By Mina Mosallanejad
Monir still remembers the unnerving sound of the intensive care unit monitors — long, repetitive beeps that erased the difference between day and night.
For months, her heart had been failing her. Walking a few steps left her breathless, and climbing a staircase felt like carrying a mountain on her chest.
Doctors had told her that her condition had progressed too far and that a transplant was her only chance of survival. But more than death itself, she feared something else: leaving behind her young daughter before watching her grow up.
“There were nights when I stayed awake until morning, staring at the hospital ceiling while trying to silence the thoughts running through my mind,” she recounted.
Death no longer felt a distant reality. It walked beside her in gloomy and grim hospital corridors and sat quietly at the edge of her bed all the time.
Waiting for a donor heart became a form of suspended existence — a life measured not in days, but in moments of uncertainty and unpredictability.
Every time the phone rang, her pulse raced. Maybe this was the call. Maybe it wasn’t. When the call finally came, Monir says her life began again.
She never learned whose heart now beats inside her chest. She does not know which family, in the middle of unimaginable loss, agreed to donate the organs of someone they loved.
But years later, she still thinks about them constantly. “Because of them,” she says, “I got to see my daughter grow up.”
Today, Monir can walk beside her child, laugh freely, and imagine a future she once believed she would never have.
“Sometimes, I place my hand over my chest and think about the strange connection between grief and survival — how one family’s tragedy became another family’s second chance at life,” she says.
Her story is not unique. Thousands of patients across Iran live in the fragile space between hope and loss, waiting for the phone call that could save them.
The long road of organ transplantation in Iran
Modern organ transplantation in Iran began with a religious ruling that changed the trajectory of medicine in the country.
On May 21, 1989, Imam Khomeini, the late founder-leader of the Islamic Revolution, issued a historic fatwa declaring organ donation from brain-dead patients religiously permissible.
Before that, many Iranian patients requiring transplants had little choice but to travel abroad, often at enormous financial and emotional cost.
After the declaration of the fatwa, Iran performed its first kidney transplant from a brain-dead donor in 1991, followed by the first liver and heart transplants in 1993. The first lung transplant took place in 2000, while the first pancreas transplant was carried out in 2006.
The Iranian parliament formally approved the Organ Transplantation and Brain Death Act in 2000, more than a decade after the fatwa.
Two years later, organ procurement units officially began operating under medical universities across the country. From there, Iran’s transplant programs expanded rapidly.
Today, Iran performs all major vital organ transplants domestically and has become one of the region’s leading transplant centers.
In southern Iran's Shiraz city alone, one major transplant center performs hundreds of liver transplants annually — a figure that has led some specialists to describe Iran as a regional “empire of liver transplantation.”
In February 2023, Iranian surgeons announced a pioneering organ donation procedure involving donation after circulatory death (DCD), also known as donation after cardiac death.
In an interview with the Press TV website at the time, Dr. Sam Zeraatian-Nejad Davani explained that the procedure had already been successfully performed on multiple donors at Hazrat-e Rasool General Hospital in Tehran.
According to Dr. Davani, the technique could increase available organs for transplant patients by 20 to 30 percent. His team successfully transplanted kidneys, livers, lungs, and a pancreas using the method.
Specialists from the Donation and Transplantation Institute (DTI Foundation) reportedly described the achievement as among the first of its kind internationally.
Among other people who helped shape that progress in this field is Dr. Katayoun Najafizadeh, a thoracic specialist and full professor at Shahid Beheshti University of Medical Sciences, who founded the lung transplant program at Masih Daneshvari Hospital.
Over the years, she has become one of the most recognizable advocates for organ donation in Iran, working not only in operating rooms but also in public education and policy.
In 2024, Dr. Najafizadeh received international recognition at the 30th Congress of The Transplantation Society (TTS), where she was honored in the Women in Transplantation section as one of the world’s most influential women in organ donation and transplantation.
A growing culture of hope and second chances
Dr. Katayoun Najafizadeh told the Press TV website that despite the challenges facing the country’s transplant system, Iran today has the medical expertise, infrastructure, and specialized teams needed to perform highly advanced organ transplant procedures.
According to Dr. Najafizadeh, between 5,000 and 8,000 cases of brain death occur annually in Iran, and nearly half of those patients have the potential to become organ donors.
Currently, around 1,000 organ donations take place in Iran each year, saving thousands of lives and giving many critically ill patients a second chance at life.
At the same time, nearly 28,000 to 30,000 patients remain on transplant waiting lists across the country — a number that, specialists say, also reflects how many lives could potentially be transformed through greater public awareness and donor registration.
“More than fifteen people lose their lives every day while waiting for an organ,” Dr. Najafizadeh said, emphasizing the urgent need for continued public education and stronger awareness campaigns.
She believes Iran already possesses one of the region’s strongest scientific and medical foundations for transplantation, and that expanding the culture of organ donation could dramatically reduce waiting lists in the years ahead.
“Among donors whose organs are not ultimately donated, many have several healthy organs that could save lives,” she told the Press TV website. “If we can connect those opportunities to patients in need, we can save thousands more people every year.”
For specialists working in transplantation, the future of organ donation in Iran now depends less on medical capability and more on public understanding, awareness, and trust — areas they say have already improved significantly over the past decade and continue to move in a positive direction.
The cultural challenge
Over the last decade, Iran has invested heavily in public awareness campaigns surrounding organ donation. Schools, advocacy groups, transplant organizations, and media campaigns have all tried to normalize conversations around brain death and donation.
