Moral identity internalization and symbolization in relation to body donation willingness: a cross-sectional study...

Body donation is essential to medical education, yet a global donor shortage persists. While prior research has identified demographic and attitudinal correlates of donation willingness, the deeper psychological factors associated with this decision remain largely unexplored. Moral identity-comprising internalization (private moral self-integration) and symbolization (public moral expression)-is a well-established prosocial motivator, but its role in body donation, a context defined by mortality salience and intangible outcomes, remains unexplored.

In this cross-sectional study, 2,327 undergraduate health professions students from Bengbu Medical University, China, completed validated measures of moral identity, death anxiety, donation-related experiences, and willingness to donate their body. Multivariable logistic regression with progressive covariate adjustment estimated independent associations of internalization and symbolization with donation willingness, controlling for sociodemographic, educational, experiential, and death anxiety factors. Subgroup analyses examined effect heterogeneity.

Both dimensions were independently associated with donation willingness. In fully adjusted models, each standard-deviation increase in internalization was associated with 56.1% higher odds of willingness (OR = 1.561; 95% CI: 1.391-1.753), compared with 22.6% higher odds for symbolization (OR = 1.226; 95% CI: 1.094-1.372). Internalization showed a graded association with donation willingness (highest vs. lowest tertile: OR = 2.701; 95% CI: 2.040-3.575), whereas symbolization was significantly associated with donation willingness only in the highest tertile. Associations were observed across most subgroups, but were not significant among nursing students or religious participants.

In this sample, moral identity internalization was more strongly associated with body donation willingness than symbolization. This suggests that internalized moral values may play a more important role than public moral expression in end-of-life donation decisions. The null findings in nursing students and religious participants suggest that the relevance of moral identity may vary across subgroups, though these exploratory findings require confirmation in future studies. This study introduces a perspective that complements the knowledge-attitude-practice paradigm, suggesting that moral identity may be a modifiable psychological construct worthy of further investigation in donation promotion efforts.