Objectives: This study evaluated the current landscape of deceased organ donation across the 5 Central Asian nations (Kazakhstan, Uzbekistan, Tajikistan, Kyrgyzstan, and Turkmenistan) and identified the multifactorial causes behind the regional “transplant gap.” The study specifically focused on renal transplant programs, which constitute the vast majority of transplant activities and waiting lists in the region.
Materials and Methods: We conducted a comprehensive analysis using a multidisciplinary approach, which included an audit of national legislative frameworks and official health ministry reports from 1972 to 2024. We performed qualitative synthesis on expert discourse from theologians, health care professionals (including urologists and transplant surgeons), and bioethicists to identify informal socio-cultural barriers. The study conformed to the 1975 Helsinki Declaration guidelines.
Results: Despite modern legal frameworks permitting deceased donation, clinical implementation remains nonexistent in most of the 5 republics, with activity almost exclusively limited to living related kidney and liver donation. Kazakhstan is the only nation with a sustained deceased donor program, where kidney transplants represent approximately 90% of the national waiting list. However, the region faces a staggering 88% family refusal rate. Religious misconceptions and the enduring influence of Tengrist “intact body” taboos were identified as pivotal factors hindering the transition from living to deceased donation.
Conclusions: The failure of deceased donation programs in Central Asia is rooted in a unique synthesis of “Folk Islam” and ancestral nomadic traditions. Because the regional transplant capacity is primarily centered around urological and nephrological care, national strategies must integrate cultural resonance into these clinical settings. Success depends on reframing organ donation as a modern manifestation of traditional nomadic values through partnerships between medical specialists and religious leaders.

Key words : Brain death, Family refusal, Islam, Renal transplantation, Tengrism

Introduction
Central Asia is a geopolitically and socio-culturally unique region comprising the former Soviet republics of Kazakhstan, Uzbekistan, Tajikistan, Kyrgyzstan, and Turkmenistan. The region, which spans an area of 4 003 451 square kilometers with a rapidly growing population exceeding 80.8 million, is facing an escalating burden of end-stage organ failure.¹ The inception of transplant activities in Central Asia is characterized by a dramatic historical shift. In the 1970s, under the centralized health care system of the USSR, the region was fully integrated into a robust deceased donation framework. During this era, more than 95% of kidney transplant procedures used deceased donors. This use was facilitated by a “presumed consent” legal doctrine rooted in the principle that the deceased’s body was state property, allowing organ retrieval without familial authorization. Uzbekistan pioneered these efforts, followed by Kazakhstan, Tajikistan, Kyrgyzstan, and Turkmenistan. However, the post-1991 collapse of the Soviet Union dismantled this infrastructure, replacing state-centered ethics with individual autonomy and a resurgence of religious identity, which, paradoxically, led to the total suspension of deceased donor programs in most of the republics.² Currently, although all Central Asia countries have successfully institutionalized living related donor transplantation, a critical “transplant gap” persists. Although deceased donation is theoretically legalized and governed by modern “Code of Health” frameworks across the region, clinical implementation is nonexistent in Tajikistan, Kyrgyzstan, and Turkmenistan. In Uzbekistan, the historical deceased donor program also remains dormant despite recent legislative updates. Only Kazakhstan maintains an active, albeit struggling, deceased donor registry. This heterogeneity in regional progress is primarily driven by profound public reluctance and systematic familial opposition at the bedside. Expert analysis has consistently identified religious beliefs as the pivotal barrier to donation.³ The main religion in the Central Asia countries is officially considered to be Sunni Islam, with 87% of the population adhering to it (about 76% in Kazakhstan, 83% in Kyrgyzstan, 86% in Uzbekistan, 92% in Turkmenistan, and 96% in Tajikistan).⁴ Numerous studies have been conducted on organ transplant from deceased donors in Islamic countries. These are nations where more than 50% of the population follows Islam. Muslim countries represent the second-largest religious group globally, with an estimated 1.6 billion adherents, that is, over 22% of the world’s population. The Quran emphasizes the value of saving a life, stating that saving the life of one person is as significant as saving the lives of all mankind. Although global Islamic jurisprudence has overwhelmingly supported organ donation as a form of “ongoing charity” (Sadaqah Jariyah), a fact evidenced by the high success rates in countries like Iran (98% Muslim, 90% donation willingness), Turkey, and Saudi Arabia, the Central Asian regions remain resistant. This suggests that the barrier is not the Quranic doctrine itself but rather a complex synthesis of “Folk Islam” and ancestral traditions. In many Central Asia societies, misconceptions regarding brain death and the sanctity of the physical body continue to hinder the acceptance of transplantation as a vital form of life-saving charity.^5,6 According to the literature, organ transplantation in many Islamic countries remains in the early stages of development, with several fundamental issues still needing to be addressed.⁷ Despite the clinical urgency, comprehensive literature addressing the multifactorial reasons for this regional stagnation is scarce. In this study, our aim was to provide a critical assessment of the current state of deceased organ donation in Central Asia, exploring the disconnect between legislative permission and socio-cultural practice, with a specific focus on how religious and traditional worldviews shape the future of transplant in the region.

