Trend: Between Approval and Fear: How Do Bulgarians View Organ Donation?

The article is based on a nationally representative survey conducted using the face-to-face method among 1,002 adult respondents between October 16 and 22, 2024, funded by the Executive Agency for Medical Supervision.

Organ donation offers a chance for a new life, but the subject is inevitably linked to significant ethical, medical, and social aspects. For a donation system to function effectively, it requires not only the presence of medical infrastructure but also public awareness, understanding, and trust. In Bulgaria, however, there is a lack of systematic knowledge regarding how people perceive donation. It is unclear to what extent they are familiar with its core aspects and what factors influence their opinions. This nationally representative survey aims to outline public attitudes and concerns related to organ donation in Bulgaria. It can serve as a foundation for future policies, information campaigns, and legislative decisions in this sensitive and socially significant field.

Do Bulgarians approve of organ donation?

First and foremost, we should highlight the positive conclusion of the study. There is no high level of fundamental disapproval toward donation within Bulgarian society. The proportion of people who do not accept donation as a whole due to ethical, moral, religious, or other value-based considerations remains below one-fifth. This is an important starting point. It creates a favorable basis for the development of effective information campaigns and policies in support of donation.

The situation would be quite different if there were a widespread belief that organ donation is inherently wrong—for example, due to beliefs regarding death, the integrity of the body, or the impermissibility of external intervention after death. In countries where such attitudes are dominant, serious difficulties are observed in building a sustainable donation system. In this context, the Bulgarian case provides grounds for moderate optimism. Furthermore, it directs attention toward other, more resolvable issues—such as awareness and trust.

Personally, do you generally approve or disapprove of organ donation?

The Main Challenges Facing Organ Donation

Lack of Familiarity with the Subject

Here, however, we come to the negative findings of the study. If we were to summarize the main factors that generate skepticism toward donation, they can be reduced to three primary ones:

• lack of familiarity with the subject,
• doubt in the process,
• as well as a refusal to discuss such matters altogether.

The survey shows that approximately two-thirds of Bulgarians remain unfamiliar with donation and the conditions under which a person can become a donor. It is particularly concerning that the same proportion of people are also unfamiliar with the irreversibility of brain death. Understanding this condition is of crucial importance for decision-making in a donation situation.

This lack of awareness also reflects more skeptical attitudes. The problem of lack of information is particularly valid for young people under 30. This is the group that finds it most difficult to express an opinion on the questions posed. Among elderly people over 70, a higher level of skepticism is observed. This can be explained by the more conservative attitudes characteristic of this segment of society.

Personally, are you familiar or unfamiliar with organ donation and the conditions under which a person can become a donor?

To what extent are you personally familiar with the concept of brain death?

From what you personally know about the condition of brain death, is there or is there not a possibility for the victim to recover from this state?

Base: 432 respondents who are familiar

Distrust in Doctors

The second aspect that causes concern is the distrust in doctors. This distrust is reflected in two main directions. The first is related to the overall undermining of authority in various spheres of public life. This trend manifests in various responses such as “fear of medical error,” “lack of competence among doctors,” etc. These suggest serious doubts about the ability of medical professionals to perform their duties professionally.

The other aspect of this distrust is ethical. Namely: concerns that doctors might be involved in illegal schemes related to donation. These fears crystallize into the concern that if a person agrees to be a donor, doctors might not make every effort to save them. Of course, this type of fear cannot be viewed outside the context of widespread distrust toward institutions in the country, including the sense of helplessness and vulnerability among citizens.

However, an important clarification must be made here. To the question “For what reasons would you personally not trust a medical diagnosis?”, the leading answers are related more to the perceived image of doctors in the public space than to actual cases of misdiagnosis. Although respondents cite medical error as a reason, it ranks last compared to other answers. This suggests that skepticism toward doctors is largely a result of increasing media attention on cases of medical errors and allegations of incompetence. Furthermore, news of violence and aggression toward medical professionals further undermines trust in the profession. Thus, an atmosphere of suspicion and uncertainty is formed in the public consciousness, which seriously hinders the building of trust, including in the field of donation.

For what reasons would you personally not trust a medical diagnosis?

Base: 259 respondents who answered that they would not trust a diagnosis of “brain death” made by a doctor

The difference between the proportion of people who approve of donation and those who agree to become donors is partly due to these fears. Although the primary reason cited by respondents is the belief that they are not physically fit to be donors—which is prevalent among older groups—the fear that doctors might not make every effort to save your life if you agree to be a donor stands out as a major reason among younger people.

Would you personally agree or not agree to donate your organs after your death?

For what reasons would you personally not agree to donate your organs after your death?

Base: 342 respondents who would not agree to become donors

Finally, as a factor influencing attitudes toward donation, we must mention the traditional reluctance of Bulgarians to discuss such topics, often explained by a fear of “tempting fate.” This difficulty in open discussion manifests not only in the context of donation but also in the overall attitude toward the prevention and prophylaxis of various diseases. Less than one-fifth of respondents have shared their opinion with their relatives on whether they would like to be donors. This shows that the topic is not discussed openly within the family. This not only makes it difficult to understand the wishes of loved ones but also presents a significant obstacle to making an informed decision if a situation arises where organ donation must be decided.

Have you personally shared or not shared your wish (whether you want or do not want to be a donor after your death) with your relatives?

One of the main difficulties is that lack of familiarity with the personal wishes of a loved one is a common factor leading to hesitation and indecision at the crucial moment. This, in turn, raises questions about the actual effectiveness of public approval for donation. Despite the fact that the high proportion of those approving in surveys seems promising, the lack of open discussion on the topic and clear positions of individuals within the family can prove to be a serious obstacle to the successful realization of transplants.

Changing these attitudes and fears takes time. To begin with, such a study provides an opportunity to understand the barriers that hinder donation. This gives us a foundation upon which we can build effective measures and initiatives aimed at overcoming existing challenges and fostering public trust in the process.