EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Donated organs are gifts of life for those with end-stage organ failure. One donor can save up to 8 lives.1 In the Western world, deceased organ transplant rates are the highest. In contrast, organs from living donors, particularly from relatives, are more common in developing countries.^2,3 However, the number of patients on organ transplant waiting lists is increasing day by day, and the increased gap between supply and demand is getting even more pronounced.^4,5 Deceased organ transplant may contribute to close this gap and to reduce mortality on the waiting list; therefore, raising awareness is crucial to encourage more individuals to donate.

The opinions and attitudes toward donation can be influenced by multiple elements, such as demographic characteristics, comorbid conditions, education (and lack of knowledge), cultural factors, spirituality, and mistrust of the healthcare system.^6-9 It has been reported that religion is one of the key factors affecting decision-making. As reported previously, according to their beliefs, individuals were concerned about violations of bodily integrity, torment of the dead body, and beliefs of “inappropriateness.”^6,7 Studies involving Turkish university students found that some of the reasons to oppose organ donation involved the inappropriate use of recovered organs, finding it disturbing and unnerving to carry an organ or tissue from another body, and believing that organ transplant is forbidden in Islam.^7,10 Because Turkey is a Muslim-majority country, this finding is not surprising. However, it should be noted that organ donation is allowed and indeed recommended by Islam.^11,12 With this notion in mind, we aimed to explore the religious side of these views (positive and negative) within the Turkish context.

As noted, there is a clear need to discuss the topic of deceased organ donation from the perspectives of different religions, to evaluate barriers and to explore ways to solve obstacles. The “International Symposium on Deceased Organ Donation and Religion” was organized by The Transplantation Society at Baskent University, Ankara, Turkey on March 12 and 13, 2020. The program included presentations by representatives of different faiths followed by panel discussions. The panel discussions were structured based on questions gathered beforehand from students at different departments within Baskent University. Misconceptions and potential barriers against organ donation and transplantation within the religious framework were discussed. In this report, our purpose was to analyze and compare the opinions, attitudes, and practices of Baskent University students and to determine the impact of religion on organ donation and transplantation.

Materials and Methods

On March 13, 2020, we sent a self-administered, Web-based questionnaire to capture the impact of a panel discussion, “Transplantation and Religion,” in which participants were able to discuss and clarify misbeliefs regarding deceased organ donation.

Participants
We targeted a sample of 361 Turkish medical and nonmedical students from Baskent University (Ankara, Turkey).

Survey creation
The survey was designed to collect panel discussion attendance (question 1), demographic data (male/female attendants, age, their department/faculty; questions 2-4), and information on attitudes and opinions toward organ donation (questions 5-9). For the last 5 questions, participants were expected to rate them from 1 (strongly disagree) to 5 (strongly agree) based on a 5-point Likert scale. The survey is depicted in Table 1.

Statistical analyses

Answers from those who attended were compared with those who did not attend using t tests or Mann-Whitney tests. In addition, we further analyzed answers from attendees. Statistical analyses were performed using Prism version 9.0.0 for Windows from GraphPad Software.

From 361 E-mails that were sent, we received 69 responses, in which 46 students attended the panel discussion, 22 did not, and 1 did not specify. The attendant group was composed of 31 women and 15 men, with 47.8% in the 18- to 25-year-old group and 43.5% older than 30 years. Most of the participants were part of the faculty of medicine. The nonattendant group was composed of students from other faculties at Baskent University (Table 2).

The results obtained from questions 5 to 9 (question 5: Are you considering becoming an organ donor?; question 6: How much of a role do you think religion has when it comes to organ donation?; question 7: How much of a role do you think media has when it comes to shaping the public opinion about organ donation?; question 8: How reliable do you think media sources are when reporting about organ donation?; and question 9: What is your comfort level about having a conversation about organ donation with a friend or a family member?) from both groups are depicted in Figure 1. There were significant differences between groups on answers to questions 6, 8, and 9, with higher values seen from those who attended the panel discussion.

In our analysis of answers for the attendant group, we found the following. For question 5, “becoming an organ donor,” the mean score was 4.04 ± 1.33. Over 50% of the participants (26/46, 54.3%) expressed their willingness by selecting 5 from the scale. There were no significant differences in answers from women versus men and in age groups of 18 to 25 years versus over 30 years of age.