Materials and Methods
We conducted an extensive search of both medical and nonmedical online resources to capture the intersection of clinical practice and socio-cultural influence. For our search, we used international databases (PubMed, Scopus, Google Scholar) and regional legal and theological archives. Keywords and Boolean operators included “Islam AND organ donation,” “brain death AND Central Asia,” “Tengrism OR ancient Turkic beliefs,” “deceased donation,” and “organ transplantation policy.” We included only sources published in English, Kazakh, and Russian to ensure linguistic accuracy and cultural context. The study involved a comparative review of the legislative frameworks currently governing transplantation in the 5 Central Asian republics. We systematically reviewed information on transplant activities available on the official websites of the Ministries of Health of Kazakhstan, Uzbekistan, Tajikistan, Kyrgyzstan, and Turkmenistan. The audit focused on the definition of brain death, the legal mechanism of consent (presumed vs informed), and the existence of national transplant coordination centers. Given the sensitive nature of organ donation, we integrated a qualitative component to our study. We analyzed written and oral opinions from a diverse cohort of stakeholders, including (1) theological experts and adherents of both Sunni Islam and Tengrism; (2) health care professionals (transplant surgeons, intensive care units, and transplant coordinators) directly involved in the clinical process; and (3) bioethicists specializing in Central Asian cultural history. This synthesis allowed us to map informal barriers that exist despite formal legal permissions. We gave special attention to the synthesis of pre-Islamic nomadic traditions (Tengrism) and their contemporary impact on medical decision-making in the region. We cross-referenced collected statistical data with reports from the WHO Global Observatory on Donation and Transplantation and national registries when available. This study, which relied on publicly available data, legislative reviews, and expert discourse analysis, was conducted in accordance with the ethical standards of the institutional review board of the University Medical Center (Astana) and conformed to the ethical guidelines of the 1975 Helsinki Declaration. Written informed consent was obtained from all participants/experts involved in the qualitative synthesis.

Results
The comprehensive analysis of the 5 Central Asian republics revealed a heterogeneous landscape in transplant activities. Although legislative frameworks are present in all states, a profound disconnect was shown between legal theory and clinical practice regarding deceased donation.

Kazakhstan
As the regional leader, Kazakhstan is the only country with a sustained deceased donation program since 2012. Currently, the National Waiting List includes 3748 patients (3354 for kidneys, 175 for liver, 149 for heart, and 15 for lungs). Despite having 40 donor organizations (hospitals) capable of certifying brain death, the conversion rate remains low; in 2024, only a small fraction of potential donors resulted in actual organ retrieval due to a staggering 88% family refusal rate.⁸

Uzbekistan
After a decades-long hiatus after the collapse of the USSR, Uzbekistan enacted a new Law on Transplantation in 2022. Despite accelerated kidney and liver transplants from living donors in Tashkent, deceased donation remains dormant. Historical data showed that, while Uzbekistan was a pioneer in the 1970s, the current system is in a state of re-institutionalization.”

Tajikistan
Transplant activities are focused exclusively on living related donors. In 2023, approximately 185 kidney and 67 liver transplants were performed.⁸ Although deceased donation was legally permitted in 2019, zero cases of organ retrieval from deceased individuals have been recorded to date.

Kyrgyzstan and Turkmenistan
Both of these nations rely entirely on living donation. Kyrgyzstan has recently increased state funding for transplants and opened its first HLA-typing laboratory in 2024; however, there is a total absence of a deceased donor registry or practical implementation.

