Adriel Andreas Goh, 21

Topic: In some countries, family members often bring up the patient’s intent on organ donation to the doctors as part of end-of-life care. Is this a utopian dream for Singapore or an impossible fallacy?

Organ donation is widely regarded as a public good. It gives the terminally ill a second chance at life, whilst allowing donors to do one last good deed even in death. However, it raises ethical and moral questions that warrant deeper exploration and analysis. In particular, the proposition that under most jurisdictions, family members commonly initiate conversations about a patient’s intent to donate organs as part of end-of-life care raises a difficult concern: is this a realistic aspiration that would improve ethical decision-making and patient autonomy, or is it a fallacy that misunderstands Singapore’s legal, cultural, and institutional realities? The idea is attractive in theory, but closer inspection suggests that Singapore cannot treat this movement as a straightforwardly achievable goal. In this essay, I will explain my belief that this practice should be better framed not as a ‘utopian dream’, but as a conditional and bounded possibility that is unlikely to become a general norm in Singapore.

At first glance, the proposal is ethically compelling. Organ donation saves lives. Further, if discussions on organ donation were family-initiated, they would remove the moral burden on practitioners to do so. Clinicians are less likely to be accused of prioritising organ gathering over patient care, and family members may be more agreeable to decisions. However, this optimistic view sits in an ivory tower of assumptions that are far from reality within Singapore’s context. The ideal is flawed due to three major assumptions. It assumes that family members know the patient’s preferences, that families have the emotional resilience to act rationally in distress, and that existing institutional frameworks support such practice.

I first draw a critical distinction between ethical desirability and practical feasibility. Engaging in taboo and awkward conversations on organ donation before death is an uncomfortable yet necessary aspect of end-of-life care for patients. The difficulty lies not in the intrinsic value of such discussions, but in their timing and social nature. End-of-life care is contentious. Filled with grief and uncertainty, it is a melancholy bag of burdens where one often finds oneself forced to maintain a strong outward front whilst internally being at one's utmost emotional vulnerability. This is acutely the case in Singapore, where family-oriented decision-making is deeply embedded within medical practice. While Singapore’s medical law is increasingly shifting towards patient autonomy, medical decisions cannot help but be treated as collective family matters. Death may be personal, but it is also not singular in its effects. A father cannot help but worry about his family’s financial situation, a mother cannot help but worry about who will care for her children, and a child may struggle to comprehend the concept of death, much less a life without his parent. In this context, bringing up such topics of organ donation risks the interpretation of a patient’s impending death as a value judgement instead of conveying a patient’s wishes. The psychological cost of initiating such a discussion may therefore be substantial.

Pre-existing legal frameworks pose another challenge to feasibility. Currently, organ donation in Singapore works on ‘presumed consent’ under the purview of the Human Organ Transplant Act 1987 (“HOTA”)¹. This already separates Singapore from jurisdictions where family consent is the leading introduction to organ donation. Under HOTA, organ donation is the legal default that subjects all Singaporeans (unless otherwise opted out) to donate specific organs after death. It diminishes the value of a family-driven moral choice. In such a scenario, this policy makes family-initiated discussions on organ donations obsolete and redundant in value, as if donation is presumed under the law, the role of the family ends up being reactive rather than proactive.

Singapore’s ‘Lasting Powers of Attorney’ also further undermines the argument that families are to initiate discussions on organ donation at the end of life. It follows the logic that autonomy is best exercised when individuals retain capacity and are able to make decisions without duress or pressure of crisis. Encouraging the use of a proxy to make decisions in advance already implicitly acknowledges that moments of incapacity are precisely when families are least well placed to articulate a patient’s wishes with clarity or confidence.

A similar parallel can be drawn from the broader evolution of medical decision-making standards. This is reflected in Singapore’s movement away from the previously used Bolam-Bolitho Test² in medical judgment, which prioritised professional expertise over individual preference while later moving towards emphasising a patient’s rights to be informed of material risks relevant to their own values³. Crucially, this shift suggests otherwise that autonomy is best exercised in times of vulnerability. Contrary, it presupposes that the ‘best’ choices require time, understanding, and reflection. It is simply counterintuitive to expect families to raise organ donation during end-of-life moments, as it risks conflating respect for autonomy with immediacy in decision-making when autonomy itself is otherwise better preserved through prior discussion and documentation than through emotionally charged exchanges at the point of death.

