Can financial rewards complement altruism to raise deceased organ donation rates?

Abstract

Background:

Organ supply–demand in developing countries worldwide has continued to widen. Hence, using a large survey (n ¼ 10,412), this study seeks to investigate whether human psychology could be used to inculcate philanthropy to raise deceased organ donation rates.

Methods:

Three models were constructed to examine multidimensional relationships among the variables. Structural equation modeling was applied to estimate the direct and indirect influence of altruism, financial incentives, donation perception, and socioeconomic status simultaneously on willingness to donate deceased organs.

Ethical considerations:

The study was approved by the University of Malaya ethics committee.

Results:

The results show that altruism amplifies the impact of socioeconomic status and donation perception on willingness to donate. Also, the results show that financial incentives cannot complement altruism to raise organ donation rates. Hence, investing in education and public awareness enhances altruism in people, which then increases the propensity to donate.

Conclusion:

Evidence suggests that governments should allocate resources to increase public awareness about organ donation. Awareness programs about the importance of philanthropic donations and the participation of medical consultants at hospitals in the processes form the foundation of such a presumptive approach.

Keywords

Altruism donation perception financial incentives structural equation modeling willingness to donate

Introduction

Organ transplantation has increased rapidly in the last decade as a consequence of medical discoveries and improved technology.^1,2 Research shows that attitudes toward use of deceased organs as a life-saving resource have been influenced by societal perception, religious leaders’ opinion, ancestral doubt and fear, as well as distrust in organ allocation procedures.^3,4 It is for these reasons the supply of organs has remained low. Intensive care units have been powerless to help patients seeking transplants because of under-sourced organ banks.⁵ Consequently, at the global level, at least 20% of patients on waiting lists die every year.^6,7

Living donations have dominated deceased organ transplantations in Malaysia. According to statistics from the Health Ministry Malaysia, as of 31 September 2019, only around 1.3% of Malaysians are registered as organ donors after death.⁸ Over the period 1991–2014, Malaysia had only 178 deceased donors, with most of them being foreigners who died in traffic accidents.⁹ Given that deceased organ donors have either died or are brain or cardiac dead, retrieving organs is less risky in these cases. It also complies with the ethics enshrined in the World Health Organization and the Istanbul Declaration, which discourage organ trafficking. The Malaysian Ministry of Health has promoted organ donation in the last few years, including issuing cards for those registering to donate, which may explain a rise in donation rate from 0.5% in 2013 to 0.7% in 2014.¹⁰ However, the rise has not been persistent as in 2018, Malaysia donation rate had dropped to 0.2%.¹⁰

Traditionally, the view that “organ donation offers a gift of life” has underpinned organ donation initiatives as it is built around human solidarity and altruism. The use of body parts after death can be undertaken through a social agreement based on knowledge and awareness, which then becomes the basis for turning one’s death into another’s life.¹¹ Altruism is often complemented with efforts to change donation perception (DP) using knowledge and awareness. This argument is in synchronization with the theory of planned behavior, which posits that behavior originates from an attitude toward it.^12,13

Although altruism is perceived as the major driving force behind willingness to donate (WTD), the widening supply–demand gap shows a need to complement existing methods to raise donation rates. It is for this reason some studies have called for increasing the role of markets through financial incentives. Market exponents posit that the inability of existing organ procurement systems to raise donation rates is due to the misleading perception that altruism is the only motivation for donors.¹⁴ While altruism and markets draw on paradoxically opposite arguments, there may be types of financial inducements that may complement rather than contradict altruism. Hence, it is important to examine whether certain types of financial incentives can complement altruism to raise donation.¹⁵ Against this backdrop, this article formulates and tests three models to compare the impact of financial incentives, DP, and altruism on WTD in Malaysia. The rest of the article presents the literature review, methodology, results, discussion, and conclusion.