Findings
Data collected highlighted an urgent need for substantial improvements and changes in legislation, a proper understanding of civil society, comprehensive support from government agencies, and enhanced education for health care professionals in the field of organ donation and transplantation. A critical shortage of donor organs persists across the entire region, resulting in high mortality rates for patients on wait lists. Our synthesis of population surveys confirmed that religious belief is cited as the primary reason for refusing deceased donation. Although none of the world religions officially oppose organ donation after death, and indeed many Islamic authorities categorize it as an act of saving humanity, the public perception in Central Asia remains largely influenced by traditionalist and “folk” interpretations of faith. Findings identified that, while health care professionals generally support transplantation, specialized training for intensive care unit staff in identifying brain death and communicating with grieving families is lacking. This “human resource gap,” combined with low public awareness, has created a cycle where potential deceased donors are simply not identified or are lost due to immediate familial opposition.

Discussion
A large portion of the Muslim population may harbor hesitations due to persistent misconceptions on organ donation within the Islamic framework. To support individuals in making informed decisions that align with their religious values, it is crucial to clarify these ambiguities. A prevalent misconception is that organ donation is strictly forbidden (haram); however, Islamic jurisprudence fundamentally promotes kindness, altruism, and the preservation of life (Maqasid al-Sharia). Organ donation aligns with these principles as it emphasizes generosity and the protection of human life and is therefore widely permitted.⁹ Concerns that organ donation interferes with the natural process of death must also be addressed by emphasizing that retrieval occurs only after brain death is rigorously confirmed and all resuscitative efforts are exhausted. This ensures that the procedure respects the dignity of the deceased while providing a “gift of life” to those in need. Notably, the Third International Conference of Islamic Jurists, held in Amman in 1986, adopted Resolution No. 5, which established that brain death is legally and religiously equivalent to cardiac or biological death.¹⁰ In Iran, the main reasons for not being willing to donate are fear of organ donation before brain death was confirmed (52%), unwillingness to mutilate one’s body (51%), and belief in organ burial (50%). In Iran, the 2000 “Organ Transplantation and Brain Death Law” legalized organ donation after brain death.¹¹ Similarly, the Council of Arab Ministers of Health developed the Unified Arab Draft Law on Human Organ Transplantation in 1987, stipulating that specialist physicians may perform transplants from both living and deceased donors to sustain life. A landmark fatwa issued in Saudi Arabia in 1982 further solidified the permissibility of deceased donation under Islamic jurisprudence, strongly encouraging the development of national kidney transplant programs. Although Islam is the predominant religion in Central Asia, the contemporary Muslim society in the region is uniquely influenced by the customs and traditions of its pre-Islamic faith, Tengrism.¹² Tengrism is an ancient spiritual system and worldview traditionally followed by the Turkic peoples. Derived from the term “Tengri” (Sky), referring to the supreme deity, this worldview was first academically characterized by the Kazakh scholar Chokan Valikhanov and later analyzed by French orientalist Jean-Paul Roux.¹³ Although Tengrism has faded as an organized institutional religion, it has left an indelible legacy on the spiritual and religious traditions of many Eurasian peoples, particularly in Central Asia. The spread of Islam has greatly diminished the overt practice of Tengrism among the Turkic peoples; however, the influence of Islam remains heterogeneous across the region. Although the integration of Islam has been more profound among Uzbeks and Tajiks, the Kazakh and more specifically the Kyrgyz populations have preserved significant elements of Tengrist beliefs, traditions, and customs for centuries, maintaining them even after the official adoption of Islam.^14-17 A notable example of this cultural persistence is in Kyrgyzstan, where Tengrism was proposed as a foundational pan-Turkic national ideology following the 2005 presidential elections.¹⁸ A critical aspect of Tengrism is the perceived subordination of the individual to the will of Tengri, especially in matters concerning the transition between life and death. Unlike the linear perspective of Abrahamic religions, Tengrism views death as a form of liberation from the physical vessel, leading to a continuation of existence in another realm. Central to this worldview is the principle of reincarnation; according to this belief, a person does not truly perish but is instead reborn into an eternal cycle of life.¹⁹ In this context, death is often denied as an absolute end and is viewed as a mere transition, a concept that draws a striking parallel to Japanese Shintoism. The prosperity of the soul in the afterlife is believed to depend strictly on the rigorous observance of burial rituals and sacrifices performed by the family. These rites are considered essential for ensuring a “smooth journey” and a favorable outcome in the next realm.²⁰, 21 The strict observance of these burial traditions, according to regional experts, constitutes the primary barrier to the development of deceased organ donation. In Tengrist-influenced societies, the liberation of the spirit and its subsequent role as a protective ancestor (Aruakh) are guaranteed only if the body is handled with absolute reverence and remains “undamaged.” Failure to follow these rituals without exception is believed to result in the deceased relative becoming an adversarial force against the family. Consequently, when transplant coordinators discuss organ donation with grieving relatives, more than 95% of refusals are motivated by the categorical necessity to honor the deceased through an intact burial, free from any bodily harm. The underlying belief that the individual will be reborn and continue life in another world with their physical integrity preserved creates a psychological and spiritual barrier that often overrides both medical necessity and official religious (Islamic) permissions for transplantation.