Published online Sep 18, 2026. doi: 10.5500/wjt.117608
Revised: February 7, 2026
Accepted: March 12, 2026
Published online: September 18, 2026
Processing time: 265 Days and 11.2 Hours
Organ transplantation is the definitive treatment for end-stage organ failure, and the gap between organ demand and donation is still a major challenge to overcome. Several countries, including Greece, have reformed their transplant framework to increase organ donation, but the long waiting times and low donor rates point to limited public awareness and engagement. Medical students, as future physicians, have a critical role within transplantation systems, as their knowledge, attitudes and engagement will affect donor identification, the consent processes and how donation is communicated to the public.
To assess Greek medical students’ knowledge and attitudes in order to inform strategies for strengthening organ donation nationally and internationally.
A cross-sectional online survey was conducted between July 2025 and September 2025 across all medical schools in Greece. A 38-item questionnaire covered baseline demographics, knowledge and attitudes toward organ donation and transplantation. Responses were summarized with descriptive statistics, and seven multivariable logistic regression models were used to identify predictors of key outcomes (significance at adjusted P < 0.05).
Among 562 respondents (mean age 21.5 years, 68.3% female), only 13.0% correctly identified all organs trans
Medical students in Greece exhibit strong intentions but limited engagement and mixed knowledge of organ donation. Strengthening transplant education, raising the visibility of national structures and fostering student-led advocacy are essential to converting willingness into action and building public trust.
Core Tip: As future clinicians, medical students will play a pivotal role in counseling families about organ donation. However, this study reveals significant gaps in core transplant knowledge and limited confidence in the Hellenic Transplant Organization. While willingness to donate is high, formal registration remains low, with altruism often tethered to family ties. This intention-behavior gap suggests that current medical education leaves future doctors underprepared to advocate effectively. Encouragingly, prior dialogue and institutional visibility correlate with supportive attitudes. Targeted curricular reform, institutional engagement and student-centered initiatives are therefore essential to bridge these gaps and empower the next generation of clinicians.
- Citation: Symeou S, Karageorgos FF, Markozannes G, Papalois V, Tsoulfas G. Knowledge and attitudes toward organ donation and transplantation among medical students in Greece: A cross-sectional survey. World J Transplant 2026; 16(3): 117608
- URL: https://www.wjgnet.com/2220-3230/full/v16/i3/117608.htm
- DOI: https://dx.doi.org/10.5500/wjt.117608
Organ transplantation is the most advanced therapeutic treatment for patients with end-stage organ failure[1]. That is because it extends survival, restores quality of life and allows recipients to return to ordinary activity[2,3]. In 2023, 172409 solid organ transplants were performed worldwide, representing a 9.5% increase compared to the previous year[4]. Despite this progress, demand continues to outpace supply, and thousands of patients die on wait lists every year[4,5]. Organ donation is an altruistic act and depends on the will of donors and their families[6]. However, as end-stage organ failure becomes more prevalent and life-sustaining therapies such as dialysis keep patients alive longer, the pressure to expand the donor pool increases[7,8]. Healthcare professionals sit at the center of the transplant ecosystem, as they identify and refer potential donors, obtain informed consent, communicate with transplant coordinators, uphold the relevant legal and ethical standards, and contribute to public education[9-11]. Their knowledge and attitudes shape both how well the donation process functions and whether it is conducted ethically[12,13]. Literature affirms that providers who are well informed and supportive of donation are consistently linked to increased donation rates and greater public acceptance[14,15].
Greece has made real progress in recent years through systemic reforms and public awareness campaigns, but underlying shortage persists. In 2023, 1377 individuals were listed for kidney transplantation, with 235 new registrations and 30 deaths occurring while on the waiting list[16]. Although the deceased donation rate rose from 3.5 to 8.3 donors per million population between 2015 and 2023, yet over the same period the average wait for a kidney lengthened from 7.6 years to 9.4 years[16,17]. These data support that the demand for organ grafts has outpaced the organ donations, and sustained, targeted policy is still needed.