Literature review

The relevant literature review to locate the study can be divided into two broad categories, namely, factors influencing donation and regimes in which donation takes place. Reviewing the factors that can increase donation rates helps to identify the suitable donation regime for particular countries, while an assessment of donation regimes can explain why donation rates are higher in some countries compared to others, as well as whether particular regimes can be introduced universally.

Factors influencing WTD

Publications addressing deceased organ donation grew from 28 in the 1990s to 913 in 2015–2020 retrieved from the Web of Science database,¹⁶ with the majority of them focusing on factors influencing donor decisions. The decision to donate organs generally requires positive perception toward donation. Studies show that DPs are shaped by trust,^17,18 attitude,^19,
20 and knowledge^21,22 about organ donation.^23,
24 One of the important barriers across various groups that has discouraged donation is distrust in the medical system.²⁵

Medical mistrust comes from doubts about the efficacy of the health system, especially over competency and fairness of professionals involved in transplantation. Perception of discrimination, which leads to the belief that organs can be unfairly allocated, is an impediment (e.g. many believe that the wealthy and politically connected will receive better medical care). Another reason of mistrust is related to the fear of having one’s organ removed while still alive,²⁶ which is referred to as “skepticism regarding brain death” in the study conducted by Moschella.²⁶ Tumin et al.²⁷ also reported the ambiguity around the beneficial usage of body parts as the main reason for the low donation rates recorded in Malaysia. Perhaps the most common fear associated with organ donation is that “doctors will kill patients to harvest their organs.” Therefore, there is a need for the introduction of proactive strategies to facilitate information sharing and engagement between potential donors and transplant professionals.²⁸

There is an extensive body of literature that discusses the role of knowledge in molding attitudes toward organ donation.^29
–31 The rationale behind this argument is the premise that greater knowledge will result in a greater WTD. A study conducted among healthcare professionals in a medical center showed that the low level of knowledge is the main reason for less intention toward deceased organ donation.²⁹ It is for this reason that the changeable variables of education, occupation, and income can positively affect organ donation rates. Higher socioeconomic status (SES) is expected to offer better access to knowledge and information, which then can help people to override taboos and other misconceptions when making decisions.^21,32 A research entitled “educate, re-educate, then re-educate…” presents the crucial role that education can play to establish the organ donation attitude in the society.³³ Another study conducted in Thailand showed that even higher SES of neighbors has positive impact on WTD.³⁴ Although a great number of authors have reported the significant influence of the socioeconomic variables of education and income on WTD organs, there is lack of consensus on whether this influence is positive or negative.^35,36 On the one hand, a study on Malaysia reported a significant influence of SES on WTD,²⁷ which is corroborated by studies conducted in Europe and Canada.^37,38 On the other hand, other studies found SES has none or negligible impact on WTD,³⁹ while a study on the United Kingdom showed an inverse relationship between SES and WTD.⁴⁰ Similarly, a study conducted in Canadian provinces showed that household income is not associated with WTD.⁴¹ These inconsistent results call for the need to re-examine the influence of SES on WTD using more robust statistical methods than those used before in Malaysian context.

The decision to donate one’s organs generally requires some degree of altruistic motivation. Promoting such altruism, however, is complex as such decisions may conflict with prevailing social knowledge, as well as cultural and religious beliefs. If critical shortages in deceased organs are appropriately understood by the public, the altruistic response could sway perceptions so as to increase donation rates.⁴² In Lafitte et al.’s⁴³ dominant but traditional model of medical donation, the charitable spirit emanating from altruism underpins most organ donation initiatives.¹⁴ It is built on the notion that medicine in general and transplantation in particular rely heavily on public trust so that equity and fairness are respected in the allocation of the scarce resource. Those individuals who tend to donate just to feel good about themselves are motivated by altruistic reasons.

