Public awareness and acceptance of xenotransplantation in China: a cross-sectional survey

Abstract

Background

Xenotransplantation using genetically edited pig organs has been considered a promising solution to the global organ shortage. However, its successful implementation depends not only on scientific advance but also on public acceptance. Empirical evidence on public awareness, acceptance, and ethical concerns regarding xenotransplantation in China remains scarce. This study was conducted to investigate public familiarity with xenotransplantation, acceptance of the technology, and factors associated with acceptance.

Methods

A cross-sectional survey was conducted among adults in mainland China based on a structured questionnaire. A convenience sampling strategy was adopted. Data regarding demographic characteristics, familiarity with xenotransplantation, acceptance under a life-saving scenario, religious considerations, and perceived impact on human organ donation were collected. Descriptive statistics, binary logistic regression, and ordinal logistic regression were used for analysis.

Results

A total of 589 valid questionnaires were analyzed. The majority of respondents (85.57%) had at least heard of xenotransplantation, although only 4.92% reported being very familiar. In a hypothetical life-saving scenario, 36.67% reported they would definitely accept xenotransplantation, while 11.54% would definitely not. Acceptance was higher among males, younger adults, medical workers, and those familiar with the technology, and lower among individuals with higher education or perceived religious conflict. Perceived religious conflict was significantly associated with acceptance (OR = 0.22, p < 0.01). Respondents with more optimistic expectations of xenotransplantation were more likely to perceive that it would weaken willingness to donate human organs (OR = 5.49, p < 0.01). The main public concerns included clinical trial safety (75%), postoperative outcomes (74%), and costs (63%).

Conclusions

Public familiarity with xenotransplantation in China remains limited, and acceptance is shaped by sociodemographic factors, religious beliefs, and familiarity with the technology. Transparent risk communication, culturally sensitive public engagement, and stratified information strategies are required to support responsible clinical translation into practice and ethical governance of xenotransplantation.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12910-026-01544-x.

Background

Globally, the severe shortage of organs available for transplantation has emerged as an increasingly serious public health challenge. Less than 10% of transplantation needs are currently met worldwide each year, with many patients dying while waiting [1]. In the United States, more than 100,000 patients were registered on the transplant waiting list in 2025, whereas only about 40,000 organs were available for transplant annually [2]. In China, the organ supply-demand imbalance is similarly pronounced. According to the China Organ Donation and Transplantation Development Report, 11,249 organ donations were reported that year, while the number of patients registered on the waiting list exceeded 140,000 [3].

To address this dilemma, scientists have actively explored various alternative strategies, including tissue engineering, artificial organs, and 3D bioprinting [4]. Although these technologies are theoretically feasible, they still face major challenges in achieving full physiological function, long-term biocompatibility, and large-scale production. In contrast, xenotransplantation—especially using genetically edited pig organs—has increasingly been regarded as one of the most feasible long-term solutions for alleviating the organ shortage due to its scalability and controllability.

Xenotransplantation involves implanting, inoculating, or injecting live cells, tissues, or organs of animal origin—or human-derived materials cultured with xenogeneic substances—into the human body [5]. With advances in gene editing technology and immunosuppressive therapies, genetically engineered pig organs have emerged as an important candidate source for replacing human organs [6]. However, the future development of xenotransplantation depends not only on scientific advances but also on broad social acceptance and ethical consensus. Unlike many other medical technologies, xenotransplantation is a relatively advanced technology, and it is still in the early stage of exploration across the country. However, it raises a range of ethical and social concerns that extend beyond questions of clinical safety and efficacy. These include concerns such as animal welfare and the moral justification for using animals as organ sources [7], the potential risk of cross-species disease transmission [8], questions relating to human dignity and personal identity [9], and issues of public trust and social legitimacy [10].Consequently, understanding public attitudes toward xenotransplantation is crucial because public perceptions may influence the social legitimacy, policy development, and future clinical implementation.

Public attitudes toward xenotransplantation differ significantly across countries and regions. A national survey in the United States showed that religious views have been shown to significantly influence many people’s medical decisions and are considered a potential barrier to accepting xenotransplantation [11]. In a survey of attitudes toward kidney xenotransplantation among different groups, physicians and dialysis patients or their relatives were more inclined to support living donor transplantation, whereas clergy often expressed no opinion. The highest approval of xenotransplantation was among physicians and dialysis patients/relatives [12]. A study in the United Kingdom found that 65.2% of respondents were familiar with xenotransplantation, and the emergence of the technology did not significantly change the public’s attitude toward human organ donation [13]. In Japan and South Korea, public attitudes are divided: public acceptance of xenotransplantation is relatively low in Japan [14], while generally positive in South Korea [15].