Within this context, the present study examines the knowledge and attitudes of Greek medical students about organ donation and transplantation. By identifying the main knowledge gaps and the factors associated with them, it aims to propose targeted educational, institutional, and student-centered measures that could strengthen awareness among future physicians. These measures could be then used as a foundation for informing policies using evidence-based data both in Greece and comparable healthcare systems. This matters partly because of timing: The last comparable study in Greece dates to 2013, before both the coronavirus disease 2019 pandemic and the 2019 recommendations for a national plan on solid organ donation, two milestones that may have significantly shifted public and professional perceptions[18-20].
The study was conducted online from July 2025 to September 2025. Data were collected through a questionnaire built in Google Forms[21], which was embedded in a dedicated web platform so that students at every medical school in Greece could take part on equal footing, irrespective of location or institution (Supplementary Figures 1-5)[22]. The platform also described the study’s aims, facilitated the informed consent process, and safeguarded the anonymity of the participants. No information that could lead to personal identification was collected at any point, in line with the relevant data protection regulations[23]. The questionnaire comprised 38 items grouped into four domains and is provided in Supplementary Table 1, while details on item structure and thematic domains are detailed in Supplementary material. The survey was distributed electronically through the social media accounts of medical student associations, institutional newsletters and official university channels. A pilot test with two medical students was conducted to identify any issues with item wording and to obtain preliminary indications of internal consistency (test-retest reliability). Each student completed the questionnaire twice, at a two-week interval, and Cohen’s kappa was calculated to assess agreement for the categorical items pertaining to knowledge and attitudes (Supplementary Table 2). Their responses were excluded from the final dataset. The target population was estimated at 8400 medical students and the minimum sample size was calculated at 384 using standard parameters [95% confidence interval (95%CI), 5% margin of error], as detailed in Supplementary material.
Submitted questionnaires were reviewed for completeness. Incomplete submissions were excluded to keep the sample size consistent across all items, and the cleaned data were then entered into a password-protected spreadsheet. Including partially completed questionnaires in our analysis would have produced different denominators from one item to the next, complicating comparisons and weakening the reliability of the reported proportions. Exclusion also reduces the risk of systematic bias, since students who skip particular questions may hold fundamentally different views from those who finish the survey. Given the sensitivity of organ donation and transplantation and the ethical constraints involved, no data imputation or ad-hoc handling of incomplete entries was applied. Students were classified as preclinical (years 1-3) or clinical (years 4-6) to reflect the differing levels of clinical exposure within Greek medical schools. Descriptive statistics were used to summarize participant characteristics and survey responses.
In order to examine potential associations between selected knowledge and attitude-related items and both baseline characteristics and modifiable predictors, seven multivariable regression models (five binary and two multinomial) were developed. Since these models were intended to assess the presence of associations rather than serve as precise prediction tools, they were not piloted, tuned, or optimized. Consequently, the results should be interpreted as measures of relationship and direction rather than validated indicators of predictive performance. Dependent variables included the correct identification of the organs transplanted from deceased and living donors in Greece, perceived graft quality by donor type, willingness for posthumous donation, willingness for living donation, possession of a donor card, and the perceived sufficiency of the Hellenic Transplant Organization (HTO) efforts to promote organ donation. Independent variables (predictors) included the place of permanent residence, year of study, specialty preference, blood donation status, prior discussion about organ donation, awareness of the HTO and personal acquaintance with a transplant recipient. Variables were selected based on their relevance to educational and policy interventions, following consensus reached through discussions among the authors. Supplementary Table 3 summarizes the rationale for each variable.
Statistical analyses were performed using R (version 4.4.2), with significance set at P < 0.05. To account for multiple comparisons, P values were adjusted using the Benjamini-Hochberg method. All statistical inferences were undertaken and reviewed by a certified biostatistician.
The study adhered to the Strengthening the Reporting of Observational studies in Epidemiology guidelines and was conducted in accordance with the principles of the Declaration of Helsinki[23,24]. Ethics approval was obtained from the Institutional Review Board of Aristotle University of Thessaloniki (Approval No. 9/15.7.2025). Informed consent was obtained from all participants, with medical student status being the only additional inclusion criterion.
