The purpose of this study was to assess: (1) medical students’ attitudes toward organ procurement and transplantation; (2) their knowledge of current legal regulations regarding organ donation; and (3) the sources of their knowledge on organ procurement and transplantation in Poland. In addition, this study sought to explore whether differences in knowledge and attitudes toward organ donation and transplantation may coexist within the same educational environment and between distinct academic tracks. By comparing medical students with those enrolled in other healthcare disciplines, the study aimed to provide empirical insight into how educational exposure and curricular content may shape students’ understanding of transplantation law and their readiness to support or discuss organ donation.

A multicenter cross-sectional survey was conducted between 2017 and 2019 among medical students of the Medical University in Białystok, Karol Marcinkowski Medical University in Poznań, Collegium Medicum of the Jagiellonian University and Medical University of Warsaw (Poland). The student population consisted of 3,006 students, including 883 students of medicine (MD program), referred to as the MD student group. The remaining 2,122 students were enrolled in other healthcare—related programs—such as nursing, midwifery, emergency medical services, and public health and were classified as students of other healthcare disciplines. All questionnaires were printed and delivered to each of the subjects personally by a member of the research team. Questionnaires were answered by students during breaks between classes or lectures. Participation in the study was voluntary and anonymous. Participants had the right to refuse to participate without giving a reason. The study protocol was reviewed and approved by the Ethical Review Board at the Medical University of Warsaw, Poland [decision number: (AUBE/81/16)]. The questionnaire was anonymous, so it was not possible to agree to participate in writing. The letter of invitation contained information that the fulfilment and return of the questionnaire implied an implicit consent to participate in the survey (see Tables 1–8).

The questionnaire was purpose-designed for this study to assess knowledge, attitudes, and declared behaviors related to organ donation and transplantation. Its development followed a structured process that included a review of prior instruments, consultation with experts in transplantology, bioethics, and medical education, and cognitive interviews with students. The tool was pilot-tested among 30 students (not included in the study) to ensure heterogeneity in educational experience. Based on their feedback, minor adjustments were made to improve clarity and readability, including rephrasing two items concerning legal regulations and simplifying response options in one attitude-related item. Although the instrument demonstrated satisfactory face and content validity, it has not undergone formal psychometric validation, which is acknowledged as a limitation of this study.

The questionnaire was prepared in two versions: one for students of medicine and one for students of other healthcare disciplines. The basic version of the questionnaire was aimed at students in the students of other healthcare disciplines group and consisted of 16 questions, including 12 single-choice questions, 4 multiple-choice questions, and a metrics section. The version targeting the students of medicine group students was expanded to include an additional two questions.

A transplantation support index was developed for the survey, which included responses to the following questions: (1) Do you support the procurement and transplantation of organs from deceased donors?, (2) Would you agree to your organs being taken in the event of your death?, (3) Would you accept your loved one’s organs being taken after their death?, (4) Do you support the removal of organs from living donors?, (5) Is organ transplantation against your religion or ethical views? All of these questions were measured on a 5-point Likert scale where 1 meant definitely no and 5 meant definitely yes. In order to create a combined index for all questions, the order of responses to the question Is organ transplantation contrary to your religion or ethical views? This resulted in a consistent interpretation of the answers for each question, with answer 1 being the most opposed basis for transplantation and answer 5 being the maximum support for transplantation. The resulting index, which summed the answers from the questions listed above, could take values from 5 to 25, where the higher the level of the index, the more support for transplantation the person surveyed presented.

The reliability of the questionnaire was tested in a pilot study conducted among second-year public health students in the end of 2017.

