A Study on the Impact of Chinese Family Culture on Citizens' Voluntary Organ Donation

Objectives: Family members’ attitude is the key factor in organ donation. This study aimed to analyze the attitude and willingness of families towards organ donation and to explore the impact of Chinese family culture on voluntary organ donation. Methods: Taking the family as a unit, a total of 15 families (59 family members) were interviewed using the semi-structured interviews. Results: Among the 59 participants, 58 had heard of organ donation, 30 were unwilling to donate organs, 25 had an intention to donate, and 13 were very taboo about it. 29 weren’t giving consent for family members’ donation, only 8 supported families to sign up as donors. Particularly, 7 participants could donate their organs but wouldn’t donate organs of family members. The family culture models were divided into the patriarchal family culture model (4 families), independent family culture model (8 families), patriarchal subversion family culture model (3 families). Based on the inuence of social and cultural factors (taking national policy as an example) on the willingness to donate organs of relatives, the family culture models were divided into the stubborn family culture model (3 families), swing family culture model(9 families), and seless dedication family culture model(3 families). Conclusions: Organ donation is still a taboo topic in Chinese families. Although the patriarchal family cultural model is no longer dominant, the father's thoughts and views still play an essential role in the whole family. Most families belong to the swing family culture model, and the willingness to donate is greatly inuenced by social and cultural factors.

The family culture models were divided into the patriarchal family culture model (4 families), independent family culture model (8 families), patriarchal subversion family culture model (3 families). Based on the in uence of social and cultural factors (taking national policy as an example) on the willingness to donate organs of relatives, the family culture models were divided into the stubborn family culture model

Background
Organ donor shortage is a serious problem in the world. According to statistics, more than 150,000 patients are waiting for organ donation in the world. On average, 17 die every day while waiting for donor organs. The demand for donor organs is increasing by 12% every year [1]. In 2010, China launched a pilot program of voluntary organ donation after the death of citizens. Traditional culture is one of the main factors that affect organ donation [2,3]. Family members' attitude towards organ donation directly affects the success of potential organ donation [4][5][6][7][8].
The form of the family-based social structure determines that the social existence of Chinese people depends on the family with blood relationships [9].In China, few citizens sign an organ donor card or make relevant wills before they die. Successful organ donation depends on their families [10,11]. If there is one family member who opposes organ donation, he or she will persuade other relatives not to sign up as a donor. Especially when the parents are against organ donation, children will not donate organs successfully even they have the willingness to donate [12][13][14][15]. If parents hold a positive attitude towards organ donation, it will also increase their children's willingness to donate. However, if the parents strongly oppose signing the organ donor card, the children will not disobey them. This phenomenon occurs in many countries [16][17][18]. After all, in China, " lial piety is the most important of all virtues" and "one's skin and hair are given by one's parents". With the growth of children, parents are getting older. Thus, they need to discuss whether to donate organs with their children. If a child does not want their parents to donate their organs, the chances of their parents' successful donation will be very low [15]. Therefore, The attitude of family members is of great importance for organ donation. In this paper, we used the semistructured interview method to analyze the attitude and willingness of family members towards organ donation and to explore the impact of Chinese family culture on voluntary organ donation.

Materials And Methods
The design and methods of the research are in accordance with the requirements of related regulations and procedures (such as GCP, ICH-GCP) as well as the ethical principles. The study was approved by The IRB of Third Xiangya Hospital, Central South University.
The semi-structured interview method was used to collect data. From August to November 2018, a total of 15 volunteer families were recruited and interviewed. Inclusion criteria: Having strong ability of expression and communication; Voluntarily participating in the study and actively cooperating.
Within 3 days after the end of the interview, one interviewer rst collated the recording into a text version of the data. To ensure the integrity and accuracy of the data, another interviewer checked the recording and text data, and then two interviewers jointly analyzed and coded the data.
The interview outline includes: (1) Have you heard about organ donation? Are you for organ donation? Is talking about organ donation a taboo?
(2) Will you sign the organ donation consent card when you get your driver's license? Will you ask your family for advice? Whose opinion will you mainly solicit?
(3) Will you agree to me/children/parents/husband or wife signing the organ donor card? Why?
(4) If the country implements some preferential policies, for example, if you agree to sign the registration card, your family members will have the priority for the donated organs, will you consider organ donation? Why?