A total of 602 medical students participated in the survey (response rate: 7.17%). After 40 incomplete submissions were excluded, 562 valid responses remained. Most participants were female (68.3%), with a mean age of 21.5 (SD 2.4) years. The majority lived in cities of more than 100000 inhabitants (55.2%) and were in their clinical years (60%). On the Greek grade point average scale (0-10), 58.8% fell in the “very good” band (6.50-8.49), 19.8% in the “excellent” band (8.50-10.00), and 4.5% had in the “good” band (5.00-6.49). For specialty preference, 27.4% leaned toward non-surgical fields, 26% toward surgical fields, and 45.9% were still undecided. Only 37.7% identified as regular blood donors. Full demographics and baseline characteristics are presented in Table 1.
| Baseline characteristics | Categories | |
| Gender | Male | 178 (31.7) |
| Female | 384 (68.3) | |
| Age | Not applicable | 21.5 ± 2.4 |
| University | National and Kapodistrian University of Athens | 75 (13.4) |
| Aristotle University of Thessaloniki | 163 (29.0) | |
| University of Ioannina | 132 (23.5) | |
| University of Patras | 41 (7.3) | |
| University of Crete (Heraklion) | 45 (8.0) | |
| University of Thessaly (Larissa) | 30 (5.3) | |
| Democritus University of Thrace | 76 (13.5) | |
| Place of permanent residence | City with > 100000 inhabitants (large city) | 310 (55.2) |
| City with < 100000 inhabitants (small city) | 153 (27.2) | |
| Rural area | 99 (17.6) | |
| Year of study | 1st-3rd (preclinical) | 225 (40) |
| 4th-6th (clinical) | 337 (60) | |
| Grades | Good (5.00-6.49) | 25 (4.5) |
| Very good (6.50-8.49) | 331 (58.8) | |
| Excellent (8.50-10) | 111 (19.8) | |
| No grades assigned yet | 95 (16.9) | |
| Preferred specialty | Surgical | 150 (26.7) |
| Non-surgical | 154 (27.4) | |
| Undecided | 258 (45.9) | |
| Regular blood donation | Yes | 212 (37.7) |
| No | 350 (62.3) |
Knowledge of deceased-donor transplantation was limited. While 35% of students said they were aware of which organs are transplanted from deceased donors in Greek hospitals, only 13% correctly identified all five (kidneys, liver, heart, lungs, and pancreas). Misconceptions were common, with some students listing the brain (2.1%), the large intestine (18.0%), the adrenal glands (19.8%) and the small intestine (23.7%; Figure 1). Regarding living donation, 31% reported awareness, and 62% correctly identified both the kidney and the liver, though some also listed the lungs (17.1%), heart (8.9%), and pancreas (7.5%; Figure 1). Among students who described themselves as aware, the proportion who answered correctly was 21% for deceased donation and 71% for living donation (Figure 2; Supplementary Tables 4 and 5). Nearly half of the students (48.7%) were unsure whether living-donor grafts perform better than deceased-donor grafts, and 91.5% believed that living donation carries serious risks beyond the usual surgical complications. Awareness of institutional structures was limited, with more than three-quarters (77.2%) not knowing that the HTO is the national authority coordinating organ donation and transplantation in Greece. Self-rated familiarity with the legal and procedural framework was also low. On a 5-point scale, 47.5% placed their knowledge of national transplant legislation at the lowest level and fewer than 1.0% at the highest, while only 32.0% reported feeling familiar with the allocation process. On objective questions, 84.7% of the students correctly identified the key prioritization criteria (medical urgency, pediatric status, and sensitization), and 90.9% recognized that not every physician is authorized to declare a patient dead. Although 79.0% knew the terms “donation after brain death” and “donation after circulatory death”, 40.8% believed that both are currently used in Greece. Donor eligibility was poorly understood, with 85.2% assuming that people with systemic illnesses cannot become donors. Self-rated familiarity with transplant candidacy was also low, with 23.3% choosing the lowest level on the 5-point scale and only 1.6% the highest. Finally, 58.4% reported being unfamiliar with xenotransplantation. Supplementary Table 6 presents students’ responses to the knowledge-related items.
