Cheong Nian Kai, 29

Topic: Importance of organ donation awareness and engagement efforts for every age group

Award: Special Mention, Open Category, 2025

The Gift of Life 

The first human allograft was performed in 1905 in the Czech Republic, successfully transplanting a cornea from a human donor to a 45-year-old blind farm labourer, restoring his sight^[1]. 120 years on, transplantation science has taken great strides, allowing for the transplantation of tissues such as skin, nerves and vessels, to major organs such as the heart, kidneys, liver and more. Beyond transplantation medicine, the journey of organ donation starts from within, blooming from one’s intrinsic desire to give up a part of oneself for another’s life. 

In Singapore, transplantation medicine has achieved significant milestones from having its first cadaveric renal transplant in 1970^[2] to now an annual 124 total organ transplants in 2023^[3], giving life to many who would otherwise suffer the complications of end-organ failure. Through legislation of the Human Organ Transplant Act (HOTA) and the Medical (Therapy, Education and Research) Act (MTERA), the process of organ donation is ingrained in and facilitated by our laws, giving hope to thousands of patients. To increase the rate of organ donation, the opt-out system was implemented in 1987 allowing HOTA to operate on presumed consent where Singapore citizens and permanent residents above 21 years old are considered to have consented to organ donation upon death unless they opt-out^[4]. Despite these efforts, the total organ transplantation rate in Singapore is still low at 20.67 donors per million population compared to the global average of 25.84 donors per million population in 2023^[3]. 

After almost 40 years, it is timely to move towards encouraging people to come forward to donate through stronger awareness and engagement efforts, to complement the current opt-out system. But one may ask, to whom should these efforts be directed towards to achieve the best outcomes – the youth, the middle-aged, or the elderly of our society? Some may argue that certain age groups should be prioritised, while others may posit that all groups are equally important. This essay will seek to discuss this in the Singapore context. 

Some may argue that the most important age group to concentrate our focus on is the elderly population because the elderly has been shown to be the least willing group to donate their organs after death in Singapore^[5], and their perceptions of organ transplantation may be influenced by old axioms and their religious beliefs^[6]. Research has also shown that lower willingness for organ donation was associated with older age^[7], while fear and uncertainty due to religion were main reasons given for not being willing organ donors^{[8, 9]}. Some elderly may believe they are too old to donate or that their organs are not fit for donation^[3], whilst others believe that this may conflict with their religious beliefs and are not certain if their religion would allow for organ donation. Hence, it is crucial for religious leaders to make their stand on organ donation clear to assuage these concerns. In Singapore for instance, Muslim religious leaders have been consulted and agreed to provide support for this cause should the need arise^[10]. Steps in legislation have also been made in this aspect, such as the inclusion of Muslims under HOTA in 2008, and the removal of the age cap in 2009^[11] to allow more cadaveric donations with stricter governance. These can be included in public health messaging to the elderly such as through HOTA/MTERA information paraphernalia, community health talks, and organ donation campaigns for opportunistic messaging to this population segment. Elderly donors can also be featured in these efforts to disprove public misconceptions that age is a contraindication to organ donation. 

On the other hand, the youth of today present a great potential for engagement in this endeavour. Without the baggage of taboos, and armed with a stronger education background, our youth are already the most willing age group to donate their organs^[5], and are in a prime position to advocate for change in societal beliefs and create generational change. This can be facilitated through our school curriculum as part of science lessons and public health campaigns to help our students stay informed on the topic, allowing them to remain open to the cause. Youth activists can even be motivated to launch their own initiatives through celebratory carnivals, donation drives, and awareness campaigns to encourage discourse on the topic to bring a larger impact to the rest of society, improving societal understanding on the topic. Support for such ground-up community initiatives to improve organ donation should be readily provided and can be from organisations such as the People’s Association or the National Organ Transplant Unit to spur on these young hearts. More importantly, increased awareness and engagement among the youth can encourage young bright minds to enter the research and development field of transplantation medicine to broaden the possibilities of organ transplantation, improving allograft success rates, survivability, and the potential of going beyond donor transplants to synthetic options to benefit millions of patients in need around the world. 

