Evaluating Altruism. (Guest Editorial)

Article excerpt

Psychiatrists are often called upon to evaluate potential living organ donors. This evaluation can be tricky, even when the potential donor is related by bonds of blood or friendship to the recipient. It is sometimes even trickier when the potential donor professes to be motivated purely by altruism and is offering to donate a kidney or part of a liver or lung to a complete stranger.

Current guidelines suggest that persons who donate should be medically and psychosocially suitable, competent, willing, free of coercion, and fully informed. Psychiatrists frequently are asked to make many of these determinations. While not extensively discussed in these guidelines, assessing a potential donor's motivations also is important. (See related article on p. 54.)

I recently evaluated someone who wished to donate a kidney to a stranger. Everyone on the transplant team was a little suspicious, in part because he was an altruistic stranger. There was concern that he might be getting payment or was being unduly influenced or coerced in some way.

It was a difficult case, partly because the potential donor was put off by questions about his decision making by our team. He felt that he was an adult making a well-considered decision and described seeking advice and counsel of people he respected prior to offering his kidney He felt our questions and our request to talk to some of the important people in his life constituted an unnecessary breach of his privacy.

In thinking about this case in particular, and about altruistic stranger donations in general, I found myself left with more questions than answers. As one example, this experience forced me to consider what it is to evaluate altruism toward strangers. Altruism is called the purest motive, one that is supposed to motivate every donor to some extent. Yet many medical professionals are not sure exactly what to make of altruistic stranger donors. An experienced member of the team said, "Oh, those altruistic strangers. They're all a little odd."

So I began wondering: Does altruism toward strangers cluster with pathologic symptoms? Could it ever be a symptom itself? When could it be pathologic? And when is it healthy?

The more I thought about it, the more I realized how complex the phenomenon of altruism is. While concepts of gift giving are best described among individuals who know one another and have reasons to perpetuate relationships, there also are writings that address the phenomenon of giving to strangers. As Thomas Murray, Ph.D., eloquently lays out in a 1987 article in the Hasting Center Report, there is a paradox in all gift giving-to strangers and nonstrangers alike. A giver's motives are both self-regarding and other-regarding. Many believe that a gift given freely is not supposed to have strings attached, but at the same time we all know that giving gifts embeds people in relationships. All cultures have norms surrounding gift giving that serve to keep socially and morally acceptable and appropriate boundaries on the activity In general, givers are not allowed to exaggerate the value of the gift. They're not allowed to show half-heartedness in giving the gift. They may not specify what they want in response to the gift.

As a psychiatrist, I also know that what might appear to be giving a gift from "purely altruistic" motivations could in fact be part of a complex defense mechanism. …