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When Altruism Isn't Moral

Friday, January 30, 2009

Our nation’s current organ donation system relies on altruism alone. A regime of donor compensation would be better.

In early 2006, Matt Thompson of San Jose, California, decided to give a kidney to Sonny Davis, a 65-year-old physicist living in nearby Menlo Park. Thompson was moved to donate after reading an impassioned plea from Davis’s wife, who had sent 140 letters to friends and relatives asking them to consider helping her husband. One of the recipients happened to be a colleague of Thompson’s, who passed it along, thinking Thompson just might heed the call. Sure enough, Thompson, a devout young Christian and former missionary, contacted the transplant program to volunteer.

But the transplant program at Kaiser Permanente of Northern California turned him down. Had Davis been a family member or a good friend, he would have been acceptable to the program. Thompson was frustrated and surprised, but he and Davis were determined to do the transplant. According to the San Jose Mercury News, they “knew they had to forge a bond that would assure Davis’ surgeons that Thompson was donating his kidney for the right reasons.” This meant, among other things, that Thompson would not profit financially. So the two developed a relationship and convinced the transplant program that no money was secretly being exchanged. On November 14, 2006, the transplant finally took place.

Far more than a human interest tale of a stranger opening his heart to a suffering soul, the story of Sonny Davis and Matt Thompson draws back the curtain on the culture of the organ transplant establishment. It shows that transplant professionals would have allowed a 65-year-old man to languish on dialysis for years or die—a strong probability given his age—while waiting for a kidney, out of fear that he might be remunerating someone for an act that would save his life.


There are about 78,000 people in queue for a kidney from a deceased donor. In places like California, the wait can be up to eight years. And unless a friend or relative gives a kidney to a loved one, he will weaken on dialysis. Four thousand people die each year because they cannot survive the wait. This explains Mrs. Davis’s frantic plea to anyone who might volunteer a kidney to her husband.

Our current altruism-only system has a dark side: It imposes coercion of its own by putting friends and family members in a bind.

The woeful inadequacy of our nation’s transplant policy is due to its reliance on “altruism.” According to the guiding narrative of the transplant establishment, organs should be a “gift of life,” an act of selfless generosity. It’s a beautiful sentiment, no question. In fact, I, myself, am a poster girl for altruism. In 2006, I received a kidney from a (formerly) casual friend who heard secondhand about my need for a transplant. In her act, there was everything for me to gain, and, frankly, not much for her. My glorious donor was moved by empathy and altruism as purely as anyone could ever be.

Yet, it is lethally obvious that altruism is not a valid basis for transplant policy. If we keep thinking of organs solely as gifts, there will never be enough of them. We need to encourage more living and posthumous donation through rewards, say, tax credits or lifetime health insurance.

But what about the Matt ThompsonSonny Davis problem: anxiety surrounding the very notion that an organ donor should receive anything of material value for his sacrifice. It is important to understand the nature of this anxiety because it is a formidable obstacle to devising a rational transplant system.


Arguments against creating incentives to donate fall into two general categories: arguments from corruption and arguments from consequence. These designations were coined by political philosopher Michael Sandel.

Arguments from consequence go like this: there is nothing intrinsically wrong with compensating donors, but it is not possible to design an incentive-based system without exploiting them. The worry is that economic straits could compel reluctant individuals to relinquish a kidney for the sole sake of enrichment.

This is indeed a troubling situation. Fortunately, it can be addressed with good policy. For example, a state government could provide compensation such as tax credits, tuition vouchers, a contribution to a tax-free retirement account, or lifelong health coverage. A non-cash reward won’t appeal to those in desperate need of financial help. What they want is quick cash, not delayed in-kind rewards. A months-long waiting period would dampen impulsivity and give more than ample time for donor education and careful medical and psychological screening. Finally, donors would receive quality follow-up care, something the current system does not ensure.

Arguments from corruption proceed from the belief that donors, and perhaps society at large, will be diminished or corrupted if organs are given in return for something of material value. Giving a kidney “for free” is noble but accepting compensation is illegitimate, a sordid affront to human dignity. Indeed, the debate surrounding incentives for organ donation sometimes resembles a titanic struggle between uplift and greed. “As a rule, the debate is cast as one in which existing relations of selfless, altruistic exchange are threatened with replacement by market-based, for-profit alternatives,” observes Kieran Healy, a sociologist at Duke University.

The desire to do well by others while enriching oneself at the same time is as old as humankind.

Dr. Luc Noel of the World Health Organization subscribes to this false choice. “There are two prevailing concepts of transplantation,” he says. “One relies on money and leads to increased inequality, besides putting a price on the integrity of the body and human dignity. The second is based on solidarity and the donor’s sole motivation to save a life.” The National Kidney Foundation warns against “self-interest on behalf of the donor.” The notion also troubles a primary care physician in Columbus, Ohio: “What sort of organ transplant program do we want,” he asks, “one that pressures the financially vulnerable with cash incentives, or one that encourages the show of kindness through a loving, voluntary gift of organ donation?”

