Abstract
Living organ donors are growing in number and account for a substantial proportion of organs transplanted. Types of living organ donors include family members, anonymous donors, and friends. Although familial donation is the most common form of living organ donation, anonymous donation and donation among friends are gaining popularity. Society has placed living organ donors at the top of the altruistic ladder. However, one's altruistic motives for living organ donation may be affected by the type of relationship he or she has with the organ recipient. Although family relationships are close, pressure and coercion from family members may make informed consent difficult. Anonymous donors do not have the pressure associated with a familial donation, but psychological and self-worth issues may influence their choice to donate. Friendship incorporates the close relationships associated with familial donation and the freedom associated with anonymous donation. Using Aristotle's definition of true friendship, the author argues that best friends are the only true altruistic living organ donors and therefore may be preferable to family donors or anonymous donors.
More than 100,000 people are currently on the organ transplant waiting list.
1 Living organ donors are becoming more common and growing in number. Although living organ donation is perhaps the most generous act one can perform for another individual, organ donation has encountered considerable debate regarding motivation on the donor's behalf. Literature has shown that donors sometimes donate based on familial pressures, increasing their own altruistic self worth, or even coercion from outside factors.
2,3 The majority of living organ donors choose to donate solely to help the recipient's quality of life, but a substantial number of donors also use organ donation as a method to increase their own self-worth. Some donors have chosen to donate anonymously so that they can “boast” about their altruism to others.
2
Various types of individuals donate living organs, with the most familiar type likely being family members (either relatives or the spouse of the recipient). Recently, 2 other types of donors have been gaining popularity: anonymous donors and donation among friends.
The degree of altruism and reasons for donating vary greatly among the 3 donor groups. However, I argue that the truest altruistic donors are those individuals who donate to a best friend. Donation to a best friend combines the altruistic nature of anonymous donation without the pressure and coercion associated with familial donation. In the present article, I discuss some of the ethical implications of familial and anonymous donation, and I argue that close friendship is the most altruistic form of donation and therefore should be the preferred type of donation in organ transplantation.
To better understand why living donation by a best friend should be the preferred type of donation in transplantation, one must understand the complex and dynamic relationship that exists among friends. According to Aristotle, certain conditions must be present for friendship to exist. First, friends must have souls.
4 Individuals who cannot experience and express emotion—especially love—cannot experience friendship. Second, friendship must be mutual, with both parties expressing equal respect and compassion for each other. Onesided friendships usually end quickly. Each party must “look out for” the other party and conduct themselves in the other's best interest. Finally, friendship is more than reciprocated good will, meaning one must reach a deeper relationship than merely wishing good fortune to another individual.
4,5
Using these aspects of friendship, Aristotle devised 4 different levels of friendship. The first 2 types of friendship are quite similar varieties of incomplete friendship. Friendships at these levels are based on one's own utility and personal gain. People engage in these relationships based on how they can benefit from what other individuals have to offer.
The third type of friendship is solely for pleasurable reasons. This type of friendship often exists within young adults looking to gain pleasurable experiences in life. However, as people age, their pleasurable wishes change, and relationships of this level disband.
The final category of friendship is the deepest and most fulfilling. Complete friendship is the friendship of good people with similar virtue. These people are best friends and wish good fortune toward each other for each other's own sake. This type of friendship lasts many years, as good nature and similar vices are timeless. However, though this form of friendship is most valued, it is also most rare.
Organ donation can be viewed as an extension of wishing good fortune on one's friend.
4 This unique and strong relationship provides the ideal altruistic foundation for living organ donation and the many aspects related to it, including informed consent, relationships, control and power, and altruism.
Informed consent is the process in which the transplant team informs the donors of the procedures, risks, complications, and events surrounding donation. Informed consent is a vital component of living organ donation and is required by federal regulations before transplant surgery occurs.
6 Thus, prospective donors must be given all necessary information to ensure that they understand all aspects and potential risks of donation.
One key component of informed consent is rationality. The decision to donate an organ should not be made immediately or hastily. Donors should approach the topic with great care, and a decision should occur only after long, in-depth discussions with physicians, family members, and transplant personnel. However, the type of relationship a donor has with the organ recipient can have an impact on the donor's ability to make a rational decision.
For example, family members often make the decision to donate quickly. The “do whatever I can to help my family” attitude is unique to familial relationships, and it often causes family members to decide to become donors immediately upon learning that a loved one needs an organ. Evidence suggests that the decision to donate to a family member is not entirely rational or even well thought out.
7 Reimer et al
8 found that nearly two-thirds of donors surveyed made the decision to donate immediately after they had learned about the possibility of donation. Deciding immediately to donate provides evidence that some familial donors believe they “have to” or “need to” donate because their loved one needs an organ. The pressures associated with familial relationships may cause rash decision-making and impinges on an informed consent.
9
In addition, it has been reported
3 that most familial donors downplay the personal impact of donation. In one study,
9 an uncle chose to donate to his nephew even though doing so would put the uncle at considerable risk. The uncle “didn't listen to anybody... he only saw the baby.” In these types of situations, donors have made decisions while traumatized by the gravity of the situation.
