Yonago Acta medica 2004;47:53–62

Knowledge of Criteria for Brain Death and Attitudes
towards Organ Donation and Transplantation of Nursing
Professionals in Tottori Prefecture, Japan
Itoko Terada, Akiko Otani†, Kimiko Hiramatsu, Miyoko Matsuo and Hisao Ito*
Department of Adult and Elderly Nursing, School of Health Science and *Division of Organ
Pathology, Department of Microbiology and Pathology, School of Medicine, Tottori University
Faculty of Medicine, Yonago 683-8503 and †Tottori Prefecture Organ Bank Foundation, Divisionof Medical and Pharmaceutical Affairs, Tottori 680-0011 JapanThe nursing professional population in Tottori Prefecture, Japan, was studied fortheir knowledge of criteria towards brain death and their attitudes towards organ
donation and organ transplantation. An attempt was also made to clarify factors
involved in issues concerning organ donation and organ transplantation. We distributed
2200 questionnaires to 9 hospitals, and obtained 1879 responses, of which 1683 werevalid. The rate of nursing professionals holding donor cards to all respondents was
384/1683 (22.8%). The length of nursing service showed no difference in improvementof awareness of brain death. Longer length of service tended to produce a negative
attitude in nurses towards donating their own organs in both brain death and cardiac
death. Subjects who were willing to donate organs to others in cardiac death were also
willing to do so in brain death. We provided some general suggestions for improving
education about organ transplantation in Japan, such as commencing provisions foreducation regarding organ donation and organ transplantation in junior high school due
to ethical issues. To more clearly identify the barriers against the improvement of thesituation surrounding organ transplantation, research needs to be cumulated for nursing
professionals.
Key words: brain death; nurses’ attitudes; organ donation; organ transplantation; questionnaire

Japan is a country where organ transplantation is
not well accepted by society and it has long beena controversial issue not only among the generalpublic but also among health care professionals.
Although the Government’s decision to accept thedefinition of brain death was officially enacted with
the Organ Transplant Bill of 1997, the number oftransplant operations has not increased because
the number of organ donors has not grown and,as a result, an extreme shortage of sufficientorgans available for transplant still remains (TheJapan Society for Transplantation, 2004). There
are several reasons for why this is still a criticalissue in Japan. One possible explanation is publicdistrust of the medical profession regarding organtransplantation in Japan (Kimura, 1991). This has
resulted from the 1st heart transplantation froma cadaveric donor in 1968. Surgeons performeda successful heart transplant from a cadaveric
donor to a patient with heart failure. However, the†Coordinator of the Tottori Prefecture Organ Bank Foundation

53

I. Terada et al.

recipient passed away 83 days after the operation.
The recipient’s history, diagnosis and previous
treatment were disclosed after the recipient’s
death, and this raised such issues as whether thetransplantation was justified at all and whether thecriterion of brain death was appropriate. Issues
arose about the donor as well (Kimura, 1991).
The major limitation of organ transplantationis the shortage of organs available for people withirreversible organ failure (Kibert and Kibert, 1992).
Therefore, widespread information regardingorgan donation and organ transplantation needs tobe provided to the general public so that a higher
rate of donation can be made possible. Nursing
professionals are well placed to play an extremely
important role in the health care needs of patients
who undergo organ transplantation. Singh et al.
(2002) asserted that it is impossible to perform
organ donation and transplantation as a regular
medical practice if health care professionals,
especially nurses, do not accept and approve oforgan donation and transplantation. As a result,health care professionals have been struggling topromote awareness of organ transplantation in theJapanese general public (Kita et al., 2000).
This study was conducted to assess theattitude to organ donation and organ transplantation
among nursing professionals at hospitals in
Tottori Prefecture, Japan, and to clarify the factors
associated with the issues regarding organ donationand transplantation. It was also intended to identify
the future direction for the development of organtransplantation status in Japan.