Last but not least, the middle-aged – this segment of our population represents an important stakeholder to engage in organ donation decisions. In the Asian context, the middle-aged of the family are often the main spokesperson for elderly patients in the healthcare setting and play crucial roles in facilitating decisions for our elderly population. Often, end-of-life discussions remain taboo in the Asian context^{[12, 13]}, deemed inauspicious and brushed aside when brought up, leading to a lack of clear communication in one’s end-of-life wishes. This often leads to difficult conversations between medical teams and patients’ families due to unclear prior expressed wishes with regards to end-of-life care including resuscitation decisions^[14], much less on organ donation. A major reason for low deceased organ donation rates in Singapore is the lack of identification of potential donors and timely referrals for transplant^{[15, 16, 17]}. Apart from medical teams ensuring timely identification for transplant referrals, patients’ families will need to be onboard with these decisions too. To engage this population segment and increase awareness of these issues, legislation concerning end-of-life decisions is a key steppingstone in its facilitation. Advanced care planning (ACP) is crucial in understanding each person’s preferences for end-of-life decisions and should go beyond resuscitation decisions to include organ donation preferences. Even if life sustaining medical decisions are to be made only by the medical team under the Mental Capacity Act^[18], and presumed consent for organ donation has been assured under HOTA, patient and family concurrence with medical decisions is still crucial^[19] even if these medical decisions are backed by the law. ACP would serve to state patients’ preferences for the medical team and their families, making many of these conversations much less challenging during critical times. Conversely, the Advanced Medical Directive (AMD) Act remains ineffectual in clinical practice, as the AMD is confidential and medical teams are not allowed to ask patients if they had enacted an AMD^[20], rendering its utility limited in the setting of end-of-life care. Weaving ACPs into Health Plans under Healthier SG with the inclusion of organ donation preferences and abolishing the AMD can reduce confusion and serve as good starting points for end-of-life discussions, improving awareness and willingness for organ donation while supported by HOTA, and even potentially improving MTERA opt-in rates. This helps families be onboard with such decisions, making it more amenable for ICU teams to refer patients to transplant coordinators in a timely manner. Focusing discussions and engagement via these enhanced ACPs and abolishing the now defunct AMD will bring greater clarity to patients and families, encouraging more to state their end-of-life preferences and generate richer discussions around organ donation, improving acceptance of such decisions. Starting these discussions early will also help the middle-aged generation prepare better for their own end-of-life decisions and may even inspire them to be organ donors themselves, increasing the rate of living organ donations. They will also be in good stead to inculcate the right values in the young and support the elderly in this effort.

In the final analysis, the decision for organ donation remains a deeply personal one rooted in altruism but represents a journey requiring strong support from one’s family and community. To achieve greater acceptance and willingness in society toward organ donation, all stakeholders must be engaged – the youth, the middle-aged, and the elderly, empowering medical teams facilitating this process. The power of youth advocacy, the prospects of addressing elderly perceptions, and the prowess of the middle-aged in bringing society together through deliberate conversations will help our society go beyond the strength of the law to embrace the spirit of altruism in giving the Gift of Life.

References

^[1] Zirm E. K. (1989). Eine erfolgreiche totale Keratoplastik (A successful total keratoplasty). 1906. Refractive & corneal surgery, 5(4), 258–261. https://pubmed.ncbi.nlm.nih.gov/2488816/

^[2] Maureen, P. (1970). The first kidney swop is a success. The Straits Times, 1. https://eresources.nlb.gov.sg/newspapers/digitised/article/straitstimes19700712-1.2.7

^[3] Global Observatory on Donation and Transplantation. (2016). Summary. Global Observatory on Donation and Transplantation. https://www.transplant-observatory.org/summary/

^[4] The Straits Times. (1987). Organ transplant Act to take effect next week. The Straits Times, 1. https://eresources.nlb.gov.sg/newspapers/digitised/article/straitstimes19870707-1.2.5

^[5] Tan, E. (2014). Youth most open to organ donation after death: Poll. TODAY. https://www.todayonline.com/singapore/youth-most-open-organ-donation-after-death-poll

^[6] Kobus, G., Malyszko, J. S., & Małyszko, J. (2016). Do Age and Religion Have an Impact on the Attitude to Organ Transplantation?. Transplantation proceedings, 48(5), 1354–1359. https://doi.org/10.1016/j.transproceed.2016.02.055