In recent years, China has made substantial progress in xenotransplantation research. Several institutions have conducted experimental studies involving non-human primates and brain-dead human recipients, reporting encouraging preliminary results [16–19]. Despite growing scientific interest, empirical research on public attitudes toward xenotransplantation in China remains limited. Existing studies have surveyed specific groups such as healthcare professionals, transplant recipients and transplant candidates [20, 21]. Evidence regarding public familiarity, acceptance, and ethical concerns remains scarce.

Therefore, this study was conducted to investigate the public’s familiarity with, acceptance of, and ethical attitudes toward xenotransplantation in China. Using a structured questionnaire survey, we examined attitudes toward xenotransplantation, religious considerations, and perceptions of its potential impact on human organ donation. The findings are expected to provide empirical evidence for decision-making and serve as a reference for constructing a governance framework for xenotransplantation.

Methods

Study population and sampling strategy

This study was a cross-sectional survey. All respondents were recruited from mainland China. Eligible participants were adults aged ≥ 18 years who voluntarily consented to complete the questionnaire. Exclusion criteria were age < 18 years and/or logically inconsistent responses.

A convenience sampling strategy was adopted for participant recruitment. Considering that the adult population in China is substantially larger than the calculated sample size, the minimum required sample size was estimated using the formula for a large population proportion:

The parameters were defined as follows: allowable error (δ) = 5%, significance level (α) = 0.05, corresponding critical value()= 1.96. Based on the latest national survey results, the estimated awareness rate ( p) was set at 70% [22]. The theoretical minimum sample size was calculated as 323. Accounting for an approximate 20% invalid questionnaire rate, the final required sample size was determined to be 404.

Questionnaire development and pilot study

The questionnaire was developed on the basis of a literature review of xenotransplantation, existing public and patient attitude surveys [13, 15, 22, 23], bioethical discussions, and the research team’s preliminary fieldwork. The final questionnaire included four demographic questions and seven questions on xenotransplantation, covering familiarity, acceptance under a life-saving scenario, perceived effects on human organ donation, religious considerations, and information needs. To ensure content validity, the initial questionnaire was reviewed by a public health expert and a bioethics expert, and subsequently revised. A pilot study was then conducted using both online (Wenjuanxing platform) and offline (public settings) approaches, including structured items and semi-structured interviews. Analysis of the pilot data revealed no substantial differences in responses between online and offline modes. Therefore, the formal survey was administered exclusively through the Wenjuanxing platform, without strictly differentiating between recruitment sources.

Data collection and data cleaning

In the formal survey, participants were recruited via online social media platforms and offline public settings (unrelated to transplantation, medicine, or biotechnology). Both recruitment channels directed participants to complete the questionnaire on the Wenjuanxing platform. Respondents came from 30 provincial-level regions across Eastern, Central, Western, and Northeastern China. Before participation, all respondents received an information sheet detailing the study’s purpose, voluntary nature, right to withdraw, data use, and researcher contact information. The study involved no clinical intervention or sample collection. Participation was anonymous, no personal identifiers were collected, data were accessible only to authorized team members, and no incentives were provided.

A total of 643 questionnaires were collected. Data cleaning was performed before analysis. Questionnaires containing invalid demographic information (e.g., clearly erroneous age entries) were excluded (n = 2). Respondents younger than 18 years of age were excluded because the study focused on adults (n = 48). In addition, questionnaires containing logically inconsistent responses were excluded (n = 4). Logical inconsistency was defined as contradictory responses across related questions. For example, some respondents reported that xenotransplantation did not conflict with their religious beliefs, but subsequently selected “conflict with religious beliefs” as a reason for refusing xenotransplantation. After data cleaning, 589 valid questionnaires were retained for analysis. The details are shown in Fig. 1.

Fig. 1.

