons in Bulgaria is covered by the state budget, which makes the procedures free for patients. Every year not a small part of the national budget is paid for dialysis procedures for people with kidney failure. For that reason European countries are aiming for more and more transplantations, as they are proving to be not only the better health alternative for the patient, but also the more beneficial in an economic aspect.

 

Table 1: Number of patients and costs of dialysis for the period 2015-2019

 

Year	2015	2016	2017	2018	2019
Number of patients on dialysis	9 266	9 962	11 727	10 616	9 863
Number of dialyses during the year (total for all)	532 086	559 728	581 092	582 440	586 333
Price per year in Bulgarian BGN	76 620 384	80 600 832	83 677 248	83 871 360	84 431 952

Source: National Statistical Institute

In the period before the Covid-19 pandemic, the number of people with kidney failure in Bulgaria is relatively high. Although the peak of patients is in 2017, generally there is a large number of people with kidney failure for the period 2015-2019. Table 1 shows an upward trend in the total number of dialysis procedures performed. In 2015 the expenses are nearly BGN 76.6 million, while in 2019 they have already risen to BGN 84.4 million.

 

Graph 1: Spent funds for the period 2015-2019 for dialysis patients

Source: Table 1

An increase in the number of dialysis procedures therefore means more funds spent during 2015-2019. It is important to note that for the analyzed period the avarage price of one hemodialysis procedure remains unchanged and is 144 BGN. [15] Taking this into account, Graph 1 shows increasing expenditures for the state regarding dialysis patients.

 

Table 2: Number of dialysis patients for the period 2020-2022

 

Year	2020	2021	2022
Number of dialysis patients	10 090	10 420	11 002

 

*The table includes individuals on both hemodialysis and peritoneal dialysis. Also reported patients were both chronic renal failure and patients dialyzed due to acute renal failure.

Source: Ministry of Health

The Covid-19 pandemic has led to many health complications among the world population. As for dialysis Table 2 shows an increasing rate among patients compared to 2019. For the analyzed 3-year period the number increased by nearly 1000 people. Every patient with kidney failure needs regular blood purification. People on hemodialysis need an average of three procedures per week.

 

Table 3: Dynamics of cost of one hemodialysis procedure for the period 2018-2022

Period	Price of one procedure (BGN)
2018	144
2019	144
2020	170
2021	170
January – April 2022	170
May – November 2022	220
December 2022	237

Source: National Health Insurance Fund

After the onset of Covid-19, the entire global economic environment changed and this led to serious inflationary processes. The price of hemodialysis in Bulgaria did not remain unaffected and underwent changes.

 

Graph 2: Dynamics of price of hemodialysis for the period 2019-2022 in BGN

Source: Table 3

Graph 2 presents the dynamics of the price of hemodialysis in Bulgaria for the last few years. The price of hemodialysis procedure has risen by over 60% compared to the year before the pandemic. The most serious impression is made by its dynamics in 2022. For 2022 the price of the procedure has changed 2 times. Only for 2022 inflation in the price of one hemodialysis procedure is close to 40%.

All these data indicate a deteriorating economic situation and poor health care. Meanwhile, the only life-saving alternative for patients with kidney failure, apart from the dialysis procedure, remains an organ transplantation. Setting aside the raised number of patients and increased inflation, the situation for the number of kidney transplantations is not improving.

Table 4: Number of patients waiting for a kidney transplant

 

Year	2018	2019	2020	2021	2022
Number of patients	1039	1044	986	906	796

Source: Executive Agency “Medical Supervision”

Although Table 4 shows a downward trend in the number of waiting people, their total amount still remains too high. It is important to note that patients on dialysis and patients waiting for a transplantation are two separate groups. Patients on dialysis are much more numerous than people waiting for transplan­ta­tion for several reasons. Not all people with kidney failure are included in the waiting list. Some of them refuse because of distrust in the system or their advanced age. Others do not receive an adequate advice from their treating doctor. Also, compatibility tests are required to include a patient in the waiting list. This is the biggest obstacle for most patients to get in the waiting list. In Bulgaria these tests are covered by the patient. A large number of people cannot afford this price. All these trends show the obvious breakthrough in the state health policy.