of the demographic characteristics of individuals.
The level of knowledge and attitudes towards
issues regarding brain death, organ donation andorgan transplantation were examined by applying
nominal and ordinal scales.
This questionnaire contained 15 items for
examining awareness and attitudes towards brain
death, organ donation and organ transplantation.
The need for education regarding organ transplantation was based on educational levels—elementary school, junior high school, high school anduniversity. These were also examined. To explore
the current attitude regarding organ transplantationin each workplace, one item was added.
Distribution of the questionnaire and subjects
Questionnaires were distributed to nursing professionals working in 9 general hospitals between
September 2003 and January 2004 through thepermission from the nursing director in eachhospital. These hospitals were selected basedon the following 2 criteria: the bed number ofover 300, and kidney transplantations from living
donors performed as a regular medical practice.
Questionnaires were subsequently distributed tonurses stationed at medical and surgical wards,
emergency units, intensive care units, high careunits and operating rooms. A cover letter was
attached that explained the purpose of the present
study and the voluntary and anonymous basisof this study. Questionnaires were returned inenvelopes provided in each workplace, then collected by the authors and kept confidential. A
total of 2200 questionnaires were distributed and1879 were returned (response rate: 85.4%). In
the present study, 1683 of the 1879 (89.6%) wereconsidered as valid responses.

Subjects and Methods
Development of the questionnaire
A questionnaire was modeled after a previous
study by an author of the present study (Hiramatsu
et al., 2003). The questionnaire was constructed to
examine professional nurses’ personal knowledge
and attitudes regarding criteria involving brain
death, organ donation and organ transplantation. It
consisted of 45 questions which included 10 items

Statistical Analysis
All responses were scored numerically for analysis,
and numbers and percentages were computedfor each question. Differences in noncontiguous
variables were tested by chi-square analysis. Cor-54

Nursing attitudes on organ donation

relations between attitude items regarding organtransplantation were examined by Pearson’s correlation coefficients analysis. Statistically significant differences were tested at a level of P < 0.05.
Statistical analysis was performed on a personal
computer with the SPSS version 11.5 software
package.

Table 1. Demographic Characteristics [n = 1683]
Characteristics

Number of subjects (%)

Age (year)
20–29
610 (36.2)
30–39
429 (25.5)
40–49
389 (23.1)
50–59
250 (14.9)
60
5 (0.3)≥
Mean ± SD
36.1 ± 10.6
GenderMale
20 ( 1.2)
Female1663 (98.8)
Work experience (year)< 10
710 (42.2)
10–19
396 (23.5)
20–29
402 (23.9)
30–39
149 ( 8.9)40
5 ( 0.3)≥
No answer
21 ( 1.2)
Mean ± SD
14.0 ± 10.3
Minimumless than 1
Maximum
47
Work experience in critcal care units
Yes
712 (42.3)
No
963 (57.2)
No answer
8 ( 0.5)
Participation in lectures or seminars
Yes
512 (30.4)
No1139 (67.7)
No answer
32 ( 1.9)
Holding a donor cardYes
384 (22.8)
No1282 (76.2)
No answer
17 ( 1.0)

Results
Demographic characteristics
The demographic characteristics of subjects areshown in Table 1. There is no significant difference
between the rate in working experience in criticalcare units and the rate of donor card holding (χ2 =
0.795, P = 0.373).
Criteria for brain death
Knowledge of criteria for brain death
In order to assess whether or not subjects
felt they had knowledge of criteria for brain death
regardless of the amount or depth of the criteria,a simple question was asked to subjects. The
question was “do you have any knowledge of thecriteria for brain death?” The rate of subjects who
claimed to have “knowledge” regarding criteria forbrain death was 1372/1683 (81.5%), and 17.4% ofthem [n = 293] claimed to have “no knowledge”
regarding criteria for brain death. When the
difference in knowledge of criteria for brain death
was analyzed according to the period worked as anurse, the length of nursing service was found tohave no effect on the development of knowledge
regarding the criteria of brain death.

Demographic characteristics are classified as age, sex,
work experience (year), work experience in critical careunits, participation in lectures or seminars and holding adonor card.
Work experience in critical care units means work
experience in environments such as emergency units,intensive care units, high care units and operating rooms.
Participation in lectures or seminars means that
subjects had some experience in attending any sort oflecture or seminar in relation to organ transplantation in
the past.
The donor cards mentioned above provide information on whether or not respondents hold donor cards;
however, it does not mean that it provides information
on whether or not respondents are willing to be organ
donors in a state of brain death or cardiac death.