Dr. Najafizadeh, who currently leads the Iranian Organ Donation Association, says awareness has improved significantly compared to previous years. Organ donation topics have even been incorporated into 11 school textbooks across the country.
Still, she believes public understanding remains insufficient.
“If you ask many people — even officials — what brain death actually means, many still do not fully understand it,” she says.
Currently, only around 10 to 12 percent of Iranian adults hold organ donor cards.
In comparison, donor registration in some countries reaches nearly 70 percent, largely because organ donor status is integrated into driver’s licenses.
Iran has recently taken similar steps. According to Dr. Najafizadeh, authorities have begun allowing organ donor registration markers to appear on driver’s licenses as well, a change she hopes will gradually improve participation.
But she insists that the deeper issue goes beyond paperwork.
“In countries like Spain, people know organ donation the same way they know football,” she said. “That level of understanding has not yet become fully rooted in our society.”
Brain death is not coma
For transplant coordinators, the most difficult conversations often happen in hospital corridors moments after families are informed that a loved one has suffered brain death.
According to Dr. Najafizadeh, the biggest reason families refuse organ donation is simple: many still believe brain death can be reversed.
“The most widespread misconception is that brain death is not real death,” she said.
The doctor repeatedly emphasized the difference between coma and brain death.
In a coma, the brain structure remains intact, and recovery may still be possible. In brain death, however, the brain cells have irreversibly deteriorated.
“There is absolutely no possibility of recovery,” she noted.
Yet families facing sudden tragedy often struggle to accept that reality.
“Some families tell us they believe a miracle may happen,” Dr. Najafizadeh said. “We tell them the miracle is not that a brain-dead person suddenly wakes up. The miracle is that life can continue in others.”
The emotional timing makes these conversations even harder. Families are usually asked to understand an unfamiliar medical concept during the worst moments of their lives.
“We are trying to explain a scientific phenomenon at the exact moment a family is in shock and grief,” she stated. “That understanding should exist before the tragedy happens.”
For that reason, transplant advocates increasingly argue that education about brain death should begin long before people encounter it in hospitals.
Iran leads West Asia in organ donation
Dr. Najafizadeh said Iran’s transplant system stands out in several important ways, making it one of the region’s strongest and most equitable models for organ transplantation.
For years, she added, Iran has ranked first in West Asia for organ donation from brain-dead donors, though globally it remains around 30th place.
According to Dr. Najafizadeh, one of the system's biggest strengths is that transplantation costs are covered by the government.
Unlike many countries where access to transplantation depends heavily on personal wealth or insurance coverage, Iran’s transplant system operates under a different model.
When the costs of organ procurement and transplantation are covered by the government, it allows both wealthy and poor patients to receive treatment under the same framework, Dr. Najafizadeh added.
In countries such as India, she noted, financial disparities can shape the transplantation process itself.
“In some places, wealthier patients effectively pay for transplantation and even compensate donor families,” she said. “In Iran, the system was designed to prevent that inequality. That means poor and rich patients benefit equally."
Iran’s centralized support system was designed to avoid that disparity. Another distinctive feature of the Iranian system is the strict confirmation process for brain death.
Under Iranian law, she explained, four separate medical specialists must independently confirm brain death before organ procurement can proceed.
Dr. Najafizadeh said this process can be difficult and time-consuming for transplant teams, but it also creates a higher level of certainty and trust.
“When all four specialists confirm brain death separately, the confidence that the patient is truly brain dead becomes much stronger,” she noted.
Still, she acknowledges that the system has weaknesses. One major issue is that education about brain death and organ donation has not yet become a mandatory part of medical training for all healthcare workers.
“Healthcare professionals are often the first people who encounter brain-dead patients,” she said. “Yet education in this field is still not fully integrated into medical curricula.”
The doctor also points to insufficient oversight of organ procurement units across the country.
While nearly all medical universities now operate donation systems, she believes stronger supervision and evaluation mechanisms are still needed to improve performance nationwide.
When crisis interrupts transplantation
Regional instability and wartime conditions have also affected Iran’s transplant system in recent months, especially following the US-Israeli war of aggression against Iran.
According to Dr. Najafizadeh, organ donation rates dropped significantly during this period because hospitals shifted their focus toward emergency care.
“The healthcare system moved into crisis mode,” she said. “Transplantation was no longer treated as the immediate priority.”
Yet for patients on waiting lists, delays can be catastrophic.
Dr. Najafizadeh compares the daily death toll among transplant candidates to a disaster that unfolds quietly and continuously.
“If fifteen patients die every day waiting for organs,” she said, “it is like a missile striking a building full of fifteen people every single day.”
Unlike sudden catastrophes, however, these losses often happen slowly — through months or years of dialysis, respiratory failure, repeated hospitalizations, and physical decline.
“When these patients die, entire families are affected. Some families may never fully recover emotionally or financially,” she added.
For that reason, she asserted that transplantation systems must remain protected even during national emergencies.
The decision that changes everything
For patients like Monir, organ donation is not an abstract medical debate. It is the thin line between absence and survival.
Years after her transplant, she still does not know whose heart saved her life. She likely never will.
“But every ordinary moment I once feared losing — every walk with my daughter, every birthday, every future plan — now exists because another family made a decision in the middle of unbearable grief,” she says.
That invisible connection between loss and survival lies at the center of every transplant story. Inside operating rooms, surgeons perform the technical work of transplantation.
But the first and most difficult step happens elsewhere — in the moment a grieving family decides that even in death, part of their loved one’s life can continue inside someone else.