Flow diagram of questionnaire screening and data cleaning procedures

Statistical analysis

Data analysis was performed using Stata 18. Descriptive statistics and correlation analyses were conducted. For descriptive statistics, normally distributed continuous data are presented as mean ± standard deviation, while non-normally distributed continuous data are presented as median (M) and interquartile range (Q25, Q75). Categorical data are described using frequencies, percentages, or proportions. Since the dependent variables were categorical, binary logistic regression and ordinal logistic regression models were employed for multivariate analysis.

Ethical approval

This study was reviewed and approved by the Public Health Ethics Review Committee of the Chinese Academy of Medical Sciences & Peking Union Medical College (Approval No.: CAMS&PUMC-IEC-2025-135).

Results

General demographic information

A total of 589 valid questionnaires were included in the final analysis, including 245 males (41.60%) and 344 females (58.40%). The largest age group comprised 18–44 years (389, 66.04%), and 52.12% held a college or undergraduate degree. The most common occupation was student (21.73%), followed by company or enterprise employees (13.92%) and medical workers (12.39%). The details are shown in Table 1.

Table 1.

General characteristics of the participants (N = 589)

Variable	Total (portion, %)
Gender
Female	344(58.40)
Male	245(41.60)
Age
18 ~ 44	389(66.04)
45 ~ 59	123(20.88)
≥ 60	77(13.08)
Education
Junior high school or below	43(7.30)
High school	49(8.32)
College or undergraduate degree	307(52.12)
Postgraduate or Doctoral student	190(32.26)
Occupation
Company/Enterprise employee	82(13.92)
Lawyer	14(2.38)
Freelancer	53(9.00)
Student	128(21.73)
Medical worker	73(12.39)
Government department employee	39(6.62)
Teachers	37(6.28)
Retired	22(3.74)
Other	141(23.94)

Familiarity with xenotransplantation

40.58% of respondents reported being somewhat familiar with xenotransplantation; whereas, the proportion of those who were very familiar was the lowest, at only 4.92%. The details are shown in Table 2.

Table 2.

Familiarity with xenotransplantation

Variable	Total (portion, %)
How familiar are you with xenotransplantation?
Not at all familiar	85(14.43)
Heard of it, but not familiar	149 (25.30)
Somewhat understand	239(40.58)
Moderately understand	87(14.77)
Very familiar	29(4.92)

Acceptance of xenotransplantation

36.67% of participants reported they would definitely accept xenotransplantation in the extreme scenario, while 11.54% stated they definitely would not accept. The details are shown in Table 3.

Table 3.

Acceptance of xenotransplantation. The acceptance referred to here means in the extreme scenario where only xenotransplantation can save lives

Variable	Total (portion, %)
Would you accept the xenotransplant?
Definitely would not accept	68(11.54)
Probably would accept	305(51.78)
Definitely would accept	216(36.67)

Males exhibited higher acceptance than females. Younger participants had the highest acceptance, while the elderly had the lowest. Acceptance generally decreased with higher education levels. Medical workers had higher acceptance than non-medical workers. Those who were more familiar with xenotransplantation were more likely to accept the technology. The details are shown in Table 4.

Table 4.

Acceptance of xenotransplantation by population group

Variable	Definitely would not accept	Probably would acceptable	Definitely would accept
Gender
Male	24(9.80)	117(47.76)	104(42.45)
Female	44(12.79)	188(54.65)	112(32.56)
Age
18 ~ 44	34(8.74)	204(52.44)	151(38.82)
45 ~ 59	21(17.07)	61(49.59)	41(33.33)
≥ 60	13(16.88)	40(51.95)	24(31.17)
Education
Junior high school or below	4(9.30)	24(55.81)	15(34.88)
High school	9(18.37)	31(63.27)	9(18.37)
College/undergraduate	33(10.75)	169(55.05)	105(34.20)
Postgraduate or above	22(11.58)	81(42.63)	87(45.79)
Occupation
Non-medical worker	61(11.82)	272(52.71)	183(35.47)
Medical worker	7(9.58)	33(45.21)	33(45.21)
Familiarity
unfamiliar	12(14.12)	50(58.82)	23(27.06)
familiar	56(11.11)	255(50.60)	193(38.29)

Unfamiliar with xenotransplantation includes only those who answered “Not at all familiar”; all other responses are considered familiar

Public concerns

Seventy-five percent of the public reported concerns regarding clinical trial safety, 74% about postoperative care and long-term outcomes, 63% about transplant costs and technical principles/development status, 46% about the ethical review and regulatory oversight, and only 7% about other issues. The details are shown in Fig. 2.

