Public Health
(1991), 105, 161 165
© The Society of Public Health, 1991
T h e I n f l u e n c e of I s l a m i c V i e w s on Public A t t i t u d e s T o w a r d s K i d n e y T r a n s p l a n t D o n a t i o n in a Saudi A r a b i a n C o m m u n i t y S. R. AI-Faqih Department of Surgery, College of Medicine and King Khalid University Hospital, P.O. Box 7805, Riyadh 11472, SaudiArabia
Public attitudes towards organ donation during life and at death were examined in a randomised survey of 850 individuals, both male and female, in a representative Saudi Arabian community in Riyadh. Demographic categories accounted were age, sex, marital status, cultural and ethnic background, educational level and occupation. Of the sampled population 87% were native Saudi and the mean age was 30.7 years. Students and teachers made up the largest occupational groups and only 8.1% were illiterate. Although only 10.1% of all subjects had signed a kidney donor card, a further 42.6% expressed willingness to do so. Acceptance of organ donation at death was highest amongst males and in the age group below 30 years ( P < 0.05). There was no differential effect of the various demographic sub-groups in willingness for kidney donation during life. Sixty-five per cent were ready to donate to a close relative and 9.3% were even prepared to do so to a non-related recipient. The Islamic view supporting concepts of transplantation provided the strongest positive influence for organ donation both during life and at death. Dread of mutilation and the fear that pre-consent may adversely affect treatment after serious injury proved potent negative influences.
Introduction
In Saudi Arabia, as elsewhere, end-stage renal failure constitutes a serious and m a j o r health problem. ~,2 T r e a t m e n t by renal transplantation affords a high degree o f success and is superior to all current forms o f conservative m a n a g e m e n t in terms o f prognosis and the quality o f life) Despite the provision o f a d e q u a t e transplant services and a national drive that has e n c o u r a g e d public acceptance o f o r g a n donation, however, the p r o g r a m m e still suffers f r o m a serious shortage o f d o n o r kidneys. 4's A t any time, 60% o f all renal failure patients in the c o u n t r y remain on the waiting list for surgery. ~ It is k n o w n that social, cultural and religious factors are prime determinants o f public attitudes towards organ donation. 6 Saudi A r a b i a stands at the heart o f the M o s l e m world and attitudes recorded in a representative c o m m u n i t y here would serve to reflect the wider Moslem viewpoint on both cadaveric and living related kidney donation. 7 This survey was therefore undertaken with the aim o f examining the influences o f Islamic views, together with those o f education and informed counselling, on the extent and direction o f public attitudes towards o r g a n d o n a t i o n in a R i y a d h c o m m u n i t y . It was also sought to determine the effectiveness o f the national c a m p a i g n for m a k i n g kidney d o n o r cards available to the general public and their impact on various sectors o f the local community.
162
S. R. Al-Faqih Materials and methods
The prospective survey employed a stratified random sampling method which included both sexes and various age groups starting from 18 years. An attempt was made to identify and to represent the different socio-economic groups present in the local community, taking account of cultural and ethnic backgrounds, educational levels and employment categories. Each subject was asked to complete a standard questionnaire, which had been designed to require unequivocal responses to simply worded demographic queries and which explored levels of information and conceptual attitudes relating to renal transplantation. Subjects who had difficulty in reading or writing were assisted by one of the interviewers. The survey covered a period of five months, starting March 1989, and comprised 850 subject interviews. All information was entered into a computer data base and then manipulated for statistical analysis.