However, pointing to the widening gap between supply and need for organs, Epstein⁴⁴ questioned whether altruism as the ethical value is capacitated enough to induce organ donation—in this vain, altruism though an admirable factor, but clearly insufficient motivation for potential donors.⁴⁵ Similarly, critics have encouraged the unleashing of market forces to raise donation rates.^29,30 While the brazen opening of organ donation to market forces can be disastrous, recent literature suggests that the provision of financial incentives to raise organ donation rates may not be altogether bad.⁴⁶ The result of an experiment consists of four treatments to raise organ donation in the United States, which showed the largest donation rates occurred when financial return is offered for being an organ donor.⁴⁷ According to this view, monetary motivations in forms of a small support to bereaved families may not be unethical since it can be a source of motivation to save or improve lives of others. As pointed out by Kekes,⁴⁸ altruism is a noble ideal that can be augmented with socially acceptable financial incentives if the excesses of markets can be checked. Examples where incentives can play this role include the recommendations of the Nuffield Report⁴⁹ where incentives to finance donors’ funerals are viewed as an ethical way to support donors’ families. These circumstances are different from typical market-determined outcomes that compromise moral obligations.^14,
50 Since financial incentives are a contextual matter according to various cultures and norms, countries treat it very differently. For example, Singapore has given some priorities to family of those who signed the donor card, whereas Israel also allows direct payments to the donor families.⁵¹ Consequently, it is worth exploring alternative mechanisms that complement altruism to raise organ donation rates in the context of Malaysia. However, for this initiative to be successful, it is necessary to examine the interrelationship between the factors shaping attitudes toward organ donation and the effect of socially acceptable financial incentives on WTD in the context of Malaysia.

Exposition of current donation systems

Country-based organ procurement models across the world can be classified broadly under explicit (opt-in) and presumed (opt-out) consent regimes. In the former, individuals can register as donors by authorizing the transplantation of their organs in the form of advanced directives or by filling up a form to provide consent through national registries. Under the opt-in regime, governments do not have the authority to procure organs unless the donor had authorized it prior to death. In the opt-out system, explicit consent is not required, as it is sufficient that the deceased person did not object during life. The absence of explicit consent is bypassed by presuming consent from potential donors.^52,53

While implementing the opt-out system in countries such as Spain and Austria^54

–57 has raised donation rates, they have been criticized for denying donor autonomy to make decisions.⁵⁸ Critics are quick to note that the presumed consent regulations deny large numbers of people freedom to make decisions as many are unaware of such laws.⁵⁹ Moreover, under the opt-out system, donation becomes a norm rather than a special act to do.⁶⁰ Hence, the argument against the opt-out system is persuasive enough to suggest that there is a need for ethical alternatives to raise organ donation rates.

The alternative policy, which has been recently proposed in the United Kingdom and in some states in the United States, is known as the “presumptive approach.”⁶¹ Respect for human dignity is at the core of this approach, but it recognizes that simply relying on altruism is not sufficient for ensuring adequate supply of organs. This is a less coercive approach than the opt-out scheme because explicit consent from donors or the next of kin is required. However, the difference with opt-in is that counselors are involved to encourage the families for the donation. Counselors are to promote donation using ethical methods while promoting the benefits of organ donation to dying patients or their next of kin.⁵⁹ As Beauchamp and Childress⁶² have argued, an outright opt-out policy would not be adopted in some countries. It is claimed that for the countries with explicit consent, contemplating conversion to presumed consent in the effort to boost organ donation rate is an important political issue.⁶⁰ Thus, it is worth seeking alternative solutions by adopting the existing opt-in framework. Malaysia has adopted an opt-in system involving both living and deceased donors. Since the donation rate in Malaysia is among the lowest in the world, this study seeks to investigate scientific alternatives for policy makers for complementing its opt-in system which could form the foundation for adopting the “presumptive approach.”