Fig. 2.

Factors of public concern about xenotransplantation. Multiple responses were allowed for the question presented in Fig. 2. Percentages were calculated based on the number of respondents who selected each option, divided by the total number of respondents (N = 589). Because multiple responses were permitted, the sum of percentages exceeds 100%

Logistic regression model results

Given the small number of respondents who selected “strongly agree” or “strongly disagree” with the statement that the clinical application of xenotransplantation would weaken willingness to donate allogeneic organs, estimates for the extreme response categories may be unstable. To ensure adequate sample size in each analytical category and to improve the interpretability of the model results, this study followed previous studies [24] and collapsed the original four-category outcome into a binary variable. Specifically, “strongly disagree” and “somewhat disagree” were combined into the disagreement group, whereas “somewhat agree” and “strongly agree” were combined into the agreement group. A binary logistic regression model was then used for the analysis.

Multicollinearity was assessed among the covariates included in the regression analysis using the variance inflation factor (VIF). The results showed that the VIF values ranged from 1.07 to 4.32, with a mean VIF of 2.30, indicating that serious multicollinearity was not present in this model. An additional file shows this in more detail (Table S1).

The regression results indicated that, after controlling for demographic characteristics and familiarity with xenotransplantation, respondents with more optimistic expectations regarding the development of xenotransplantation technology were more likely to agree that the clinical application of xenotransplantation would weaken willingness to donate allogeneic organs. Compared with respondents with the least optimistic expectations about technological development, those with relatively optimistic expectations had higher odds of agreeing with this statement (OR = 3.43, p < 0.01), while those with the most optimistic expectations had even higher odds of agreement (OR = 5.49, p < 0.01). The details are shown in Table 5.

Table 5.

Results of logistic regression model for agreement that xenotransplantation will reduce organ donation willingness. Dependent variable: agreement that xenotransplantation will reduce organ donation willingness

Variable	Odds ratio (95% CI)
Expectation of clinical application of xenotransplantation within five years
Strongly disagree	Reference
Somewhat disagree	2.81***(1.42–5.56)
Somewhat agree	3.43***(1.71–6.89)
Strongly agree	5.49***(1.93–15.60)
Gender
Male	1.10(0.78–1.56)
Female	Reference
Age	0.99(0.98–1.00)
Education
Junior high school or below	Reference
High school/Vocational school	1.38(0.59–3.21)
College/Undergraduate	0.98(0.49–1.95)
Postgraduate or above	0.86(0.42–1.76)
Occupation
Non-medical worker	Reference
Medical worker	1.22(0.71–2.08)
Familiarity with xenotransplantation
Not at all familiar	Reference
Heard of it but not familiar	0.80(0.45–1.43)
Somewhat understand	0.85(0.49–1.48)
Moderately understand	0.59(0.30–1.16)
Very familiar	2.21*(0.88–5.55)
Observations	589
Model statistics	Pseudo R² = 0.039

Odds ratios (ORs) are reported with 95% confidence intervals (CIs) in parentheses. Reference categories are indicated as “Reference”. Robust standard errors were used. * p < 0.10, *** p < 0.01

Then, an extreme scenario was defined in the questionnaire: only xenotransplantation can save your life, and an ordinal logistic regression model was used to examine factors associated with acceptance of xenotransplantation. The dependent variable, acceptance of xenotransplantation, was coded as follows: 1 = definitely not accept, 2 = probably accept, 3 = definitely accept. Before model estimation, the proportional odds assumptions were assessed using the Brant test. The null hypothesis was not rejected (χ² =16.56, p = 0.12), indicating that the ordinal logistic regression model was appropriate for this outcome [25]. In addition, multicollinearity diagnostics were conducted. The VIF values of the included variables ranged from 1.05 to 4.27, with a mean VIF of 2.04, suggesting that there was no serious multicollinearity among the covariates in this model. An additional file shows this in more detail (Table S2).

The regression results showed that perceived conflict between receiving a pig organ transplant and one’s religion or beliefs was an important factor hindering acceptance of xenotransplantation. Compared with respondents who reported no religious or belief-related conflict, those who perceived such a conflict had significantly lower odds of reporting a higher level of acceptance of xenotransplantation (OR = 0.22, p < 0.01). In contrast, greater familiarity with xenotransplantation was positively associated with acceptance. Compared with respondents who completely did not understand xenotransplantation, only those who were“very familiar”with xenotransplantation had significantly higher odds of reporting a higher level of acceptance (OR = 5.72, p < 0.01). The details are shown in Table 6. After replacing the familiarity of xenotransplantation with a continuous variable, this conclusion still held (OR = 1.30, p = 0.003). An additional file shows this in more detail (Table S3).

