Awareness and attitudes towards organ donation among Egyptian physicians: A single-centre study from a tertiary academic hospital

Abstract

BACKGROUND

In Egypt, living donor liver transplantation is currently the only option for patients with end-stage liver disease. Although efforts to establish a national deceased organ transplantation programme are currently ongoing, implementation of the organ transplantation law faces challenges in terms of executive regulations and cultural barriers. Continuous medical education is must for promoting organ donation successfully.

AIM

To evaluate awareness of and attitudes towards organ donation programmes among Egyptian physicians.

METHODS

This online cross-sectional survey was conducted at Ain Shams University Hospitals for more than 1 month (August 2024). A questionnaire covering demographics, knowledge, and attitudes towards organ donation was distributed through an online platform.

RESULTS

A total of 391 physicians participated (42.9% MD holders, 35.9% master’s degree holders, and 21.2% residents). Most participants (79.6%) represented medical specialties. Satisfactory general knowledge of organ transplantation was reported by only 20% of the participants, whereas 50% were aware of the Egyptian organ transplantation law. With respect to attitudes, 42% accepted being a living donor, and 38% would donate to a relative. With respect to deceased donations, 40% agreed to be donors, whereas 28% remained undecided.

CONCLUSION

Despite limited specific knowledge of organ donation and transplantation laws, Egyptian physicians demonstrate a generally positive attitude towards becoming organ donors. Continuous medical education is essential to promote organ donation successfully.

Key Words: Living donor liver transplantation; Deceased transplantation; Organ donation; Awareness and attitude; Deceased organ donation

Core Tip: In this cross section survey of a total of 391 physicians participated (42.9% MD holders, 35.9% Master’s degree holders, and 21.2% residents). Most (79.6%) represented medical specialties. Satisfactory general knowledge of organ transplantation was found in only 20% of participants, while 50% were aware of the Egyptian organ transplantation law. Regarding attitudes, 42% accepted being a living donor, and 38% would donate to a relative. For deceased (cadaveric) donation, 40% agreed to be donors, while 28% remained undecided. The survey highlight a poor specific knowledge regarding organ donation and transplantation laws, However, Egyptian physicians demonstrate a generally positive attitude toward becoming organ donors.

INTRODUCTION

Solid organ transplantation is a life-saving procedure for patients with end-stage organ failure[1]. This rapidly evolving branch of modern medicine has saved countless lives and reduced the need for invasive treatments such as dialysis, long-term oxygen therapy, or mechanical ventilation[2]. Although organ donation has significantly improved survival rates and quality of life, a critical shortage of available grafts remains a global challenge[3].

In Egypt, solid organ transplantation is currently limited to living donor kidney and liver surgeries. Patients with other terminal conditions, such as heart failure or severe malabsorption, have no curative options unless deceased donor transplantation is fully implemented[4]. Although the Egyptian Parliament legalized organ procurement from deceased donors in 2010, clinical practice remains largely restricted to living donors[5]. While highest Islamic and Orthodox religious authorities in the country have approved deceased donation, some still stress that organs cannot be procured from a brain-dead person[6]. Overcoming cultural and logistical obstacles is mandatory for establishing a successful national programme. Many physicians and health care providers disagree on the definition of death, and country-wide unacceptance of deceased donation persists among the general population. For example, ancient Egyptians and pharaohs preserved their postmortem bodies in preparation for resurrection and the afterlife. Other ancestral rituals reflect the belief that the body is a gift from God and must be returned “in peace”, not “in pieces” to God. These beliefs hinder people’s acceptance of deceased donation. Assessing the knowledge and attitudes of physicians is a vital first step in this process[6,7].

MATERIALS AND METHODS

Study design and population

This online cross-sectional survey was conducted at Ain Shams University Hospitals and the Faculty of Medicine in August 2024. Eligible participants included graduates, house officers, residents, and staff physicians from all departments. Undergraduate students were excluded.

Study procedure

The survey link was distributed via social media platforms (WhatsApp and Messenger) and through direct personal communication. A cover letter outlined the inclusion criteria and invited participants. To prevent missing data, answering all survey questions was mandatory.

Questionnaire tool

The questionnaire was adapted from validated literature[7,8] and consisted of three sections (Supplementary material).