 

Table 5: Kidney transplantations performed in Bulgaria by 2016-2023 (as of 03.08.2023) [16]

 

Year	2015	2016	2017	2018	2019	2020	2021	2022	2023
Number of cadaver donors	19	17	19	16	16	4	14	14	9
Transplantations from a cadaver donor	38	26	32	20	23	2	19	11	14
Transplantations from a living donor	13	11	8	5	13	6	14	1	1
Total kidney transplantations	51	37	40	25	36	8	33	12	15

By law, a patient with kidney failure can receive an organ in only two ways. One is to be on the waiting list and, if compatible, receive an organ from a cadaver donor. The other way is for relatives or a close person to donate an organ volun­tarily. All over the world trade in organs is prohibited, although many people resort to this extreme measure when their country does not have adequate trans­plant policies. Table 5 shows the situation in Bulgaria. It can be clearly seen that the number of cadaver donors for the last years did not exceed 20 which is extremely insufficient.

 

Graph 3: Dynamics of kidney transplantations from living and cadaveric donors for 2015-2023

Source: Table 5

Graph 3 expresses the dynamics of kidney transplantations in Bulgaria. An alarming trend is observed in cadaver donor transplantations. For the period 2015 – 2019 the number of cadaver donors decreased. It is not surprising that it reached its lowest point precisely in 2020 when after the appearance of Covid-19 hos­pi­tals closed doors for planned surgical operations. In 2021 an encouraging growth is noticed, but practically it is due to the realized surgeries which were not made in 2020.

The line of transplantations from a living donor varies quite a bit over the years, but in general their number is lower. This type of transplantations is not a defining indicator for the effectiveness of a country’s transplant policy. This is because the decision for these transplantations is made personally by the citizens with the aim of helping a close person, especially considering the minimal chances to obtain a kidney from a cadaver donor. In Bulgaria the chance of a patient on the waiting list to receive a kidney is about 1,4%-1,5%.

The line of total transplantations also shows a negative trend. It is a logical derivative mostly of the number of cadaver donors. It should be noted here that in the presence of one cadaveric donor, the kidneys could be transplanted to two separate patients if there is compatibility. This is also a very important factor in determining the effectiveness of the donation policy. As for kidney transplanta­tions, one cadaver donor could hypothetically relieve the health system with two patients. Consequently, transplantations from a cadaver donor are the real indi­cator of the transplant policy success.

However, as Graph 3 shows since 2015 the total number of transplantations has decreased by about 2 times. From an economic point of view, this is a very disturbing indicator, since transplantation costs the state 3,5 times less than dialysis. [17]

 

Framing effect as a rhetorical tool

The famous economist and psychologist Dan Ariely draws attention to this social but no less significant from an economic point of view problem of willingness to donate organs in some European countries. This turns out to be a global problem as the quality of life and health of the world’s population are deteriorating. Ariely’s interest is based on a particular scientific article from 2003 “Do Defaults Save Lives?” that presents a strange phenomenon of extreme differences in willingness of organ donation in several countries in Europe. What the data shows is a surprising mix of countries that are extremely willing to donate and those that are not at all willing to donate organs. [18]

 

Graph 4: Effective consent in % [19]

To some extent it is assumed that the reason why this could happen is cultural and religious differences. This assumption is quickly rejected, as it is obvious that countries with similar culture and religion show radically different results. The only precedent among countries reluctant to donate organs is the Netherlands. Its share is significantly higher than the other countries marked in gray – 27.5%. The reason for this result is rooted in the way the survey responses were collected. During the process each citizen is asked personally to fill out the survey. In other words, people’s attention is deliberately directed to the survey.

Despite the different way the surveys are conducted, this still does not explain why some countries are more willing to donate organs than others. The answer lies in using the tools of rhetoric and the so called framing effect. [20] The term is introduced by Daniel Kahneman and Amos Tversky and has a central role in their landmark work Prospect Theory. [21] The framing effect is a way of presenting information under conditions of uncertainty. Such a decision is not easy and definitely puts the person in a situation of uncertainty. The idea is to lead people to a decision that favors those who frame the question.

In this regard, the way the question in the survey is formulated turns out to be the basis of the huge differences between the answers of the countries in the EU. The question is asked in two different ways. The first requires action by the respon­dents if they want to join the donor campaign. The second one requires action if the respondent doesn’t want to join the donor campaign.

 

Figure 1: Organ donation survey in EU countries 2003 [22]

 

Questionnaire card 1:

Check the box if you want to join the organ donation program

Questionnaire card 2:

Check the box if you don’t want to join the organ donation program

Johnson and Goldstein’s study shows that the framing effect is a powerful tool to be used even in organ donation policies. For countries such as Denmark, Netherlands, Great Britain, Germany, is used Questionnaire card 1. In Austria, Belgium, France, Hungary, Poland, Portugal and Sweden Questionnaire card 2 is used. This questionnaire requires the respondents’ action if they do not want to donate organs and it is the reason for the higher results in favor of organ donation in the respective countries.

