Timothy Koh, 23

School: National University of Singapore

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?

Fostering Open Family Conversations on Organ Donation in Singapore

In 2022, Singapore’s deceased organ donation rate stood at 3.56 per million population donated, below the global rate of 6.84. Spain, however, has the world’s highest organ donation rate at 47.02¹, despite both countries adopting similar opt-out systems under which adults are presumed to be organ donors unless they opt out. This significant disparity suggests that Singapore’s challenge in increasing organ donation rates lies not in legislation, but in societal attitudes towards end-of-life matters, where cultural taboos surrounding conversations on death remain deeply entrenched. Nevertheless, this essay argues that a norm in which family members openly communicate patients’ organ donation intentions to doctors should not be regarded as an “impossible fallacy”. Rather than a “utopian dream”, it can be an achievable reality through government initiatives in public education that encourage more open family conversations on end-of-life care.

End-of-life care is a medical care approach for individuals approaching the final phase of life, maximising comfort for patients while providing support to families². Discussions during end-of-life care include advance care planning and organ donations. Organ donation in Singapore is governed by the Human Organ Transplant Act (HOTA) and the Medical (Therapy, Education and Research) Act. The HOTA covers the kidneys, heart, liver and corneas, with Singapore Citizens and Permanent Residents aged 21 and above presumed to be organ donors. Individuals may choose to opt out but those who do so will have a lower priority on waiting lists if they need an organ transplant in the future. While opt-out rates for HOTA have held steady at three per cent annually³, Dr Wong Yu Lin, director of the Neurosurgical Intensive Care Unit at Tan Tock Seng Hospital, said that many family members “cannot accept the presumed consent under HOTA and feel that their loved one would not have wanted to [donate their organs]⁴.” Because of the automatic opt-out nature of the act, the issue of consent is less likely to arise in family conversations. Consequently, when patients become incapacitated without sharing their wishes, family members often reject organ donation. Hence, it is highly improbable for families to bring up their loved one’s intentions to doctors because they have not discussed such issues before, originating from a widespread cultural reluctance to discuss death.

This cultural reluctance stems from beliefs surrounding superstition, bad luck and filial piety found in many Asian cultural contexts. Conversations about death are viewed as taboo, rooted in religious beliefs that speaking openly on such kinds of topics may cause misfortune, fear and emotional pain⁵. As such, these conversations may not merely be uncomfortable but regarded as inauspicious. These attitudes are reflected in a Singapore Management University study which found that only 53 per cent of respondents were comfortable discussing their own death in 2019⁶. 

With that, this essay explores Spain’s model of organ donation and transplantation, a country that has the world’s highest donation rates. The Spanish model operates similarly to Singapore’s, where citizens are organ donors by default but have the right to opt out. Beyond this legislation, Spain’s framework stands out for multiple reasons. The Spanish government emphasises the creation of policies that build trust and confidence between the healthcare system and the public. As healthcare professionals in Spain are given consent to communicate directly with the media, this allows them to hold educational programmes for journalists, who in turn enlighten the public on organ donation. Hence, the Spanish public has developed a high level of trust and awareness in their transplantation system. Furthermore, specialised training programmes are conducted for transplantation coordinators to communicate effectively with the families of deceased organ donors. As a result, even though family consent is required, the country has seen lower family refusal rates as compared to other European countries⁷. 

Having analysed Singapore’s death culture and the strengths of Spain’s transplantation system, this essay contends that the root problem of Singapore’s low organ donation rates stems from the culture of avoiding conversations on death. As a result, many citizens have low awareness and preparedness on end-of-life issues, according to a report by the Singapore Hospice Council⁸. Singaporeans have also expressed confusion with the complexity of the organ donation framework⁹. Therefore, a key challenge the country faces is in raising awareness and shifting societal attitudes on a deeply rooted societal issue. For instance, the government’s efforts to increase the country’s fertility rate, a sensitive topic, have achieved mixed results. An increasing number of Singaporeans have expressed disinterest in having children, specifically due to the rising cost of living¹⁰.  Similarly, the personal nature of organ donation, which is closely tied to family and personal values, means that such decisions ultimately rest with the individual and their family. Hence, questions may arise as to whether increased public education can significantly shift attitudes regarding organ donation.

