Kantianism, Intercultural Differences, and Attitudes Toward Organ Donation Among First-Year Nursing Students

Introduction

Intensive therapy is a medical field that is intertwined with medical ethics, especially end of life issues. Medical professionals face not only a circulatory death, which takes place when the heart stops beating. Due to the modern intensive care techniques, vital functions, such as circulation, respiration, and diuresis, can be artificially maintained, even if irreversible cessation of brain function took place. Thus, death in such a case needs to be confirmed in accordance with neurological criteria.

Brain death is not perceived similarly in each society and culture. The percentage of individuals who deny brain death differs from country to country. There are a lot of factors affecting this issue, including differences in access to education and information, traditional and religious beliefs, and legal and ethical issues [1–4].

Individuals who experience brain death could become organ donors for transplantation. Nevertheless, desire to collect organs (for helping others) cannot be our only motivation for brain death confirmation. It is our duty to confirm a patient’s death regardless of the patient’s willingness to become an organ donor or not.

Today, medicine is able to improve the quality of life and to prolong life expectancy even if someone is experiencing end-stage organ failure. Despite this, many patients need a new organ in order to sustain their life. Artificial techniques that replace organ functions are becoming increasingly popular, available, and efficient. Unfortunately, they are still cost-intensive and inconvenient for long-term use. Allogeneic (from different person) organ transplant remains the gold standard for a great number of patients, such as those with end-stage chronic kidney disease, chronic respiratory failure, or advanced liver cirrhosis; however, the limitation for allogeneic transplantation is the shortage of organs. This is a global issue but differs from country to country. Attitudes toward organ donation differ between cultures, religions, and world regions. There is a need to enhance organ donation worldwide, which requires educational efforts [5].

The Light Triad Scale (LTS) measures 3 traits regarding positive aspects of interpersonal relations: faith in humanity, humanism, and Kantianism (understood as perceiving others as “ends in themselves” and refraining from treating people as objects or means to achieve goals) [6]. There is a lack in scientific data correlating LTS results and opinions on brain death and transplantations. The LTS is quite new, and novel results are still being published. For instance, in recent years, many studies have used the scale. LTS scores correlate negatively with those of the Moral Injury Symptom Scale for Health Professionals [7,8]. Moreover, the level of LTS reflects life and job satisfaction, as well as spiritual care among Polish hospice workers [9]. Thus, higher levels of LTS traits are beneficial for medical professionals in their everyday life. It has been found that optimism, self-efficacy, and resilience are positively correlated with faith in humanity, while optimism is positively correlated with humanism among university students [10]. Moreover, LTS results correlated positively with self-coherence, psychological well-being, and treatment adherence in patients with type 2 diabetes [11]. This means that factors assessed by the LTS are related to beneficial personality traits in clinical and academic settings. LTS scores were found to be positively associated with perspective-taking and value co-creation behavior among AirBnB customers [12]. Additionally, childhood neglect was found to be negatively correlated with LTS traits, while LTS traits were negatively associated with malevolent creativity in emerging adults [13]. The above studies explain the potential origins of low LTS scores as well as the social influence of the traits examined by the scale in everyday life.

Traits included in LTS are non-negligible in many settings. It can be assumed that individuals with higher scores on the LTS will be more understanding toward ethical issues. Higher levels of opposition against brain death and organ donation can be expected among Africans in comparison with Europeans.

The aim of this study was to investigate whether there are intercultural differences between Polish students and students from Zimbabwe and other African countries in perceiving selected ethical issues of intensive therapy. Moreover, the influence of traits included in the LTS on these issues was evaluated. Although attitudes toward brain death and organ donation have been explored in various cultural and clinical contexts, little is known about how these ethical views connect to underlying personality traits. The LTS, which measures prosocial qualities, such as humanism and Kantianism, has gained increasing attention in healthcare populations. However, no previous research has examined whether these traits affect perspectives on intensive care choices, acceptance of neurological criteria for death, or willingness to donate organs. This gap is significant, given the ethical complexity of end-of-life decisions and the cultural differences in perceptions of brain death. By investigating how LTS traits relate to ethical attitudes among nursing students from diverse cultural backgrounds, we aim to offer initial insights into a relationship that has not been previously studied.

Material and Methods

This was a cross-sectional survey conducted at the Faculty of Health Sciences, Powiślańska Academy of Applied Sciences. Data were collected during regular class sessions within a single academic term, and all first-year students from the Polish (PL) and English division (ED) programs were invited to participate, under the same conditions. A brief standardized explanation of the study was provided, after which students gave voluntary consent and completed the anonymous paper-based questionnaire individually in the classroom. The survey included demographic questions, the LTS (language version matched to each group [6,14]), and 3 questions about attitudes toward brain death and organ donation. Completed forms were collected immediately and entered into the statistical dataset for analysis. One student in the ED group did not consent to participate, without giving a reason, and was excluded from the study. In total, 82 replies were obtained. Forty-two of participants were Polish (PL) while 40 were ED students. The students in the ED group came from Zimbabwe (36), Nigeria (2), Zambia (1) and South Africa (1). The PL group consisted of 38 women and 4 men, and the ED group consisted of 27 women and 14 men.