Attitudes of family members towards organ donation
In this study, a total of 59 subjects from 15 families were included. They were numbered by letters: N1, N2, N3, N4, N5… N14, N15.The interviewees included close relatives such as grandparents, parents, children, aunts and their husbands, brothers, and sisters (cousins), etc. The youngest interviewee was 16 years old and the oldest was 74 years old.
Of the 59 family members interviewed, 58 had heard of organ donation. During the interview, it was found that the ways for citizens to understand organ donation are also diverse. Most of the interviewees knew organ donation by TV, newspaper, magazine, mobile phone, and computer. However, only 24 of them clearly said that they had talked about organ donation, mainly with friends, classmates, or colleagues, and few talked about organ donation with family members. Of all the interviewees, only 9 indicated that they had considered organ donation. Among the 59 people who participated in the family interview, 30 stated they were reluctant to donate organs, 13 of them explicitly said it was a taboo to talk about this topic, and 25 expressed their intention to donate organs. The results are shown in Table1.
Through interviews, we found that the public had a certain understanding of organ donation. In daily life, if there is no certain opportunity or demand, organ donation will not be discussed. Especially in the family, organ donation is still a taboo topic. Most interviewees said organ donation has nothing to do with their lives. Young interviewees thought that they were still young and had never thought about it. While some others said that as they were old, it's useless to donate organs that were aging. Some suggested that organ donation should be considered only when the body had incurable diseases. Although most interviewees agreed that organ donation is worth promoting, many of them were hesitant when asked whether they would like to donate organs or not. During the interview, it was found that those who were willing to donate organs were not taboo about the topic of organ donation, and they were relatively calm when talking about death.
In the process of organ donation, the attitude of family members is one of the most important factors that affect the success of organ donation. We surveyed whether the Page 7/17 family members agree to other family members signing the organ donor card. The results are shown in Table 2. The impact of the family culture models on organ donation Through interviews, we classified family culture models into the patriarchal family model, independent family model, and patriarchal subversion family model according to whether there is patriarchy or patriarchal subversion in the family. Additionally, according to whether the willingness of family members to donate organs will change with social and cultural factors (taking the national policy as an example), family culture models were classified into stubborn family culture model, swing family culture model, and selflessdedication family culture model. See Figure 1. Each family has a classification of family culture models. See Table 3.
The patriarchal family culture model The patriarchal family culture model does not represent a family that is completely father-centered or listens to the father 's opinions but refers to the father 's opinions or ideas that can greatly affect the wife 's and children 's ideas and decisions. Besides, in the N11 family, the mother did not agree to organ donation and thought it was a taboo. The father was not willing to sign the organ donor card, but he was willing to sign it when the national leaders took the lead in signing it. At this time, the mother's attitude also changed with the change of the father's attitude.
It is obvious that the patriarchal family is dominated by the father. As the spiritual pillar of the family, whether the father signs the organ donor card directly affects the whole family's attitude and decision on organ donation.
The independent family culture model In the independent family culture model, each member of the family has independent thoughts and the opinion of one family member will not easily affect the decisions of the whole family. Everyone has the same status in the family. This is the current model of most families in China. There is no obvious class division in the family, and there is no "monopoly of power". For example, in the N5 family, the father was in favor of organ donation. As for whether the family members are willing to donate organs after death, he will respect the wishes of the family members. However, the mother was not willing to donate organs after death and opposed to the attitude of family organ donation, not willing to donate organs by relatives. The daughter was neutral on this issue and would respect the decision of her parents. She would respect her parents' decision. The patriarchal subversive family culture model In the patriarchal subversive family model, the father does not occupy the "central" position in the family, and there are members in the family who can affect the decision of the whole family, generally the mother, wife, or children. The patriarchal subversive family model can also be classified into two categories. One is the "feminist" family model, in which the mother or wife plays a very important role. For example, in the N7 family, there is a more obvious tendency of "feminism". During the interview, the father attached great importance to the opinions of the mother and agreed with organ donation. When deciding whether to sign the organ donor card, he would consider the opinions of his family, especially his wife.
The other is the "children deciding" family model. Children play a leading role in the family because with the growth of children, parents grow old slowly. At this time, children's discourse power at home also increases, and parents often listen to their children's opinions. For example, in the N2 family, grandparents said that whether they donated organs was decided by posterity (including children, grandchildren, etc.). The father and mother also said that they should consider their children's opinions.
It depends on our children's decisions. We don't know anything when we die. You can do whatever you like. They will decide whether to donate our organs. (N2 grandpa, 71 years old; N2 grandma, 68 years old) The stubborn family culture model In the stubborn family culture model, most of the family members hold a negative attitude towards organ donation, and it is not easy to change with social and environmental factors.
Take the N8 family as an example, the mother thought organ donation was a taboo, saying that no matter whether there was a national policy for it or not, she would not donate organs.
If you ask someone else for their opinions about organ donation, you will be scolded. It's not good. I will not donate my organs anyway because I want to have a complete body. (N8 mother, 50 years old) The swing family culture model