^20-23 Kazakhstan serves as a critical benchmark for the region, having performed its first kidney transplant from a deceased donor on April 17, 1979, in Almaty. Historically, all organ transplants in the country until 2000 utilized deceased donors. However, a significant paradigm shift occurred with the Minister of Health’s Order on August 11, 2010, which established rigorous rules for determining biological and, crucially, irreversible brain death. Before this, transplants were limited to donors after cardiac death. The legal recognition of brain death marked a transformative turning point, enhancing graft survival rates and patient life expectancy, culminating in the first multiorgan retrieval (heart and kidneys) from a brain-dead donor in 2012 in Astana.²⁴ Since 2010, the infrastructure has greatly expanded. By 2015, 9 clinics were operational; today, Kazakhstan maintains 7 specialized transplant centers. Despite this technical capacity, a stark imbalance remains, with approximately 90% of liver and kidney transplants currently performed with living related donors. The Republican Coordination Center for Transplantation, established in 2012, manages the National Waiting List, which currently shows 4113 patients on the list. This includes 3748 individuals awaiting kidneys (including 76 children), 196 requiring liver transplants (12 children), 143 needing heart transplants (5 children), and 26 requiring lung or heart-lung complexes. Although the state budget is fully subsidizing all surgical procedures, medications, and rehabilitation, the organ shortage remains the primary limiting factor.²⁴ Kazakhstani law prohibits the commercialization of organs and the retrieval of organs from deceased minors. This necessitates that children requiring deceased-donor heart or lung transplants seek treatment abroad, funded by the state. The legal system operates under the principle of presumed consent, allowing citizens to register their decision on the Ministry of Health’s web portal. However, public engagement with this system reveals a deep-seated reluctance.²⁵ Of 35 000 registered citizens, an overwhelming 86% have officially opted out, with only 16% consenting to postmortem donation. Independent surveys of 9875 citizens across 3 major cities corroborate this trend; 22% have expressed willingness to donate, 46% are categorically opposed, and the remainder cite lifestyle habits (22%) or indecision (10%) as barriers.²⁶ The disparity between potential and actual donors highlights a systemic crisis. In 2022, only 9% (4 of 44) of potential donors with confirmed brain death became actual donors. This figure saw a marginal increase to 12.5% in 2023 and 12.2% in 2024.27 Analysis by the Republican Coordination Center has identified the following primary drivers for familial refusal. (1) Religious beliefs account for 59% as the primary metaphysical barrier. (2) Indecision accounts for 18%, with relatives’ inability to assume responsibility for the deceased’s remains. (3) Cognitive dissonance on brain death accounts for 12%. Relatives often misinterpret mechanical ventilation and a beating heart as signs of potential recovery. (4) Fear of commercialization accounts for 7%, and (5) distrust of medical personnel accounts for 4%.²⁸ These data underscore that, despite advanced clinical equipment, qualified specialists, and full state funding, the program’s success is stalled by socio-cultural and psychological factors rather than technical or financial ones. Clinical transplant procedures in Tajikistan began in 2009. Despite achieving high technical proficiency through a long-term partnership with the Shiraz Transplant Center and performing 185 kidney and 67 liver transplants in 2023, the program has remained limited exclusively to living related donors. Although deceased donation was officially legalized under the 2019 Health Code, zero instances of organ retrieval have been recorded to date. The program faces a persistent trust deficit and deeply entrenched societal aversion to postmortem procedures. Additionally, financial accessibility is a significant challenge, as the state covers only 20% to 30% of transplant costs in specific cases.^29-31 Uzbekistan, once a regional pioneer in transplantation, saw its deceased donor program paralyzed by restrictive legislative shifts in the 1990s. Although clinical activities had resumed after 2010, reaching over 540 kidney transplants by late 2021, the system currently operates exclusively through living related donation. The 2022 Law “On Transplantation of Human Organs and Tissues” has officially permitted deceased donation, but the strict “opt-in” model requires notarized lifetime consent. Overcoming this “moral-ethical bottleneck” and operationalizing the mandated Unified State Register for Donors and Recipients have remained the primary hurdles for the nation’s transplant infrastructure.^32-34 Kyrgyzstan is undergoing a significant transition from a heavy reliance on foreign medical services, where 95% of transplants were historically conducted abroad, to a state-supported local infrastructure. Clinical activity since 2012 has been modest and limited to living related donors (~65 cases), but a 2024 presidential directive now provides state funding for local procedures and established the nation’s first HLA-typing laboratory. Although the 2024 Law On the Transplantation of Human Organs and Tissues officially expanded the donor pool and permitted deceased donation, the nation continues to have a massive wait list (2700 patients) and the same deep-seated socio-cultural resistance to postmortem retrieval seen across the region.³⁵, 36 Transplantation in Turkmenistan is the most nascent in the region, with clinical activities by local specialists only beginning in 2021. Capacity remains highly centralized at a single facility in the capital, which performs approximately 10 living related transplants annually. The system has faced severe systemic barriers, including a critical shortage of qualified transplant specialists and dialysis machines, alongside the absence of a domestic HLA-compatibility laboratory. Although the 2013 Law on Organ and Tissue Transplantation established a “positive consent” model requiring explicit familial authorization, no deceased donor transplants have been performed to date. Consequently, the nation remains entirely dependent on living related donation and international medical tourism.³⁷