The range of possible points for each of the LTS subscales is 4 to 20. The 3 statements (evaluated on a Likert scale: 1=I strongly disagree to 5=I strongly agree) concerning ethical aspects of intensive care were as follows: (1) Brain death does not exist. (2) I would like to be an organ donor for transplantation if my brain dies. (3) Each patient should be intensively treated even if the treatment is a source of extra suffering and there is no hope for full recovery.

The above 3 statements assessing attitudes toward brain death, organ donation, and intensive treatment were chosen to address core ethical issues commonly discussed in intensive care medicine. These items reflect key areas identified in previous research on end-of-life decision-making and organ donation attitudes, specifically, acceptance of neurological criteria for death, willingness to donate organs after death, and preferences regarding continuing intensive treatment when prognosis is limited. The questions were designed to be brief and straightforward for a classroom survey, aiming to gauge general value-based attitudes rather than clinical judgments. While not derived from a formal, validated scale, each item aligns with well-established ethical themes in critical care and transplantation research and aimed to serve as a practical, focused measure of students’ baseline perspectives.

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2024). According to Polish regulations on non-interventional research with adult participants, anonymous questionnaire studies that do not collect sensitive personal data or involve medical procedures are exempt from mandatory review by a bioethical committee. This exemption is specified in national research ethics guidelines and is reflected in Powiślańska Academy’s internal policy on student survey research. Because the present study involved voluntary, anonymous completion of a standard educational questionnaire without any clinical intervention, it met the criteria for exemption from formal ethics committee approval.

Statistical analysis was performed and the figures were obtained with jamovi software. Non-parametric tests were used (Mann-Whitney U, chi-square, Spearman rho) because the survey responses involved ordinal data (Likert-scale items), and several variables’ distributions deviated from normality in this relatively small sample. These tests do not depend on assumptions of normal distribution or equal variances, making them suitable for comparing groups and examining correlations in datasets of this size and nature. Their use helps ensure that the statistical analysis remains reliable and appropriate for the data collected.

Results

Figure 1 presents histograms showing the distribution of results divided into the ED and PL groups. Results of the LTS (4 to 20 scale) are presented in the upper line, while the results of the 3 items concerning ethical aspects of intensive care (1 to 5 scale) are presented in the lower line.

Characteristics of the PL and ED groups is presented in Table 1. Cronbach alpha values of the LTS are 0.700 for the faith in humanity subscale, 0.824 for the humanism subscale, 0.758 for the Kantianism subscale, and 0.878 for the total score. Significant differences between the PL and ED groups concerned age and acceptance for being an organ donor. Students in the PL group were significantly older (Table 1), but age did not correlate with any other parameter. Acceptance of being an organ donor was lower in the ED group (r=−0.528) (Table 1, Figure 1). In correlation analysis, LTS subscales were significantly correlated with each other. Moreover, the LTS Kantianism subscale correlated negatively with answers to the item “Brain death does not exist,” indicating that those who do not believe in brain death tend to present lower Kantianism level. What is more, answers to the questions “Each patient should be intensively treated…” and “I would like to be an organ donor…” were correlated negatively with each other (Table 2).

Discussion

Because there is currently a true revival of nursing in Poland, and an increasing number of people choose this field as a second profession, the nursing students in the PL group were older than those in the ED group. The positive correlations found in the present study between the LTS subscales seemed expected, as they were observed in previous studies as well [6,12–15].

The most relevant intercultural difference concerned acceptance of being an organ donor. Reliable data on transplantation are limited in many countries in Sub-Saharan Africa, and several countries do not yet have official transplantation programs. Many barriers were noticed that need to be overcome to improve the negative attitudes toward being an organ donor, including healthcare infrastructure, socio-economic barriers, cultural and religious beliefs, legal and ethical challenges, and disease burden (effect of infectious and non-communicable diseases) [1].

In some cultural groups within Africa, organ removal after death is believed to lack respect for the body or spiritual continuity [16]. There are very conservative interpretations of religious texts among some African Muslims and Christians that state organ donation could be contrary to divine will [1,17]. Studies show a public knowledge gap, and only few countries, such as Nigeria and South Africa, have adopted strategies to overcome this gap [1,17,18]. Some individuals believe that organ donation mutilates the body, is done illegally, or makes fulfilling funeral traditions difficult [1]. It is crucial to understand that there are wide intercultural differences between different tribes, nations, and religions. The African continent is highly diverse, and barriers to transplantation differ across countries and communities, requiring context-specific solutions.

