Donavan Quek, 21

Topic: Society’s attitude towards organ donation reveals more about its fears than its hopes.

Between Fear and the Gift of Life 

Introduction

In Singapore, a kidney patient waits an average of eight to nine years for a transplant. Over five hundred patients currently sit on the national waitlist. These are not merely statistics but years of dialysis, diminishing quality of life, and the unease of wondering whether a stranger's generosity will arrive in time. Even as medical science has made organ transplantation routine and safe, donation rates remain constrained not by biology, but by belief. The proposition that society's attitude toward organ donation reflects more about its fears than its hopes is, at first glance, an indictment of a society that cannot face death generously enough to give life. This essay argues that it is something more precise and more demanding than that. Singapore's relationship with organ donation is indeed scaffolded upon fear. Fear of death; fear of bodily violation; and fear of institutional overreach. But this essay contends that these fears are not antithetical to hope. Instead, they are their moral grammar. The path to a more compassionate culture runs not around our fears, but through them.

The Architecture of Fear

To understand why organ donation provokes such visceral resistance, one must first understand what the psychology of mortality actually predicts. Terror Management Theory (TMT), developed by Jeff Greenberg, Sheldon Solomon, and Tom Pyszczynski, builds on Ernest Becker's foundational claim in The Denial of Death that ‘The idea of death, the fear of it, haunts the human animal like nothing else.'¹  Becker argued that the majority of human culture (religion, legacy, heroism, nationalism) functions as an 'immortality project' which allows individuals to feel they transcend biological death. Greenberg, Solomon, and Pyszczynski operationalised this through 'mortality salience' experiments, demonstrating that individuals briefly reminded of their own death subsequently showed heightened hostility toward those with different worldviews and intensified identification with their own cultural group². 

Organ donation forces ‘mortality salience’ into unavoidable focus. For many communities shaped by Confucian, Buddhist, Taoist, and folk religious traditions in which the body retains spiritual significance during transitional rites after death and communal obligations to the deceased are concrete and ritualistic, the prospect of organ removal does not merely feel uncomfortable³. This increases resistance to any perceived violation of that framework⁴.

However, I argue that there are specific conditional preconditions under which the conversion of fear into hope requires the right conditions. The question we must answer is precisely what are the right conditions?

The HOTA Paradox

Singapore's Human Organ Transplant Act (HOTA), enacted in 1987, operates on an opt-out basis: Citizens and Permanent Residents above twenty-one are presumed to consent to donation of their kidneys, liver, heart, and corneas upon death, unless they have explicitly opted out⁵.  At first glance, HOTA appears to be rational policy design at its most elegant, circumventing emotional hesitation through legal presumption. However, families in Singapore retain a de facto power of veto, and medical teams regularly defer to family objections even when the deceased had not opted out. The UK's NHS Blood and Transplant service has documented that family consent is significantly more likely when the deceased had previously expressed their wishes, showing how this policy alone is insufficient⁶.

This gap points to a philosophically deeper fear, and it is here that Immanuel Kant’s formulation, the Formula of Humanity, explains the intuitive resistance that many Singaporean families cannot articulate but nonetheless feel. The Formula of Humanity demands that one 'act so that you treat humanity, whether in your own person or in that of another, always as an end and never as a means only.'⁷ The opt-out design, however well-intentioned, carries an implication that many families experience as a violation of this principle. Where their loved one's body will be instrumentalised, made a means to another's survival, without the kind of genuine, personal, relational consent that Kant's framework demands. The legal presumption substitutes administrative mechanism for moral agency, and in doing so, it generates in those who experience it the intuition that something morally significant has been bypassed. The fear of HOTA as institutional overreach is thus philosophically grounded, not merely emotional and cannot be resolved by legal clarification alone.

The Mechanism by Which Fear Becomes Hope

What actually causes a grieving family, terrified of loss and violation, to arrive at the decision to give a stranger the gift of life? The answer lies in identifying the difference between evading death and facing it.

Most of us live in quiet conspiracy against our own mortality. We acknowledge death – yes, everyone dies, eventually. Yet we keep it at arm's length, tucked into a safe vagueness that never quite touches us personally. In Being and Time, Heidegger argued that the ordinary human relationship to death is one of evasion. This evasion, Heidegger argued, forecloses authentic existence: 'because I do not own my death, I do not truly own my life, my relationships, or my values.' Authentic being-toward-death, by contrast, means facing one's finitude as one's own most possibility – not with resignation, but with the clarity that comes from no longer evading what is inescapable. This is the precise mechanism that links fear to hope in the organ donation context. The families who have emerged from the organ donation process and described it as transformative are not describing a process in which fear was overcome. They are describing a process in which fear was followed all the way through. Wherein the full weight of loss was felt without evasion and at the bottom of that weight, they discovered their capacity for a love that does not stop at the boundary of one person's life⁸. The gift of a loved one's organs is not a suppression of grief, but grief completed. It is love that continues to act even when the person who bore it can no longer do so.