For question 6, “the role of religion in organ donation,” the mean score was 3.98 ± 1.36, with no differences due to sex or age. Half of the participants (23/46, 50%) believed in the important role of religion in organ donation (as indicated by selection of 5 on the Likert scale).

For question 7, “the role of the media in shaping the public opinion about organ donation,” the mean score was 4.04 ± 1.36, with 54.3% selecting 5 in their answers. There was a difference in answers from men versus women, with women having a mean of 4.42 ± 0.96 and men having a mean of 3.27 ± 1.75 (Figure 2). There were no differences according to age groups.

For question 8, “reliability of media sources when reporting about organ donation,” the mean score was 3.96 ± 1.30, with no significant differences in answers according to sex or age.

For question 9, “your comfort level about having a conversation on organ donation with a friend or a family member,” the mean score was 4.5 ± 1.03. There were no significant differences according to sex; however, there was a difference with regard to age, with students older than 30 having a higher score (4.85 ± 0.9 vs 4.23 ± 1.24; P = .41) (Figure 3).

The most important findings of this study were the differences between those who participated in the panel discussion compared with those who did not, with a high level of agreement among the questions from those who attended.

Religion played less of a role with regard to organ donation in those who did not participate in the presentations (close to 3, neutral), regardless of sex or age compared with a level of agreement in those who attended. Also, attendees were more inclined to rely on reports provided by the media and showed a higher level of comfort about having a conversation related to organ donation.

When analyzing the answers from those who did attend, we observed that 55.4% of the university students stated that they would “most likely” donate their organs and 13.8% would “consider” donating their organs. It was found that half of the Baskent University students who attended the panel discussion believed that religion has a significant role in decision-making when it comes to organ donation and transplantation. We saw differences only in men versus women in question 7 and in age in question 9. Women were more in agreement toward media having a more important role in shaping public opinion on organ donation, and attendees older than 30 years felt more confident to discuss topics related to organ donation with friends and family.

The role of religion deserves a more in-depth discussion. In a 2002 study, Akgun and colleagues reported that 49.5% of Baskent University students expressed willingness to donate their organs after death.⁷ In other previous studies conducted at Turkish universities, a range of numbers were reported with regard to willingness to donate an organ. A study published by Kose and colleagues showed that 71.7% of university students were willing to donate their organs after death. Reasons for their approving attitude included not needing their body after death (5.8%) and acquiring merit in God’s sight (30.7%).¹³ In a study on last-term university students, it was reported that 58.7% of 1270 students were considering organ donation.⁶ Sagiroglu and colleauges¹⁴ reported that 96.4% of medical and law students considered organ transplant as an important therapeutic method. The frequency was 95.8% for medical students and 97.9% for law students.

Arisal and colleagues as well as Stephenson and colleagues have described that bodily integrity was the most important factor that negatively affected participants’ attitudes toward organ donation.^15,16

In a study from 2002, religious beliefs were only a minor reason given for opposing organ donation and transplantation, with only 8.9% of participants stating this.7 In another older study conducted by Kececioglu and colleagues, the vast majority (86%) of religious people (including imams, Quran teachers, religious city officials, and physicians working in religious organizations) stated that organ donation was an honorable humane act that would be acceptable from the Islamic point of view and that they would donate their organs.¹⁷ More recently, Kocaay and colleagues reported that, for most students, organ donation was regarded to be consistent with religion (68.6%), with 24.6% of students being uncertain.¹⁸ In a study from the same year, Kose and associates reported that a small percentage of students had a negative view toward organ donation, with 3.7% believing that they would commit a sin if they were to donate.¹³ However, Nacar and colleagues found that 19.8% of medical students were against organ donation because of religious reasons.¹⁹ In 2017, Gürdil Yilmaz and colleagues²⁰ reported that, although 52.1% of students found organ transplantation to be appropriate in Islam, some still saw religion as an obstacle for organ transplantation. The authors also reported that one of the main reasons for being against donation or being uncertain was the fear of disruption of body integrity after death, as reported by 20.6% of medical students.²⁰ Another study also showed that one of the most frequent reasons why students did not wish to donate organs was the belief of inappropriateness related to religion,⁶ a fact found in the report from Sagiroglu and associates with regard to some medical students, who also believed that organ donation was not religiously appropriate.¹⁴ With regard to surveys among religious officials, although most believed in the importance or organ donation (90.8%), the rate of those considering it was low (57.9%).²¹