Statistical analysis was carried out using R version 3.5.1. The results of data collected during the research process were presented using basic descriptive statistics, according to the measurement scale of the individual variables. Categorical variables were presented using frequency measures: the number n and the percentage of the whole group. Quantitative variables were described using measures of central tendency and measure of dispersion. Normality of distribution of quantitative variables in subgroups was checked using Shapiro–Wilk, Kolmogorov–Smirnov tests. Equality of subgroups was checked by chi-square test. Comparison of groups of students of medicine and other majors was performed using the chi-square test (categorical variables) or non-parametric tests (Mann–Whitney U and Kruskal–Wallis) for quantitative variables because the assumptions of the parametric test were not met (high skewness of data, lack of normality of distribution, and lack of equality of groups). When statistically significant differences were found in the Kruskal–Wallis test, Dunn’s post-hoc test was performed to identify specific subgroups responsible for the differences found. Bonferroni correction for multiple comparisons was applied. For analyses of data on large groups of respondents, as in the case of the present study, statistical tests indicate the statistical significance of even non-significant differences between groups that may not be significant. Therefore, for a complete picture of the statistical analysis performed, a measure of the strength of the effect of the difference found was calculated for each test in addition to the significance level p testing the statistical significance of the difference between groups. Measures of the strength of the effect appropriate to the statistical tests used were used. For the chi-square test with tables of dimension 2 × 2, it was the phi coefficient (ϕ), while for tables of larger dimensions it was the Cramer’s V coefficient (V). For nonparametric tests, on the other hand, Glass’s rank bisection correlation coefficient (rg) was used with the U-Mann Whitney test or epsilon-square coefficient (ε2) for the Kruskal-Wallis test.

Women represented just over half of the students of medicine group (63%) and the vast majority of the students of other healthcare disciplines (90%). A statistically significant difference in sex structure between the two groups was confirmed with a significantly higher percentage of women in the students of other healthcare disciplines, but the difference was of weak strength, ϕ = 0.05, p < 0.001. Students of medicine group were of a median age of 21 years, with the youngest being 18 years old and the oldest 32 years old. In contrast, the students of other healthcare disciplines had a median age of 22 years, and the age range of this group of subjects ranged from 18 to 55 years. It was confirmed that the mean age of students of other healthcare disciplines was significantly higher than that of students of medicine, but with a weak strength of effect, rg = −0.14, p < 0.001. In the case of place of residence before entering the study, students from the students of medicine group most often indicated cities with population over 200 thousand (32%), while the students of other healthcare disciplines group most often indicated a village as their place of residence (33%). Both groups differed significantly in the structure of answers in the question about place of residence with a strong effect, V = 0.18, p < 0.001. The students of other healthcare disciplines significantly more often lived in the countryside (33% vs. 19% for students from the students of medicine group, p < 0.001), while students from the students of medicine group more often lived in large cities (50–100 thousand inhabitants, 100–200 thousand inhabitants, and larger). Taking into account the education of both parents, the respondents of the groups differed in a statistically significant manner with a very strong difference for both mother’s (V = 0.31, p < 0.001) and father’s (V = 0.38, p < 0.001) education. The students of medicine group was dominated by indications of higher education (both mother—75% of respondents and father—66%, compared to 41% and 26%, respectively, for the students of other healthcare disciplines group). In the students of other healthcare disciplines group, secondary education was most frequently indicated (46% for mother’s education and 56% for father’s education). Respondents in the students of other healthcare disciplines group were significantly more likely to have parents with primary (p < 0.001 for both father’s and mother’s education) and secondary (p < 0.001 for both parents) education than students in the students of medicine group. Students in the students of medicine group were significantly more likely to have both parents with a college education (p < 0.001 for both parents). Both groups of respondents indicated most often that they had a satisfactory material situation (44% from the students of medicine group and 52% of students from the students of other healthcare disciplines group). A statistically significant difference between both groups in the structure of answers about the material situation with a strong effect was confirmed (V = 0.15, p < 0.001). Students in the students of medicine group significantly more often than students in the students of other healthcare disciplines group answered that they had a bad material situation (p < 0.001), while students in the students of other healthcare disciplines group significantly more often indicated a satisfactory (p < 0.001) or good (p = 0.007) material situation.