Table 6.

Results of ordinal logistic regression model for acceptance of xenotransplantation. Dependent variable: acceptance of xenotransplantation

Variable	Odds ratio (95% CI)
Religious conflict
No	Reference
Yes	0.22***(0.13–0.39)
Gender
Female	Reference
Male	1.53**(1.09–2.14)
Age	0.99(0.98–1.00)
Education
Junior high school or below	Reference
High school/Vocational school	0.41**(0.19–0.90)
College/Undergraduate	0.75(0.41–1.40)
Postgraduate or above	0.98(0.50–1.90)
Occupation
Non-medical worker	Reference
Medical worker	1.24(0.72–2.15)
Familiarity with xenotransplantation
Not at all familiar	Reference
Heard of it but not familiar	1.02(0.60–1.74)
Somewhat understand	1.43(0.89–2.32)
Moderately understand	1.33(0.72–2.45)
Very familiar	5.72***(2.02–16.16)
Observations	589
Model statistics	Pseudo R² = 0.06
Brant test for proportional odds assumption	χ² = 16.56, p = 0.12

Odds ratios are reported with 95% confidence intervals in brackets. Robust standard errors were used. The Brant test did not reject the proportional-odds assumption; therefore, the ordinal logistic regression model was retained. ** p < 0.05, *** p < 0.01

Discussion

Public familiarity with xenotransplantation

This study found that 85.57% of the public reported having heard of xenotransplantation, which is consistent with previous findings in China and higher than those reported in the results in the US (59.5%) and the UK (65.2%) [13, 23]. This may be partly attributable to the relatively high education level of our sample. People with higher education generally have stronger information-seeking abilities and a greater willingness to learn, which may contribute to higher awareness of cutting-edge medical technologies. This suggests that when promoting xenotransplantation, attention should be paid to differences in information accessibility and understanding across educational groups.

Second, regarding gender and age, males exhibited higher acceptance of xenotransplantation than females, consistent with UK findings, suggesting that gender differences may be cross-culturally consistent. Younger participants had the highest acceptance, and older adults the lowest, which differs from the UK findings [13]. One reason for this difference may be that older adults trust traditional medical approaches more when making medical decisions. This suggests a need for differentiated communication strategies that address the core concerns of different age groups in public communication.

Third, as the education level increased, acceptance of xenotransplantation generally tended to decrease, which is inconsistent with previous findings in China [26]. This may be explained by the fact that individuals with higher education are more critical in information processing and more likely to focus on potential risks and uncertainties, such as cross-species infection, immune rejection, and long-term safety [27]. This suggests that improving scientific literacy does not necessarily lead to unconditional acceptance of new technologies; instead, it may be accompanied by more cautious risk assessment. Therefore, when promoting this technology to highly educated groups, transparent risk communication and evidence-based support should be emphasized.

Fourth, regarding occupational background, medical workers had higher acceptance than non-medical workers, which differs from previous conclusions [28]. This may be because medical workers are more optimistic about this technology. Medical workers are increasingly concerned about the organ shortage for transplant patients and are familiar with the technical pathways of xenotransplantation, which makes them more inclined to see it as a potential solution. However, this finding should be interpreted cautiously to avoid unrealistic treatment expectations from patients that may arise from insufficient risk communication driven by excessive optimism of medical staff. A scientific and balanced cognitive framework should first be established within professional groups.

Fifth, this study confirmed that those more familiar with xenotransplantation are more willing to accept the technology [26]. This indicates that information exposure is an important factor associated with acceptance, but the source, content, and presentation of information also determine the direction of cognitive effects. Finally, the main public concerns were clinical trial safety data, postoperative care and long-term outcomes, transplant costs, technical principles and development status, ethical review and regulatory oversight, and others. This suggests that in future technology promotion and policy-making, priority should be given to addressing public concerns about safety and long-term outcomes, while maintaining ethical transparency to enhance social trust.

