Strangers, intimates, and altruism in organ donation

While accepting that altruistic strangers, as a class, should be allowed to donate organs, Ross et al. (1) argue that they should do so only when evaluation by the transplant team reveals no medical concerns, while intimates (family or friends) should be allowed to donate even when there is some increased, but acceptable, medical risk. They base their conclusion on linkages between intimacy, duty, blame, and whether altruism is pure or not, most of which stem from their own particular definition of what constitutes an altruistic act. I argue that both their definition and its application can be faulted and conclude that strangers should be able to choose, and be permitted, to assume the same level of risk as intimates when being considered for organ donation. In 1990, long before transplanters talked of “Good Samaritan” donors, we had developed a classification that included “altruistic strangers” as one of the categories of living donors (2). If altruism is the most acceptable basis for organ donation, it could be argued that strangers are the most acceptable donors. The transplant profession, however, while emphasizing altruism, often finds ways of blocking its expression. Friends and strangers wishing to donate are still viewed with suspicion in many transplant centers. The United Kingdom, even now, still puts enormous legal hurdles in the path of intimate living genetically unrelated donors and specifically excludes donation by altruistic strangers (3). Ross et al.’s (1) conclusion that altruistic strangers should not be allowed to assume the same relatively high level of risk as intimates is yet another example of the well meaning encumbrance of altruism. The term “altruism” was introduced in 1851 by Auguste Comte to denote our benevolent—as opposed to selfish (egoistic)—propensities. Ross et al.’s (1) particular definition of an altruistic act is that it is “one motivated primarily or solely by respect and concern for the preferences and needs of others, freely chosen rather than done out of a duty or obligation, and at some cost or risk to the agent.” They argue from this that because intimates can contemporaneously be both other-regarding and self-serving they cannot be “purely” altruistic, while strangers, devoid of duties and obligations, are “purely” altruistic. Their definition, however, ignores the nuances and complexities of altruism, particularly in its relationship to self-interest, about which there continues to be intense current debate (4). What is clear is that altruism does not negate every element of self-interest. This Janus-like quality of altruism can be found even in Ross et al.’s own definition, for “primarily” for others leaves some room for “secondarily for self.” Ross et al. (1) argue that intimates should be allowed exposure to higher risk than strangers because they have moral obligations/duties that make them less altruistic than strangers, and also because they do not necessarily want to separate their own from their intimates’ interests. Consent is not an issue, according to Ross et al., because the need to balance altruism and self-interest in intimate situations does not necessarily negate the possibility of voluntary consent. Their position that moral obligations diminish altruism is a direct result of self-referencing to their definition of altruism and is thus open to challenge when the definition itself is challenged. On the other hand, their argument that lesser altruism should translate into greater risk, besides being profoundly confusing, is challengeable from within their definition. A compelling argument, for example, can be made for the opposite conclusion: that altruistic strangers should be allowed exposure to higher risk. In specifying “at some cost or risk,” Ross et al. clearly acknowledge that strangers, to be altruistic, must accept the real likelihood of harm if it exists. Altruism, in other words, even by their definition, demands sacrifice. Logically, the higher the level of altruism the higher the level of sacrifice to be expected, and therefore the higher the level of risk that should be tolerable. It is inconsistent on the part of Ross et al. to insist on the element of sacrifice in altruism and then argue that the very people willing to express that sacrifice must be protected from themselves. Furthermore, even if we were to credit the unsatisfactory linkage between obligations and risk, Ross et al. (1) miss the point that altruistic strangers, while being the purest of altruists, may also have their own equally binding sense of intimacy, obligation, and duty to the recipient, which the transplant team may miss if they work with constraining definitions and preconceptions. These senses, and their linkage to motivation, are self-generated and internal to the person wishing to donate. They do not come into existence through the external agency of definitions, philosophers, or transplanters. They resonate with some of the varied reasons (5) why strangers in such surprisingly large numbers express a willingness to donate to needy patients on waiting lists (6,7). The altruistic stranger might have internalized