Analysis of the value of the calculated index of transplantation support, in the entire study group of students showed that it had a median response of 23.00 (IQR: 21.00–24.00) with a maximum possible value of 25. This overall score reflects generally strong pro-donation attitudes among students, yet notable differences emerged between the two study groups. Among medical students, the median Transplantation Support Index (TSI) was 24.00 (IQR: 21.00–25.00; mean ± SD: 23.41 ± 3.02), while among students of other healthcare disciplines it was 22.00 (IQR: 20.00–24.00; mean ± SD: 21.87 ± 3.45; p < 0.001). The analysis of the structure of answers to individual questions for the entire study group shows that the highest number of answers supporting transplantation (answers 4—yes and 5—definitely yes) was given to the question about supporting transplantation from deceased donors (97% of respondents) and to the question about taking the respondent’s own organs after death (91%). The remaining questions received supportive response rates of 80%–82%. It is worth mentioning the double-digit percentage of respondents who could not specify their preference (answer 3-difficult to say) for the questions concerning: transplantation from a close relative, obtaining organs from living donors, and knowledge concerning compatibility of transplantation with the religion. The percentage of undecided respondents was lowest for the question about support for transplantation from deceased donors (2%). Responses indicating a position against transplantation (responses of 1—definitely no and 2—no) accounted for 1%–6%, depending on the question (1% for the question on support of transplantation from deceased donors, and 6% in the question on living donor organ procurement). Taken together, these results indicate that while nearly all students support organ donation in principle, uncertainty remains around living and family-related donation, suggesting that ethical and emotional aspects of transplantation evoke greater hesitation.

For students of medicine, support for transplantation (answers 4—yes and 5—definitely yes) was also highest for aspects related to the procurement of organs from deceased donors (97%) and consenting to the procurement of respondents’ own organs after death (93%). For the remaining questions, support ranged from 86% to 89% depending on the question. The percentage of those opposed to transplantation (answers 1—definitely no and 2—no) was lowest for the question on procurement of organs from deceased donors (2%), while for the other questions it was 3%–5%, depending on the question. The percentage of undecided was lowest for the question on organ procurement from deceased donors (1%), while it was highest for the question on consent for organ procurement from a loved one (9%) and the question on organ procurement from living donors (10%). Overall, medical students presented a more consistent and affirmative stance across all domains of transplantation, reflecting both higher confidence and lower indecision compared with their peers from other healthcare disciplines.

In the students of other healthcare disciplines, the highest support for transplantation (answers 4—yes and 5—definitely yes) concerned—similarly as in the students of medicine-taking organs from deceased persons (96%) and consent for own organs after death (90%). Other aspects, i.e., questions about transplantation from a loved one, organ procurement from living donors, and knowledge regarding compatibility of transplantation with one’s religion, received 78%–79% support. The lower support in these areas is primarily related to the presence of those unable to state an opinion (answer 3—hard to say), 15%–17% of respondents, depending on the question (compared to 7%–10% for the students of medicine). The percentage of those opposed to transplantation (answers 1—definitely not and 2—no) was 1%–7% depending on the question (compared to 2%–5% for the students of medicine). The highest number of responses against transplantation concerned aspects of organ procurement from living donors (7%), while the lowest number concerned organ procurement from deceased persons (1%). The contrast between groups was most pronounced in questions requiring personal or relational commitment, such as consenting to donation from a loved one or evaluating the compatibility of transplantation with ethical or religious beliefs where indecision among non-medical students reached nearly twice that observed among medical students.

Next, the level of the transplantation support index and its components were compared between the groups of students of medicine and other healthcare disciplines. A statistically significant difference in the mean level of the transplantation index between both groups of students was confirmed, but of weak strength, rg from 0.09 to 0.17, p < 0.001. Students of medicine had significantly higher levels of support than students of other healthcare disciplines (median = 24.00 and median = 22.00, respectively). The difference in overall transplantation support between both groups was statistically significant but of weak strength (rg = 0.20, p < 0.001). Importantly, the pattern was consistent across all component questions, confirming that medical students not only express stronger support but also demonstrate a more consolidated attitude toward transplantation ethics and practice.

The analysis also includes verification of the hypothesis that the percentage of undecided persons differs between students of medicine and students of other healthcare disciplines. For this purpose, the percentage of those who gave a 3—hard to say answer to each question included in the transplantation support index was compared between groups. It was confirmed that for each question the percentage of undecided was significantly higher in the students of other healthcare disciplines than in the students of medicine (p < 0.001 for each question). The power of the effect of the confirmed difference was highest for the questions: Do you accept the possibility of organ donation from a loved one after death? and Is organ transplantation compatible with your religion or ethical views? and had a moderate level.