Conclusions
The advancement of deceased organ donation in countries in Central Asian is a multi-faceted challenge influenced by economic development, government prioritization, and, most critically, societal attitudes. Although the justification for deceased organ donation is broadly accepted across the global Muslim community, in both the East and the West, the general public in Central Asia remains deeply hesitant. To bridge this gap, it is essential to shift the national discourse from the mere legalization of organ donation toward fostering a sense of moral obligation and collective social responsibility. Islam, like other major world religions, does not prohibit organ donation; thus, the divergence in public opinion in Central Asia suggests a cultural rather than a purely theological conflict. Spiritual leaders in the region hold diverse perspectives; many leaders provide full support, but others view transplantation as incompatible with local interpretations of religious and cultural sanctity. Followers of Tengrism, or those influenced by its cultural legacy, often lack awareness regarding the clinical reality of organ donation, viewing the practice as foreign to their ancestral customs. The enduring belief in a profound metaphysical connection between the living and the spirits of the ancestors (Aruakhs) remains a dominant psychological factor. Consequently, practices such as medical dissection or organ retrieval are frequently regarded as taboo, as they are perceived to violate the physical integrity required for the spirit’s journey. Religion should not be viewed as an insurmountable barrier; instead, this barrier must be transformed into a vital ally. Because local imams and religious authorities are often the first point of contact for families facing the crisis of brain death, building formal partnerships with them is crucial. Providing these leaders with comprehensive medical education on the organ allocation process and the scientific determination of brain death is essential to dispel misconceptions and build trust in the healthcare system. The Turkic people possess a deep-rooted tradition of honoring the deceased, epitomized by the folk wisdom “the dead are not satisfied, the living are not rich” (Өлі разы болмай, тірі байымайды). This reverence is historically reflected in the construction of grand mausoleums and elaborate ceremonies where the deceased were bid farewell with their belongings. Although the Islamic faith has reshaped these funeral practices, they have adapted into a unique synthesis that preserves original cultural significance. The successful development of deceased donation in Central Asia depends on cultural resonance. Efforts must be made to frame organ donation not as a violation of the body but as a modern manifestation of the ancient nomadic values of sacrifice and mutual aid. Only through a collaborative approach involving health care providers, religious authorities, and cultural historians can the region overcome its “metaphysical deadlock” and provide a future for thousands of patients on wait lists.