Nevertheless, this essay argues that the government plays a key role in building trust and confidence in the country’s transplantation system. Its initiatives to increase mental health literacy, a similarly complex and personal issue, have demonstrated that expanded public education can successfully drive attitude shifts towards social norms. For instance, the government has undertaken efforts in raising awareness of mental health through Health Promotion Board outreach campaigns¹¹ and mental health education in schools¹². Such initiatives equip individuals with stress coping techniques and counter existing mental health stigmas. These efforts have coincided with an Institute of Mental Health study seeing a higher number of respondents able to recognise common mental health conditions, from 42.3 per cent in 2014 to 58.9 per cent in 2022. The study also assessed that there was an “improvement in public perception” of those with mental health conditions¹³. While economic circumstances are a key driver in Singaporeans’ decisions on having children, public campaigns on mental health literacy mainly aim to increase awareness and change societal attitudes. Since the root problem of Singapore’s low organ donation rates does not lie in economic restraints but in the nation’s death culture and lack of understanding of the organ transplantation framework, this essay argues that public education is an effective way to raise awareness on this issue. Given that the government is the most trusted institution in Singapore¹⁴, comparable efforts to raise mental health literacy rates should be utilised in building a greater understanding of organ donation.

Furthermore, younger Singaporeans have demonstrated increased openness towards conversations on death and organ transplantation. Dr Will Loh, consultant at the National University Hospital, said that he had recognised a “culture change” amongst younger individuals who are not as attached to traditional beliefs of the physical body and are more prepared to donate their organs after death¹⁵. Additionally, the previously cited survey had found that the proportion of respondents comfortable with discussing their own death increased from 36 per cent five years ago to 53 per cent in 2019¹⁶. These attitude shifts amongst the younger generation show that there are opportunities for the government to play a greater role in facilitating more open discussions amongst families.

As such, given Singaporeans’ continued confusion over the complexity of the organ transplantation framework, public education initiatives must reach out not only to the younger generation but also to individuals across different age groups. Currently, the Live On Festival, an initiative started by the National Organ Transplant Unit, has targeted youths to express their thoughts on organ donation through art and writing¹⁷. Such initiatives can be expanded into neighbourhood outreach programmes to reach out to older demographics. In addition, drawing from Spain’s media communication strategy, documentaries or news bulletins on Singapore’s transplantation system could be aired during prime-time television slots, where families are more likely to be watching TV together. Local drama serials that have older target audiences can also address end-of-life topics, normalising such conversations within homes. These measures allow individuals to understand the donation process and recognise the impact that their organs can have on saving lives, encouraging more to make their organ donation wishes known to family members. When such intentions are clearly communicated, family members would be reassured that they are not acting against their loved one’s wishes. Hence, they are more likely to raise the patient’s intentions to doctors during end-of-life care discussions.

While a “utopian dream” implies an unattainable fantasy, this essay concludes that a norm in which family members bring up their loved one’s organ donation intentions to doctors is an achievable goal for Singapore. Although death will likely remain a culturally taboo topic in the country, sustained public engagement initiatives can incrementally shift attitudes on end-of-life discussions. A greater understanding of the country’s organ transplantation system can encourage more open family conversations on end-of-life matters, helping to address the key problem of family members being unaware of their loved one’s final wishes. Ultimately, every organ donation is a life-saving resource, and concerted government action is vital in developing a more open culture surrounding organ donation in Singapore, whilst respecting individuals’ personal wishes.