In the study group, almost half of the respondents were able to correctly identify the legal requirements for consent for organ procurement (49%), with 66% in the students of medicine group and 41% of respondents in the students of other healthcare disciplines group. The wrong answer was given by 45% of respondents, while 7% of respondents admitted that they did not know the legal regulations related to transplantation. Students who incorrectly answered the question about legal regulations connected with transplantation, most often answered that in order to carry out transplantation, the consent of the donor given during his/her lifetime was necessary (23% of the entire group), or the consent of the family of the deceased (20%). A marginal percentage of respondents (2%) answered that there were no legal regulations concerning transplantation in Poland. It was confirmed that students of medicine differed statistically significantly from students in other majors in terms of their knowledge of transplantation regulations, with a strong power of the effect of the difference indicated (V = 0.23, p < 0.001). Students of medicine group were significantly more likely to know the law related to transplantation (p < 0.001), while students of other healthcare disciplines group were significantly more likely than those in the students of medicine group to incorrectly indicate that in order to harvest organs from the deceased, the deceased’s consent was needed while they were alive (p < 0.001) or the consent of the deceased’s family (p < 0.001).

Respondents most often indicated that they get their knowledge about transplantation from college classes (63%) and the Internet (62%), slightly less often from television (36%). The comparison of the frequency of indicating particular channels of acquiring knowledge about organ transplantation between the students of medicine and students of other healthcare disciplines groups indicates that the representatives of the latter group significantly more often indicated television (p < 0.001) and the Internet (p < 0.001). For both channels, however, the strength of the effect of the difference between the two groups was weak (ϕ = 0.07 and ϕ = 0.08, respectively). The frequency of indicating the other knowledge transfer channels considered was not significantly different between the two groups.

More than half of the respondents (58%) have encountered a social campaign on organ transplantation, 27% gave a negative answer. The remaining 15% of respondents were unable to say whether they had encountered a similar campaign. A statistically significant difference was confirmed between the students of medicine and students of other healthcare disciplines groups in terms of frequency of contact with the organ transplantation public awareness campaign, but with weak strength of effect (V = 0.07, p < 0.001). Half of the respondents in the study group (52%) indicated that they had classes related to transplantation medicine during their studies, and 38% of the respondents gave a negative answer in the considered question. The remaining 10% of the respondents did not remember whether the topic of organ transplantation was covered in their study program. A statistically significant difference was confirmed between the students of medicine and students of other healthcare disciplines groups in the percentage of indications that transplantation medicine classes were present during their studies, with a moderate strength of effect, V = 0.10, p < 0.001. Students of other healthcare disciplines were significantly more likely to indicate that they had transplantation-related classes during their studies than students of medicine group (p = 0.002, 54 and 47% of respondents from both groups, respectively).

Results obtained in own research confirm a general trend observed in support for transplantation in Poland. Regular surveys carried out by CBOS show that 93% of Poles are favorable to the idea of transplantation, 80% of Poles agree for taking organs after death and 11% are against it (23). In a study by H. Sahin and O. Abbasoglu of 1,541 students of medicine from 104 countries, 94.4% said they supported organ transplantation, 4.3% chose do not know, and 1.4% opposed the idea of donation (24). A high level of acceptance for organ transplantation (99.6%; n = 273) was indicated in a study among students of the Medical University of Bialystok by Rydzewska-Rosołowska et al. ((25)). Transplantation of organs to living donors was supported by 98.9% of students, and 97.1% of students supported transplantation of organs from deceased donors. In a survey of 558 students of medicine at the Aristotle University of Thessaloniki, 93.9% of respondents supported the idea of organ donation, but nearly 80% of Greek students were not aware of the legal regulations in this area (26). Similarly, recent research conducted in Finland in 2025 confirmed strong support for organ donation among students of medicine (97.6%) and nursing (94.5%). Comparable levels of global support coupled with uneven legal literacy and variable readiness to discuss donation with families have been documented in recent studies in Canada, Turkey, Brazil, Saudi Arabia, and Hong Kong, suggesting a broadly shared pattern across diverse legal and cultural settings (17–22). This international confirmation of positive attitudes aligns closely with the findings of the present study and highlights that healthcare students, regardless of country, represent a highly receptive group for transplantation-related education and promotion (27).