Several reasons can be presented for the respondent’s lack of action. The first and most logical is that people do not respond because they simply do not pay attention to what is written – tend to ignore it or simply do not notice it. Dan Ariely’s point of view is people tend to ignore the survey, but the reason is not because they do not care. It is a difficult decision and so people prefer to abdicate and let someone else take it for them. This removes the burden of the decision-making process.

In Bulgaria, there are various reasons for the lack of willingness to donate organs which are determined by the national psychology. According to a survey from 2019 by sociologist Boryana Dimitrova, Bulgarians’ willingness to donate has decreased for the last few years before the survey – from 40% to 35% against an EU citizens average level of 53-55%. The reasons for this negative trend are due to:

• fear that in case of an accident sufficient efforts will not be made to save the person;
• superstition that they can cause bad circumstances;
• people do not want to think about fatal things;
• moral-religious – unwilling to go against nature. [23]

It turns out that in Bulgaria the main reasons for refusing to donate organs are related to superstition and distrust in the system.

Discussion questions and suggestions for dealing with the problem

There are many problems in the transplant policy in Bulgaria and a con­sistent and complex strategy is required to deal with them. For this reason, various measures are required – financial, legislative and communicative mea­sures related to usage of tools and techniques of modern rhetoric. The fi­nancial measures are associated with more expenditures which should be looked at as a future investment. Firstly, the compatibility test should be paid by the state. Often a person with kidney failure is unable to carry out a full-fledged work activity. Therefore, patients cannot be expected to bear these costs by themselves, especially when the more transplantations are made, the more eco­nomic benefit for the state. Secondly, increasing doctors’ salaries will encourage them to care more for brain-dead potential donors. It will also increase their willingness to persuade relatives to donate the organs of the deceased and consequently to perform more transplant surgical operations. To think about an option in which there is an expert who communicates with the families about organ donation instead of doctors, following the example of Spain, is also a very good alternative.

The legislative framework should not be underestimated either. At the moment, relatives are the determining factor for donation after death. The card that expresses the willingness to become a donor should be legalized. The opinion of the deceased should take precedence over the opinion of the family.

There are other alternatives for conducting a different policy, following the example of countries like Spain – every citizen is a donor by presumption, except in case of written refusal. Here the tools of rhetoric can mainly be used. A national campaign should be held to acquaint the citizens with the advantages of donation and dispel all their fears.

In order to cover different social groups, it is recommendable to use dif­ferent methods and channels of communication. As for young people, it is im­perative to have an online campaign that reaches them through social net­works. The most appropriate is communication through influencers on Insta­gram, Face­book and Tik-Tok. For the middle-aged citizens, this could happen through tele­vision communication of expert interviews – doctors, economists, politicians and PR specialists. For the third age people, it would be very appropriate their GP doctor to properly explain the benefits of donation. It is important for commu­nication to cover equally all society groups, as some of them may not be potential donors, but with the current legislative framework, they could end up being people who make the final decision to donate.

Conducting a campaign based on the example of countries with a high rate of willingness to donate could lead to a better result. For Bulgaria it would be very effective to use a survey card that requires citizens to take an action if only they do not want to become donors. In this case, framing the question appro­priately would lead to a higher number of potential donors. Regardless of which of the approaches will be used it is very important for all of the mentioned measures to be consistent and mutually coordinated.

 

Conclusion

Globally, people waiting for a kidney transplantation are many times more than those waiting for a transplantation of any other type of organ. It is kidney failure that spends the most money on life-sustaining therapy. All countries around the world are trying to solve the problem of organ shortage and provide more opportunities for transplantations. Despite the innovation provided by 3D printing, apparently the mass printing of organs is still far in the future. Precisely because of this, countries must pursue a consistent and complex policy to im­prove the status of their national health system regarding transplant opportunities. There are examples in Europe showing that this is possible.

In recent years, in Bulgaria, downward trends in this field of health care have been noticed. People with chronic kidney failure are increasing and trans­plant surgeries are decreasing. The population does not recognize this problem and no measures are taken to change this attitude. The scientific literature shows that, although national psychology and religion, there are working methods that can significantly improve the state of the health system and the money paid for dialysis could be spent much more purposefully.