Materials and methods

This study has applied structural equation modeling (SEM) to estimate the relative influence of the different variables simultaneously, since people tend to make decisions on the basis of several factors at the same time.⁶³

Analytical framework

We developed three models that provide a multidimensional view of the relationships among the study variables. In Model 1, we took financial incentives (represented by cash incentives, deceased family support, and financing funeral expenses), SES, DP, and altruism as independent variables and WTD as the dependent variable. In Model 2, altruism was treated as a mediator and financial incentives as a moderator, which allows the assessment of their capacity to increase WTD (Figures 1 and 2). Model 3 is a disaggregated version of Model 2, where the components of SES (education, income, and occupation) and DP (attitude, trust, and knowledge) were taken as independent variables. Components of financial incentives, namely, cash incentives, financing funeral expenses, and bereaved family support, are deployed as moderators and altruism as the mediator. Model 3 provides a clear view of the relationship identifying the most influential components on WTD (Figure 3).

Figure 1.

Factors influencing willingness to donate.

Figure 2.

Role of financial incentives and altruism in the relationship between SES, DP, and WTD.

Figure 3.

Effect of components of financial incentives, SES, and DP on WTD.

Measurement

The method adopted for the measurement of factors that influence WTD deceased organs is explained in this section. SES, DPs, altruism, and financial incentives are used as exogenous variables, mediating variables, or moderating variables, whereas WTD is defined as an indigenous variable. The SES indicators considered in this study are personal income, education, and occupation. DP was measured through attitudes toward donation, general knowledge, and trust. Trust was measured from the responses to three questions: whether procedures required to become organ donors are a hindrance; whether the transplant unit is perceived to be fair in allocating organs; and whether physicians harvesting and transplanting organs are perceived to have adequate competence to do so.

The responses were recorded as “no” (0), “not sure” (1), and “yes” (2). The knowledge about organ transplants required the respondents to choose one answer on a 5-point Likert-type scale comprising “non-existent” (1), “poor” (2), “scant” (3), “average” (4), and “good” (5). Altruism was captured by three Likert-type scale questions on participation of respondents in charity-related work or donation. Financial incentives were measured by asking respondents the situation under which they would agree to donate their organs rather than opting out. The financial choices are as follows:whether they were compensated with cash rewards of MYR10,000, whether they would be financed for their funeral expenses, or whether financial support will be offered to one dependent of the deceased. Responses for each of the three incentives were recorded as a binary variable. WTD was measured as a binary variable of 1 for willing to donate responses and 0 for unwilling to donate responses.

Sampling

The data for analysis were collected through a survey conducted in Kuala Lumpur for the Ministry of Health, Malaysia. To test the robustness of the questionnaire, a pilot study was conducted prior to the main survey, in which 100 persons were drawn from the telephone registry to participate in face-to-face interviews. The pilot study indicated that a randomly stratified sampling procedure would be difficult to manage, as 29 persons could not be reached at their home phones at different times during the day, while a further 33 individuals refused to participate in the survey. Therefore, the team proceeded to use a voluntary sampling procedure whereby respondents were approached from five hypermarkets, five government hospitals, two universities (one public and one private), and two locations with large concentrations of shopping and commercial operations in the year 2014 (January 15 until August 15). All respondents were passers-by at where our enumerators were positioned with no attempt to identify the purpose of their presence there, which was deliberately chosen to increase the response rate. Those who turned down the request included a number who simply declined to participate in the face-to-face interview without even listening to the purpose of the survey, and hence, the convenience survey did not record those numbers. We recorded all voluntary participants’ responses. The convergent and discriminant validity of the questionnaire were confirmed by checking the values of average variance extracted (AVE), composite reliability (CR), and factor loading.

The study was approved by the University of Malaya ethics committee. Two professors with the assistance of two doctoral students and six enumerators conducted the survey. Malaysian volunteers aged 18 and above participated in the survey. A total of 10,412 respondents filled up the questionnaires. Table 1 presents the data by demographic and socioeconomic characteristics. The sample comprised more females (58.8%) than males (41.2%). The mean participant age was 34 years, and their ethnic background were 71.9% Malays, 14.0% Chinese, and 14.1% Others. We included Indians to the “Others” category because their numbers were too small for a statistically meaningful analysis. Finally, the breakdown by religion was 71.6% Muslims, 12% Hindus, 9.4% Buddhists, and 7% others. Christians were added into the Others category because their numbers were small.