References

1.    Julian Savulescu and Sumytra Menon, “Commentary: Patients are dying unnecessarily while waiting for organ donors,” Channel News Asia, July 24, 2024, https://www.channelnewsasia.com/commentary/organ-donation-transplant-brain-death-family-parents-children-isaac-loo-4498006 ↗ (opens in new tab)

2.    “Palliative Care vs. End-of-Life Care: What’s the Difference?,” Singapore Hospice Council, November 25, 2024, https://www.singaporehospice.org.sg/palliative-care-vs-end-of-life-care-whats-the-difference/ ↗ (opens in new tab)

3.    Sherlyn Seah and Louisa Tang, “Singapore faces shortage of organ donations; more than 500 patients waiting for transplant,” Channel News Asia, December 19, 2025, https://www.channelnewsasia.com/singapore/organ-donation-shortage-transplant-moh-kidney-patients-5646451 ↗ (opens in new tab)

4.    Jalelah Abu Baker, “'Are you sure he is dead?': Doctors struggle with families’ lack of understanding of HOTA,” Channel News Asia, January 20, 2026, https://www.channelnewsasia.com/singapore/human-organ-transplant-act-doctors-families-understanding-887136 ↗ (opens in new tab)

5.    Mishelle Tongco, “Depression, fear and deterioration: Why some Asian families avoid speaking about death,” Australian Broadcasting Corporation, May 7, 2023, https://www.abc.net.au/news/2023-05-07/withholding-information-in-asian-families/102266318 ↗ (opens in new tab)

6.    Tessa Oh, “Singaporeans more open to talking about death and care for the sick: SMU study,” Channel News Asia, October 5, 2019, https://www.channelnewsasia.com/singapore/singaporeans-more-open-talking-about-death-and-care-sick-smu-study-5697451 ↗ (opens in new tab)

7.    Simon Streit et al., “Ten Lessons From the Spanish Model of Organ Donation and Transplantation,” Transplant International 36, no.1 (2023): 5-8, https://doi.org/10.3389/ti.2023.11009 ↗ (opens in new tab).

8.    Singapore Hospice Council, “SHC Death Literacy Index Study Report (2025),” (Singapore: SHC, 2025).  https://www.singaporehospice.org.sg/e-library/docs/shc-death-literacy-index-study-report-2025/ ↗ (opens in new tab)

9.    Seah and Tang, “Singapore faces shortage of organ donations.”

10. Soo Fang Chin, Syarafana Shafeeq and Megan Wee, “Singapore wants more babies. Will a radical reset reverse the fertility crunch?,” The Straits Times, March 17, 2026, https://www.straitstimes.com/singapore/singapore-wants-more-babies-will-a-radical-reset-reverse-the-fertility-crunch ↗ (opens in new tab)

11. Ministry of Health Singapore, “Improving Public Recognition of Mental Health Conditions,” January 7, 2025, https://www.moh.gov.sg/newsroom/improving-public-recognition-of-mental-health/ ↗ (opens in new tab)

12. Ministry of Education Singapore, “Mental Health,” accessed May 22, 2026, https://www.moe.gov.sg/education-in-sg/our-programmes/mental-health ↗ (opens in new tab)

13. Li Ying Lee, “Singaporeans more aware of mental health conditions; less stigma over such issues: IMH study,” The Straits Times, November 19, 2024, https://www.straitstimes.com/singapore/singaporeans-more-aware-of-mental-health-conditions-have-less-stigma-imh-study ↗ (opens in new tab)

14. Soo Fang Chin, “Govt remains most trusted institution in S’pore: Survey,” The Straits Times, March 12, 2024, https://www.straitstimes.com/singapore/government-the-most-trusted-institution-in-s-pore-survey ↗ (opens in new tab)

15. Terence Heng, “Commentary: Death is the destination we all share,” Channel News Asia, May 08, 2024, https://www.channelnewsasia.com/commentary/singapore-death-ageing-population-conversations-living-funeral-michelle-mike-ng-4318211 ↗ (opens in new tab)

16. Oh, “Singaporeans more open to talking about death and care for the sick: SMU study.”

17. Live On Festival, “About Live On Festival,” January 09, 2026, https://festival.liveon.gov.sg/about/ ↗ (opens in new tab)

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)