Socio-demographics: Data collected included age, sex, marital status, religion, residence, specialty, and academic degree.

Knowledge and awareness: Eleven questions on general organ donation and five questions on Egyptian logistics/law were adapted from Hamed et al[8]. Each correct answer was awarded one point. Individuals with scores ≥ 60% were categorized as having “adequate knowledge”.

Attitudes: This section included questions concerning willingness to donate, factors influencing decisions, consent protocols, and methods for promoting donation.

Sample size

To calculate sample size, we reviewed results from a previous study[8] which showed that 65% of the studied group had adequate knowledge about organ donation with a margin of error +/- 5 at 95%CI, a calculated sample size of at least 350 participants was sufficient to measure the knowledge and the attitude of the physicians towards organ donation. Our study included a non-randomized sample of 391 Egyptian physicians working at Ain shams university hospitals. Sample size was calculated using PASS 15 program.

Ethical statement

The current research was conducted in accordance with good clinical practice and the principles outlined in the Declaration of Helsinki after the approval of the research protocol was obtained from the Faculty of Medicine, Ain Shams University Ethical Committee (FMASU-R38/2025). Informed consent was obtained electronically before the survey commenced. Data privacy and confidentiality were strictly maintained.

Statistical analysis

Data were analyzed using IBM SPSS Statistics version 24. Quantitative data are presented as mean ± SD, while categorical data are expressed as frequencies and percentages. The χ² test was used for group comparisons, with a P value ≤ 0.05 considered statistically significant. Please ensure that the intended meaning has been maintained in this edit. Please ensure that the intended meaning has been maintained in this edit.

RESULTS

Demographics and professional characteristics

The mean age of the 391 participants was 36.3 ± 9.8 years. The cohort comprised 284 (72.6%) females and 107 (27.4%) males. Most participants resided in urban areas (91.6%). Professional backgrounds included medical (74.9%), academic (16.1%), and surgical (9%) specialties. The academic qualifications of the participants were as follows: MD/professors (35.1%), master’s degree holders (34.5%), and residents/house officers (30.4%). Only 20.7% of the participants had earlier experience working with a transplant team (Table 1).

Table 1 Sociodemographic and academic characteristics, n (%).

Variables			Total 391 (100%)
Sociodemographic characteristics	Age (mean ± SD), range (min-max)	36.3 ± 9.8 years, 51 (19-70)
	Sex	Male	107 (27.4)
		Female	284 (72.6)
	Marital status	Single	130 (33.2)
		Married	244 (62.4)
		Divorced	4 (1.1)
		Widow	13 (3.3)
	Religion	Muslim	373 (95.4)
		Christian	18 (4.6)
	Residence	Urban	358 (91.6)
		Rural	33 (8.4)
Academic characteristics	Speciality	Academic	63 (16.1)
		Medical	293 (74.9)
		Surgical	35 (9.0)
	Title, MD degree	Resident/house officer	119 (30.4)
		Master’s degree; assistant lecturer/specialist	135 (34.5)
		Lecturer/consultant	70 (18)
		Assistant professor	13 (3.3)
		Professor	54 (13.8)
	Previous experience with transplant team	Yes	81 (20.7)
		No	310 (79.3)

Knowledge and awareness

Questions assessing physicians’ awareness of organ donation were divided into two groups based on the percentage of correct responses; three questions had more than 60% correct answers (Figure 1A). These three questions were related to the knowledge that brain-dead patients can serve as potential organ donors, the source of donated organs, and the understanding of brain death, respectively. The correct answers for these questions were provided by 294 (75%), 340 (87%), and 372 (95%) physicians, respectively. For eight questions, fewer than 60% of the answers were correct (Figure 1B). These questions were about immunological matching before donation; 35 physicians (9%) answered correctly, indicating the frequency of risks for living donors; 126 physicians (32.2%) responded correctly, and 148 of the participating physicians (37.9%) knew the Egyptian laws governing organ donation. Knowledge about the possibility of accepting grafts from patients with malignancy, hepatitis, diabetes mellitus or cardiovascular disease was correct among 70 (17.9%), 83 (21.2%), 130 (33.2%), and 89 (22.8%) physicians, respectively. A total of 118 physicians (30.2%) had correct knowledge of the age limits for living donation. Among participants who had more than 60% correct answers, 68 (17.3%) physicians had good (adequate) knowledge scores and 324 (82.7%) had poor (inadequate) knowledge scores (Figure 2). The responses to the set of questions about knowledge of Egyptian logistics and practice are presented in Figure 3; the initiation of the Egyptian renal transplantation programme was known to 178 physicians (45.5%), and the beginning of the liver transplantation programme in Egypt was known to 197 physicians (50.4%). Only 60 participating physicians (15.5%) were aware that transplantation from deceased people is legally approved in Egypt. The source of solid organs and the supervision and regulatory policies of the Ministry of Health for organ transplantation were known to 220 (56.3%) and 305 (78%) of the participating physicians, respectively.