The insufficiencies of conventional organ donation campaigns are not a failure of information provision or legal design. I argue that it is the failure to create the conditions for authentic engagement with mortality. Campaigns that emphasise the cheerful and minimise the emotional weight of death in order to make donation feel easier are paradoxically working against themselves⁹. They are reinforcing the evasion that Heidegger diagnosed as the primary obstacle to genuine care. What is needed is not less weight, but the right ‘container’ for the weight that is already there.

What This Means for Each of Us

If the argument above is correct, then the path to a more generous donation culture is not primarily a policy problem. It is a personal and relational one, and it begins not in a hospital but in an ordinary conversation that most of us have never had.

Consider what it would mean to tell your family, today, that you have chosen to donate. Not as a declaration of virtue, but as an act of love made in full awareness – the acknowledgement that your body can become someone else’s chance at life. That conversation does not require comfort with death. It requires the willingness to follow your fear far enough to discover what it is protecting, and then to choose to extend that protection outward.

Singapore’s Live On campaign documents what happens when people make that choice. A father who receives a liver watches his daughter grow up. A young man whose corneas restore a stranger’s sight never meets the family whose grief made it possible. These stories are evidence of what fear looks like when it completes its journey, when love that began as the protection of one person becomes the gift of life to another. Robert Cialdini’s research on commitment and consistency demonstrates that people who articulate their values to their families become far more likely to act on them; the act of having the conversation is itself transformative¹⁰. The goal is not to produce a declaration but to produce a shared understanding that has already done the work of authentic being-toward-death before any crisis arrives.

Conclusion

Singapore’s attitudes toward organ donation reveal deep fears. Fear of mortality, of bodily violation, of institutional power displacing familial love. The standard response to this finding is to treat it as an indictment, as evidence that society has not yet matured enough to face death generously. These fears are not failures; when followed with courage, they act as moral guidance for a kinder society.

Becker wrote that the denial of death is the engine of human culture. But culture’s highest expressions are not its denials. They are their genuine confrontations. The family that chooses, in the worst moment of their lives, to allow a stranger to live because of their loved one’s generosity is not managing grief efficiently but completing it. The five hundred people on Singapore’s waitlist do not need a society that is fearless. They need a society brave enough to follow its fears all the way through and to discover that on the other side of every genuine fear is the value it was always guarding, waiting to be given away.

References

1.    Ernest Becker, The Denial of Death (1973)

2.    Jeff Greenberg, Sheldon Solomon, and Tom Pyszczynski, 'Terror Management Theory of Self-Esteem and Cultural Worldviews: Empirical Assessments and Conceptual Refinements,' Advances in Experimental Social Psychology 29 (1997).

3.    Sheldon Solomon, Jeff Greenberg, and Tom Pyszczynski, The Worm at the Core: On the Role of Death in Life (London: Allen Lane, 2015).

4.    Population Policy and Reproduction in Singapore: Making Future Citizens (London: Routledge, 2012); Tong Chee Kiong, Rationalizing Religion: Religious Conversion, Revivalism and Competition in Singapore Society (Leiden: Brill, 2007).

5.    Human Organ Transplant Act (Cap. 131A), Singapore, 1987 (revised 2012)

6.    NHS Blood and Transplant, Annual Report on Cardiothoracic Transplantation (Bristol: NHS Blood and Transplant, 2023).

7.    Kant, Groundwork of the Metaphysics of Morals, 4:429. 'Act so that you treat humanity, whether in your own person or in that of another, always as an end and never as a means only.'

8.    Erica R. Salter and Arthur Caplan, 'The Donor Family Experience,' Journal of Clinical Ethics 25:3 (2014); and Cynthia L. Gries et al., 'Family Member Satisfaction and Emotional Well-Being Following Organ and Tissue Donation,' Critical Care Medicine 34:2 (2006).

9.    Jamie Arndt et al., 'The Intrinsic Self and Defensiveness: Evidence that Activating the Intrinsic Self Reduces Self-Handicapping and Conformity,' Personality and Social Psychology Bulletin 28:5 (2002).

10. Robert B. Cialdini, Influence: The Psychology of Persuasion, revised ed. (New York: HarperCollins, 2007).

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)