Giving Until it Hurts?: Altruistic Donation of Solid Organs

If a competent adult seeks to act altruistically and offers to donate a solid organ unconditionally, and the adult understands the risks and benefits of the procedure, and voluntarily consents to the procurement, then his or her wishes should be respected (Ref. 1, p 441).

As medicine lengthens the lives of chronic renal patients, deceased organ procurement has not kept up with demand. In 2001, living donors exceeded cadaveric ones.² As the need for solid organs, especially kidneys, has increased, a new trend has emerged in transplant medicine. The practice of allowing living, unrelated donors has increased in recent years. Beginning in the 1990s, the acceptance of this procedure has gained momentum. The altruistic donor may have had little or no previous interaction with the recipient. There is active debate surrounding this practice.^1,3,4

Having been asked to evaluate such a patient, I sought guidance on how to approach the assessment. Transplant ethicists utilize two principles to guide altruistic evaluations: autonomy and lack of coercion.⁵ Transplant centers vary in their evaluation processes, but there is some uniformity. Rodrigue et al.⁶ conducted a survey of transplant centers in the United States. They found that although there are similarities in the assessment of potential donors, there are regional differences in how assessments are performed. There are also differences in the flexibility of criteria regarding who is permitted to donate and who is disqualified as a donor. (For example, some regions do not allow donation if the donor learned of the opportunity through media outlet solicitation.) It is worthwhile to explore the issues that arise out of an altruistic donation and the concerns that should be raised in an evaluation of a potential organ donor. I will discuss ethics-related dilemmas that are raised within the transplant community with a focus on the nature of altruism itself and its impact on the consent process.

It is widely thought that there are benefits in the practice of altruistic donation.⁵ Donors garner an increase in self-esteem and the organ pool increases. There are instances in which groups come en masse to a transplant center offering to donate their organs.⁵ Others seek to donate their organs to a stranger with whom they become linked online. Today, there are many Web sites with the explicit goal of matching would-be donors with recipients, such as matchingdonors.com.

Altruistic organ donation presents some challenging questions of ethics. Directed donation (when a donor and recipient are not matched by relation) can lead to genetic mismatching. These arrangements can be made without consideration for graft survival, the severity of illness of the recipient, or who may benefit more greatly (a utilitarian approach to organ allocation: e.g., consider children versus older recipients). A discussion of the allocation of organs is outside the scope of this article, but it is another difficult question that altruistic donation raises. (For a thorough discussion of these concerns, an article by Steinberg² is recommended.) There is also the concern that internet pleas for an organ elicit emotional responses by would-be donors. These donors may be unaware of the other treatment options available to those with chronic kidney disease.

Some guidelines have been established for the evaluation of such donors.^7,8 These include a psychosocial component, but when more complex mental illness exists, further assessment is often requested. With a psychiatric evaluation, there is expectation that psychological status will be investigated on a deeper level. To what extent do we want to unravel the complexities of someone's motives? Are we to examine the nature of altruism itself? Several psychoanalysts have discussed the notion of altruism. George Vaillant described it as a mature defense, an outgrowth of reaction formation. “Altruism involves getting pleasure from giving to others what you yourself would like to receive…. [It] allows a user outwardly to steer a course exactly counter to some inner unconscious passion” (Ref. 9, p 110).

Others have sought to refine definitions of altruism. Seelig and Rosof¹⁰ offer several different types of altruism. Proto-altruism is biologically derived and is readily seen in maternal care for offspring. Genuine care is provided with the benefit of watching one's progeny flourish and carry on one's genes. Generative altruism is nonconflictual pleasure in fostering the success of another, a concept most would associate with altruism. Pseudoaltruism originates in conflict and serves as a defensive cloak for underlying sadomasochism. And finally, psychotic altruism manifests in bizarre forms of caretaking behavior and associated self-denial based in delusion.

Should an assessment take into account these complex motives? How can such an assessment be standardized? Moreover, should the outcome of donation (i.e., the incredible benefit that may come to a chronic kidney patient who has been sustained on thrice weekly dialysis sessions) be factored in to any weighing of the donor's motives? A cooling-off period is sometimes employed to assess the quality of a donor's motives and seems a reasonable compromise in not thwarting a potentially life-altering process for the recipient.

Another aspect of the stranger donation that bears mentioning is the intensity of emotional impact. Patients’ family members generally share in the process of care for their ailing loved ones. Their experience gives them perspective on the difficulties associated with kidney disease and transplantation. If they choose to donate a kidney, it is after much consideration of risk and benefit. Individuals motivated by altruism are thrust into an emotionally fraught situation and their ability to act autonomously and without coercion can be compromised, even if they themselves believe they are acting out of a desire to help.

With regard to consent, emotionality poses a problem. Should we utilize general guidelines for obtaining consent?¹¹ Family members who donate organs will see a benefit in their loved one's having a successful procedure; this possibility factors into any discussion of risks and benefits during a consent process. However, strangers may not garner such a benefit. Does that shift the equation toward greater risk/lower benefit? We place limits on the level of altruism we allow. For example, we would not accept a living heart donor for obvious reasons. How far are we willing to extend the line of altruism and under what conditions? The procedures for the harvest of organs have improved and most donors are able to live full lives on one kidney. It bears noting that should an organ donor develop kidney failure in the remaining kidney, their donation is taken into account in determining their place on the recipient list.

For transplant clinicians, donors provide the possibility of an effective treatment for a chronic disease that afflicts an increasing number of individuals. Altruism is a boon that on the surface seems to have limited drawbacks. If the donor is acting autonomously and without financial remuneration, there are only genetic-matching impediments to overcome. However, as mental health professionals, do we have an obligation to scratch below the shine of such giving behavior? Should competency be assessed as it would be in a patient undergoing elective surgery? Should there be a sliding scale for assessing competency to give informed consent for organ donation in which the altruism of the donor can be factored as a benefit to the donor?

As discussed by Gutheil and Appelbaum,¹² a competency evaluation seeks to determine the individual's ability to communicate a choice and to understand benefits, appreciate risks, and rationally manipulate the information. They specifically discuss the concept of a sliding scale, but warn of its inherent subjectivity. There is no doubt that such subjectivity exists within regions, institutions, and individuals. In the case of organ transplantation, should we allow greater risk to the donor knowing the potential benefits in store for the recipient? In some regions, given the paucity of organs available, greater risk is already allowed and stranger donors are impeded as little as possible.

With regard to the patient whom I saw and who prompted this article, there were many red flags, including ongoing substance abuse and poorly controlled mood symptoms alongside personality issues. The patient was flip when asked about possible consequences. I felt comfortable in recommending a delay of six months for further counseling and a reassessment. However, had there been just personality problems, I wonder whether I would have been justified in offering the same opinion. There are many questions that are raised by the specter of altruistic donation. As there are no “right” answers, a discussion among forensic psychiatrists would be useful in assisting those who may be called on to offer an opinion on how to approach the unique nature of altruistic solid organ transplantation.

• American Academy of Psychiatry and the Law