9 The way in which familial donors do not acknowledge personal risk also brings into question their ability to make a rational decision.
In contrast, recipients in living anonymous donations (LADs) are unknown to donors, so donors have additional time to contemplate their decision.
5 Thus, from a standpoint of time to make and contemplate a decision to donate, LAD donors have more time to think, and thus do not feel the “obligation” associated with familial donation.
Unlike family members and anonymous donors, friends conduct themselves for each other's benefit. This type of relationship allows for a more rational decision with friendship donation, and it allows the donor to analyze all possible situations arising from an organ donation to a friend. Friends have the benefit of time associated with LAD because they do not have blood ties or an obligation to the recipient. However, their close relationship with the recipient allows for a more personal and unique decision to donate.
Coercion may be a major factor in living organ donation because the donor and recipient often have a close relationship, which can possibly enable one to pressure the other toward donation. It is likely that familial donors undergo more coercion than anonymous donors.
11 Scheper-Hughes
12 described how one patient explained to his physician that any of his sisters should unhesitatingly offer themselves as blood marrow donors by stating “it's what families are supposed to do.”
Living organ donation should be a completely voluntary act because the benefit is for the recipient and not the donor. However, in a study by Lennerling et al,
13 64% of potential donors had taken the initial steps to offer themselves to become a donor. For the remaining potential donors, the recipient initially asked (13%), a physician asked (22%), or other family members asked (9%).
13 Another study
16 found that 41.1% of participants felt it was appropriate or completely appropriate to ask a family member to donate a kidney, and 35.6% of those surveyed had done so. In an ideal world, 100% of the living donations conducted should be initiated by the donor and not the recipient. These examples provide strong evidence of the pressures and responsibilities family members often feel when another family member needs an organ transplant.
18,13,14 In familial donations, pressures from family members can create extreme mental and psychological stress for the donor and prevent informed consent.
With these concerns in mind, LAD has benefits over familial donation. In LAD, donors experience less coercion and manipulation than those in familial donations
3 because it is more likely that donors are acting autonomously and without familial pressures. According to Henderson et al,
2 donors in LADs are the only living donors that can truly give an informed consent.
Friends, similar to anonymous donors, do not carry pressures associated with familial ties. As Aristotle explained,
4 close friendships do not occur because both parties feel they must perform certain responsibilities for each other. Rather, friendship occurs because people share a common generosity for each other. Any coercive behavior that can hinder one's choice is rarely found in true friendships. For the benefit of the friendship, friend donors would first consider the decision and educate themselves before requesting to be a donor. Likewise, a true friend recipient would not allow his or her friend to make a quick, rash decision of such magnitude solely so that they could benefit. Thus, one reaches a true informed consent because one can avoid the familial pressures associated with being “asked” or “expected” to donate.
Although some might argue that Aristotle's first 2 types of friendships do have pressures, complete friendship (ie, the fourth type) is mutual and not based on any duty or responsibility. Aristotle's first 2 types of friendship are founded on personal gain and personal happiness. Theoretically, one recipient would “pressure” or “coerce” his or her friend into organ donation because of the gain acquired by the recipient. One can even further theorize that the donor could donate to his or her friend because now the donor can “flaunt” his new altruistic accomplishment to others. Best friends are still extremely close to one another, often closer than those in familial relationships. This unique but free relationship allows for the ability to help a loved one in a desperate time of need, without making uninformed decisions often found in familial donations.
One reason to favor familial donation is the strong desire that relatives often possess when helping other family members in a time of need. In a study by Daar,
11 most familial donors stated their motivation to donate stemmed from the desire to save the recipient's life or to avoid the loss of a loved one. In a study of living kidney donors in Minnesota, Simmons et al
15 found that 65% of prospective familial donors stated they would be very disappointed upon not being able to donate and 72% stated it was easy to donate.
Furthermore, familial relationships benefit as a result of living organ donation. One study
16 found that, out of 524 kidney donors, 53% said their relationship with the donor recipient had improved after organ donation, while only 2% said it had worsened. Another study by Papachristou et al
3 found that donors who displayed a high level of love for the relative receiving the organ donation were more inclined to donate because donation was a means to express their regard towards the recipient.
Relationships among anonymous donors are hard to ascertain. They may donate to experience increased satisfaction, a greater sense of meaning, or personal motivation.
Donation among friends is similar to familial donation because of the strong relationship and the emotional tie friends feel towards each other. Even though the donor and recipient are not genetically related, relationships with friends can be stronger and closer than relationships with family members. Generous acts such as organ donation can strengthen friendships, because they provide evidence of the deep and caring relationship through the eyes of generosity.
Negative aspects have been associated with familial donation because of donors' wishes for acceptance and power. In some situations, familial donors sought additional attention from family members.
2 The act of donating to a family member may gain positive recognition from a parent. In addition, familial donation may bolster a damaged self-esteem.