Results
Seven hundred and fifty-three respondents returned data sufficient for inclusion in statistical analysis, rendering a compliance rate of 88.6%. The mean age was 30.7 years ( S D ± 11) and the modal age 23 years. O f all respondents included in the study, 36% were female and 87% were Saudi nationals. Table I shows recorded attitudes towards the kidney donor card (KDC) related to demographic categories. There is a significant relationship between these attitudes and age, sex, marital status, occupation and the level of formal education. Completion of a KDC appeared relatively o f greater acceptance to males, all those under 30 years of age, single persons, students, military personnel and those in skilled occupations. There was no significant difference between the attitudes recorded in Saudi subjects and the minority group (13%) of non-Saudis. Acceptance of a K D C increased with the level of formal education gained by a respondent. Of all respondents 10.1% had already signed a KDC. Of these, only a handful (7.9 %) had voluntarily sought out a KDC, whilst the overwhelming remaining majority had signed a card on being approached by personnel of the National Kidney Foundation. A further 42.6% of all respondents expressed themselves willing to sign a KDC, so that the overall rate of acceptance o f post-mortem organ donation was 52.7%. O f all respondents 65.2% were willing to donate during life (LRD) to parents, siblings, children and close relatives, and a further 9.3% were even willing to donate during life to a non-related recipient. The overall rate o f acceptance for L R D was consequently 74.5%. Around one-quarter (24.8%) of all respondents were firm in their expressed willingness to subject themselves for LRD. There appeared to be no differential effect in respect to LRD of age, sex, marital status, ethnic background, occupation or the level of education, as was noted with analysis of acceptance o f a KDC. Two-thirds of all subjects affirmed their awareness of the Islamic Ulema ruling encouraging organ donation both during life and after death (Table II). Of the 12.5% of all respondents who professed ignorance of the existence of a KDC, the greater part also admitted to being unaware of the Islamic viewpoint on organ donation. There was a strong association between knowledge of the Islamic view on transplantation and willingness for organ donation during life or on death (P < 0.0001). Of the 52.7% of all respondents who expressed willingness to sign a KDC, the majority (82.4%) affirmed this to be based solely upon religious grounds. A further 7.6% indicated that their acceptance may have been influenced by the added publicity associated with the national campaign. O f those unwilling to sign a KDC, 45.4% stated that they did not want
163
Kidney Transplant Donation in Saudi Arabia
Table I Attitudes towards signing a kidney donor card (KDC) related to demographic characteristics Total
Respondents' attitude No. willing (%) No. unwilling No. unsure (%)
(%)
P
Age Under 30 years Over 30 years
470 283
253 (53.8) 144 (50.9)
174 (37.0) 88 (31.1)
43 (9.2) 51 (18.0)
0.00092
Sex Male Female
481 272
268 (55.7) 129 (47.4)
171 (35.6) 91 (33.5)
42 (8.7) 52 (19.1)
0.00015
Ethnic" origin Saudi Non-Saudi
655 98
349 (53.3) 48 (49.0)
225 (34.3) 37 (37.8)
81 (12.4) 13 (13.2)
NS
Marital status Single Married Widowed/divorced
318 409 26
178 (56.0) 209 (51.1) 10 (38.5)
116 (36.5) 140 (34.2) 6 (23.1)
24 (7.5) 60 (14.7) 10 (38.4)
0.00023
Occupation Students Teachers Military Administrative Housewives Skilled labour Businessmen Unskilled labour Unemployed
222 138 124 102 92 31 13 9 15
123 (55.4) 62 (44.9) 80 (64.5) 57 (55.9) 36 (39.1) 20 (64.5) 4 (30.8) 5 (55.6) 7 (46.7)
82 (36.9) 60 (43.5) 35 (28.2) 42 (41.2) 25 (27.2) 6 (19.4) 6 (46.1) 1 (11.1) 2 (13.3)
17 (7.7) 16 (11.6) 9 (7.3) 3 (2.9) 31 (33.7) 5 (16.1) 3 (23.1) 3 (33.3) 6 (40.0)
0.00001
Education level University Secondary school Intermediate Elementary Illiterate
312 222 81 77 61
173 (55.4) 112 (50.4) 56 (69.1) 35 (45.4) 21 (34.4)
116 (37.2) 89 (40.1) 16 (19.8) 26 (33.8) 15 (24.6)
23 (7.4) 21 (9.5) 9 (11.1) 16 (20.8) 25 (41.0)
0.00001
their bodies mutilated after death, and a further 21.4% were unsure of what was involved and felt that they needed greater reassurances. Discussion
The apparent paradoxical disparity shown here between the greater numbers of subjects willing to donate during life than after death (74.5% versus 52.7%) m a y be readily explained by the strong family ties inherent in Saudi Arabian and Moslem culture. Moreover, these respondents were more positive as regarding their stand towards organ donation during life than after death: only 0.7% professed uncertainty towards L R D as c o m p a r e d with 12.5% towards a signed K D C . A professed aversion to mutilation after death was the overriding reason given by 45.4% of our respondents against their willingness to sign a K D C and this is not unique to a Saudi