Apart from fear and mistrust in the system, there is a lack of mass cam­paigns to acquaint the population with the benefits of donation for the society. Regardless of what measures are taken, the legal framework should be upgraded and the opinion of potential donor should be taken into account. Examples from different countries show that donation by default is one of the most effective policies which significantly improves people’s quality of life and relieves the state budget.

 

References and Notes

[1] Mah, J., Johnston-Webber, C., Prionas, A., Bušić, M., Streit, S., Wharton, G., Mossialos, E., & Papalois, V. (2023). Organ Donation in Croatia: The Importance of a National Champion, a Comprehensive Plan, and International Collaborations. Transpl Int. May 25; 36, 11011.

[2] Živčić-Ćosić, S., Bušić, M., Župan, Ž., Pelčić, G., Anušić Juričić, M., Jurčić, Ž., Ivanovski, M., & Rački, S. (2013). Development of the Croatian model of organ donation and transplantation. Croatian medical journal, 54(1), 65–70.

[3] Българи в Испания. (2023). Испания е номер 1 в света по брой трансплантации на глава от населението. Информационен сайт на българите в Испания – ИСБИ. https://bulgaros.ovh/испания-е-номер-1-в-света-по-брой-трансп/. Retrieved on 10.08.2023. [Balgari v Ispania. (2023). Ispania e nomer 1 v sveta po broy transplan­tatsii na glava ot naselenieto. Informatsionen sayt na balgarite v Ispania – ISBI. https://bulgaros.ovh/ispania-e-nomer-1-v-sveta-po-broy-transp/. Retrieved on 10.08.2023.]

[4] Barcelona Metropolitan. (2010). Q&A: Spanish organ donor scheme: https://www. barcelona-metropolitan.com/living/qa-spanish-organ-donor-scheme/. Retrieved on 10.08.2023.

[5] Citizens Advice Bureau Spain. (2018). After Death in Spain Are You Automatically an Organ Donor? https://www.citizensadvice.org.es/after-death-in-spain-are-you-automatically-an-organ-donor/. Retrieved on 10.08.2023.

[6] E-Citizens portal of the Republic of Croatia. Organ donation: https://gov.hr/en/organ-donation/782. Retrieved on 10.08.2023.

[7] European Commission. (2014). Spain has the highest rate of donation of deceased people’s organs in Europe. El Médico Interactivo. https://health.ec.europa.eu/ system/files/2016-11/ev_20141126_art06_en_0.pdf. Retrieved on 10.08.2023.

[8] Mahenthran, T. (2021). The new ‘opt-out’ organ donation English law: Is the NHS ready for this? Clinical medicine, 21(1): e92–e93.

[9] Welsh Government services and information. (2018). Organ donation consent rates in Wales highest in the UK. https://www.gov.wales/organ-donation-consent-rates-wales-highest-uk-0. Retrieved on 10.08.2023.

[10] European Parliament briefing. (2020). Organ donation and transplantation – Facts, figures and European Union action. https://www.europarl.europa.eu/RegData/ etudes/BRIE/2020/649363/EPRS_BRI(2020)649363_EN.pdf. Retrieved on 12.08.2023.

[11] Willis, B. H., & Quigley, M. (2014). Opt-out organ donation: on evidence and public policy. Journal of the Royal Society of Medicine, 107(2), 56–60.

[12] Министерство на здравеопазването. Закон за трансплантация на органи, тъкани и клетки: https://www.mh.government.bg/media/filer_public/2020/10/07/ zakon_za_transplantaciq_na_organi_tykani_i_kletki.pdf. Retrieved on 12.08.2023. [Ministerstvo na zdraveopazvaneto. Zakon za transplantatsia na organi, takani i kletki: https://www.mh.government.bg/media/filer_public/2020/10/07/zakon_za_ transplantaciq_na_organi_tykani_i_kletki.pdf. Retrieved on 12.08.2023.]

[13] Донорска карта: https://www.zajivot.bg/donorska-karta. Retrieved on 11.08.2023. [Donorska karta: https://www.zajivot.bg/donorska-karta. Retrieved on 11.08.2023.]

[14] Николова, Н. (2019). Желанието за донорство трябва да се изразява приживе и лично. Интервю. Mediapool. https://www.mediapool.bg/zhelanieto-za-donorstvo-tryabva-da-se-izrazyava-prizhive-i-lichno-news298129.html. Retrieved on 11.08.2023. [Nikolova, N. (2019). Zhelanieto za donorstvo tryabva da se izrazyava prizhive i lichno. Intervyu. Mediapool. https://www.mediapool.bg/zhelanieto-za-donorstvo-tryabva-da-se-izrazyava-prizhive-i-lichno-news298129.html. Retrieved on 11.08.2023.]