Knowledge of criteria for brain death and holding
donor cards
As shown in Fig. 1, a significant difference
was found between the rate of subjects who claimed to have knowledge of criteria for brain deathand the rate of subjects who hold the donor cards.
Donor card holders claimed to have “knowledge”
about the criteria of brain death more than no-55

I. Terada et al.
holders (χ2 = 16.871, P < 0.001). However, 10.7%
of card holders [n = 41] claimed to have “noknowledge” about the criteria for brain death.

Knowledge and attitudes of criteria for braindeath
As shown in Fig. 2, there was also a significant difference concerning knowledge about thecriteria of brain death and the attitude that brain
death could be recognized as the� � ����
death of a human being. Subjects
who answered that they knew what������
brain death was had more positive�� � ����
responses regarding the attitude that��� brain death could be recognized as
the death of a human being than������������ � �����
subjects who claimed to have noknowledge of criteria for brain
�
��
��
��
��
��� ���
death ( χ 2 = 32.860, P < 0.001).
However, more than half of the���� � �����
���� ���������
������� ���������
Fig. 1. Knowledge of criteria for brain death by holding donor cards. Of subjects could not respond whether
or not brain death was the death of1683, 1649 answers were given to this issue.
a human being.
� � ����

Attitudes regarding organ transplantation and donation���� ����������� � �����

���������� ����������� � ����

�

��

��

��

��� ���

������ � �����
Fig. 2. Knowledge of and attitudes for criteria for brain death. Of 1683,
1652 answers were given to this issue.
��������

��������

���������� � ����

���� � ��������
���� �����

������� � ����������
�����
�

��

��

��

��

��� ���

���� � �������� ����������� ���������

�������

������ �������� ������

Fig. 3. View of organ transplantation by different states of death. The
responses were from all subjects.

56

Promotion of organ transplantation
As shown in Fig. 3, the majority of subjects expressed the viewfor organ transplantation carefully
and not strongly regardless ofwhether the organ is from a braindead donor or from a cardiac-deaddonor. Even though all subjects
were nursing professionals, 20% ofthem could not decide whether or
not they were for organ transplantation.
Organ donation for others
The rate of subjects who responded that they would donate
their organs to others in brain deathwas 391/1683 (23.2%). Of 1683,
374 subjects (22.2%) responded
that they would not donate theirorgans to others in brain death.
Similarly, 24.2% of subjects [n =Nursing attitudes on organ donation

Donation of family member’s organs
As shown in Fig. 6, even thoughfamily members of subjects expressed
a wish to donate their own organs
before they became brain-dead orin a state of cardiac death, 11% ofsubjects did not agree with donating
their family member’s organs toothers. Furthermore, around 35%
of subjects could not decide whether
they would agree with donating
their family member’s organs toothers although their family member
had already expressed a wish to
donate their organs to others in brain
death or cardiac death.

� � ����

������ �� ������� �������

������

� ��
�����
�����
�����
� ��
�

��

��

���

��

�������

����� ���

���������

Fig. 4. Attitude for organ donation in a brain-dead state by the length ofnursing service. Of 1683, 1650 answers were given to this issue.
� � ����

������

������ �� ������� �������

408] responded that they would
donate their organs to others
in cardiac death, and 22.2% ofsubjects [n = 373] responded thatthey would not donate their organs
to others in cardiac death. Morethan half of the subjects could
not decide whether or not theywould donate their organs to othersin either brain death or cardiac
death. In addition, there were no
significant differences between
nursing experience in critical careunits and the attitude of organ
donation for others. Interestingly,
the length of nursing service tend to
produce negative attitudes insteadof positive attitudes on donation of
their organ in both brain death andcardiac death as shown in Figs. 4
and 5.

� ��
�����
�����
�����
� ��
�

��

��

���

��

�������

����� ���

���������

Fig. 5. Attitude for organ donation in a cardiac-dead state by the length ofnursing service. Of 1683, 1639 answers were given to this issue.
� � ����

���

���
��
��
��
��
�

�����

��������

����� ��� �������� ������

����������� ���� � ������ ����� ����������������� ���� � ������ ����� ����������������� ������� � ������ ����� ����Fig. 6. Donation of family member’s organ by difference states of death. The responses were from all subjects.