In summary, public acceptance of xenotransplantation is jointly influenced by various sociodemographic and cognitive factors, with significant differences between groups. Future technology promotion and public communication should develop stratified, precise, and transparent information strategies based on these differences, thereby facilitating social acceptance and clinical translation of xenotransplantation in China.

Perceived impact of xenotransplantation on human organ donation

This study found that respondents with more optimistic expectations of xenotransplantation technology were more likely to believe that the future clinical application of xenotransplantation could reduce public willingness to donate human organs. One possible explanation is that individuals who view xenotransplantation favorably may perceive it as a potential alternative source of organs and therefore expect a reduced reliance on human organ donation. However, whether xenotransplantation may ultimately affect donation behavior, donation rates, or public support for organ donation remains uncertain. From a broader bioethical perspective, some scholars have raised concerns that if xenotransplantation were to become widely available, it could influence public understandings of altruism, solidarity, and the social values traditionally associated with organ donation [29]. Other scholars have argued that xenotransplantation and allogeneic transplantation are likely to coexist in the long term rather than function as mutually exclusive alternatives [30]. Furthermore, previous studies have suggested that increased organ availability through xenotransplantation could expand transplant eligibility and potentially increase overall demand for transplantation [31]. These findings suggest that public perceptions of the relationship between xenotransplantation and human organ donation deserve continued attention. Future public communication should provide balanced information regarding both the potential benefits and limitations of xenotransplantation, enabling informed public understanding as the technology continues to develop.

Factors associated with acceptance of xenotransplantation

Regression results showed that even in the extreme scenario where receiving a pig organ transplant is the only life-saving option, perceived religious conflict related to the use of pig organs remained significantly associated with lower acceptance of xenotransplantation. Previous studies have suggested that attitudes toward xenotransplantation may vary across religious and cultural contexts [31]. Some religious scholars and authorities have argued that the use of pig-derived medical products or organs may be permissible in life-threatening situations under the principle of necessity. However, interpretations may vary across religious communities and among individual believers [32–34]. In China, the major religions commonly recognized include Buddhism, Taoism, Islam, Catholicism, and Protestant Christianity, yet approximately 90% of the population reports no formal religious affiliation [35]. Ethical concerns related to xenotransplantation have been discussed in relation to different religious traditions. For example, some scholars have suggested that perspectives emphasizing non-harm toward living beings may raise ethical questions regarding xenotransplantation. However, interpretations vary substantially both within and across religious traditions, and empirical evidence remains limited [36]. However, interpretations vary substantially both within and across religious traditions, and empirical evidence regarding religious attitudes toward xenotransplantation remains limited. Further research is needed to better understand how religious beliefs, theological interpretations, and perceived doctrinal conflicts may shape attitudes toward xenotransplantation in different cultural contexts.

This study found that higher self-reported familiarity with xenotransplantation was associated with greater acceptance, consistent with previous findings from China [20, 37, 38]. However, given the cross-sectional design, the direction of this association cannot be determined. Individuals who are already supportive of emerging biomedical technologies may be more likely to seek information about xenotransplantation and therefore report greater familiarity. Notably, greater familiarity does not always translate into greater acceptance. A study of Dutch kidney transplant candidates found that willingness to accept xenotransplantation decreased after participants received more detailed information about the procedure [39]. Together, these findings suggest that acceptance of xenotransplantation is shaped not only by familiarity but also by perceptions of risks and benefits, ethical considerations, and trust in scientific and regulatory institutions. Therefore, efforts to support the responsible development of xenotransplantation should extend beyond information provision and emphasize transparent communication and public engagement.

Therefore, alongside advances in xenotransplantation technology, there is an urgent need to develop targeted public communication strategies. First, systematic public science and risk communication should be strengthened, providing comprehensive and transparent explanations of the technological prospects and potential risks, including immune rejection, long-term functional uncertainty, and cross-species infection. In this process, special concerns from different cultural backgrounds should be respected. Under the premise of fully informed consent, equal opportunities for choice should be provided to different groups to avoid unnecessary resistance caused by cultural sensitivity. Second, differentiated communication strategies should be developed for different populations. For risk-sensitive groups, such as highly educated individuals, medical professionals, transplant patients, and their families, more detailed preclinical data and regulatory information should be provided to foster rational and objective risk assessment.

