(Illustration by Dung Hoang)
How do cultural norms shape the outcomes of public health policy, and can organizational innovation overcome deeply embedded resistance? A new study of organ-donation rates in Singapore and Taiwan suggests that a more legally permissive policy doesn’t necessarily yield better results.
Wan-Zi Lu, an assistant professor of sociology at Stony Brook University in New York, came to the subject through a dinner conversation with a friend. At the time, she was a teaching assistant for a philanthropy course. One reading profiled a billionaire who, after donating much of his fortune to social causes, decided to give one of his kidneys while still alive. His family strongly opposed the decision.
“We know money and a kidney are very different,” Lu recalls thinking, “but what exactly is different?” Why would families resist what many regard as an act of profound generosity?
Lu found an answer in the Confucian principle of filial piety, which holds that the body is a gift from one’s parents and should remain intact. Across much of East Asia, organ donation can be viewed as disrespectful, inauspicious, or inconsistent with honoring one’s ancestors. The stigma is not only theoretical. Lu collected accounts of neighbors discouraging donations, schoolteachers warning children about the practice, and even transplant surgeons supporting donation professionally but opposing it when it involved their own relatives.
Singapore and Taiwan share this cultural inheritance, yet they adopted strikingly different approaches to organ donation. More than three decades ago, Singapore became one of the first countries in the world to implement an opt-out system for deceased donation, presuming consent unless individuals explicitly decline. Taiwan took the opposite approach, requiring people to opt in and effectively granting families veto power over donation decisions. Even when a person has registered as a donor, relatives must consent at the time of death.
Given this policy difference, Singapore would be expected to have significantly higher donation rates, since it has a much larger pool of eligible donors. But Lu found that Taiwan actually had higher rates. To understand why, Lu examined legislative archives and conducted interviews with personnel at major transplant centers in both countries.
On paper, Singapore’s opt-out policy functions as intended. Most eligible citizens remain in the donor pool (only 3 percent opt out) because opting out carries a clear disincentive: Those who remove themselves are deprioritized should they later need a transplant. Yet many of Lu’s interviewees were unaware that the policy existed or had no recollection of the notification sent when citizens turn 21.
Perhaps because of the law, Singapore had less formal coordination of donation than Taiwan. Many medical practitioners noted that hospitals varied in reporting potential donation candidates, with some lacking professional staff devoted to discussion options with relatives, and some not even doing transplants.
What’s more, families were often shocked to learn, amid acute grief, that a loved one’s organs could be procured without their explicit consent, and found ways to resist. Some families take relatives home to avoid a brain-death diagnosis. Lu even documented cases in the 2000s in which relatives attempted to stop organ recovery, prompting hospitals to call the police. Several publicized incidents deepened cultural distrust.
Taiwan took a different approach. Recognizing that legislation alone could not overcome cultural resistance, hospitals invested in what Lu calls “remoralization.” Specialized transplant coordinators begin building relationships with families early, often when patients first arrive at the hospital, not at the moment of brain death. They frame donation as an act of generosity consistent with families’ values and emphasize that the final decision remains with the family. The relationship, Lu argues, is horizontal rather than hierarchical.
Singapore’s centralized, efficiency-oriented model proved poorly suited to end-of-life decisions. Taiwan’s more distributed approach treated each family interaction as an opportunity for dialogue, generating the trust needed for consent. “In certain kinds of contexts,” Lu says, “or maybe in decisions that are higher stakes, both emotionally and culturally, a more horizontal relationship makes all the difference.”
The findings underscore the importance of genuine informed consent. Families who completed Taiwan’s process often became advocates for organ donation, not because they were persuaded, but because they felt empowered to decide for themselves.
“Dr. Lu’s fascinating investigation of the paradoxical finding of vastly different organ-donation rates in two societies that share cultural norms is crucial,” says Michelle A. Josephson, a professor of medicine and director of education at the Transplant Institute at the University of Chicago. “Her research reveals the ramifications of the interplay between societal structural and cultural influences in transplant medicine.”
Find the full study: “Rationality
or Relationality in Life and Death: Regulating Organ Donation in Singapore and
Taiwan” by Wan-Zi Lu, American
Sociological Review, vol. 90, no. 5, 2026.
Read more stories by Daniela Blei.