Our own research also revealed gaps in students’ knowledge of current legislative solutions. In the entire study group, nearly 49% of students correctly indicated the current model of regulation, respectively 66% for the students of medicine and 41% for the students of other healthcare disciplines group. It is disturbing that as many as 45% of the students gave an incorrect answer, and 7% admitted to having no knowledge on the subject. The students of medicine group was significantly more likely to indicate the correct answer. In contrast, the students of other healthcare disciplines group was significantly more likely than students of medicine group to indicate the non-mandatory model of explicit consent or necessary family consent. These findings are consistent with results from Portuguese universities, where Costa Silva et al. (28) found that although 92% of medical students correctly identified the “opt-out” legal model, less than 40% could name basic immunosuppressive drugs used after transplantation. This indicates that even in countries where legal knowledge appears sufficient, essential clinical knowledge may still be lacking. Thus, the issue is not only legal literacy but also the breadth and depth of content covered in education programs.

These disparities are not merely individual but stem from structural and curricular factors. In many Polish universities, legal education related to transplantation is fragmented, often integrated into ethics or health policy courses without explicit learning outcomes or assessment. Non-medical programs such as nursing, midwifery, and public health rarely put an emphasis on a distinct component on transplantation law, even though these professionals frequently interact with families and patients in clinical settings. This curricular gap may explain why 20% of our respondents incorrectly believed that family consent is required and 23% thought that explicit donor consent during lifetime is necessary. Such misconceptions likely reflect deficiencies in procedural and communication training rather than theoretical understanding, suggesting the need for systemic rather than ad hoc educational reforms. Moving beyond the general call for “more education,” a concrete and standardized framework should be developed. One possible solution would be to implement a short, mandatory micro-module on transplantation law and professional responsibility (approximately 6–8 h) for all healthcare programs, ideally integrated into the second or third year of study. This module could include scenario-based assessments and simulation exercises testing students’ ability to communicate with families and verify objections in the Central Register. Complementary integration of transplantation topics into ethics and clinical communication courses would further strengthen learning transfer. Measurable indicators such as a minimum 80% pass rate on legal knowledge tests and periodic curriculum audits could ensure long-term consistency across universities. As shown by Abbasi et al. (29), legal education that combines lectures, case analysis, and assessments has been effective in improving medical students’ cognitive domains in medico-legal knowledge. Similarly, Chen et al. (30) demonstrated that a case-based curriculum integrating legal and ethical scenarios enhanced students’ confidence, communication with patients and families, and understanding of the legal dimension of clinical practice.

In comparative terms, Poland’s presumed consent (opt-out) model aligns legally with countries such as Spain and Austria, yet the observed donation rates and knowledge levels remain substantially lower. This discrepancy supports previous findings that legislative models alone do not determine donation outcomes. In Spain, the long-standing opt-out framework is reinforced by intensive public education, clinical coordination, and social normalization of donation (7, 12). Similarly, Austria maintains high donation rates through strong institutional infrastructure and consistent communication between healthcare providers and the public. Conversely, countries with opt-in systems, such as Germany or Turkey, continue to face barriers related to family consent, limited awareness, and sociocultural hesitation despite widespread support in principle (10, 24). The influence of cultural and religious beliefs on donation attitudes has also been confirmed in other academic settings. A recent studies among students in Turkey revealed that while participants generally expressed positive views toward blood donation, their willingness to donate organs was considerably constrained by knowledge gaps, religious concerns, and personal apprehensions (31, 32). These cross-national contrasts indicate that universal challenges, such as emotional and ethical ambivalence or insufficient legal literacy manifest differently depending on national contexts and educational traditions, emphasizing the importance of comprehensive, context-sensitive educational strategies. A particularly noteworthy finding is the comparatively large proportion of “undecided” respondents among non-medical students, reaching up to 17% in questions concerning living or family-related donation. This group likely represents individuals with ambivalent or insufficiently formed attitudes, potentially reflecting a lack of knowledge, limited exposure to clinical contexts, or uncertainty arising from religious and ethical considerations. Similar patterns have been described in studies from Turkey and Poland, where hesitation toward organ donation was associated with perceived moral conflict and low confidence in understanding legal or medical procedures (31–33). From a public health perspective, this “undecided” cohort may constitute the most malleable target group for educational interventions, as their views appear not firmly opposed but rather shaped by informational deficits and emotional reservations. Future studies should explore this group qualitatively to better understand the cognitive and affective factors underlying indecision and to guide targeted communication strategies.