Paradoxically, our current transplant system makes every donation seem like a “loving, voluntary gift of organ donation.” Think about it: there is no other legal option. Some altruistic donations come as close to the technical definition: my experience would be one of those. Yet, our current altruism-only system has a dark side: It imposes coercion of its own by putting friends and family members in a bind. They might not want to donate, but they feel obligated, lest their relative die or deteriorate on dialysis. Sociologists have written about familial dynamics that involve guilt, overt pressure, or subtle threats. Consider the “black-sheep donor,” a wayward relative who shows up to offer an organ as an act of redemption, hoping to reposition himself in the family’s good graces. Some donate as a way to elicit praise and social acceptance. For others, donation is a sullen fulfillment of familial duty, a way to avoid the shame and guilt of allowing a relative to suffer needlessly and perhaps even die.

As famed anthropologist Marcel Mauss observed in his classic work, The Gift, gifts are never free; they demand reciprocity. “The [given] objects are never completely separated from the men who exchange them,” he learned from his work with Polynesian natives in the early 1900s.The same applies to organs. The “tyranny of the gift” is an artful term coined by sociologists Renee Fox and Judith Swazey to capture the way in which immense gratitude at receiving a kidney can morph into a sense of constricting obligation. In their 1992 book, Spare Parts: Organ Replacement in American Society, the authors write, “The giver, the receiver, and their families, may find themselves locked in a creditor-debtor vise that binds them one to another in a mutually fettering way.” Indeed, the virtue of market-like exchanges is that they are emotionally liberating.

An unusual take on altruism comes from the National Kidney Foundation, a vocal opponent of incentivizing organ donation. According to Dolph Chianchiano, its senior vice president for health policy and research, the NKF believes that compensating donors will “cheapen the gift.” Such an affront to would-be donors will cause them to hold onto their organs. On one level, this seems absurd. Can you imagine a brother telling his ailing sister, “Gee, sis, I would have given you my kidney but now that I hear that someone across town is accepting a tax credit for his donation, well, forget it.”

But if Chianchiano is correct—that some people will withhold voluntary action if remuneration is available to others—then, paradoxically, a regime of donor compensation would be quite the boon to such “altruists.” They would have bragging rights: They were the ones who acted out of generosity, not for material gain, a distinction that not only allows them to retain the “warm glow” that comes from performing acts of charity but also intensifies it. Given the importance of “social signaling” through gift-giving (“look at me, so generous, so civic-minded!”) the opportunity to accentuate the distinction should be most welcome.

No wonder scholars ranging from philosophers to evolutionary biologists to psychologists and economists are skeptical about whether true human altruism even exists. It is more realistic to envision a broad middle ground between the poles of selflessness and greed. It is the arena in which most organ donation already plays out. And it is where compensated donation would likely reside, too.

Transplant professionals would have allowed a 65-year-old man to languish on dialysis for years or die while waiting for a kidney, out of fear that he might be remunerating someone for an act that would save his life.

Simply look at our daily lives. Financial and humanitarian motives do not reside in discrete realms. Moreover, it is unclear how their comingling is inherently harmful—the goodness of an act is not diminished because someone was paid to perform it. The great teachers who enlighten us and the doctors who heal us inspire no less gratitude because they are paid. A salaried firefighter who risks her life to save a child trapped in a burning building is no less heroic than a volunteer firefighter. Soldiers accept military pay while pursuing a patriotic desire to serve their country. The desire to do well by others while enriching oneself at the same time is as old as humankind. Indeed, the very fact that generosity and remuneration so often intertwine can be leveraged to good ends: to increase the pool of transplantable organs, for instance.

The practice of assigning values to body parts has roots in antiquity. The Code of Hammurabi provides an elaborate schedule of compensation for them; for example, it specifies that if an individual should “knock out the teeth of a freed man, he shall pay one-third of a gold mina.” Today we routinely assign valuation to the body. Human blood plasma is collected primarily though paid donation. Personal injury lawyers seek damages for bodily harm to their clients. The Veterans Administration puts a price on physical disabilities. We pay for justice in the context of personal injury litigation in the form of legal costs, and for our very lives in the form of medical fees. There is little reason to believe—nor tangible evidence to suggest—that these practices depreciate human worth or undermine human dignity in any way.


It is all too easy to romanticize altruism. Sociologist Amitai Etzioni urges the postponement of paying for organs in favor of what he calls a “communitarian” approach “so that members of society will recognize that donating one’s organs . . . is the moral (right) thing to do . . . it entails a moral dialogue, in which the public is engaged, leading to a change in what people expect from one another.” Thomas A. Shannon, a professor of religion and social ethics, writes, “I would think it a tragedy if . . . we tried to solve the problem of the organ shortage by commodification rather than by the kindness of strangers who meet in the community and recognize and meet the needs of others in generosity.”

To be sure, these skeptics have a right to their moral commitments, but their views must not determine binding policy in a morally pluralistic society. A donor compensation system operating in parallel with our established mechanism of altruistic procurement is the only way to accommodate us all. Moreover, it represents a promising middle ground between the status quo—a procurement system based on the partial myth of selfless altruism—and the dark, corrupt netherworld of organ trafficking. The current regime permits no room for individuals who would welcome an opportunity to be rewarded for rescuing their fellow human beings; and for those who wait for organs in vain, the only dignity left is that with which they must face death.

Sally Satel is a resident scholar at the American Enterprise Institute. She is the editor of “When Altruism Isn’t Enough” (AEI Press).

Image by Darren Wamboldt/the Bergman Group.

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