When a person experiences brain death - a condition in which brain functions are irreversibly lost - the medical team responsible for organ transplantation informs the family and presents them with the option of organ donation. On one hand, it is essential to find a potential recipient who meets all the necessary compatibility factors, while on the other hand, it is necessary to obtain the family's consent. Often, it is the latter that proves much more challenging.

And many psychological and social aspects influence it. In the decision-making process regarding organ donation, emotions, beliefs, and the broader social environment from which the family of the deceased person comes can play a key role. Additionally, the moment of informing the family about the death of their loved one can be crucial for whether the family will agree to the donation.

A lack of trust in the system, the taboo surrounding death, insufficient information, the absence of systematic education and campaigns, social stigma, prejudices, local communities, as well as the strong emotional reaction of the family after a loss are factors that significantly influence the final decision on whether the organs will be donated or not.

Helping families to make a decision

In some countries, the practice implies involving trained psychologists and social workers in the process of communicating with the family of the deceased. In Serbia, such a practice is not institutionalized. Doctors working in intensive care or neurosurgery units, where potential donors are most often identified, are primarily responsible for delivering the news of death and initiating conversations about donation.

A psychiatrist who worked at the University Clinical Centre of Serbia says for Vreme that neither in the time when he worked at the clinic nor nowadays have psychiatrists and psychologists participated in this process, and that this has never been a practice. However, he adds that such involvement would be significant if it were institutionalized.

An anaesthesiologist, clinical assistant at the faculty, and one of the coordinators for transplants at the University Clinical Centre of Serbia, Saša Knežević, explains for Vreme that when a family loses their loved one, they are not prepared for the tragedy, and it is a significant unpleasant surprise for them. However, he states that they must gather strength to decide whether they want to donate the deceased's organs in those moments, as doctors do not have much time to wait. This, he believes, is one of the problems in the transplantation process, as people cannot be allowed to think for days about whether it would be good for them and for the deceased or not.

In countries where the involvement of psychologists and psychiatrists in the transplantation process is practiced, their task is to help the family process the information about the death of a loved one in the most humane way possible, as well as to create a space where the decision about donation can be made without a sense of pressure. Their role is not to persuade but to inform, support, and clarify any dilemmas that families may have. In practice, in Serbia, this entire responsibility falls on the transplantation coordinators and medical staff in the departments where the patient was hospitalized.

The way in which death is communicated significantly impacts the emotional reaction of the family. Experiences of doctors in some countries show that the most effective method is when there is a dedicated team that approaches the family—one part of the team informs them about the death, while another introduces the topic of donation in a specially prepared conversation. In such an approach, it is important not to create a sense of obligation but to respect the family's right to make an informed decision.

The psychiatrist interviewed by Vreme believes that involving psychiatrists and psychologists in the transplantation process could lead to better management of the strong emotional reactions experienced at the moment of loss. Even when families are not opposed to donation in principle, emotional trauma can block their ability to think rationally about such a delicate matter. Without support and prior knowledge, people usually respond with ‘no’ – not because they don’t want to help, but because they are not ready.

However, even when an individual expresses a desire to donate their organs, or provides consent in some form, this is not sufficient in Serbia for it to be carried out; the family must also give consent after the death, which often does not happen, despite the donor's wishes. In addition to legal shortcomings in this area, from this perspective, the role of psychologists or psychiatrists would be even more significant in appropriately approaching the family of the person declared brain dead.

The greatest form of humanity

Anaesthesiologist Saša Knežević tells for Vreme that organ donation is the greatest form of humanity and maturity of a society, not only in medicine but also in all relationships within society—emotional, economic, and social. It is an indicator of empathy, humanity, understanding, and care for others.

He adds the specificity that it is built extremely slowly and is very fragile, like a house of cards, and just one small move can bring it down. Therefore, he says, it is crucial how everything is interpreted – ‘every word we speak influences human lives.’ In previous years and decades, many people who do not understand medicine, from certain politicians to various other sectors, have commented on transplantations, and we have paid for that with lives, explains the interviewee.

In Serbian law, there is a presumed consent, which means that all individuals who have not signed a declaration with their chosen doctor explicitly opposing organ donation—there are a few hundred such cases at the level of the Republic of Serbia—can become donors in the event of brain death. However, the law stipulates that their family must be consulted. If they are legally married, the spouse is asked; if they are not, their parents, children, or closest relatives are asked whether they agree to the donation.

Awareness and prejudices

There is still a deeply rooted distrust in the healthcare system and suspicion of abuses in Serbia, which can certainly affect decisions about donation. The public is often not convinced that the donation process will be fair, unbiased, and in accordance with the law. Media sensationalism in the past has further damaged trust. Although such abuses that are the subject of scepticism do not exist in practice, as established procedures are in place, this has been confirmed by several doctors interviewed by Vreme.

Besides, death is rarely discussed openly within families, and the decision about donation is made in a moment of shock, without prior preparation. The lack of public education and the absence of a clear strategy for normalizing conversations about donation further complicate the change in attitudes. In many cases, families simply do not know what attitude their deceased loved one would have taken, as they have never discussed it. Death remains a significant taboo topic. For this reason, most people do not express their views on donation during their lifetime, which makes it even more difficult for families to make a decision when faced with loss.