Table 1.

Demographic and socioeconomic characteristics.

Characteristics by	N (prevalence)	Mean + SD
Demographic
Age	10,353	34.35 + 8.25
Ethnicity
Malay	7491 (71.9)
Chinese	1459 (14.0)
Others (mainly Indian)	1462 (14.1)
Religion
Islam	7453 (71.6)
Buddhist	979 (9.4)
Hindu	1254 (12.0)
Others (mainly Christian)	726 (7.0)
Gender
Men	4293 (41.2)
Women	6119 (58.8)
Socioeconomic status
Educational level
Primary	295 (2.8)
Secondary	2507 (24.1)
Higher secondary	5821 (55.9)
Tertiary	1789 (17.2)
Occupation
Unemployed	1949 (18.7)
Clerical and general work	6398 (61.4)
Professionals and Managerial	2065 (19.9)
Income	10,337	36,436.4 + 35,512.27

Source: Computed from University of Malaya survey.

SD: standard deviation.

Respondents’ education attainment comprised 17.9% tertiary, 55.9% higher secondary, 24.1% secondary, and 2.8% primary. The breakdown by occupation revealed that 19.9% of them held professional and managerial positions; 61.4% worked as general, supervisory, and clerical personnel; and 18.7% were unemployed. The mean annual income was MYR36,436 with a standard deviation of MYR35,512. Based on the 2016 Salaries and Wages Survey by Department of Statistics Malaysia, the average monthly income of employees is reported to be MYR26,198.⁶⁴ This shows that the monthly income of those who participated in our survey has been above the average of national income. In 2014, the Ministry of Economic Affairs Malaysia used the Poverty Line Income (PLI) level if MYR980,⁶⁴ meaning that individuals with annual income below MYR11,760 are considered poor. The above statistics shows that none of the participants have been close to poverty line. It is worth mentioning that the rate of poverty in Malaysia for 2014 has been reduced to 0.6%.⁶⁵

Validation

We validated the models before analyzing the data. The model fitness results presented in Table 2 indicate that all three models have the appropriate values of goodness of fit index (GFI), confirmatory factor index (CFI), and root mean square error of approximation (RMSEA), which confirm that these models can be used for analysis.

Table 2.

Goodness of fit indices.

Model	GFI	CFI	RMSEA
Model 1	0.892	0.881	0.061
Model 2	0.894	0.885	0.045
Model 3	0.913	0.904	0.053

GFI: goodness of fit index; CFI: comparative fit index; RMSEA: root mean square error of approximation.

Results

Table 3 presents the results from Model 1, which indicate that all factors have significant positive influence on WTD. However, the magnitude of their coefficients differs considerably. Particularly, altruism (0.208), DP (0.146), and SES (0.138) have stronger impact on WTD than financial incentives (0.033). Clearly, the results support the long-held view that altruism is the prime driver of WTD. However, the other results suggest that other factors can complement altruism to raise WTD, including financial incentives.

Table 3.

Factors influencing WTD.

Hypothesis	Value
Socioeconomic status → WTD	0.138^a
Donation perception → WTD	0.146^a
Altruism → WTD	0.208^a
Financial incentives → WTD	0.033^a

Source: Computed from University of Malaya survey.

WTD: willingness to donate.

^a Existence of statistically significant relationship at 1%.

Hence, Model 2 was developed to treat altruism as a mediator and financial incentives as a moderator in the relationship between SES and DP, and WTD. While Model 1 examined all factors influencing WTD, Model 2 investigated whether introducing monetary incentives can complement altruism to raise WTD in Malaysia.