the concept of altruism being linked to “brotherly love,” as it is in some definitions of altruism, and might, in a cosmic sense, consider all human beings to be an extended family. After all, the Human Genome Project demonstrated that our DNA is 99.9% identical. This leads us to conclude that the very distinction Ross et al. have drawn between intimates and strangers, based on existence of duty/obligation, may not exist in the mind and calculations of the altruistic stranger, and surely that is what should matter. Ross et al. (1) further argue that if the wish of an intimate to donate were to be thwarted by the transplant team, then the intimate could be blamed because he or she has a duty to donate, while a stranger, by this logic, could not be blamed because he or she does not have such a positive duty. This raises two specific counter arguments. First, it ignores the fact that altruism is linked to duty. In the deontological conceptualization of altruism, for an agent to be altruistic, it is not enough simply to help others. The agent owes others. Kant and other philosophers have emphasized in altruism this specific element of duty on the part of the agent to do good for others, rather than to focus simply on the interests (in Ross et al.’s definition “preferences and needs”) of others. Ross et al., on the other hand, hold duty to be a result of intimacy and, further, that duty diminishes altruism. Second, the bigger and more serious fallacy in this argument is that the locus of blame is totally misplaced. Because the decision to donate or not is to be made by the transplant team (which Ross et al. crucially insist must have its own decisive moral role) and not by the potential donor, it follows that neither the intimate nor the stranger can be held accountable and therefore blameworthy. So what is the appropriate moral posture for the transplant team? I would argue that once a class of donors (genetically related, genetically unrelated intimates, spouses, strangers, etc) is considered by societal and professional consensus to be acceptable, a more defensible (and less paternalistic) moral position would be for the transplant team to consider that its duty is always to maximize safety for the individual donor. In practice, this means that each potential living donor, intimate or stranger, must be treated as a unique person. Because the risk of uni-nephrectomy is not altered by intimacy with, or distance from, the potential recipient, I would argue that to treat the individual potential donor as representing a class of donors would lead to distortions and expose the transplant team to the accusation of applying double standards on the pretext of protecting an altruistic stranger who does not, as an individual, require more protection than an intimate. Conversely, although unintended, Ross et al.’s (1) approach could be interpreted as not the protection of altruistic strangers but, in effect, the exposure of intimate donors to greater risk. In other words, once a decision is made to process a potential donor the decision whether to proceed to donation or not should be based on the level of individual risk, not on the level of intimacy. By trying to make judgments in this context not only as care-givers but also as interventionist moral gatekeepers, members of the transplant team place themselves in a particularly awkward position. In January 2002, we heard that 57-year-old veteran journalist, Mike Hurewitz, died as a result of donating a segment of his liver to his 54-year-old physician brother, Adam, for whom the transplant operation was successful (8). A newspaper editor who knew Mike well said this of him: “This was one of the most decent, selfless people I have ever worked with. He was going into it because it was the ultimate act of kindness” (9). Whether Mike was selfless generally, or was selfless only in this particular instance, his loving act towards his brother would still be “purely” altruistic because no one (even by Ross et al.’s arguments) would consider a 57-year-old person duty-bound and therefore blameworthy for not assuming a 1:100 chance of death by donating a segment of his liver to his brother. This newspaper editor, obviously meaning to convey how altruistic Mike was, correctly juxtaposed “selfless” and “ultimate act of kindness,” leaving no room (“ultimate”) for distinguishing the altruism of intimates from that of strangers. In this real life demonstration, Mike was no less altruistic when he put his life on the line for his beloved brother than a stranger might have been. There are two logical conclusions. One, it is an unwarranted generalization to hold that altruism within families (and by extension between intimates) is negated or diminished simply because there might exist duties/obligations. Second, Ross et al.’s elevation of the rather Shinto concept of “purity” as a qualifier that distinguishes the altruism of intimates from that of strangers to the level not only of moral relevance but also of clinical determinacy is ultimately insupportable. It leads to a distinction that neither Adam nor the newspaper editor would recognize.

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