Discussion
Factors triggering citizens to think about organ donation This study adopts qualitative interview research based on the family. The selected objects are not de ned as family members or people who are close to organ donation. It can re ect the public's knowledge about and attitude towards organ donation to a certain extent. According to the results of this study, we found that the public only heard about organ donation, but did not have a deeper understanding of organ donation policies. Therefore, more work needs to be done to inform the public about organ donation in China.
In Chinese families, organ donation is still a taboo topic. The main reasons are as follows: Organ donation is related to death; once the topic of death is involved, most people are very afraid of it [19,20].
According to Chinese traditions, the deceased should be laid to rest. It is disrespect for the dead if their organs are donated because their bodies would become incomplete [6,[21][22][23]. From the perspective of the family, "as one's fair and skin were given by one's parents, one should not have them damaged, which is the beginning of lial piety". As a result, it is a taboo to talk about it with family members [24][25][26][27][28]; the Chinese are deeply in uenced by Buddhist thoughts; many Chinese believe in karma, and think that if the body is not complete after death in this life, they will be disabled in the next life [29,30].
Among the 59 interviewees, 29 did not agree to their family members donating organs. It can be seen that the organ donation resistance from the family members was great [8,21,30]. Some interviewees thought that they were willing to donate organs after death, but they were reluctant to let their families donate organs. Most of them were mothers. This is in line with the "mother spirit" in Chinese culture. Most mothers are sel ess and dedicated to the family [31].
The impact of the family culture model on organ donation According to whether there is patriarchy or patriarchal subversion in the willingness to donate organs, the family culture model can be classi ed into the patriarchal family culture model, the independent family culture model, and the patriarchal subversion family culture model. In the Three-Character Classic, it is said that "there should be affection between father and son, as well as the love between husband and wife. Brothers should be kind to each other; the elder is amiable and the younger respectful. Harmony should be maintained among families". The traditional concept of family organization structure in China is based on the Confucian "three ethical disciplines" of father and son, husband and wife, and brothers.
However, with the development of the times, the family structure tends to be simpli ed. The family size is becoming smaller and smaller, and the family relationship is gradually changing. In the traditional family relationship, the father is the center of the family, while the mother and the children are the two points around the "center". Thus forming a more stable family relationship structure, similar to a pyramid, which is embodied in the traditional family ethics such as lial piety and obedience. With the progress of society, the patriarchal idea in family relations has been gradually weakened, and replaced by the plane family relations. Under the in uence of equality, democracy, and other ideas, the relationship between father, mother, and children constitutes a plane tripartite relationship, and any one of the three parties no longer has an overwhelming advantage in family relations [32]. Although the family structure is not dominated by patriarchy, it is not easy to completely discard the idea of patriarchy that has lasted thousands of years. In most families, the father's thoughts and views play an important role in the development of the whole family or spiritual culture.
According to whether the willingness of family organ donation is in uenced by social and cultural factors, the family can be classi ed into the stubborn family culture model, swing family culture model, and sel ess dedication family culture model. Among the 15 families interviewed, most of them are swing families. They know little about the procedures and laws of organ donation. Their willingness to donate organs is greatly in uenced by social and environmental factors. Given the existence of a large number of such families, the state should increase the publicity of organ donation knowledge, introduce feasible preferential policies for organ donation, and strengthen the supervision of the organ donation process.

Conclusions
Organ donation is not only individual behavior, but also closely related to family culture. In Chinese families, organ donation is still a taboo topic, and the resistance from family members against organ donation is great.
According to whether the willingness of family organ donation is dominated by the father, the family culture models can be classi ed into the patriarchal family culture model, independent family culture model, and patriarchal subversive culture model. According to whether the willingness of family organ donation is in uenced by social and cultural factors, the family culture models can be classi ed into the stubborn family culture model, swing family culture model, and sel ess dedication family culture model. At present, the patriarchal idea in the family relationship has been gradually weakened, but in most families, the father's thoughts and views still play an important role in the whole family. Besides, most families are in the swing family culture model, and the organ donation willingness is greatly in uenced by social and environmental factors. Different family culture models in China have different in uences on organ donation. Understanding the family culture models will help promote organ donation work and increase the consent rate. Declarations