Model 2 results show that altruism amplifies the impact of SES and DP on WTD (Table 4). Comparing the results of direct effect with the indirect effect of SES and DP on WTD with altruism as a mediating variable demonstrated that altruism showed a higher effect than in Model 1 on the other variables. As presented in Table 4, the magnitude of the direct effect of SES is 0.149, whereas its indirect effect through altruism is 0.191. Similarly, the impact of DP increased from 0.155 to 0.162 when altruism was treated as a mediator. Furthermore, the results show that financial incentives do not play a moderating role in the relationship between SES, DP, and WTD, as the coefficients are insignificant. Hence, the results reject the relevance of monetary incentives as an instrument for increasing donation rates.

Table 4.

Comparing relationship between SES, DP, and WTD.

Hypothesis	Value
Socioeconomic status → WTD	0.149^a
Donation perception → WTD	0.155^a
Altruism → WTD	0.218^a
Role of altruism as mediator
Socioeconomic status → Altruism → WTD	0.191^a
Donation perception → Altruism → WTD	0.162^a
Role of financial incentives as moderator
Socioeconomic status → WTD	0.014
Donation perception → WTD	0.031

Source: Computed from University of Malaya survey.

SES: socioeconomic status; DP: donation perception; WTD: willingness to donate.

^a Existence of statistically significant relationship at 1%.

The results from Model 2 show that altruism remains the most significant influence on WTD even when considered alongside other influences. However, when altruism is used as a mediator, the coefficients of the component variable of DP rise: that is, attitude (from 0.182 to 0.223), trust (from 0.145 to 0.186), and knowledge (from 0.138 to 0.177) (Table 5). Therefore, the results suggest that changing people’s attitudes about deceased organ donation and elaborating on the positive aspects of donation as a “gift of life to humans” enhance altruistic behavior in potential donors. Also, having a transparent donation process that provides detailed information about bereaved families, as well as gaining confidence and trust on authorities, doctors, and nurses involved in transplantation can promote further altruism. Furthermore, providing grounds for public to gain more knowledge about transplantation can stimulate the philanthropic sense, which can increase WTD. Among the components of SES, Education (0.079) has a higher impact on WTD compared to occupation (0.024) and income (-0.014). Negative coefficient associated with income indicates that individuals in higher income category are less willing to donate organs upon death. Retaining altruism as the mediator, the indirect effect of education and occupation increases to 0.105 and 0.041, respectively (Table 5). However, the coefficient associated with income becomes insignificant. These results suggest that education and occupation (but not income) play an important role in evoking altruism and consequently WTD.

Table 5.

Mediating role of altruism in the relationship between socioeconomic status and donation perception, and WTD.

Hypothesis	Value
Income → WTD	–0.014^a
Education → WTD	0.079^a
Occupation → WTD	0.024
Trust → WTD	0.145^a
Knowledge → WTD	0.138^a
Attitude → WTD	0.182^a
Income → Altruism → WTD	0.049
Education → Altruism → WTD	0.105^a
Occupation → Altruism → WTD	0.041^a
Trust → Altruism → WTD	0.186^a
Knowledge → Altruism → WTD	0.177^a
Attitude → Altruism → WTD	0.223^a

Source: Computed from University of Malaya survey.

WTD: willingness to donate.

^a Existence of statistically significant relationship at 1%.

Among the components of financial incentives, only financing the funeral slightly moderated the relationship that attitude (0.053), knowledge (0.038), trust (0.041) have with WTD (Table 6). Insignificant results of moderating effect of cash incentives and bereaved family support expose that cash compensation is not deemed ethical by respondents, as organ donation primarily relies on moral grounds. The acceptance of financing the funeral is significant because people perceive it as an honor rather than financial support. In sum, no form of financial incentives should be used as a means of increasing WTD. Instead, focus should be on altruism, as it emerged as the key influencing factor for the WTD. SES and DP can inculcate the sense of altruism in potential donors. In-depth analysis clearly shows that investing in education and public awareness ensures that adequate knowledge about donation is gained, allowing individuals to attain trust in the process. Surprisingly, the results obtained here revealed a negligible role of cash incentives and deceased family support.