Attitudes toward donation were generally favorable, even if formal commitment was uncommon. Overall, 63.4% of respondents said they were willing to donate their organs after death, yet only 8.2% held a donor card. Among those willing to donate, just 12.4% were actually registered (Supplementary Figure 6). Willingness for living donation was higher still (95.0%), though it was often conditional with 74.0% said their decision would depend on the recipient. Asked whom they would donate to, most named a close family member (79.0%) or a child (16.0%), while 26.0% said they would donate regardless of recipient’s identity. In a hypothetical scenario in which they themselves needed a transplant, 57.1% would prefer a graft from a living donor. Personal exposure to transplantation was limited and only 21.2% knew a transplant recipient or a candidate. Even so, 67.3% had discussed donation with friends or relatives, and within that group just 24.1% had a relative with direct transplantation experience (Supplementary Figure 7).
Most (65.1%) felt the HTO is not doing enough to expand the national donor pool. At the same time, 86.8% a role for medical students in promoting organ donation, and 69.0% favored a mandatory transplantation course in the medical curriculum. Similarly, 84.5% agreed that innovations such as artificial intelligence-assisted donor-recipient matching and improved preservation technologies could raise donation rates and improve transplant outcomes in Greece. Table 2 presents students’ responses to the attitude-related items.
| Question | Category | n (%) |
| Relative who has undergone organ transplantation or is waiting for a compatible graft | Yes | 119 (21.2) |
| No | 443 (78.8) | |
| Discussing organ donation and transplantation with family and friends | Yes | 378 (67.3) |
| No | 184 (32.7) | |
| Willingness to donate after death | Yes | 356 (63.4) |
| No | 206 (36.6) | |
| Possessing a donor card (registered donor) | Yes | 46 (8.2) |
| No | 516 (91.8) | |
| Willingness to become a living organ donor | Yes | 534 (95.0) |
| No | 28 (5.0) | |
| Preference for a specific recipient among medical students willing to become living organ donors (leave blank if you would consent to become a donor regardless of your relationship with the recipient/unconditionally) | A close family member (e.g., parent, sibling, spouse, grandparent etc.) | 312 (79.0) |
| Own child | 63 (16.0) | |
| Child regardless of relationship | 12 (3.0) | |
| A close friend but not family | 8 (2.0) | |
| Conditional donation to specific recipients | 395 (74.0) | |
| No preference (unconditional) | 139 (26.0) | |
| Preference for type of graft for potential own needs | Living-donor graft | 321 (57.1) |
| Deceased-donor graft | 241 (42.9) | |
| Perceived efficiency of HTO’s efforts to promote organ donation | Yes | 196 (34.9) |
| No | 366 (65.1) | |
| Medical student’s role in promoting organ donation and transplantation in Greece | Yes | 488 (86.8) |
| No | 74 (13.2) | |
| Implementation of mandatory transplant course in medical curriculum | Yes | 388 (69.0) |
| No | 174 (31.0) | |
| Implementation of modern technologies would expand the donor pool in Greece | Yes | 475 (84.5) |
| No | 87 (15.5) |
Several associations reached statistical significance. Students who had previously discussed organ donation with their friends or relatives were more likely to express willingness for posthumous donation [odds ratio (OR) = 2.38, 95%CI: 1.64-3.47, adjusted P < 0.001]. Awareness of the HTO was strongly associated with possession of a donor card (OR = 6.60, 95%CI: 3.25-13.91, adjusted P < 0.001), and with the perception that the HTO is making sufficient efforts to promote organ donation nationally (OR = 2.21, 95%CI: 1.43-3.41, adjusted P = 0.01). Additionally, students with a preference for surgical specialties were more likely to believe that grafts from living donors are superior to those from deceased donors (OR = 2.15, 95%CI: 1.09-4.22, adjusted P = 0.027).