In different religious doctrines, various negative and positive opinions can be found. In their 2020 study conducted in Israel, Tarabeih and colleagues stated that members of Christianity, Islam, and Judaism all expressed a low willingness to donate organs after death. Even when no religious ruling prohibits or restricts organ donation, either living or deceased, a great number of religious responders were still puzzled, clinging onto unjustified prejudices.²² With regard to Islam, although there are variations in different sects, organ donation is predominantly allowed and accepted as a sacred life-saving act of kindness due to the fact that life itself is considered precious in Islamic doctrine.^23,24 In their study, Oliver and colleagues¹⁴ also mentioned that, although internationally most Islamic scholars endorse organ donation, many believers are still hesitant. The issue of organ donation has been discussed by the Christian Science Board of Directors, and the decision to donate is seen as a personal choice. However, in Buddhism, brain death is a problematic concept due to the belief that spiritual “consciousness” may remain in the body for days after death. Mostly because of this, there are many different conclusions, including leaving it to individual decision or completely opposing it.²⁵ No matter what doctrine, it would not be wrong to say that there are contrasting teachings, but the decision is predominantly left to the individuals themselves.

Because we live in a world of technology and constant development, we expected to find mass media to be one of the primary ways for people to obtain knowledge and stay up-to-date. As anticipated, 54.3% of the students in our survey stated that media had a major effect in shaping their opinions and attitudes toward organ donation and transplantation. In a 2002 study of Baskent University students, it was reported that, of all the students who were aware that organ donation was possible, 55.9% first heard about the procedure through mass media.⁷ Kose and associates similarly reported that students acquired their knowledge about organ donation and transplantation from television/radio (81.3%), newspaper/journals (79.3%), their environment and friends (28.2%), books (21.4%), and the internet (15.2%).¹³ In the study by Akkas and associates,²⁴ both first-year and sixth-year medical students stated that they obtained their information from social media, internet, and television, with another study reporting that even most religious officials (70%) indicated mass media as their source of information.²¹ Arisal and colleagues reported a statistically significant relation between media and a positive attitude toward organ donation in participants.¹⁵ Sato and associates suggested that, because television is extensively viewed by people, it can be considered as one of the most important sources of information and that it should be used actively for campaigns and spreading accurate information.²⁵ In their study, Moray and colleagues stated that, especially in developing countries, educating the public and raising awareness on organ donation and transplantation is crucial and suggested that enhanced television coverage and public access to news on patients with chronic organ disease, transplantation, and organ donation could increase rates of donation.²⁶

Of note, organ donation was supported by the participants and panelists at the panel discussion, as well as religious representatives who could not attend due to the COVID-19 pandemic.^27-29 However, it is important to continue working toward increasing deceased donations to reduce organ shortages.²⁹

Our study has several limitations. The participants consisted of students from a single university, which cannot be generalized to all Turkish university students, let alone to the Turkish population. In addition, religions of participants were not questioned due to ethical considerations. Our assumptions were based on the fact that most Turkish people are Muslim. Also of note, because of the COVID-19 pandemic, international participation in the symposium and also the number of responses were not as high as anticipated.

Although religion has an undeniable effect on the decision-making process, our survey showed that more than half of the university students who attended or did not attend the panel discussion, regardless of sex and age, were willing to donate their organs. Throughout the years, media campaigns have been carried out to increase the number of deceased donations. Although donation numbers are increasing, the number of patients on organ waiting lists has continued to grow at even higher rates. We strongly believe that education is key to overcoming the obstacles that might be caused by religious beliefs. Therefore, medical, educational, and religious scholars, as well as the media, should collectively work together to raise awareness about organ donation, thus contributing to increasing access to transplantation worldwide.

Volume: 19 Issue: 7 July 2021

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