Table 6.

Moderating role of financial incentives in the relationship between socioeconomic status and donation perception, and WTD.

Moderating variable	Relationship	Value
Cash incentives	Income → WTD	0.014
	Education → WTD	0.031
	Occupation → WTD	0.029
	Trust → WTD	0.041
	Knowledge → WTD	0.038
	Attitude → WTD	0.025
Financing funeral	Income → WTD	0.024
	Education → WTD	0.047
	Occupation → WTD	0.028
	Trust → WTD	0.041^a
	Knowledge → WTD	0.038^a
	Attitude → WTD	0.053^a
Bereaved family support	Income → WTD	–0.013
	Education → WTD	0.028
	Occupation → WTD	0.044
	Trust → WTD	0.036
	Knowledge → WTD	0.041
	Attitude → WTD	0.057

Source: Computed from University of Malaya survey.

WTD: willingness to donate.

^a Existence of statistically significant relationship at 1%.

Discussion

Altruism has been shown to function as the main driver of WTD in Malaysia, which is commonly believed to be a self-generating phenomenon. However, the results yielded by this study reveal that even altruism can be evoked by education and awareness about the transplantation process. The evidence indicates that uneducated individuals, who have never performed pro-social acts and have no previous experience of organ transplantation or even blood donation, are those most likely to reject organ donation.⁶⁶

The robustness of the findings suggests that there is a need for government intervention in the donation system. To provoke altruism, governments should take initiatives to establish awareness campaigns, form transparent organ transplantation procedures, and create a venue for close interaction among health authorities, nurses, and doctors. Health authorities and hospital consultants should play proactive roles in gaining public trust to convince potential donors. When people are assured that the transplantation process is ethical and equitable, it is likely that more individuals would exhibit philanthropy so as to become willing donors.⁶² In addition, the younger generation should be taught the benefits of organ donation at the school level. Thus, a relevant curriculum promoting deceased donation as a social norm needs to be devised for pupils. When targeting the less educated and unaware strata of society, it is essential to provide them with relevant knowledge about donation. They should be aware that one deceased body can save or improve the quality of life of other individuals who are in a life-threatening stage.⁶⁷

Owing to the fact that financial incentives have failed to convince organ donors, the core focus of policies should remain on complementing altruism. These initiatives can be considered as complementing the “presumptive approach” in which altruism remains the principal motive. This approach portrays organ donors and recipients as members of a community that derives benefits from the acts of individuals for society’s overall benefit.

Conclusion

The driving force behind this study was the desire to find a solution for low donation rates in countries, such as Malaysia. The study exposed some notable loopholes in the current donation system in Malaysia so as to offer practical solutions with evidence strongly, suggesting the importance of the presumptive approach. The results highlighted the need for raising awareness and expanding public education on organ donation issues, and consequently why governments should adopt a proactive role to stimulate altruism, especially when the government in many countries may not be able to enforce the opt-out system. In addition to political repercussions, the opt-out regime is perceived by many to be a threat to people’s freedom. Against this backdrop, creating awareness programs appears to be the most viable strategy to raise organ donation rates.

Footnotes

Acknowledgements

We are grateful to the Higher Education Ministry, Malaysia for awarding us the funding and the Organ Transplant Unit, Ministry of Health, Malaysia for endorsing the survey.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Ministry of Higher Education of Malaysia under the UM/MOHE High Impact Research Grant (Project No. UM.C/625/1/HIR/MOHE/ASHS/05). The funding bodies had no role in the study design, data collection and analysis, and writing of the paper.

ORCID iD

Hamid Sharif Nia

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