Organ donation in SG: Major hurdles remain despite ‘presumed consent’ law

In Singapore, the number of people assumed to be an organ donor sharply contrasts with the actual number of those willing to donate, and this discrepancy is driven by barriers related to emotions and culture or religion.

The nation’s ‘presumed consent’ legislation—the Human Organ Transplant Act (HOTA)—adopts an opt-out system, in which an individual is considered a potential donor unless they expressly declare that they do not want to be one. Under this system, opt-out rates are low at 2–3 percent. However, a recent study has revealed that the proportion seems much higher, with up to 15 percent of individuals refusing to donate their organs after death.

In the study, a team of researchers from the National University Health System conducted an interview in a public housing estate in Bishan. A total of 799 individuals participated, among whom 79 percent were Chinese, 13 percent were Indians, and 7 percent were Malays. In terms of religious affiliations, most were Christians (32 percent), 25 percent were Buddhists, and 24 percent were atheists.

Of the participants, 85 percent (n=679) were agreeable to organ donation after death, while 81 percent (n=649) expressed their willingness to assent to donations of family members’ organs. However, when presented with a realistic scenario of a deceased’s donation, 128 of the 649 participants who responded positively to the donation of their family members' organs held back their willingness (difference in paired proportion before vs after the scenario, 16 percent; p<0.001). [Front Public Health 2021;9:712584]

Reluctance around gifting organs

Emotions, as well as culture or religion, appeared to play the greatest role in the decision to become an organ donor or to assent to donate a family member’s organs. Most participants said they would be “too upset and unprepared to make a decision” and would “want the body to be intact for religious reasons.”

Knowledge gaps regarding the organ donation process were also at play. A lot of participants, for example, had the misconception that brain death certification was not a stringent process, were not aware that there are four organs (kidney, liver, cornea, and heart) that can be procured under HOTA, or did not know that HOTA was an opt-out system.

In a multivariable logistic regression model, knowledge correlated with the willingness to donate and assent. Specifically, being aware that HOTA was an opt-out system (based on presumed consent) was significantly associated with willingness to donate (adjusted odds ratio [aOR], 3.41, 95 percent confidence interval [CI], 2.08–5.59). Meanwhile, the strongest predictors of willingness to assent were knowing that brain death is irreversible (aOR, 2.15, 95 percent CI, 1.60–2.89) and knowing that organs could be procured from brain dead patients (aOR, 2.08, 95 percent CI, 1.50–2.89).

Overcoming hurdles

These findings, according to the researchers, underscored that families must be given time to adjust to the shock of the death of their kin before considering donation and that the mere implementation of a presumed consent system was insufficient to boost organ availability.

One way to overcome the emotional barrier is by pronouncing death and requesting for organ donation on separate occasions, in addition to increasing family support during grieving to protect the psychological wellbeing of family members while increasing the likelihood of assent, the researchers said. [Transplantation 2017;101:S1-16; Brit Med J 2009;338:b991]

They also believed that extensive public education to disseminate knowledge on the presumed consent system, benefits of organ donation, transplant process, and brain death criteria should help normalize organ donation.

“While the presumed consent system holds much potential to increase organ donation rates, this study provides clear evidence that policymakers need to invest heavily in increasing transplant provisions, while promoting public education on multiple aspects of organ donation to effectively boost donor rates,” the researchers said.

“The process of obtaining assent from family members to procure organs from deceased relatives should also be further refined, centred around empathy, and sensitivity,” they added.