We have to also consider the power dynamics between families and medical professionals. What happens when families defer strongly to medical authority? This deference cuts both ways. Pressure is built when families stay silent on organ donation for fear of appearing presumptuous. Conversely, when families show support, other family members less comfortable with the idea may feel compelled to stay silent.

Thus, the notion of family-initiated discussions being inherently more sincere should be critiqued as coercion does not disappear simply by deciding who speaks first. It merely changes form, moving from institutional pressure to intra-familial pressure. In Singapore, where harmony and filial piety are socially emphasised, this shift proves to be more problematic.

Idealising family unity also comes at risk. The proposal assumes that families speak collectively and that they align with the patient’s wishes. In reality, families are often divided, especially in times of distress. Where a family member may recall the donor expressing support for organ donation, another may reject the claim, emphasising religious or cultural objections. Family members may even challenge the validity of other members’ support, citing bigger stakes in the matter due to closer familial relationships. In seeking out the advice of medical professionals, it may even exacerbate conflict as it brings in another dimension of dispute. This could ultimately delay decision-making and undermine trust in moments where clarity and familial unity are most needed.

Against this backdrop, the realities of family-initiated discussions begin to show. What was initially thought to be a universally desired norm has been shown to only work under exceptional conditions. The proposal is not entirely impossible, but it simply suggests that feasibility is highly context specific. In scenarios where families are harmonious, organ donation is discussed early, and patients’ wishes are unambiguous, such discussions can naturally and constructively occur. In such cases, the practice mirrors its intended utopia in alignment with autonomy, altruism, and compassion.

Nonetheless, we cannot make these cases precedents. Treating them as a model for systemic reform risks confusing the exceptional with the typical. A healthcare policy has to be built on the assumption that ‘perfect’ family dynamics are outliers. It has to be grounded in foreseeable human limitations where no family can fully prepare for the sudden news of terminal disease and death.

A more realistic approach would be to focus not on who raises the issue at the bedside, but on when and how preferences are formed and recorded. Improving organ donation practices in Singapore boils down to opening up more opportunities for earlier, calmer conversations. Inculcating preparedness and rationality can be done through advance care planning, education, and accessible mechanisms for recording consent or refusal. This way, end-of-life discussions become less morally charged because decisions were already set out prior to the heightened stress and emotions that follow. Families are then relieved of the burden of initiating or opposing donation in moments of crisis.

In this lens, the topic itself might be slightly misplaced. Simplifying the issue into two ends of the spectrum as an “utopian dream” or “impossible fallacy” risks overlooking a third possibility: that the aspiration is misdirected. Perhaps the goal should not be to normalise family-initiated organ donation discussions at the end of life, but to make such discussions largely unnecessary at that stage. Where they do occur, they should be the reaffirmation of an established decision, not the moment of its creation.

The idea of family members raising organ donation as part of end-of-life care should be acknowledged and applauded for its positive intent, but it ultimately falls short in becoming an adoptable and reliable practice for Singapore. Emotional realities, cultural norms, and pre-existing legal structures are simply too great of factors on its feasibility. It is therefore unable to be framed as either a pure utopia or an outright fallacy, but perhaps a limited and conditional possibility. While Singapore can use such aspirations to fuel the movement for a better healthcare system, treating it as the central benchmark would risk unnecessary burdens on families and physicians, and go against current, more effective avenues in the pursuit of patient autonomy. 

References

1.    Section 4 of the act

2.    Bolam v Friern Hospital Management Committee [1957]

3.    The ‘Modified Montgomery Test’ developed in Hii Chii Kok v Ooi Peng Jin London Lucien and another [2017] SGCA 38

Disclaimer: Please note that the views and opinions expressed in the essays for the Live On Festival 2026 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 ↗ (opens in new tab)