Several other associations were statistically significant in the initial analysis but did not remain significant after correction for multiple comparisons. Specifically, students in clinical years were more likely to consider posthumous donation. Willingness for living donation was also higher among students with a relative who had undergone transplantation and among those aware of the HTO. Furthermore, donor card possession was higher among students who had previously discussed organ donation with relatives or friends. Finally, perceptions of the HTO’s efforts differed by blood donation status and by preference for a surgical specialty. Table 3 summarizes the results of the multivariable regression analyses. Supplementary Table 7 provides the validity metrics and overall measures of fit for the regression models.
| Predictors | Dependent variables/outcomes [OR (95%CI), unadjusted P value, adjusted P value] | ||||||
| Independent variables | Willingness to donate after death (yes vs no) | Willingness to become a living organ donor (yes vs no) | Donor card possession (yes vs no) | Correct knowledge of deceased donor organs (correct vs wrong) | Correct knowledge of living donor organs (correct vs wrong) | Perceived quality of graft per donor type (living is better vs no difference) | Perceived sufficiency of HTO efforts (yes vs no) |
| Residence (big city vs rural) | 0.82 (0.49-1.34), P = 0.43, adjusted P = 0.77 | 0.78 (0.46-1.33), P = 0.36, adjusted P = 0.81 | 1.55 (0.62-4.49), P = 0.38, adjusted P = 0.77 | 0.94 (0.49-1.86), P = 0.84, adjusted P = 0.95 | 1.02 (0.63-1.63), P = 0.94, adjusted P = 0.96 | 1.28 (0.67-2.44), P = 0.45, adjusted P = 0.45 | 1.04 (0.63-1.73), P = 0.89, adjusted P = 0.95 |
| Residence (small city vs rural) | 0.91 (0.52-1.59), P = 0.75, adjusted P = 0.93 | 1.04 (0.58-1.88), P = 0.89, adjusted P = 0.35 | 0.97 (0.31-3.22), P = 0.96, adjusted P = 0.96 | 0.81 (0.37-1.76), P = 0.58, adjusted P = 0.88 | 0.79 (0.47-1.34), P = 0.39, adjusted P = 0.77 | 0.94 (0.45-1.96), P = 0.87, adjusted P = 0.87 | 1.16 (0.66-2.03), P = 0.61, adjusted P = 0.89 |
| Semester (clinical vs preclinical) | 1.54 (1.05-2.62), P = 0.028, adjusted P = 0.16 | 0.68 (0.45-1.05), P = 0.80, adjusted P = 0.26 | 1.83 (0.76-4.89), P = 0.20, adjusted P = 0.64 | 1.14 (0.66-2.02), P = 0.64, adjusted P = 0.90 | 1.20 (0.83-1.76), P = 0.32 adjusted P = 0.77 | 1.54 (0.90-2.65), P = 0.11, adjusted P = 0.11 | 0.96 (0.65-1.43), P = 0.84, adjusted P = 0.95 |
| Specialty preference (surgical vs non-surgical) | 0.92 (0.56-1.52), P = 0.75, adjusted P = 0.93 | 1.14 (0.65-2.00), P = 0.66, adjusted P = 0.82 | 0.48 (0.20-1.11), P = 0.092, adjusted P = 0.38 | 0.88 (0.44-1.73), P = 0.70 adjusted P = 0.93 | 0.79 (0.49-1.28), P = 0.34, adjusted P = 0.77 | 2.15 (1.09-4.22), P = 0.028, adjusted P = 0.027 | 0.58 (0.36-0.94), P = 0.027, adjusted P = 0.16 |
| Discussion with friends and family (yes vs no) | 2.38 (1.64-3.47), P = 5.94 × 10-6, adjusted P < 0.001 | 0.77 (0.51-1.18), P = 0.24, adjusted P = 0.86 | 3.93 (1.49-13.59), P = 0.012, adjusted P = 0.10 | 1.17 (0.67-2.09), P = 0.59, adjusted P = 0.88 | 1.25 (0.87-1.82), P = 0.23, adjusted P = 0.64 | 0.72 (0.42-1.22), P = 0.22, adjusted P = 0.22 | 1.19 (0.81-1.78), P = 0.38, adjusted P = 0.77 |
| Relative who has undergone organ transplantation or is waiting for a compatible graft (yes vs no) | 0.88 (0.57-1.38), 0.59, adjusted P = 0.88 | 1.65 (1.03-2.64), P = 0.038, adjusted P = 0.26 | 0.77 (0.32-1.69), P = 0.53, adjusted P = 0.88 | 1.33 (0.72-2.35), P = 0.34, adjusted P = 0.77 | 1.10 (0.71-1.70), P = 0.68, adjusted P = 0.92 | 1.01 (0.55-1.87), P = 0.97, adjusted P = 0.97 | 0.85 (0.53-1.32), P = 0.47, adjusted P = 0.81 |