Ethical and governance implications

In the Chinese context, recent regulatory reforms have highlighted the importance of ethical governance in emerging biomedical technologies. The Regulations on Administration of Clinical Research and Clinical Translational Application of New Biomedical Technologies and Regulations on the Implementation of the Drug Administration Law of the People’s Republic of China have strengthened requirements for ethical review, clinical research oversight, risk management, and regulatory accountability. Against this policy background, understanding public attitudes toward xenotransplantation is not only relevant to the future clinical implementation of this technology but also contributes to broader discussions regarding responsible innovation, public trust, and societal oversight of emerging biotechnologies. Public engagement should therefore be regarded as an important component of ethical governance, helping ensure that technological development remains aligned with societal values and public expectations.

Limitations

This study has several limitations. First, it examined overall attitudes toward xenotransplantation without distinguishing between organ types (e.g., kidney, liver, heart), and acceptance may vary by organ, which could affect the accuracy of our findings. Second, convenience sampling was used for recruitment. As a non-probability sampling method, this may introduce selection bias and limit sample representativeness. Although the study achieved broad geographical coverage, respondents were unevenly distributed across regions, with a substantial proportion concentrated in several provinces. Thus, the sample is not geographically representative of the Chinese population. Third, key variables such as familiarity with and acceptance of xenotransplantation were measured using single-item questions with broad response categories. While this approach reduced respondent burden and was suitable for an exploratory survey, single-item measures may have limited reliability and may not fully capture the complexity of the constructs. Another limitation concerns the measurement of religion. The survey did not collect information on other cultural, ethnic, or value-based perspectives. Instead, respondents were only asked whether their religious beliefs conflicted with the use of pig-derived organs. This measure captures perceived religious conflict related to xenotransplantation but does not reflect the complexity and diversity of religious beliefs and traditions. Finally, some questions were hypothetical, and responses may deviate from actual behavior, limiting the practical applicability of our conclusions. These factors should be considered when interpreting the results.

Conclusions

This study provides empirical evidence regarding public familiarity with, acceptance of, and ethical attitudes toward xenotransplantation among respondents in China. Most respondents had at least some awareness of xenotransplantation, and acceptance was generally high when xenotransplantation was presented as the only life-saving treatment option. Greater familiarity with xenotransplantation was associated with higher acceptance, whereas perceived conflict with religious beliefs was associated with lower acceptance. In addition, respondents who held more optimistic expectations regarding the future development of xenotransplantation were more likely to believe that its clinical application could reduce willingness to donate human organs.

These findings suggest that public attitudes toward xenotransplantation are shaped not only by familiarity but also by ethical values, religious considerations, and perceptions of the broader social consequences of the technology. As xenotransplantation continues to advance toward clinical application, transparent risk communication, meaningful public engagement, and robust ethical and regulatory oversight will be important for fostering public trust and supporting the responsible development of this emerging biotechnology.

Future research should employ more representative samples and longitudinal or mixed-method approaches to further explore how public attitudes evolve as scientific evidence, clinical experience, and regulatory frameworks continue to develop.

Authors’ contributions

JW, HL, and DW jointly conceived and designed this study. XZ, HL, and JW collaboratively designed the questionnaire. JW, HL, MH, and XZ were responsible for data collection. HL and DW performed the data analysis. JW, HL, and DW drafted the initial manuscript. JW undertook the critical review and major revision of the manuscript. XZ provided overall guidance and advice throughout the manuscript revision process. XZ revised important intellectual content of the paper and reviewed the final manuscript. All authors contributed to the interpretation of results. All authors read and approved the final manuscript. JW, HL, and DW contributed equally to this work. XZ serves as the corresponding author of this study.

Funding

Not Applicable.

Data availability

Data generated in this study are available from the corresponding author upon request.

Declarations

Ethics approval and consent to participate

This study was reviewed and approved by the Public Health Ethics Review Committee of the Chinese Academy of Medical Sciences & Peking Union Medical College (Approval No.: CAMS&PUMC-IEC-2025-135). The ethical approval document, including the official seal, is provided as a supplementary PDF file in the manuscript submission system. The research was conducted in accordance with relevant ethical guidelines and regulations for studies involving human participants. The questionnaire was fully anonymized and did not reveal any of the participants’ personal information or any other detail that could be used to identify them. A form to obtain their informed consent was included in the introductory section of the questionnaire, where the participants were required to confirm that they understood the research-related information and expressed their willingness to participate in the study by clicking an “Agree” button or checking a consent box.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.