Objectives: This paper explores health care professionals’ potential attitude toward organ donation if the presumed consent system were to be implemented in Malaysia, as well as factors associated with this attitude.
Materials and Methods: We used self-administered questionnaires to investigate the attitude of 382 health care professionals from the University of Malaya Medical Center between January and February 2014. The responses were analyzed using logistic regression.
Results: Of the 382 respondents, 175 (45.8%) stated that they would officially object to organ donation if the presumed consent system were to be implemented, whereas the remaining 207 (54.2%) stated that they would not object. The logistic regression showed that health care professionals from the Malay ethnic group were more likely to object than those from Chinese (adjusted odds ratio of 0.342; P = .001) and Indian and other (adjusted odds ratio of 0.341; P = .003) ethnic groups. Health care professionals earning 3000 Malaysian Ringgit or below were more likely to object than those earning above 3000 Malaysian Ringgit (adjusted odds ratio of 1.919; P = .006). Moreover, respondents who were initially unwilling to donate organs, regardless of the donation system, were more likely to object under the presumed consent system than those who were initially willing to donate (adjusted odds ratio of 2.765; P < .001).
Conclusions: Health care professionals in Malaysia have a relatively negative attitude toward the presumed consent system, which does not encourage the implementation of this system in the country at present. To pave the way for a successful implementation of the presumed consent system, efforts should be initiated to enhance the attitude of health care professionals toward this system. In particular, these efforts should at most target the health care professionals who are Malay, earn a low income, and have a negative default attitude toward deceased donation.
Key words : Deceased donor, Informed consent system, Organ donation
Malaysia has a serious shortfall in human organs, to the extent that in December 2014 more than 18 000 patients were waiting for a transplant.1 On average, only 60 living and 30 deceased transplants are performed every year.2 Because living donation has resulted in organ trafficking around the world, improving deceased donation rates appear to be the only efficient solution to address this shortfall in organs. The Declaration of Istanbul states that the “therapeutic potential of deceased organ donation should be maximized [and] efforts to initiate or enhance deceased donor transplantation are essential to minimize the burden on living donors.”3
There are evidences that the presumed consent system (PCS), in which everyone is a donor unless he or she objects during his or her lifetime, produces higher deceased donation rates than the informed consent system (ICS), in which only those who registered during their lifetime are considered for posthumous organ donation.4-6 However, some argue that the higher donation rates reported by countries applying the PCS are not merely attributed to this system but also to other factors, such as the appropriate organization of the organ donation and transplant process7,8 and public trust in the medical system.9,10
Malaysia has been applying the ICS since 197411 and reporting poor deceased donation rates (0.5 deceased donations per million population) and escalating rates of patients awaiting organ transplant (600 patients per million population).1,2 One argued strategy to promote deceased donations in Malaysia is a change from the ICS to the PCS.12
One of the major factors that influences deceased organ donation is the attitude of health care professionals (HCPs).13-15 They play a crucial role in the process because they are responsible for identifying the potential donor, approaching the donor’s family to obtain consent, and contacting organ donation coordinators.13 The attitude of HCPs can also drive the public attitude toward deceased organ donation.16-18 Therefore, successful implementation of the PCS requires the support and endorsement of HCPs.
An earlier research in Malaysia found that only 47.8% of HCPs were willing to donate organs after death.13 The same study reported that the attitude of HCPs was correlated with their ethnicity and sex but not with their age or profession.13 However, to our knowledge, no study has investigated attitudes of Malaysian HCPs toward organ donation if the PCS were to be implemented. Hence, this study sought to investigate the potential attitude of HCPs toward deceased donation if the PCS were to be implemented in Malaysia, as well as factors associated with this attitude.