| Blood donation (yes vs no) | 1.40 (0.96-2.06), 0.082, adjusted P = 0.38 | 1.23 (0.82-1.86), P = 0.32, adjusted P = 0.55 | 1.82 (0.93-3.62), P = 0.084, adjusted P = 0.38 | 1.24 (0.73-2.07), P = 0.42, adjusted P = 0.77 | 1.06 (0.73-1.52), P = 0.77, adjusted P = 0.93 | 0.94 (0.57-1.55), P = 0.80, adjusted P = 0.80 | 0.61 (0.41-0.89), P = 0.012, adjusted P = 0.10 |
| Acknowledgment of HTO (yes vs no) | 1.40 (0.88-2.25), 0.16, adjusted P = 0.59 | 1.69 (1.05-2.74), P = 0.032, adjusted P = 0.50 | 6.60 (3.25-13.91), P = 3.03 × 10-7, adjusted P < 0.001 | 1.44 (0.80-2.55), P = 0.23, adjusted P = 0.64 | 1.26 (0.82-1.98), P = 0.30, adjusted P = 0.77 | 1.63 (0.92-2.88), P = 0.093, adjusted P = 0.094 | 2.21 (1.43-3.41), P = 0.0034, adjusted P = 0.01 |
These results reveal both gaps and strengths in medical students’ knowledge and attitudes toward organ donation and transplantation, with clear implications for medical education and public health policy. As the future healthcare workforce, medical students will be expected to counsel patients and their families and to actively participate in transplantation pathways[25,26]. Their level of understanding and engagement may therefore shape not only their own attitudes but also how well the national transplant system operates[27].
A central finding was that most students were not fully aware of which organs are transplanted in Greece. Fewer than one in five correctly identified all five organs currently procured from deceased donors, whereas a Canadian survey found that 60% of medical students correctly named the organs routinely used[28]. Knowledge of living donation was greater, with 62% identifying the kidney and liver, but incorrect responses remained common. Interestingly, no difference in knowledge was observed between students in the clinical and preclinical years, suggesting that these gaps persist throughout medical school. The latter observation may be explained by how transplantation is taught. In Greece, it is covered only briefly, usually as a small component within broader courses such as nephrology, immunology, surgery, and emergency medicine. No medical school offers it as a mandatory course, and where dedicated teaching does exist, it tends to be confined to elective courses that emphasize technical details rather than donation pathways, legislation, allocation and clinical-decision making. Clinical exposure during rotations may therefore be inconsistent, leaving key concepts unconsolidated and allowing misconceptions to persist. Taken together, these findings support the need to integrate organ donation and transplantation more deliberately in the medical curriculum, so that students graduate with a consistent knowledge base[29-31].
Responses on living donation organs offer a complementary perspective. Although living-donor liver transplantation (LDLT) remains an uncommon practice in Europe, it is increasingly performed in high-volume centers in India, Türkiye, South Korea, and the United States[4,32,33]. Greece by contrast, is still developing LDLT, with only two such procedures performed nationally in 2024[32,34]. The fact that more than half of students knew that LDLT has been carried out in Greece suggests they are keeping pace with recent national developments, and is consistent with their broader engagement and support for educational initiatives Ultimately, these responses further support the view that structured teaching could build on this existing interest and sustain longer-term involvement in transplantation[35].