Beyond the dichotomy of opt in and opt out systems, recent scholarship has emphasized deeper ethical and structural challenges within organ donation frameworks. Ambagtsheer et al. (2024) highlight emerging debates concerning donor anonymity in kidney exchange programs, the inclusion of individuals with limited decision making capacity, and the ethical legitimacy of compensation mechanisms (34). These factors demonstrate that societal trust and transparency remain central to sustaining donation systems. Similarly, Lewis et al. (35) argue that a comprehensive understanding of organ donation requires integrating legal literacy with ethical reasoning, especially regarding autonomy, informed consent, and justice. Addressing these dimensions through academic education is essential to prepare healthcare students for the moral complexity of transplantation practice.

In the survey conducted by CBOS, the model of consent given during life has a similar number of supporters as the one in which the absence of objection is sufficient. In 2016, 43% of Poles opted for the explicit consent model and 42% for the implicit consent model. Comparing the 2012 survey, it should be noted that respondents were less likely to choose the explicit consent model (23, 36). Compared to the nationwide study, in which in 2016 20% of respondents correctly answered, the students surveyed definitely more often indicated the model of implicit consent as valid, in the CBOS study the model of implicit consent was more often advocated by respondents aged 25–34 years. It can be assumed that this solution is more often chosen by younger age groups (23). It is worth emphasizing that knowledge of current legislation in this area can affect the process of organ transplantation. A nationwide survey shows that Poles either have no knowledge of this topic at all or indicate an incorrect answer.

The information provided by medical personnel is crucial in creating a social climate around the topic of transplantation. This is why the knowledge gained during university education is so important. Students, as future professionals in the health sector, must provide accurate information based on sound knowledge. In addition, they should use clear concepts with which to communicate with the public in a concise manner to prevent irrational fears of organ donation (37).

It should be noted that the most common sources from which students obtained information on organ transplantation were academic classes (62.6%), the Internet (61.8%), television (35.5%) and books (18.8%) (38, 39). The finding that the Internet represents the second most common source of information (62%) is particularly concerning, as online materials on transplantation often include unverified or outdated content. Heavy reliance on digital sources without adequate academic guidance can perpetuate myths about consent, brain death, and the legal role of families. Therefore, university-based curricula should incorporate elements of critical information appraisal, such as short workshops or assignments focusing on evaluating online sources and distinguishing between official legal documents (e.g., the Transplantation Act, Poltransplant reports) and informal media narratives. Strengthening digital literacy in this domain is essential to reduce misinformation and enhance evidence-based communication with patients and the public.

It is worth mentioning that half of the students from the entire study group indicated that they had classes on transplantation issues during their studies, nearly 40% denied having such classes, and 10% did not remember whether this topic was covered in their academic classes. A comparison between the students of medicine and students of other healthcare disciplines groups showed that students from other majors were more likely to indicate that they had had classes on the topic discussed than students of medicine. This may be due to the fact that transplantation issues are covered in different subjects and students were not able to identify this as one subject throughout their studies.

As H. Sahin and O. Abbasoglu point out, in order to provide future physicians with the necessary knowledge and equip them with appropriate attitudes regarding organ donation, an appropriate educational strategy is necessary. The curricula of many medical universities do not give adequate emphasis to this topic. Determining students’ knowledge about organ donation is considered the first step to developing such an educational model. In the study cited above, participants who received a course in organ donation showed higher scores than participants who did not receive such education (18). Darlington et al. (40) in their work also emphasize the important role of holding regular seminars for medical students on organ procurement and transplantation.

In a recent Polish study by Mikla et al. (33) similar deficits in formal education were identified. The authors emphasized the role of family discussions and social campaigns in shaping attitudes and knowledge among students. Notably, the absence of family conversations on the subject correlated with less clarity regarding the legal framework. These observations support the thesis that academic teaching should not only provide factual knowledge but also encourage intergenerational dialogue and ethical reflection.

This study shows that the participants represent a group of future health care professionals directly or indirectly influencing the process of organ donation. Therefore, proper education of this group is extremely important, as it can significantly affect the number of transplants performed.

As emphasized by Radunz et al. (41) health care professionals should be the most knowledgeable group in the field of organ donation. The problem of organ shortage is a health care problem and can be solved by a strong attitude of physicians and other health care personnel. Early education of health care professionals thus appears to be a factor that can serve to maximize the benefits of a limited donor pool.