Materials and Methods
To achieve the above-mentioned objectives, a survey was undertaken at the University of Malaya Medical Center between January and February 2014, which is the largest medical and transplant center in Malaysia. A group of social scientists and physicians collaborated to design a self-administered questionnaire to explore the attitude of HCPs toward the PCS. In light of the existing literature,13 we expected the probability of objection to donating organs under the PCS to be about 0.5. Thus, for 5% precision level and 95% confidence level, 380 respondents were needed to meet the study objectives.19 Although a larger sample size is always preferable, the investment required in terms of both money and time for data collection is a limitation for all researchers.19 Therefore, given the available resources, we distributed 400 questionnaires, 382 of which were completed and returned, producing a response rate of 95.5% (Table 1).
The questionnaire first asked respondents for their demographic and socioeconomic information. To gauge the respondents’ default attitudes toward organ donation, they were asked whether they were willing to donate organs after death or not. Next, respondents were presented with the following question: “If the Malaysian government implements the policy of PCS, in which you are automatically registered as a deceased donor, would you sign the form to register your objection?” The questionnaire gave respondents 2 options: “Yes, I will sign the form to register my objection” and “No, I will not sign the objection form.” We expected that some respondents may not have knowledge on the legislative systems of organ donation (the PCS and the ICS), and so a written explanation about each system and its functioning mechanism was provided in the questionnaire.
The association between the potential attitude of HCPs toward the PCS (dependent variable) and various independent factors were assessed. In the first stage, a bivariate analysis (Pearson chi-square test) tested the association between objection to donating organs (dependent variable) and several independent variables (Table 2). A 5% significance level was used as the rejection criterion. In the next stage, factors that revealed a significant association were regressed against the dependent variable by applying a multiple logistic regression. The dependent variable was assigned a value of “1” in case the respondent stated that he or she would sign the objection form, whereas a value of “0” was assigned if a respondent declared that he or she would not sign the form. To ensure that our results were not driven by respondents’ default attitude toward organ donation or their involvement in organ donation and transplant activities, we controlled for these 2 factors in the logistic regression. To avoid overfitted estimates, we ensured a minimum of 10 outcome events per predictor variable.20,21 The variance inflation factor was calculated to test the collinearity between the independent variables. Statistical analyses were performed using SPSS 20.0 (SPSS Inc, Chicago, IL, USA).
All human studies were reviewed by the University of Malaya Research Ethics Committee (reference number UM.TNC2/RC/H&E/UMREC-35). All respondents gave their informed consent before their inclusion in the study, and the research protocols conformed to the ethical guidelines of the 1975 Helsinki Declaration.
Of the 382 respondents, 208 (54.5%) were nurses and 174 (45.5%) were doctors. Most respondents were female (70.4%), above 30 years old (75.7%), married (59.2%), and earning 3000 Malaysian Ringgit (MYR; 3000 MYR is ~920 in US dollars) and above (66.5%). Only 39.3% of respondents were involved in organ donation activities (Table 1). The default attitude toward organ donation showed that 56.5% of HCPs were willing to donate organs after death, whereas the remaining 43.5% were unwilling (Table 1). Of the total 382 respondents, 175 (45.8%) stated that they would register their objection to donate their organs if the PCS were to be implemented in Malaysia, whereas the remaining 207 (54.2%) stated that they would not object.
The bivariate analysis (Table 2) showed that the attitude of HCPs toward the PCS was significantly associated with ethnicity, personal monthly income, household monthly income, profession, involvement in organ donation and transplant activities, and default attitude toward deceased donation (P < .01). Sex, age, and marital status were not associated with objection to donate organs under the PCS.
The results of the logistic regression (Table 3) revealed that individuals with Malay ethnicity were about 66% more likely to object to donation under the PCS than the Chinese (adjusted odds ratio of 0.342; P = .001) and Indian and other (adjusted odds ratio of 0.341; P = .003) ethnic groups. Lower income respondents (ie, < 3000 MYR) were 1.7 times more likely to object to donation under the PCS than respondents with higher income (≤ 3000 MYR) (adjusted odds ratio of 1.704; P = .030). The default attitude toward donation of HCPs was a significant predictor of attitude toward the PCS. Respondents who were initially unwilling to donate organs after death were about 2.7 times more likely to object to donation under the PCS (adjusted odds ratio of 2.765; P < .001). On the other hand, household monthly income, profession, and involvement in organ donation and transplant activities were not significant predictors in the logistic regression.