Students were also notably uncertain about how well living-donor grafts perform. Many did not know whether these outperform grafts from deceased donors, though those interested in surgical specialties were more likely to recognize their advantage. Donor safety was another common concern, with more than 90% believing that living donation carries serious risks beyond the standard surgical complications. This contrasts with international evidence, which shows low perioperative morbidity and favorable long-term outcomes after living kidney donation[36-38]. These views may reflect a limited ability to find, appraise, and interpret the outcomes reported in international studies, along with little direct contact with living donors and transplant recipients. Without the chance to observe typical recovery and long-term follow-up in both donors and recipients, students may overestimate how often rare adverse events occur. Greece’s comparatively low transplant volumes likely compound the problem by further limiting opportunities to see expected outcomes in routine practice[39,40]. Left unaddressed, these perceptions may weaken future physicians’ ability to counsel patients and to advocate for living donation as a central strategy against organ shortages.
Especially concerning was that more than three-quarters of the respondents were unaware of the HTO and its role as the central coordinating body for organ donation in Greece. This is important, as in countries with high-performing transplant systems, such as Spain, the national transplant organization is not only a well recognized structure but also closely associated with sustained success in organ donation[41]. A similar relationship appeared in the present study, where students who knew of the HTO, were more likely to be registered donors and to regard its efforts as sufficient, reflecting how closely institutional visibility and trust go together[41]. Raising the HTO’s profile during undergraduate training may therefore be a practical way to foster early engagement and support informed advocacy from the start of medical practice.
Low awareness of the HTO may also help explain why formal registration remained uncommon despite high willingness to donate posthumously. While 63% of respondents reported being willing to donate, only 8% held a donor card, and just 12% of those willing were registered. This intention-behavior gap has been well documented internationally, but it is particularly wide here. Earlier surveys of Greek medical students have likewise found low donor-card possession (5.6%-8.7%), whereas markedly higher rates have been reported elsewhere, including 31% in Poland and 82% in Canada[20,42-44]. Other factors may also contribute to this discrepancy, including uncertainty about relatives’ wishes and unfamiliarity with Greece’s soft opt-out framework, both of which can deter formal registration. Negative perceptions of national efforts may further reduce the motivation to act, as reflected in the 65% who felt that the HTO is not doing enough to expand the donor pool.
A similar pattern emerged for living donation, where attitudes were broadly favorable but often hinged on who the recipient would be. Although 95% of students said they were willing to donate during their lifetime, only about a quarter were willing to do so regardless of the recipient’s identity. This conditionality may reflect prevailing sociocultural norms in Greece, where altruistic acts tend to be directed toward family and close social ties[45,46]. It may also be shaped by the current legal framework, which generally limits living donations to relatives and close acquaintances, with kidney paired exchange being a notable exception[47].
Improving knowledge and engagement will require the involvement of medical schools, national transplant bodies, and students themselves[48,49]. A transplantation course should become an established part of formal medical education, beginning in the late preclinical years and revisited during clinical rotations so that learning builds over time. It should cover the ethical principles, the procedural and legislative framework of organ donation, and the role of national structures in the field. Teaching should also emphasize active-learning approaches, including case-based discussions, critical appraisal of the transplantation literature, and simulated graft allocation and prioritization, which develop reasoning skills and connect knowledge to real clinical situations[50,51]. Supervised clinical exposure, such as observing donor and candidate evaluation, allocation, and transplant care directly, would then connect what students learn to what they see in practice[52]. Strengthening the HTO’s visibility and credibility is equally important[41]. A student advisory council within the HTO, with representatives from every national medical school, could establish a direct channel of communication between students and the HTO. Through this, students would gain further exposure to how the organization operates, and could work with it to shape educational policies, increase transparency, and build trust. Such involvement would also give students early experience of leadership and help them become effective advocates for organ donation[53]. Another priority is addressing the gap between intention to donate and registration. One way to do this is to build digital registration into the systems students already use, such as university portals, student ID systems, medical student associations, and national electronic health records, lowering the administrative barriers that keep students willing to donate from registering. Together, simpler registration and broader digital outreach could integrate donation into students’ developing professional identity and daily life[54-56]. Students themselves can contribute through peer-led educational and research initiatives. Backed by faculty mentors and transplant professionals, these could rely on direct conversation between peers, which was linked to greater donor willingness in the present study[53,57,58]. Conferences and targeted campaigns could complement these efforts by building knowledge and bringing more attention to donation. Testimonies from living donors and transplant recipients shared through university lectures or professional meetings, could counter exaggerated fears about donor safety and show the difference transplantations can make while opening up discussions and building a more evidence-based understanding[59,60]. Finally, digital tools including interactive learning platforms, mobile applications, and virtual reality simulations, could reinforce these efforts, keeping students engaged and deepening their understanding of transplant procedures[61-63]. In summary, these proposals outline a feasible and adaptable framework to strengthen medical education in organ donation and transplantation. Although developed in the Greek context, its emphasis on curriculum integration, institutional engagement, and student-centered initiatives is likely to translate to other settings facing similar educational and system-level barriers. These approaches may therefore inform international efforts to improve donation literacy and support sustainability of transplantation programs worldwide. Table 4 summarizes these future directions and sets out specific, actionable recommendations for implementation.