57

I. Terada et al.

Undergoing organ transplantation
As shown in Fig. 7, undergoing organtransplantation as a recipient when he or she
was suffering from an incurable disease, 29.1%
of subjects [n = 490] said they would undergo
organ transplantation and 25.0% of subjects [n= 421] said they would not: 44.1% of subjects
could not decide whether they would undergo
organ transplantation or not. On the other hand,in the case where a subject’s family member
was suffering from an incurable disease, many
more subjects (51.0%, n = 858) approvedof their family member undergoing organtransplantation.

� � ����

��������

���������
������
�

��

���

��

��

��

��� ���

����� ��� �������� ������

������ � �����
Fig. 7. Undergoing organ transplantation. The responses
were from all subjects.

“against” and “cannot decide”. Question 4 wasdone the same way. Many small but significant
correlations were identified because of the sizeof the number of subjects (1683). However, several findings were identified as shown in Table
3. Subjects who agreed that brain death was thedeath of a human being had a positive reaction
regarding the view of organ transplantation fromboth brain-dead (r = 0.226, P < 0.001) and cardiacdead donors (r = 0.178, P < 0.001). They also
expressed a wish to donate their organs when they
are in both a brain-dead state (r = 0.137, P < 0.001)
and a cardiac-dead state (r = 0.084, P < 0.001).
Further, they agreed on donating their family

Correlations between questions
Pearson’s correlation coefficient analysis was applied to identify significant correlations among all
the questions in Table 2. However, before applying
Pearson’s, there was some difficulty because 4
choices were prepared for Questions 3 and 4 while
3 choices were prepared for the rest in Table 2.
Therefore, when Pearson’s was used in this study,
the 4 choices were recalculated as 3 choices.
For instance, in Question 3 (Are you for organtransplantation from a brain dead donor?), the 4choices, “for strongly”, “for carefully”, “against”
and “cannot decide”, were changed to 3 of “for”,

Table 2. Contents of the questionnaire: 11 questions
Q1
Q2
Q3
Q4
Q5
Q6
Q7

Do you have any knowledge of the criteria for brain death?
Do you agree with the idea that a individual who is brain dead is dead as a human being?
Are you for organ transplantation from a brain dead donor?
Are you for organ transplantation from a cardiac dead donor?
If you are in a brain dead state, would you wish any of your organs donated?
If you are in cardiac dead state, would you wish any of your organs donated?
Would you agree with a family member having an organ donated in a brain-dead state if he/she holds a signed
donor card?
Q 8 Would you agree with a family member having an organ donated in a cardiac-dead state if he/she holds a signed
donor card?
Q 9 Would you agree with a family member having an organ donated in a cardiac-dead state if he/she does not holda signed donor card?
Q10 Do you wish to undergo organ trasnplantation if you are suffering an incurable disease?
Q11 Would you wish that your family member undergo an organ transplantation if he/she is suffering incurable
disease?

58

Nursing attitudes on organ donation

Table 3. Correlations between questions

Q1
Q2
Q3
Q4
Q5
Q6
Q7
Q8
Q9
Q10
Q11

Q1

Q2

Q3

Q4

1

0.166** 0.099** 0.091**
10.226** 0.178**10.694**
1

Q5

Q6

Q7

Q8

Q9

Q10

Q11

0.076**
0.137**
0.065**
0.057*
1

0.062*
0.084**
0.028
0.081**
0.82**
1

0.076**
0.155**
0.159**
0.127**
0.186**
0.179**
1

0.067**
0.124**
0.139**
0.184**
0.134**
0.209**
0.737**
1

0.01
0.046
0.049*
0.026
0.106**
0.122**
0.151**
0.142**
1

0.017
0.085**
0.093**
0.093**
0.108**
0.152**
0.133**
0.181**
0.075**
1

0.009
0.055*
0.125**
0.117**
0.08**
0.094**
0.096**
0.134**
0.048
0.489**
1

Pearson’s correlation coefficient was applied to identify significant correlations among 11 questions in Table 2.
* P < 0.05.
** P < 0.01.

member’s organs in both brain death (r = 0.115, P< 0.001) and cardiac death (r = 0.124, P < 0.001)
if their family member had expressed a wish to doso beforehand. The highest correlation coefficient
was identified between the variable for Question
5 (If you are in a brain dead state, would you wish
any of your organs donated?) and the variable for
Question 6 (If you are in cardiac dead state, would
you wish any of your organs donated?) (r = 0.820,
P < 0.001).