S. R. Al-Faqih
164
Table II The relationship of awareness of the Islamic viewpoint with public attitudes towards signing a kidney donation card (KDC) and consent for living related donation (LRD) Total
No. willing (%)
KDC Aware Not aware
499 254
302 (60.5) 95 (37.4)
LRD Aware Not aware
495 253
399 (80.6) 162 (64.0)
Respondents' attitude No. unwilling (%)
No. unsure (%)
P
159 (31.9) 103 (40.6)
38 (7.6) 56 (22.0)
0.00001
96 (19.4) 9t (36.0)
0 (0.0) 0 (0.0)
0.00009
Arabian community. 8 O f other arguments raised, such as an expressed uncertainty of the validity of Islamic views on transplantation, the most potent by far is the deep-seated apprehension that a signed K D C renders an individual more easily expendable in the event of serious injury, and that treating physicians and surgeons would be offered a greater licence to terminate life-sustaining support. The low number of respondents (10.t%) who had actually signed a KDC, notwithstanding the finding that a much larger number (52.7%) would have been willing to do so, reflects the need for intensified c o m m u n i t y activity on the part of health and transplant authorities. Various measures have been attempted elsewhere, in other countries, in a bid to improve procurement of d o n o r organs and p r o m o t e availability of the option of endorsing donation. In the USA the driving licence serves the dual purpose of a K D C and permission to drive. In some European countries, presumed consent (implied consent) towards donation is applicable. However attractive such legislative measures may appear, they arouse considerable public criticism and there is a continuing call for some form o f prior written consent from donors. 6'8'9 Implied consent and the sale of organs for the purpose o f transplantation are not acceptable concepts in Saudi culture. However, there is strong support from learned Moslem authorities (the Ulema) who, after careful deliberation, have endorsed the concepts of transplantation and sanctioned organ donation, both during life and after death, providing always that written consent is available from the donor or the next of kin.~° It is noteworthy that this accounted for the most positive influence on public attitudes towards organ donation in this survey. An overwhelming majority (82.4%) of respondents who had expressed willingness to sign a K D C cited religious belief as their motive in doing so. It is evident from this survey that there is strong public support for transplantation in the Saudi Arabian c o m m u n i t y and that the major positive influences are family bonding and religious belief. These are undermined by the traditional dread of mutilation after death and a misguided fear that pre-consent to organ donation may adversely influence treatment policy. Only public education programmes, supported by the media and by health and religious authorities, that offer an insight into hospital policies in relation to cadaveric transplantation, will serve to allay these fears.
Acknowledgements Thanks are due to Dr Sulaiman Al-Shammari and Dr Bamgboye, of the Department of Community and Family Medicine, for help with data collection and statistical analysis. I am grateful to Mrs Teresita Aliling for secretarial assistance.
Kidney Transplant Donation in Saudi Arabia
165
References 1. Ministry of Health (1989). Current Statistics of the National Kidney Foundation, Riyadh, Saudi Arabia. 2. A1 Suwailem, A. (1987). National Kidney Foundation Bulletin (Riyadh) 1, 3 8. 3. Morris, P.J. & Jones, B. (1988). Transplantation versus dialysis: a study of the quality of life. Transplantation Proceedings, 20, 23-26. 4. Abomelha, M. S., Al-Khader, A. A., Jawdat, M., Chang, R. & Satissi, D. (1984). Experience of renal transplantation at Riyadh Armed Forces Hospital, Saudi Arabia. Proceedings of the Second International Middle East Symposium on Organ Transplantation, Riyadh, pp. 34-36. 5. AI-Otaibi, K., A1-Khader, A. & Abomelha, M. (1985). The first Saudi cadaveric kidney transplant. Saudi Medical Journal, 6, 217 223. 6. Mannincn, D . L . & Evans, R.W. (1985). Public attitudes and behaviour regarding organ donation. J./t.M.A., 253, 3115. 7. EI-Bushra, E. (1989). Health care pattern and planning in Saudi Arabia. Geojournal, 18, 361-368. 8. Corlett, S. (1985). Public attitudes toward human organ donation. Transplantation Proceedings, 17 (Suppl. 3), 103 110. 9. Gebel, H. & Lindskoug, K. (1988). A survey of public attitudes toward cadaveric organ donation in a Swedish community. Transplantation Proceedings, 20, 431. 10. The Senior Ulema Decree No. 99, dated 6 Dhul'qada 1402 Hijra (t982), on organ donation for transplantation, Riyadh, Saudi Arabia.