| Domain | Action: Future perspectives |
| Educational | Introduction of transplantation as a mandatory module in medical curricula: (1) Longitudinal beginning in the preclinical years and reinforced during clinical years; and (2) Cover ethical principles, the procedural and legislative framework of organ donation, and the role of national structures in the field |
| Adoption of active learning approaches: (1) Case-based teaching; (2) Critical appraisal of the transplantation literature; and (3) Simulated graft allocation and recipient prioritization | |
| Clinical immersion of students: Structured, direct observation of donor and candidate evaluation, allocation, and transplant care | |
| Institutional | Strengthening the HTO’s visibility and credibility: (1) Establish a student advisory council with representatives from every national medical school; (2) Give students firsthand exposure to how the organization operates; and (3) Promote transparency and leadership |
| Modernizing donor registration: Build digital registration into the systems students already use, such as university portals, student ID systems, medical student associations, and national electronic health records | |
| Student-centered | Encouraging peer-led initiatives: (1) Support peer-led educational and research initiatives that rely on direct conversation between peers; and (2) Conferences and targeted campaigns for medical students |
| Promoting direct interaction with living donors and organ recipients: Testimonies from living donors and transplant recipients, at conferences or university events | |
| Technological tools to sustain engagement and deepen understanding: (1) Interactive learning platforms; (2) Mobile applications; and (3) Virtual reality simulations of transplant procedures |
This study has several limitations. First, its cross-sectional design precludes causal inference thus, observed associations should be interpreted as descriptive rather than explanatory. Second, the response rate was low, with only 562 of approximately 8400 medical students responding (response rate 7.17%). This introduces the risk of self-selection bias and non-response bias, as participation is more likely among students with higher interest or prior exposure to transplantation. Consequently, the respondents may not represent the broader Greek medical student population, and these findings should not be treated as population estimates. The direction of bias remains uncertain. Knowledge and positive attitudes may be overestimated if respondents were disproportionately motivated or better informed, while the behavior-intention gap in the wider population could be patterned differently than the present data suggest. Third, the assessment of measurement properties was limited. Internal consistency and temporal stability were explored with only two students, which is an insufficient number to support any claim of validity or reliability. This pilot check should therefore be read only as an indicator of item comprehension, not as psychometric evidence. The regression analyses, for their part, were meant to identify associations rather than deliver clinical-grade predictions, so the models were not optimized for discriminative performance. Reliance on self-reported data also introduces the possibility of recall and social desirability bias. Finally, splitting students into two groups (preclinical and clinical) may oversimplify their exposure, since curricula differ across institutions and related concepts are introduced unevenly through each medical program.
This study revealed mixed knowledge among Greek medical students and a profound gap mismatch between willingness to donate, and actual registration. However, their intentions and attitudes were largely positive, and many supported future reforms and more active involvement of medical students in organ donation efforts. Communication and institutional visibility also appear to matter, as both prior discussion of donation and awareness of the HTO were associated with greater engagement. Taken together, these findings suggest that investing in medical students while they are still in training represents an important and promising approach with the potential to build a more effective donation system in the years ahead.
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