Scientific Papers

Attitudes and factors influencing organ donation decision-making in Damascus, Syria: a cross-sectional study

Organ donation is the key to achieving self-sufficiency in addressing organ failure cases in Syria. While kidney transplantation is prevalent in Syria10, other tissue transplants are scarce, with only one kidney transplant in 1979, three heart transplants in 1990, and two liver transplants in 2017 and 20198,11. In 2019 alone, 5407 renal transplants were performed12, and now, kidney, cornea, and bone marrow transplants are possible13,14. Despite legal provisions prohibiting organ commercialism15,16, most kidney transplants in Syria rely on it10, which poses a risk to society. The only solution is to promote tissue donation through the healthcare system. Therefore, the present study aims to evaluate people’s willingness to donate their body parts through a questionnaire administered to those present at a central hospital in the capital. Academic intellectuals have also expressed their opinions on organ donation, which may influence the public perception and policy making on this issue. A systematic review and a study highlighted the complexity and multifactorial nature of organ donation decision-making, and suggested modifying educational programs, social behavior and school curricula to promote organ donation7. Some studies focused on the opinions of university students, as they represent a potential source of donors and future health professionals, and found that knowledge, awareness, attitude, willingness and trust are important factors that affect their opinions on organ donation3,8,17.

The results of our study demonstrate that 62.8% of respondents were willing to donate their organs after death, which is higher than the rates reported in prior research conducted in Syria, Saudi Arabia, South Korea, and Morocco (51%, 42%, 60.9%, and 57.6%, respectively)8,18,19,20,21, but it is slightly lower than the rate reported in a Jordanian study (72%)22.

Our study found that, similarly to prior research conducted in Syria, Turkey, and Saudi Arabia8,23,24, the primary motivation for organ donation was to help others. This was particularly evident during the survey period, which coincided with a devastating earthquake in Syria and Turkey that brought people together in solidarity, especially from the healthcare perspective, where exceptional care is needed, and organ transplantation plays a crucial role. Another significant motivation was the notion of “why not.” Given that we are discussing donation after death, this suggests that these individuals are not opposed to the principle of donation and are not hindered by any religious or legal barriers. Rather, they prioritize their own safety and recognize that the body holds no importance after death, making organ donation an easy decision.

In terms of obstacles to organ donation, religious beliefs are the most significant deterrent, as observed in previous studies19,25,26. Syria has a predominantly Muslim population, though both Islam and Christianity do not prohibit organ donation. People are cautious about whether donation is a religious taboo or not. It was not confirmed for some time whether organ donation was halal or haram in Islam, but a fatwa was issued by Dar Al Iftaa in Saudi Arabia in 1995, allowing donation. In Syria, the supreme Islamic religious authorities issued a decision in 2001 allowing organ procurement from deceased persons, provided a relative’s approval is obtained12. Nevertheless, some individuals may not be aware of these legislative developments, leading to a lack of knowledge about their religion’s stance on organ donation after death27. However, a previous study in Saudi Arabia reported the opposite, with religious beliefs serving as an incentive for organ donation18. The second most significant obstacle is a lack of knowledge about organ donation, which is unsurprising given the weak scientific awareness and media coverage in this area. Religious beliefs are equally obstructive to both genders, although women are more affected by the lack of knowledge. We speculate that men are more knowledgeable because they are more involved in society, as they are primarily responsible for providing for their families in our Eastern cultures.

There is no effect of age on the decision to donate. In contrast to studies that showed that approval of organ donation is lower among the elderly20,28. We did not find any significant difference among different age groups. We have never witnessed any large-scale awareness campaigns at any time affecting any of the age groups, and the idea of organ donation as a whole is new to the entire Syrian society, young or old. Nor was gender associated with consent to donate, similar to a study23. In contrast to Jordanian and German studies where females are more willing to donate28,29,30. In addition, there is no association between the educational level and the decision to donate, as the issue of organ donation has never been part of any educational path. However, in Moroccan and German studies, a positive effect of a higher level of education was found20,28.

In addition to the challenge of a shortage of donors, which our survey results suggest we may overcome, there are other obstacles to organ transplantation in Syria. We require a donation system and a medical team specializing in organ transplantation at the national level. This includes the need for medical teams to perform transplants, train healthcare staff, and prepare hospitals for successful transplantation16. While the Syrian government initiated a project to start liver transplantation, it was interrupted by the war, and even bone marrow transplants were not adequately organized due to the conflict16. There are two models for the donation system: opt-in and opt-out. However, morally and legally defensible policies for opt-out are challenging in many developing countries31. Furthermore, although we have an organ donation center, it is currently ineffective11,32. It is critical to revitalize the center and establish an institution that safeguards donors from fraud or organ trade. All aspects of the donation process should be transparent and publicly available33, so that people can trust doctors and the healthcare system as a whole. Lack of trust in doctors has been identified as a significant barrier to organ donation in previous studies26. It is crucial to increase awareness of organ donation through social media, healthcare professionals, and educational institutions. Religious awareness may also contribute to the dissemination of organ donation34,35, so it should be an integral part of organ donation awareness campaigns. The family plays a significant role in overturning the desire of a deceased relative to donate their organs36 and can influence the donation decision positively or negatively. Therefore, it is essential to create an awareness platform that targets families as a whole, rather than just individuals, to ensure better awareness and a confirmed decision. By promoting organ donation among prominent individuals, such as notables and medical professionals, Turkey successfully bolstered its organ donation rates, demonstrating the effectiveness of enlisting influential social figures in advocating for this cause37.

Implications and recommendations

The findings of this paper have important implications for improving the organ donation situation in Syria and other similar contexts. First, it is essential to raise public awareness about the religious and legal aspects of organ donation, as well as the benefits and risks involved. This can be done through media campaigns, educational programs, and community outreach initiatives that target both men and women of different age groups and educational levels. Second, it is necessary to establish a national organ donation system that ensures the ethical and transparent allocation of organs, respects the wishes and rights of donors and recipients, and provides adequate support and follow-up for both parties. Third, it is vital to develop the medical infrastructure and human resources required for organ transplantation, such as specialized teams, training programs, and hospital facilities. These steps would help overcome the barriers to organ donation and transplantation in Syria and increase the availability and quality of this life-saving procedure.


The survey questions were limited and did not cover other significant factors that may influence participants’ decisions regarding organ donation. We did not explore the topic of organ donation before death. Furthermore, the study was conducted in only one major hospital. Additionally, This study was limited by the use of face-to-face interviews, which may have created a social desirability bias and affected the validity, reliability, and generalizability of the data. While individuals may express support for organ donation to help others, their inclination toward financial gain through organ sales remains uncertain, a predilection that may be accentuated amid the backdrop of Syria’s economic crisis. Discussing organ donation in a society characterized by a pervasive organ trade presents inherent challenges. Consequently, an imperative proposition emerges: the imperative eradication of organ trade as a preliminary measure, followed by the endeavor to disseminate the organ donation within the society. The variance among religions was not part of our discourse, as the focal point of our research was not to scrutinize of religion’s direct influence, but rather to identify the fundamental impediments encountered in the context of donation principles. It is noteworthy that future research endeavors should comprehensively explore the influence of religion on this subject matter.

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