The value of the variance inflation factor was lower than 1.4 across all independent variables. This low value indicates that the multiple logistic regressions were free of collinearity problems.
Although there are evidences that the PCS yields higher deceased donations,4-6 there are 3 key factors that imply that Malaysia is not ready to implement this system in the foreseeable future. The first factor is the anticipated public negative attitude toward this system. Our recent survey in a previous study revealed that 63.9% of the public would object to donating organs posthumously if the PCS were to be implemented in Malaysia.22 The second factor is the prevailing high rate of consent refusal of families regarding donation of organs of their deceased relatives, which is currently estimated to be around 70%23 and expected to increase further under the PCS.9 The third is the lack of adequate medical infrastructure and skilled HCPs to cope with any increase in donation and transplant activities.12,24
The role of HCPs in organ donation overlaps with all of the above-mentioned factors. This is due to their primary role in driving the public attitude toward donation, approaching families to obtain consent, and performing organ donation and transplant activities.13,16-18 These imply that the attitude of HCPs is key to the success of the PCS. Our results reveal that HCPs have a relatively negative attitude toward the PCS, since approximately 45.8% of them would object to donating organs under this system. It would also turn the positive initial attitude of about one-third of HCPs to a negative objection to donation. Hence, besides the above-mentioned factors, our results add another crucial and overlapping factor that discourages the implementation of the PCS in Malaysia, which is the current negative attitude of HCPs toward this system.
Our results reveal that both ethnicity and personal income are significant predictors of HCPs’ objection to organ donation under the PCS, with Malay and lower-income HCPs more likely to object than their counterparts. Earlier research on public attitude toward the PCS has shown parallel results on ethnicity but opposite findings on income.22 In other words, among the public, the Malays and higher income groups were significantly more likely to object to donation than their counterparts under the PCS.22 In addition, age was found to be a significant predictor for public objection to the PCS,22 whereas our study revealed that age was an insignificant predictor of HCP objection to the PCS.
Health care professionals were found to have a relatively negative attitude toward the PCS, which, when taken together with other factors, does not encourage the implementation of the PCS at present. Consequently, if the PCS were to be implemented in Malaysia, efforts should be dedicated to reduce the negative attitude of HCPs toward this system. These efforts should primarily target HCPs who are Malay, those who earn a low income, and those who have a negative default attitude toward deceased donation. A better HCP attitude toward the PCS would pave the way to the successful implementation of this system in the future.
The University of Malaya Medical Center is the most important public center for organ transplantation in Malaysia. However, the viewpoints of HCPs in private medical centers might not be the same as those elicited in this research. In addition, the correlation between variables may not mean causation. Thus, future studies should explore time variant data to establish causation.
Volume : 17
Issue : 1
Pages : 1 - 5
DOI : 10.6002/ect.2017.0214
From the 1Department of Administrative Studies and Politics, the
Research Management and Monitoring, the 3Department of Economics, the
4Department of Medicine, the 5Dean’s Office, Faculty of Medicine, and the
6Department of Nursing Science, University of Malaya, Kuala Lumpur, Malaysia
Acknowledgements: The authors acknowledge the financial support provided by the University of Malaya under the Wellness Research Cluster research grant (RG511-13HTM) and the University of Malaya Research Ethics Committee for approving this study (Reference Number: UM.TNC2/RC/H&E/UMREC). The authors declare no conflicts of interest.
Corresponding author: Makmor Tumin, Department of Administrative Studies and Politics, Faculty of Economics and Administration, University of Malaya, 50603 Kuala Lumpur, Malaysia
Phone: +603 7967 3690
Table 1. Background of Respondents
Table 2. Respondents’ Objections to Deceased Organ Donation Under the Presumed Consent System: Bivariate Analyses
Table 3. Factors Associated With Health Care Professionals’ Objections to Donate Organs Upon Death Under the Presumed Consent System: Logistic Regression