Figure 1 Knowledge questions for organ donation. A: > 60% correct answers; B: < 60% correct answers.

Figure 2 General knowledge about organ transplantation.

Figure 3 Knowledge about Egyptian logistics and practice of organ transplantation.

Attitudes and agreement towards organ donation

Most participants either agreed (n = 183, 46.8%) or strongly agreed (n = 167, 42.7%) that organ transplantation should be promoted, whereas only five (1.3%) strongly disagreed. A majority believed that priority should be given to critically ill patients, with 56% (n = 217) agreeing and 26% (n = 103) strongly agreeing. With respect to living donation, 163 physicians (41.6%) were willing to donate regardless of the recipient’s identity, whereas 157 (40.2%) would only donate to relatives; the remaining 71 (18.2%) completely refused living donation. With respect to postmortem donation, 168 participants (43%) were willing to register their consent, 117 (29.9%) rejected the concept, and 106 (27.1%) remained undecided. These data are summarized in Table 2.

Table 2 Attitudes towards organ transplantation, n (%).

Attitudes towards organ transplantation		Total 391 (100%)
Organ transplantation should be promoted	Strongly agree	167 (42.7)
	Agree	183 (46.8)
	Disagree	36 (9.2)
	Strongly disagree	5 (1.3)
Priority should be for critically ill patients	Strongly agree	103 (26)
	Agree	217 (56)
	Disagree	58 (15)
	Strongly disagree	13 (3)
Agree to be a living organ donor	Yes	163 (41.6)
	For relatives only	157 (40.2)
	No	71 (18.2)
Agree to be a deceased organ donor	Yes	168 (43.0)
	No	117 (29.9)
	Not decided	106 (27.1)

An analysis of the reasons for refusing organ donation (Figure 4) revealed that 30.7% of the respondents might have considered organ donation if the recipient was a relative. Primary concerns included fear of body disfigurement (11.8%) and a lack of confidence in current organ procurement practices (11.5%). Religious beliefs and the risk of organ trafficking were each cited by 10% of the respondents. In addition, 8.2% expressed fears regarding unfair organ allocation or receiving suboptimal medical care. A smaller proportion (5%) feared organ procurement before the confirmation of death, whereas 5.1% cited medical reasons for refusal. Cultural barriers were the least common reason, reported by only 2.3% of the respondents.

Figure 4 Reasons for rejection of organ donation.

Attitudes towards accepting to receive organ/graft (Table 3) showed that 234 participants (59.8%) would accept a graft from a stranger if required. However, most refused to authorize postmortem donation for family members, whether for a child (76.7%, n = 300) or an adult (72.1%, n = 282). With respect to living donation, 97.2% (n = 376) maintained that the donor consent must be provided. With respect to post-mortem donation, 57.8% of the physicians believed that consent should be granted by the family, whereas only 13.3% favoured the spouse as the consenting authority; 28.6% were uncertain. Opinions regarding unclaimed bodies were divided: 36.3% did not suggest a specific legal authority, whereas others proposed that consent must be provided by a judge (24.5%) or doctor (16.9%). Conversely, 14.6% believed that no authority should provide consent, suggesting a preference against using unclaimed bodies. Only 7.7% accepted charitable organizations as consenting authorities.

Table 3 Ethical aspects of organ transplantation, n (%).