(1991), 105, 161 165
© The Society of Public Health, 1991
T h e I n f l u e n c e of I s l a m i c V i e w s on Public A t t i t u d e s T o w a r d s K i d n e y T r a n s p l a n t D o n a t i o n in a Saudi A r a b i a n C o m m u n i t y S. R. AI-Faqih Department of Surgery, College of Medicine and King Khalid University Hospital, P.O. Box 7805, Riyadh 11472, SaudiArabia
Public attitudes towards organ donation during life and at death were examined in a randomised survey of 850 individuals, both male and female, in a representative Saudi Arabian community in Riyadh. Demographic categories accounted were age, sex, marital status, cultural and ethnic background, educational level and occupation. Of the sampled population 87% were native Saudi and the mean age was 30.7 years. Students and teachers made up the largest occupational groups and only 8.1% were illiterate. Although only 10.1% of all subjects had signed a kidney donor card, a further 42.6% expressed willingness to do so. Acceptance of organ donation at death was highest amongst males and in the age group below 30 years ( P < 0.05). There was no differential effect of the various demographic sub-groups in willingness for kidney donation during life. Sixty-five per cent were ready to donate to a close relative and 9.3% were even prepared to do so to a non-related recipient. The Islamic view supporting concepts of transplantation provided the strongest positive influence for organ donation both during life and at death. Dread of mutilation and the fear that pre-consent may adversely affect treatment after serious injury proved potent negative influences.
Introduction
In Saudi Arabia, as elsewhere, end-stage renal failure constitutes a serious and m a j o r health problem. ~,2 T r e a t m e n t by renal transplantation affords a high degree o f success and is superior to all current forms o f conservative m a n a g e m e n t in terms o f prognosis and the quality o f life) Despite the provision o f a d e q u a t e transplant services and a national drive that has e n c o u r a g e d public acceptance o f o r g a n donation, however, the p r o g r a m m e still suffers f r o m a serious shortage o f d o n o r kidneys. 4's A t any time, 60% o f all renal failure patients in the c o u n t r y remain on the waiting list for surgery. ~ It is k n o w n that social, cultural and religious factors are prime determinants o f public attitudes towards organ donation. 6 Saudi A r a b i a stands at the heart o f the M o s l e m world and attitudes recorded in a representative c o m m u n i t y here would serve to reflect the wider Moslem viewpoint on both cadaveric and living related kidney donation. 7 This survey was therefore undertaken with the aim o f examining the influences o f Islamic views, together with those o f education and informed counselling, on the extent and direction o f public attitudes towards o r g a n d o n a t i o n in a R i y a d h c o m m u n i t y . It was also sought to determine the effectiveness o f the national c a m p a i g n for m a k i n g kidney d o n o r cards available to the general public and their impact on various sectors o f the local community.
162
S. R. Al-Faqih Materials and methods
The prospective survey employed a stratified random sampling method which included both sexes and various age groups starting from 18 years. An attempt was made to identify and to represent the different socio-economic groups present in the local community, taking account of cultural and ethnic backgrounds, educational levels and employment categories. Each subject was asked to complete a standard questionnaire, which had been designed to require unequivocal responses to simply worded demographic queries and which explored levels of information and conceptual attitudes relating to renal transplantation. Subjects who had difficulty in reading or writing were assisted by one of the interviewers. The survey covered a period of five months, starting March 1989, and comprised 850 subject interviews. All information was entered into a computer data base and then manipulated for statistical analysis.