Need of education for organ transplantation
Concerning the period appropriate to provide education regarding organ transplantation according toeach educational stage, the findings are shown in
Fig. 8. Only 37.6% of subjects expressed the viewof need for education about organ transplantationin elementary school, and 24.4% of subjects expressed the view of no need for education aboutorgan transplantation at that stage. On the other
hand, more than 60% of subjects expressed thev i ew t h a t t h e r e i s a n e e d� � ����
for education about organtransplantation in junior highschool (64.1%), high school(76.9%) and university (77.3%).
Interestingly, the perception of
the need for education aboutorgan transplantation in eacheducational stage develops inproportion to the level of eacheducational stage.

���
���

��

��

��

��

�

���������� ������ ������ ���� ������
������ ����

���� ������

����������

����������� ������

Fig. 8. Need of education for organ transplantation. The responses were from all subjects.

59

I. Terada et al.
� � ����
���� ������������ ������� � ����

���������� ������������ ������� � �����
����������

��

��

��

��� ���������

�������������� ���

���� � �����

Fig. 9. Discussion about organ transplantation at work. Of 1683, 1602 answers were given to this issue.

circumstances can be expressed on driving licenses,
the license doubling as a donor card in case of
accident-related death. So it is considered that therate of people who hold the donor cards is higher in
Canada than in Japan. This study, however, reveals
that the issue is not only the rate of the people who
hold donor cards, but also the low level of positive
attitude towards donating their organs to others.
There was no significant difference foundbetween nursing experience in critical care units
and the attitude towards organ donation in thisstudy. O’Connell (1991) asserts that nursing
professionals, especially working in critical careunits, must take responsibility in making their own
decision regarding donating organs. Therefore,
nursing professionals, especially in critical careunits, should be educated more about organ donation and primarily explore their own attitudes
towards organ donation.
A significant difference was found between
the knowledge of the criteria for brain deathand the attitude in which brain death could berecognized as the death of a human being. Subjects who had knowledge about the criteria ofbrain death had more positive attitudes regarding
the opinion recognizing brain death as humandeath than subjects who had no knowledge. Thisfinding showed that learning about criteria forbrain death could lead to a more positive attitude
on the criteria for brain death in general. Further
analysis revealed that subjects who had a positive
attitude on the criteria for brain death tended to

The Current situation regarding organ transplantation in workplaces
In order to examine the current situation regardingorgan transplantation in workplaces, one simple
question was asked: “Do you ever talk about organtransplantation in your workplace?” Only 15.9%
of subjects said “yes”, 64.5% said “no”, and 16.5%
were “uncertain”. Figure 9 shows the findings
expressed by the differences between subjects
who had some experience in studying organ transplantation in the past and subjects who had noexperience. Subjects who had experience tended
to discuss organ transplantation much more thansubjects who had no experience. In any case, over
50% of subjects in both categories said they did not
discuss organ transplantation in their workplaces.

Discussion
One of the most important findings in this study
was that there were only 22.8% of subjects holding
donor cards among nursing professionals, and only
54.2% of subjects who held donor cards showed
a willingness to donate their organs to others. In
a study on Canadian nursing professionals [n =102], 62% of Canadian nurses held donor cards
and 90% of them said they were willing to donate
their organs to others (Kiberd and Kiberd, 1992).
In Canada, the wish to donate organs in critical60