In spite of numerous cultural differences between the students in the ED and PL groups, there was no significant difference in LTS results. African countries are rarely included in cross-cultural research on personality. Nevertheless, humanism is known to be a relevant trait among Nigerians [19]. This fact corresponds with the results of the present study, which showed that the humanism LTS score was the highest score among students in the ED group (Table 1), even if most of the participants were from Zimbabwe.

Acceptance for being an organ donor correlated negatively with answers to “Each patient should be intensively treated…” and, interestingly, did not correlate with belief in brain death. Most students (in both groups) generally were aware (or neutral) of brain death existence, even if Africa faces problems with the concept of brain death similar to those concerning transplantations [20–22]. Similar results of the ED and PL groups could be an effect of the process of their medical education (even if at a quite early stage).

The negative correlation between the LTS Kantianism score and answers to the item “Brain death does not exist” indicates that those with high Kantianism levels tend to believe in brain death. Kantianism corresponds with values such as respecting others’ dignity, showing empathy, and refraining from manipulative or exploitative behavior. In other words, this trait correlates with treating others as subjects rather than objects. There is no available scientific data which directly connects level of Kantianism and opinions on brain death. Nevertheless, we can assume that such a correlation is not accidental, and those individuals who perceive people as “ends in themselves” are more likely to agree that brain death ends one’s life. In fact, intensive artificial life support of an individual with signs of brain death, and refraining from proper definitive verification, is an insult to dignity and shows a lack of empathy.

Although the LTS has not been correlated with opinions on organ donation, other personality traits influence the effectiveness of social media educational campaigns (regarding organ donation issues). Extraversion of participants is associated with the effectiveness of a transformational (emotional) message, while individuals presenting high levels of neuroticism are more likely to benefit from an informational campaign. Agreeableness has been investigated as a predictor for effectiveness of informational and transformational messages [23].

What is particularly interesting, we found no correlation between consideration of brain death and attitude toward becoming an organ donor. Students in the ED group indicated a belief in brain death but still rarely accepted organ donation. Education about brain death is not sufficient in this population, since the intercultural differences are much more impactful than the knowledge alone, corresponding with a previous study that identified several contributing factors acting as socioeconomic, cultural, and infrastructural hurdles [1].

The study has several key limitations. The overall sample size was small, which reduces statistical power and increases the chance that smaller effects might be missed. This also affects the stability of correlation estimates, as associations found in small samples can be more affected by outliers or sampling variation. Additionally, the ED group included students from multiple countries, each with different cultural, religious, and social backgrounds. Although they participated in the same program, this diversity may have introduced unmeasured variability that could not be examined separately and might limit the accuracy of intercultural comparisons. Finally, we used only 3 items to measure ethical attitudes; while these questions cover important themes, they provide a limited view of more complex ethical areas. Collectively, these factors limit how broadly the findings can be applied beyond this particular group and highlight the need for larger, more diverse samples and more detailed measures in future research.

Nevertheless, this study had significant and interesting findings. Further cross-sectional studies including a full spectrum of societies are needed to evaluate all psychological factors and personality traits affecting individuals’ attitude toward brain death and organ donation. The main novel findings of this research concern correlations between traits of LTS and ethical aspects of intensive therapy as well as transplantations.

In this study, the term “intercultural differences” refers to variations in attitudes and perspectives that stem from students’ diverse cultural backgrounds, influenced by their countries of origin, social environments, traditions, and educational experiences before entering the nursing program. The comparison between Polish and English division students aims to highlight differences in cultural context rather than biological or ethnic differences. Students from Zimbabwe, Nigeria, Zambia, and South Africa were grouped together into an English division because they followed the same educational path, received identical instruction, and completed the same English-language version of the survey under the same conditions. This grouping reflects a shared academic context rather than assuming cultural homogeneity. However, it is important to recognize that these countries have diverse cultural, religious, and social backgrounds; therefore, the results should be seen as representative of this specific group of internationally recruited students, not of any individual country or cultural group.

Conclusions

The data collected in this study revealed that personality is a factor that plays a relevant role in perceiving the issue of brain death. Kantianism, a trait measured by the LTS, is associated with higher acceptance toward brain death. Those who perceive people as “ends in themselves” are more likely to accept that life ends when the brain has not survived. This field also needs to be addressed to create better communication between medical professionals and patients’ family members and to enhance organ donations. Interestingly, there is a lack in correlation between consideration of brain death and attitude toward becoming an organ donor. Students from Zimbabwe and other African countries usually believe in brain death but still rarely accept organ donation. Higher level of acceptance toward donation among Polish students, by comparison, is the most significant intercultural difference.