Results
Seven hundred and fifty-three respondents returned data sufficient for inclusion in statistical analysis, rendering a compliance rate of 88.6%. The mean age was 30.7 years ( S D ± 11) and the modal age 23 years. O f all respondents included in the study, 36% were female and 87% were Saudi nationals. Table I shows recorded attitudes towards the kidney donor card (KDC) related to demographic categories. There is a significant relationship between these attitudes and age, sex, marital status, occupation and the level of formal education. Completion of a KDC appeared relatively o f greater acceptance to males, all those under 30 years of age, single persons, students, military personnel and those in skilled occupations. There was no significant difference between the attitudes recorded in Saudi subjects and the minority group (13%) of non-Saudis. Acceptance of a K D C increased with the level of formal education gained by a respondent. Of all respondents 10.1% had already signed a KDC. Of these, only a handful (7.9 %) had voluntarily sought out a KDC, whilst the overwhelming remaining majority had signed a card on being approached by personnel of the National Kidney Foundation. A further 42.6% of all respondents expressed themselves willing to sign a KDC, so that the overall rate of acceptance o f post-mortem organ donation was 52.7%. O f all respondents 65.2% were willing to donate during life (LRD) to parents, siblings, children and close relatives, and a further 9.3% were even willing to donate during life to a non-related recipient. The overall rate o f acceptance for L R D was consequently 74.5%. Around one-quarter (24.8%) of all respondents were firm in their expressed willingness to subject themselves for LRD. There appeared to be no differential effect in respect to LRD of age, sex, marital status, ethnic background, occupation or the level of education, as was noted with analysis of acceptance o f a KDC. Two-thirds of all subjects affirmed their awareness of the Islamic Ulema ruling encouraging organ donation both during life and after death (Table II). Of the 12.5% of all respondents who professed ignorance of the existence of a KDC, the greater part also admitted to being unaware of the Islamic viewpoint on organ donation. There was a strong association between knowledge of the Islamic view on transplantation and willingness for organ donation during life or on death (P < 0.0001). Of the 52.7% of all respondents who expressed willingness to sign a KDC, the majority (82.4%) affirmed this to be based solely upon religious grounds. A further 7.6% indicated that their acceptance may have been influenced by the added publicity associated with the national campaign. O f those unwilling to sign a KDC, 45.4% stated that they did not want
163
Kidney Transplant Donation in Saudi Arabia
Table I Attitudes towards signing a kidney donor card (KDC) related to demographic characteristics Total
Respondents' attitude No. willing (%) No. unwilling No. unsure (%)
(%)
P
Age Under 30 years Over 30 years
470 283
253 (53.8) 144 (50.9)
174 (37.0) 88 (31.1)
43 (9.2) 51 (18.0)
0.00092
Sex Male Female
481 272
268 (55.7) 129 (47.4)
171 (35.6) 91 (33.5)
42 (8.7) 52 (19.1)
0.00015
Ethnic" origin Saudi Non-Saudi
655 98
349 (53.3) 48 (49.0)
225 (34.3) 37 (37.8)
81 (12.4) 13 (13.2)
NS
Marital status Single Married Widowed/divorced
318 409 26
178 (56.0) 209 (51.1) 10 (38.5)
116 (36.5) 140 (34.2) 6 (23.1)
24 (7.5) 60 (14.7) 10 (38.4)
0.00023
Occupation Students Teachers Military Administrative Housewives Skilled labour Businessmen Unskilled labour Unemployed
222 138 124 102 92 31 13 9 15
123 (55.4) 62 (44.9) 80 (64.5) 57 (55.9) 36 (39.1) 20 (64.5) 4 (30.8) 5 (55.6) 7 (46.7)
82 (36.9) 60 (43.5) 35 (28.2) 42 (41.2) 25 (27.2) 6 (19.4) 6 (46.1) 1 (11.1) 2 (13.3)
17 (7.7) 16 (11.6) 9 (7.3) 3 (2.9) 31 (33.7) 5 (16.1) 3 (23.1) 3 (33.3) 6 (40.0)
0.00001
Education level University Secondary school Intermediate Elementary Illiterate
312 222 81 77 61
173 (55.4) 112 (50.4) 56 (69.1) 35 (45.4) 21 (34.4)
116 (37.2) 89 (40.1) 16 (19.8) 26 (33.8) 15 (24.6)
23 (7.4) 21 (9.5) 9 (11.1) 16 (20.8) 25 (41.0)
0.00001
their bodies mutilated after death, and a further 21.4% were unsure of what was involved and felt that they needed greater reassurances. Discussion
The apparent paradoxical disparity shown here between the greater numbers of subjects willing to donate during life than after death (74.5% versus 52.7%) m a y be readily explained by the strong family ties inherent in Saudi Arabian and Moslem culture. Moreover, these respondents were more positive as regarding their stand towards organ donation during life than after death: only 0.7% professed uncertainty towards L R D as c o m p a r e d with 12.5% towards a signed K D C . A professed aversion to mutilation after death was the overriding reason given by 45.4% of our respondents against their willingness to sign a K D C and this is not unique to a Saudi
