Cultural Attitudes of Asian-Americans Toward Death Adversely Impact Organ Donation A.H.S. Cheung, D.L. Alden, PhD., and M.S. Wheeler O RGAN DONOR shortage remains a major obstacle in transplantation. While the waiting list keeps growing each year, the number of cadaveric donors has not in- creased proportionately. 1 This has led to a longer waiting time for some patients, and death while waiting for a vital organ for others. Minority groups in the United States, including Asian- Americans, have been reluctant to consent to organ dona- tion. 2,3 This is most unfortunate since it is well established that cadaveric kidney survival is improved when the donor and recipient are of the same race. 4 In the United States while Asian-Americans made up 3.0% of the population (pop), they only represented 1.5% of cadaveric donors in 1995. 1 As of October 1997, Asian-Americans made up 4.9% of the total number of patients registered on the National Transplant Waiting List in the United States. 5 In our local population, from January 1989 to October 1997, a total of 128 cadaver donors were obtained. Caucasians made up 33.4% of the population, but represented 53.9% of donors. Conversely, Asian Americans (Chinese, Japanese, Filipino) made up 43.7% of the population, but only represented 25% of the donors. 6 This reluctance toward organ donation in Asians has been well documented also in Asia. Why is that? The objective of this study was to evaluate cultural attitudes and beliefs in Asian Americans and compare them with Cauca- sians to determine whether there is an affect on organ donation. MATERIALS AND METHODS Mail surveys were sent to a random sample of two–thousand household residents in a predominantly urban county of a Western state in the United States (total population near 850,000). Ques- tionnaires were sent which examined issues that might influence attitudes and behaviors regarding organ donation. The issues covered included demographic data, beliefs in an afterlife, death rituals, communal orientation, healthcare provider trust, other organ donation attitudes, and possession of an organ donation card. Some questions were measured on a 7–point “agree/disagree” scale, while others were binary (yes/no, true/false). A $1 incentive was included along with a cover letter explaining that the study was academic in nature and that all responses were confidential. IRB approval had been obtained. Seven hundred and fifty-two questionnaires were returned for an overall response rate of 37.6%. Given the age limits on suitability of organs for trans- plant, only individuals between ages 16 to 60 were included for further analysis. In addition, respondents from ethnic groups that were not the focus of this research were deleted. Results were then compared between Asian Americans (Japanese, Chinese, Korean, and Filipinos) and Caucasians. Statistical analysis was performed using logistic regression model, Student’s t test, and chi-square test, with significance set at P  .05. RESULTS The demographics of the overall sample and comparisons between Asian Americans and Caucasians are shown in Table 1. Relative to US national averages, respondents in this study were more often females, have higher levels of education, and have a higher annual income. In addition, the distribution of Asian Americans was somewhat skewed from the national averages with Japanese-Americans con- stituting the largest group in the study, a position held by Chinese-Americans nationally. In comparing Asian Americans and Caucasians, the groups did not differ significantly in age, education, gender, or marital status. But there were significant differences in religious affiliation and income. The large number of Asian Americans picking Buddhism was expected and could pos- sibly account for cultural effects which might influence organ donation. The income was higher in Asian Ameri- cans, but the association was not strong as  indicated only a 2.7% proportional reduction in error in predicting income from knowing ethnicity (P  .46). Descriptive statistics indicated a variety of significant differences between the two cultural groups on variables of interest in organ donation (see Table 2). Asian Americans had significantly lower scores on sense of responsibility toward the general community, higher scores on the impor- tance of maintaining body integrity after death, and lower scores on doctor trust with respect to organ donation, as From the Department of Surgery, University of Hawaii School of Medicine, St. Francis Medical Center (A.H.S.C., M.S.W.) and Department of Marketing, University of Hawaii, College of Busi- ness Administration (D.L.A.), Honolulu, Hawaii. Study supported in part by grant funded by the George F. Straub Trust. Address reprint requests to Alan H.S. Cheung MD, Depart- ment of Surgery, University of Hawaii School of Medicine, St. Francis Medical Center, Honolulu, Hawaii. © 1998 by Elsevier Science Inc. 0041-1345/98/$19.00 655 Avenue of the Americas, New York, NY 10010 PII S0041-1345(98)01156-7 Transplantation Proceedings, 30, 3609–3610 (1998) 3609