Furthermore, family members may exhibit overbearing control over the recipient after transplantation. Scheper-Hughes
12 describes a couple of such cases, including a father who would screen his son's love letters after he gave a kidney to his son, and a sister donor who refused to let her brother (the recipient) ride motorcycles or go out to parties. Both people felt risky or adverse activities would damage “their” kidney. Instead of giving their kidney to the recipient, the donor's felt they “lent” their kidney.
Scheper-Hughes described this control over the organ recipient as the “tyranny of the gift,” in which the gift (organ) comes with indebtedness to the family member.
12 This theory has been reason for some recipients to consider nonfamilial donations. In one such described case,
12 an organ recipient chose to travel to another country to receive an organ instead of asking a family member. She did this because when you receive an organ from a family member, you “owe them your life... its always a big problem, like a constant weight hanging over your head.”
Anonymous donors do not encounter such control or “ownership” of their organs because they rarely know the recipient of their organs. The control and power aspect often associated with familial donation is absent with LADs. This absence of control and power allows the LAD donor to make a more altruistic decision.
Familial relationship is centered on responsibility and duty. With friends, there is no responsibility or duty. Acts that occur in the best interest of the friend are done because one individual truly cherishes the other and wishes nothing but good fortune and sake for the other individual. Thus, although society might expect debts for such actions, friends throw the debts aside by knowing the other would do the same if the roles were reversed.
17
Although organ donation is designed to benefit the recipient, studies have shown beneficial results on the donor's behalf as well. Quality of life in terms of general health, vitality, and mental health has been reported to be substantially higher in organ donors after donation.
8 In addition, many donors have reported experiencing psychological benefits, including a lasting increase in self-esteem resulting from the knowledge of saving a loved one's life.
18 Donation often is an opportunity for exceptional experience, personal development, and an opportunity to distinguish oneself.
3 However, these beneficial results should not be one's primary motivation for donation.
Whereas familial donors donate based on a relative's need and sickness, anonymous donors usually donate as an extension of their beliefs and lifestyle. For many anonymous donors, donation is an extension of an already altruistic and philanthropic life.
2 Unrelated donor candidates have been found to be statistically significantly more likely than related donor candidates to be registered organ donors.
19 One study
2 found that anonymous donors viewed donation as an integral part of their spiritual belief system and also were more likely to donate blood, volunteer extensively, and be registered bone marrow donors. Henderson et al
2 noted the most common motivation for anonymous donors was improving the quality of life for another individual. For example, one anonymous donor said, “I don't care who gets my kidney, family, friends or stranger.... God doesn't have a club. God's works are for everyone.”
7 Many unrelated donors also experience an increase in self-esteem after organ donation, particularly because no obligation exists.
20
However, anonymous donors' motivations are not always the most altruistic. Anonymous donors often feel that donation will be a method to repay society.
2 Some donors are more likely to use the donation as a method to seek attention, or make a statement against their family.
2 An altruistic donation should be solely for the recipient's benefit. In instances in which they donate to seek attention or to make a statement to their family, anonymous donors are donating for their own benefit and own self-esteem rather than for the recipient's improved quality of life. Contributing to society can be altruistic if societal contribution is the end goal of donation. However, contributing to society is rarely the end goal of anonymous donors. Rather, it is secondary to anonymous donors' goal to increase their own self worth or self-esteem. Thus, one can argue that anonymous donors, while not exposed to the same coercion as familial donation, often donate for their own benefit rather than the recipient's benefit.
This would not be the case with friendship donation. True friendships would prevent one individual from donation solely so that he or she makes a contribution to society or repaid debt. Individuals are donating to someone they know deeply instead of donating to society in general. The deep and rich nature of a complete friendship would not allow the possibility of donating for society's benefit.
True friendships provide ample opportunities for altruistic acts for each other. Organ donation is an extension of these acts, and another opportunity to help one's friend in a time of need. Instead of feeling the necessity to “pay someone back,” or “return the favor,” friendship exists because of a sphere of mutuality, allowing for a foundation of altruism.
17 The very nature of friendship is a perfect foundation for altruistic acts and philanthropy.
One barrier to friend donation is the inability to accurately determine the level of friendship. Although some friendships have ties that are often stronger than familial ties, it is difficult to determine the quality of the relationship and whether a friend is donating to benefit his or her friend or not. In today's society, we often assume family donations occur for the best interest of the recipient because of the family bonds. Because friendships do not have blood ties, it is often difficult to ascertain the reasoning behind a friend donation. This barrier should be kept in mind when considering friendship donation.
I recommend that the sincerest and truest form of friendship to be the preferred type of organ donation. Other types of friendship that are based on utility and benefit toward oneself should not be used. These friendships are foundations for pressure and coercion of one individual on another. Organ donation is for the benefit of a dying individual, and those in relationships for their own benefit would be in an ideal environment to attempt to exploit their friend and convince them to be an organ donor. Thus, anything less than the ideal mutual complete friendship would not be acceptable for altruistic friendship organ donation.
I thank David W. Towle, DO, MS, for serving as a mentor during the preparation and final submission of this article.