S. R. Al-Faqih
164
Table II The relationship of awareness of the Islamic viewpoint with public attitudes towards signing a kidney donation card (KDC) and consent for living related donation (LRD) Total
No. willing (%)
KDC Aware Not aware
499 254
302 (60.5) 95 (37.4)
LRD Aware Not aware
495 253
399 (80.6) 162 (64.0)
Respondents' attitude No. unwilling (%)
No. unsure (%)
P
159 (31.9) 103 (40.6)
38 (7.6) 56 (22.0)
0.00001
96 (19.4) 9t (36.0)
0 (0.0) 0 (0.0)
0.00009
Arabian community. 8 O f other arguments raised, such as an expressed uncertainty of the validity of Islamic views on transplantation, the most potent by far is the deep-seated apprehension that a signed K D C renders an individual more easily expendable in the event of serious injury, and that treating physicians and surgeons would be offered a greater licence to terminate life-sustaining support. The low number of respondents (10.t%) who had actually signed a KDC, notwithstanding the finding that a much larger number (52.7%) would have been willing to do so, reflects the need for intensified c o m m u n i t y activity on the part of health and transplant authorities. Various measures have been attempted elsewhere, in other countries, in a bid to improve procurement of d o n o r organs and p r o m o t e availability of the option of endorsing donation. In the USA the driving licence serves the dual purpose of a K D C and permission to drive. In some European countries, presumed consent (implied consent) towards donation is applicable. However attractive such legislative measures may appear, they arouse considerable public criticism and there is a continuing call for some form o f prior written consent from donors. 6'8'9 Implied consent and the sale of organs for the purpose o f transplantation are not acceptable concepts in Saudi culture. However, there is strong support from learned Moslem authorities (the Ulema) who, after careful deliberation, have endorsed the concepts of transplantation and sanctioned organ donation, both during life and after death, providing always that written consent is available from the donor or the next of kin.~° It is noteworthy that this accounted for the most positive influence on public attitudes towards organ donation in this survey. An overwhelming majority (82.4%) of respondents who had expressed willingness to sign a K D C cited religious belief as their motive in doing so. It is evident from this survey that there is strong public support for transplantation in the Saudi Arabian c o m m u n i t y and that the major positive influences are family bonding and religious belief. These are undermined by the traditional dread of mutilation after death and a misguided fear that pre-consent to organ donation may adversely influence treatment policy. Only public education programmes, supported by the media and by health and religious authorities, that offer an insight into hospital policies in relation to cadaveric transplantation, will serve to allay these fears.
Acknowledgements Thanks are due to Dr Sulaiman Al-Shammari and Dr Bamgboye, of the Department of Community and Family Medicine, for help with data collection and statistical analysis. I am grateful to Mrs Teresita Aliling for secretarial assistance.
Kidney Transplant Donation in Saudi Arabia
165
References 1. Ministry of Health (1989). Current Statistics of the National Kidney Foundation, Riyadh, Saudi Arabia. 2. A1 Suwailem, A. (1987). National Kidney Foundation Bulletin (Riyadh) 1, 3 8. 3. Morris, P.J. & Jones, B. (1988). Transplantation versus dialysis: a study of the quality of life. Transplantation Proceedings, 20, 23-26. 4. Abomelha, M. S., Al-Khader, A. A., Jawdat, M., Chang, R. & Satissi, D. (1984). Experience of renal transplantation at Riyadh Armed Forces Hospital, Saudi Arabia. Proceedings of the Second International Middle East Symposium on Organ Transplantation, Riyadh, pp. 34-36. 5. AI-Otaibi, K., A1-Khader, A. & Abomelha, M. (1985). The first Saudi cadaveric kidney transplant. Saudi Medical Journal, 6, 217 223. 6. Mannincn, D . L . & Evans, R.W. (1985). Public attitudes and behaviour regarding organ donation. J./t.M.A., 253, 3115. 7. EI-Bushra, E. (1989). Health care pattern and planning in Saudi Arabia. Geojournal, 18, 361-368. 8. Corlett, S. (1985). Public attitudes toward human organ donation. Transplantation Proceedings, 17 (Suppl. 3), 103 110. 9. Gebel, H. & Lindskoug, K. (1988). A survey of public attitudes toward cadaveric organ donation in a Swedish community. Transplantation Proceedings, 20, 431. 10. The Senior Ulema Decree No. 99, dated 6 Dhul'qada 1402 Hijra (t982), on organ donation for transplantation, Riyadh, Saudi Arabia.