	Ethical aspects of organ transplantation		Total 391 (100%)
Attitude towards none self-grafts	Agree to receive graft from stranger if needed	Yes	234 (59.8)
		No	157 (40.2)
	Agree to donate child family member after death	Yes	91 (23.3)
		No	300 (76.7)
	Agree to donate adult family member after death	Yes	109 (27.9)
		No	282 (72.1)
Who should give the consent for?	Living donor	Donor	376 (97.2)
		Others	11 (2.8)
	Donation after death	Family	226 (57.8)
		Spouse	52 (13.3)
		Friend	1 (0.3)
		Don’t know	112 (28.6)
	Unclaimed dead bodies	Charitable organization	30 (7.7)
		Doctors	66 (16.9)
		Judge	96 (24.5)
		None	57 (14.6)
		Don’t know	142 (36.3)

With respect to measures to promote donation, the most effective motivators were prioritizing donors for future transplants (61%) and providing free health care for the donors’ families. In addition, 33% suggested monetary benefits for families, whereas 18% favoured honorary awards (Figure 5).

Figure 5 Measures to promote organ donation.

Comparison of knowledge levels regarding organ donation by sociodemographic and academic characteristics revealed statistical significant difference between low, moderate and highknowldge regarding age, sex, academic title and working in the field of transplantation (Table 4).

Table 4 Comparison of knowledge levels regarding organ donation by sociodemographic and academic characteristics, n (%).

Variable	Category	Knowledge			χ², P value
		Low knowledge 324 (82.9%)	Moderate knowledge 51 (13%)	High knowledge 16 (4.1%)
Age: (years)		35.7 ± 9.8	37.5 ± 7.9	42.8 ± 11.2	4.5032, 0.0121
Sex	Female	256 (90.1)	22 (7.7)	6 (2.1)	38.892, < 0.0011
	Male	68 (63.6)	29 (27.1)	10 (9.3)
Marital status	Single	113 (86.9)	13 (10.0)	4 (3.1)	4.071, 0.667
	Married	196 (80.3)	36 (14.8)	12 (4.9)
	Divorced	4 (100.0)	0 (0.0)	0 (0.0)
	Widowed	11 (84.6)	2 (15.4)	0 (0.0)
Religion	Christian	15 (83.3)	3 (16.7)	0 (0.0)	0.963, 0.618
	Muslim	309 (82.8)	48 (12.9)	16 (4.3)
Residence	Rural	24 (72.7)	6 (18.2)	3 (9.1)	3.377, 0.185
	Urban	300 (83.8)	45 (12.6)	13 (3.6)
Title	Resident/demonstrator	111 (93.3)	5 (4.2)	3 (2.5)	22.800, 0.0041
	Master/assistant lecturer/specialist	110 (81.5)	21 (15.6)	4 (3.0)
	MD/lecturer/consultant	50 (71.4)	17 (24.3)	3 (4.3)
	Assistant professor	11 (84.6)	1 (7.7)	1 (7.7)
	Professor	42 (77.8)	7 (13.0)	5 (9.3)
Specialty	Academic	56 (88.9)	7 (11.1)	0 (0.0)	4.200, 0.380
	Medical	241 (82.3)	38 (13.0)	14 (4.8)
	Surgical	27 (77.1)	6 (17.1)	2 (5.7)
Work on organ donation	No	281 (90.6)	23 (7.4)	6 (1.9)	64.229, < 0.0011
	Yes	43 (53.1)	28 (34.6)	10 (12.3)

¹Statistically significant < 0.05.

²Anova test.

χ² test was used.

DISCUSSION

Public misconceptions, along with cultural and religious beliefs, continue to negatively affect donor willingness. Furthermore, potential donors and their families often encounter significant ethical, psychological, and procedural barriers[6,9,10]. In Egypt, living donor liver transplantation remains the only viable option for patients requiring liver replacement. Although the Egyptian Parliament passed a legislation in 2010 recognizing brain death and permitting deceased organ transplantation, the enactment of executive regulations is still pending. A primary obstacle to expanding these programmes remains the lack of societal acceptance with respect to the concept of brain death[6,11].

In the present study, the awareness, knowledge, and attitudes of Egyptian physicians towards organ donation were evaluated. Our findings provide an acceptable understanding of the diagnosis of brain death and the potential sources of donated organs. However, knowledge regarding the criteria for deceased donor grafts, living donor eligibility, associated risks, and the Egyptian legal framework governing transplantation is limited. Overall, only 17.3% of the participants demonstrated “good” knowledge, whereas 82.7% demonstrated “poor” knowledge.