[15] Петров, А. (2021). Ниво на информираност на пациентите с хронично бъбречно заболяване по отношение на бъбречната трансплантация и значение на информираността при избора на бъбречно заместително лечение. Дисертационен труд. Медицински университет – Варна. [Petrov, A. (2021). Nivo na infor­miranost na patsientite s hronichno babrechno zabolyavane po otnoshenie na bab­rechnata transplantatsia i znachenie na informiranostta pri izbora na babrechno za­mestitelno lechenie. Disertatsionen trud. Meditsinski universitet – Varna]

[16] Ministry of Health and Executive Agency “Medical Supervision”. (2013). Статистика – органни трансплантации: https://iamn.bg//трансплантации/статистика-органни-трансплантации/л Retrieved on 11.08.2023. [Ministry of Health and Executive Agency “Medical Supervision”. (2013). Statistika – organni transplan­tatsii: https://iamn.bg//transplantatsii/statistika-organni-transplantatsii/l Retrieved on 11.08.2023.]

[17] Паскалев, E. (2020). Проф. Паскалев: Трансплантираният пациент е 3 и половина пъти по-евтин за държавата от този на диализа: Интервю. Здраве. https:// www.zdrave.net/ГОСТ-на-zdrave.net/Проф.-Паскалев–Трансплантираният-пациент-е-3-и-половина-пъти-по-евтин-за-държавата-от-този-на-диализа/u13494. Retrieved on 12.08.2023. [Paskalev, E. (2020). Prof. Paskalev: Transplantiraniyat patsient e 3 i polovina pati po-evtin za darzhavata ot tozi na dializa: Intervyu. Zdrave. https://www.zdrave.net/GOST-na-zdrave.net/Prof.-Paskalev–Transplantiraniyat-patsient-e-3-i-polovina-pati-po-evtin-za-darzhavata-ot-tozi-na-dializa/u13494. Retrieved on 12.08.2023.]

[18] Johnson, E., & Goldstein, D. (2003). Do Defaults Save Lives? Science, 302, 1338–1339.

[19] Otsuka, N. (2013). Organ donations, gym memberships, and savings commitments: a new approach to financial inclusion. IDB Lab. https://bidlab.org/en/news/1166/ organ-donations-gym-memberships-and-savings-commitments-new-approach-financial-inclusion. Retrieved on 12.08.2023.

[20] Tversky, A., & Kahneman, D. (1981). The Framing of Decisions and the Psychology of Choice. Science, 211, 453–458.

[21] Tversky, A., & Kahneman, D. (1979). Prospect Theory: An Analysis of Decision under Risk. Econometrica, 47(2), 263–291.

[22] Ariely, D. (2009). Are we in control of our own decisions?. TED official website: https://www.ted.com/talks/dan_ariely_asks_are_we_in_control_of_our_own_decisions. Retrieved on 11.08.2023.

[23] Бозукова, М. (2019). Готовността на българите за донорство намалява: https://www.mediapool.bg/gotovnostta-na-balgarite-za-donorstvo-namalyava-news299844.html. Retrieved on 10.08.2023. [Bozukova, M. (2019). Gotovnostta na balgarite za donorstvo namalyava: https://www.mediapool.bg/gotovnostta-na-balgarite-za-donorstvo-namalyava-news299844.html. Retrieved on 10.08.2023.]

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[Petrov, A. (2021). Nivo na informiranost na patsientite s hronichno babrechno zabo­lyavane po otnoshenie na babrechnata transplantatsia i znachenie na informira­nostta pri izbora na babrechno zamestitelno lechenie. Disertatsionen trud. Me­ditsinski universitet – Varna]

 

Ivet Tileva, PhD is an assistant at the “International Economic Relations and Business” Department at University of National and World Economy. She has got professional experience in the field of B2B marketing, sales and communications. Her scientific interests are in the field of: international trade, economic psychology, business communications and leadership.

 

Manuscript was submitted: 30.08.2023.

Double Blind Peer Reviews: from 01.09.2023 till 11.09.2023.

Accepted: 14.09.2023.

Брой 57 на сп. „Реторика и комуникации“, октомври 2023 г. се издава с финансовата помощ на Фонд научни изследвания, договор № КП-06-НП4/72 от 16 декември 2022 г.

Issue 57 of the Rhetoric and Communications Journal (October 2023) is published with the financial support of the Scientific Research Fund, Contract No. KP-06-NP4/72 of December 16, 2022.