Nursing attitudes on organ donationagree with the view for organ donation and organtransplantation. Kim et al. (2004) asserted thatlack of clarity in the definition of death was one of
the major barriers on organ donation. Therefore,
there is a need to provide education to clarify thedefinition of death in the current legislation for abetter understanding of circumstances surroundingorgan donation and transplantation.
The length of nursing service does not produce an improvement in knowledge regarding thecriteria for brain death. This study also discloses
that the length of nursing service tend to develop
negative attitudes instead of positive attitudes innursing professionals regarding donation of theirorgans in both brain death and cardiac death. However, a study regarding nurses’ knowledge andattitudes to organ donation and transplantation in
the United States conducted by Matten et al. (1991)
reported that the more experienced nurses tended
to be willing to donate their organs in criticalcircumstances and undergo organ transplantation
when they suffered an irreversible organ failure
disease. They also asserted that education on thesubject of organ donation and organ transplantation
was essential to nursing professionals, and it
should be included in the training programs in
hospitals. Furthermore, they expressed a viewthat it was important that educational programson organ donation and transplantation should be
repeated periodically (Matten et al., 1991). Another study revealed that nursing professionals’
attitudes towards organ donation were positively
correlated with their knowledge (Bidigare andOermann, 1991). They also suggested that education of nursing professionals should be provided
in all areas of the organ donation and organtransplantation process. Van Da Walker (1994)
maintained that detailed information such as thecurrent success rate of organ transplantation needed
to be provided in educational programs. In Japan,
the educational system should be organized ineach hospital and educational programs should be
provided for the improvement of attitudes to organ
donation and organ transplantation.
We observed another interesting finding
by Pearson’s correlation coefficient analysis for

significant correlations among the results ofquestions. The highest correlation coefficient was
identified between the attitude to donate organs in abrain-dead state and the attitude to donate organs in
a cardiac-dead state. In other words, subjects who
were willing to donate organs to others in cardiac
death had an inclination to do so in brain death aswell. This finding raises the issue that brain deathas the definition of human death does not make asignificant difference to people who are willingto donate their organs in critical circumstances.
Similar findings were presented by a study conducted in Kagoshima Prefecture, Japan (Mulvey, 2003).
Mulvey asserted that the definition of brain deathas the death of a human being was not a key factor
for people in expressing their attitude regardingorgan donation in a brain-dead state.
The present study also examined the need toprovide education regarding organ transplantation
at certain educational levels—elementary school,
junior high school, high school and university.
It was revealed that there were fewer responses
to the need for education regarding organ transplantation in elementary school. On the contrary,
more responses were gained regarding theneed for education in junior high school, highschool and university. The consideration of providing education regarding organ donation andtransplantation in junior high school may be appropriate. Chabalewski et al. (2002) maintainedthat education regarding organ donation andtransplantation should be referred to not only by
clear explanation of the process of donation andtransplantation, but also by the ethical issues surrounding it. It may be necessary to proceed withthe education step by step according to the level ofunderstanding of this issue.
Overall, we attempted to explore the knowledge of criteria for brain death and the current
attitudes to organ donation and organ transplantation
among nursing professionals at hospitals in
Tottori Prefecture, Japan. We also provided somemeaningful general suggestions for improvement
regarding the situation of organ transplantationin Japan. However, further research needs to be
carried out on nursing professionals to more clearly61

I. Terada et al.

identify the barriers against the improvement of
the situation surrounding organ transplantation.
Subjects might need to be focused on in order toacquire more concrete information for the development of organ transplantation status, particularlyin the clinical area of hospitals.

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6 Kimura R. Japan’s dilemma with the definition ofdeath. Kennedy Inst Ethics J 1991;1:123–131.
7 Kita Y, Aranami Y, Aranami Y, Nomura Y, Johnson K,
Wakabayashi T, et al. Improving public awarenessof organ transplantation in Japan. Prog Transplant
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EP, Woehlke PL, Richardson CE, et al. Nurses’
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10 O’Connell DA. Ethical implications of organtransplantation. Crit Care Nurs Q 1991;13:1–7.
11 Singh P, Kumar A, Pandey CM, Chandra H. Levelof awareness about transplantation, brain death andcadaveric organ donation in hospital staff in India.
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Acknowledgments: This work was supported in partby a Grant-in-Aid for Research on Regional Disease
Protection from the Tottori Prefecture Health Promoting
Council.
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Received August 4, 2004; accepted August 25,2004
Corresponding author: Itoko Terada

62