Knowledge levels varied significantly across specific topics, with correct response rates ranged from 15.3% regarding the legality of deceased donation in Egypt to 78% concerning supervision by the Ministry of Health. This overall knowledge deficit among physicians may be attributed to several factors. First, transplant medicine is addressed only in brief in postgraduate curricula, and educational campaigns targeting nontransplant specialists are lacking. Furthermore, only 20.7% of the respondents reported clinical experience with a transplant team. In Egypt, transplant services are largely centralized in tertiary centres, which limits exposure for the wider medical community.

A review of similar international studies revealed wide variation in knowledge levels, with inadequate understanding reported among medical staff, students, and the general public alike. Knowledge scores ranged from 24% in the general population to 65% among university students[7-14]. These discrepancies often arise from differences in participant age, education levels, and the presence of national awareness campaigns.

Despite these knowledge gaps, our study revealed a strong positive attitude towards promoting organ donation and prioritizing critically ill patients. This likely reflects physicians’ professional awareness of transplantation as a life-saving therapy for end-stage organ failure—a perspective that may be less prevalent among the general public. Similar positive attitudes have been observed globally, including among health care professionals in India (55.6%)[12] and the public in Saudi Arabia (58.5%)[15], primarily driven by the understanding that organ donation saves lives[13].

Most of our participants expressed a willingness to be living donors—either in general (41.6%) or for relatives (40.2%), and 43% were open to register as deceased donors. Notably, cultural and religious barriers were minimal. The primary concerns among those who rejected donation included perceived lack of experience at transplant centres and fear of body disfigurement. These responses underscore the need for institutional reassurance with respect to diagnostic accuracy, donor medical care, equitable organ allocation, and the prevention of organ trafficking. While nearly 90% of surveyed physicians agree that organ transplantation should be promoted, only 17.3% demonstrated adequate technical and legal knowledge. This discrepancy is the most impactful finding of the study. The present study suggests that the primary barrier to the expansion of transplantation services in Egypt is not a lack of professional or ethical willingness but rather a profound educational deficit. The fact that only 15.5% of participants were aware that deceased donation is legally approved in Egypt is particularly striking and points towards a failure to disseminate regulatory information within the medical community. While nearly 90% of surveyed physicians agree that organ transplantation should be promoted, only 17.3% possess what is categorized as adequate technical and legal knowledge. This discrepancy is the most impactful finding of the paper. It suggests that the primary barrier to the expansion of transplantation services in Egypt is not necessarily a lack of professional or ethical willingness, but rather a profound educational deficit. The fact that only 15.5% of participants were aware that deceased donation is legally approved in Egypt is particularly striking and points toward a failure in disseminating regulatory information within the medical community.

Akeely et al[14] emphasized that established programmes with defined policies are essential for physician education, whereas Alghamdi et al[15] recommended broader public awareness campaigns to capitalize on existing positive attitudes towards donation. However, attitudes towards donating organs from one’s own family members remained conservative; most physicians were reluctant to authorize postmortem donation for their children or adult relatives. The consensus was that although the individual should decide during their lifetime, family consent remains pivotal after death. Given the ethical sensitivity of these decisions, guidance from specialized physicians is crucial to increasing family consent rates.

Participants identified free medical services for donor families and “donor priority” (granting registered donors’ priority if they ever require a transplant) as the most effective incentives for promoting donation.

Although this study represents the assessment of physician awareness and attitudes towards donation in a tertiary University hospital in Cairo among Egyptian physicians, it is limited by its single-centre design and 1-month duration. Future multicenter studies encompassing diverse regions across Egypt are strongly warranted.

CONCLUSION

While Egyptian physicians exhibit a positive attitude towards organ donation, significant knowledge gaps persist. Health education is needed to address these knowledge gaps and to correct long-standing social and religious misconceptions. Addressing these issues and reducing the stigma surrounding donation are essential steps towards establishing a sustainable deceased donor transplantation programme in low- and middle-income countries such as Egypt.

ACKNOWLEDGEMENTS

All staff members of Ain Shams Center for Organ Transplantation.