^[7] Loch A, Hilmi I, Mazam Z, Pillay Y, Choon D. (2010). Differences in attitude towards cadaveric organ donation: observations in a multiracial Malaysian society. Hong Kong J Emerg Med, 17(3):236–243. https://journals.sagepub.com/doi/abs/10.1177/102490791001700306

^[8] Riyanti S, Hatta M, Norhafizah S, Balkish MN, Mahmud Z, Hamizatul Akmal AH, et al. (2010). Donation by sociodemographic characteristics in Malaysia. Asian Soc Sci, 10(4):264–272. https://ccsenet.org/journal/index.php/ass/article/view/33812

^[9] Mithra, P., Ravindra, P., Unnikrishnan, B., Rekha, T., Kanchan, T., Kumar, N., Papanna, M., Kulkarni, V., Holla, R., & Divyavaraprasad, K. (2013). Perceptions and attitudes towards organ donation among people seeking healthcare in tertiary care centers of coastal South India. Indian journal of palliative care, 19(2), 83–87. https://pmc.ncbi.nlm.nih.gov/articles/PMC3775029

^[10] Khaw, B. W. (2008). Parliament Speech 21 Jan Closing Speech for the HOTA (Amendment) Bill. Ministry of Health. https://www.moh.gov.sg/newsroom/parliament-speech-21-jan-closing-speech-for-the-hota-amendment-bill

^[11] National Organ Transplant Unit (NOTU). (2025). Who is eligible to be a donor. Government of Singapore. https://www.liveon.gov.sg/about-organ-donation/who-is-eligible-to-be-a-donor

^[12] Lin Goh S. S. (2018). Singapore Takes Six Steps Forward in 'The Quality of Death Index' Rankings. Asia-Pacific journal of oncology nursing, 5(1), 21–25. https://pmc.ncbi.nlm.nih.gov/articles/PMC5763434/

^[13] Vashisht, A., Gutman, G., & Kaur, T. (2023). ACP Conversations with Chinese and South Asian Patients: Physicians' Perspectives of Barriers and Facilitating Factors. Canadian geriatrics journal : CGJ, 26(4), 486–492. https://pmc.ncbi.nlm.nih.gov/articles/PMC10684305/

^[14] Malhotra, C., & Chaudhry, I. (2024). Barriers to advance care planning among patients with advanced serious illnesses: A national survey of health-care professionals in Singapore. Palliative & supportive care, 22(5), 978–985. https://pubmed.ncbi.nlm.nih.gov/37005352/

^[15] Fu, K. X., Tan, S. L. J. J., & Loh, N. W. (2025). Organ donation in the paediatric intensive care unit: Time for change?. Annals of the Academy of Medicine, Singapore, 54(1), 1–2. https://annals.edu.sg/organ-donation-in-the-paediatric-intensive-care-unit-time-for-change/

^[16] Siddiqui, S., & Tee, L. H. (2019). What Intensivists Say About an Opt-Out System for Organ Donation. Transplantation proceedings, 51(6), 1651–1654. https://pubmed.ncbi.nlm.nih.gov/31399156/

^[17] Kwek, T. K., Lew, T. W., Tan, H. L., & Kong, S. (2009). The transplantable organ shortage in Singapore: has implementation of presumed consent to organ donation made a difference?. Annals of the Academy of Medicine, Singapore, 38(4), 346–348. https://pubmed.ncbi.nlm.nih.gov/19434338/

^[18] Office of the Public Guardian. (2016). Mental Capacity Act (Chapter 177A). Code of Practice, 4. https://www.msf.gov.sg/docs/default-source/opg/code_of_practice_eng_oct16.pdf

^[19] Jalelah A. B. (2019). 'Are you sure he is dead?': Doctors struggle with families’ lack of understanding of HOTA. CNA. https://www.channelnewsasia.com/singapore/human-organ-transplant-act-doctors-families-understanding-887136

^[20] Tan, G. M. Y. (2022). Wills, AMDs and LPAs – What’s the Difference?. Singapore Medical Association. https://www.sma.org.sg/news/2022/September/Wills-AMDs-and-LPAs--Whats-the-Difference

Disclaimer: Please note that the views and opinions expressed in the essays for the Live On Festival 2025 are those of the participants and are not endorsed by the National Organ Transplant Unit (Ministry of Health).

To learn more about organ donation and organ transplantation in Singapore, please visit www.liveon.gov.sg