Additionally, the social perception of transplantation is often associated with the suspicion that ‘only the wealthy get priority’ or that organs are given ‘to someone through connections.’ These prejudices, although largely inaccurate in practice, significantly undermine the willingness of citizens to participate in the system—either as donors or as family members of the deceased. If the public does not believe that the organ will go to ‘the one who needs it the most,’ the very concept of solidarity loses its meaning.

Cultural differences between smaller and larger communities also significantly impact the decision to donate organs. In larger cities, citizens have more trust in the healthcare system, they are better informed, and are more inclined to make individual decisions. In smaller communities, traditional values prevail, along with fear of body desecration and suspicion of institutions. The attitude of the local priest or community can play a crucial role. The lack of education often leads to the spread of myths, while solidarity in smaller communities is more often associated with ‘our people’ rather than anonymous recipients.

Insufficient awareness poses one of the problems. The educational system does not include content that addresses the topic of donation and transplantation. Unlike countries with high donation rates, Serbia lacks continuous educational programs aimed at various groups—youth, parents, the elderly, and religious communities. National campaigns are conducted sporadically and rarely have a long-term effect. Donation is still perceived as an exception rather than a civic value. On the other hand, many citizens do not even know which documents they need to sign if they wish to be donors. In countries where education about organ transplantation is elevated to a higher level, donors are portrayed as heroes through campaigns, while recipients are depicted as grateful individuals who are living a new life. In this way, collective feelings of meaning and value in donations are built.

There is also a stigma surrounding the instrumentalization of the body. Some citizens feel discomfort at the idea of their loved one's body being ‘opened’ and an organ being ‘taken.’ This bodily perception of death is infused with deep emotional and cultural symbols: the integrity of the body is linked to dignity and peace after death. The lack of public education leads to transplantation being perceived as a ‘violation’ of that peace.

Anaesthesiologist Knežević agrees that the greatest uncertainties arise from insufficient awareness. He believes that the issue is not a lack of humanity and selfishness, as one might think at first glance, but rather it is about inadequate information and prejudices. ‘Many of us are slaves to the small communities we come from and the various customs, judgments, and prejudices that prevail in them,’ says the interviewee.

He shared a story about an organ donation. People came from a small village from the eastern Serbia. They were humane and agreed to organ donation, however asking the information not to be spread around, which is their discretionary right, because people in the village might think that they have sold the organs. In some communities, we are the slaves to prejudices, customs, and what others will say, concludes the interlocutor, adding that the situation is quite different when one of our own needs an organ.

Transplantation is least of all medicine, explains Knežević, adding that nothing can happen without the citizens' understanding, that it is a process where there can be no rivalries, whether political, racial, or religious. The imperative must be that it is for the benefit of all of us. We may clash, confront, and disagree on many other matters, but we must be united in this matter. This is a common interest and something we all need to work on, the anaesthesiologist clearly emphasizes.

Attitude of religious communities

The issue of organ donation is often linked to religious beliefs. However, most traditional religious communities in Serbia – Orthodox, Catholic, and Islamic – do not oppose organ donation, and some even actively support it, emphasizing the idea of saving lives as an act of mercy. The problem is that these messages are rarely conveyed to the public in a clear and systematic way.

Just as the Serbian Orthodox Church has a significant influence on shaping attitudes and beliefs in Serbian society, questions often arise about the attitude of this institution on the act of transplantation itself. Although there may be some prejudices in parts of the public that church communities potentially do not agree with transplantation, or at least do not look favourably upon it, the situation in practice is quite the opposite.

The Serbian Orthodox Church confirmed its attitude on organ transplantation in 2022, emphasizing that the decision is correct if the donor has voluntarily given consent. The statement referred to a decision made by the Holy Assembly of Bishops back in 2004, which endorsed organ transplantation if the donor had voluntarily bequeathed their organs and if the donor's family gave consent posthumously. The same statement indicated that the Holy Assembly of Bishops also supports the transplantation of organs from living persons, provided that the life of the donor is not endangered.

On the other hand, the Catholic Church expressed its view in 1994, considering organ donation as a morally good act of mercy and love. The attitude that the Church encourages both organ donation after death and transplantation as morally and ethically acceptable is further supported by official statements from the Vatican.

A good example of how the Church has encouraged organ donation is Spain, a country with a highly developed donation system. There, the Catholic Church legitimized and supported the idea of donation in a way that fostered societal trust in the system, without the barriers that arise from religious beliefs in other countries. Its role was cultural-intermediary and moral, rather than legal-institutional. The Church normalized donation through religious support, helping the public accept 'presumed consent' (in the Spanish system, all individuals are potential donors unless they explicitly refuse), and priests are often present in hospitals when families are informed of the death of a loved one.

Islam also permits organ transplantation under certain conditions. Most Islamic legal authorities (especially in Sunni schools) consider that organ donation after death is permissible and commendable, provided it is done voluntarily, without commercial benefit, and if it saves another person's life. Transplantation must be conducted with respect for the body, and it is important that there is clear consent from the donor. While some more conservative views still express concerns about violating bodily integrity after death, there is widespread religious support for organ donation in most Muslim countries nowadays.

Author: Filip Mirilović, journalist of the weekly ‘Vreme’