It should still be taken into account that studying is a process during which attitudes and beliefs towards many social phenomena are formed among young people including organ procurement and transplantation, and due care must be taken to equip them with pro-transplantation attitudes (42, 43). As indicated by the European Commission, students have been identified as one of the most helpful social groups among the population of the European Union for the formation of positive attitudes towards organ procurement and transplantation (44). It is emphasized that students represent a high level of altruistic social commitment and have a strong influence on their family members, friends, acquaintances, neighbors (45).

Our results are in line with contemporary Polish evidence showing that medical students generally declare strong support for transplantation, yet decisions regarding donation on behalf of relatives are strongly influenced by family discussions, a sense of moral duty, and solidarity, while the absence of such conversations is associated with reduced willingness to donate (33). Single university studies from Bialystok confirm nearly universal acceptance of transplantation but also reveal gaps in the acceptance of brain death criteria, limited readiness for postmortem donation, and the decisive role of family in the donation process (25, 46). In the broader student population, beyond medical programs, positive attitudes do not consistently translate into concrete actions, with low rates of actual donor registration indicating a gap between declared support and real behavior (47). Furthermore, in the area of tissue donation such as corneal transplantation, knowledge deficits persist across different social groups in Poland, and the disparity between demand and the number of procedures performed underscores the importance of targeted education and public campaigns (48). Collectively, these findings reinforce our recommendation for systematic, standardized, and multidisciplinary education on transplantation across all health related academic programs. Poland’s opt-out model presents an apparent paradox: despite a presumed consent system, national donation rates remain among the lowest in the European Union. Our findings suggest that this paradox may, at least partially, originate from micro-level knowledge and communication deficits among healthcare students and professionals. When nearly one in five respondents believes that family consent is required, the legal framework of presumed consent becomes functionally undermined. In practice, uncertainty about the law may lead to unnecessary hesitation in donor identification or family discussions, effectively reintroducing a “family veto” into a system where it does not legally exist. Addressing these misconceptions through structured education could therefore have macro-level implications, potentially improving the efficiency of the opt-out system and increasing actual donation rates.

Our findings highlight the urgent need to reinforce educational strategies in the field of organ donation and transplantation. Previous studies confirm that targeted and structured educational programs significantly improve medical students’ knowledge and acceptance of transplantation (49, 50). Moreover, online and institution-based interventions have been shown to increase willingness to donate organs among university communities, demonstrating that well-designed educational activities can influence not only knowledge but also attitudes and intentions (51). Given the heavy reliance on informal online sources observed in this study, structured academic interventions are essential to ensure that future healthcare professionals base their knowledge on verified and legally accurate information rather than social media or non-specialist websites. Therefore, the integration of dedicated modules into medical curricula, combined with interactive and accessible educational formats, may provide a comprehensive framework for equipping future healthcare professionals with the necessary competencies to promote organ donation.

This study has several limitations. A major methodological limitation of this study is that the questionnaire and the Transplantation Support Index (TSI) were not subjected to a formal psychometric validation process. While the questionnaire was developed with expert input and pilot-tested to ensure clarity, it lacks established measures of content validity, construct validity, and internal consistency. Consequently, the reliability of individual subscales and the interpretability of composite scores may be limited. The TSI should therefore be regarded as an exploratory indicator, intended to provide a preliminary framework for assessing students’ overall support for organ transplantation. Future research should focus on developing and validating a standardized instrument based on this initial version. The study was conducted exclusively among students from four Polish medical universities, which may limit the generalizability of findings to other institutions or countries. Moreover, differences in curricula between universities, as well as potential gaps in the coverage of transplantation-related issues, could have influenced students’ responses and thus affected the comparability of results. The use of a self-reported questionnaire could have introduced social desirability bias, particularly in responses related to attitudes and ethical beliefs. Additionally, the data collection spanned from 2017 to 2019, a period during which educational curricula and public discourse surrounding transplantation may have evolved. Therefore, temporal variations in students’ exposure to transplantation-related content cannot be ruled out. The cross-sectional design also precludes any causal inferences regarding the relationship between educational exposure, knowledge, and attitudes. Another methodological limitation is the absence of multivariate modeling. Because the study database was fully anonymized and aggregated by subgroups, it was not possible to perform logistic or ordinal regression analyses to identify independent predictors of high transplantation support or correct legal knowledge. As a result, potential confounding effects between sociodemographic and educational variables could not be controlled for. Future research based on this instrument should prospectively collect individual-level data to allow for comprehensive multivariate analysis.