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How altruistic organ donation may be (intrinsically) bad
  1. Ben Saunders
  1. Correspondence to Dr Ben Saunders, Social Sciences, University of Southampton, Southampton SO17 1BJ, UK; b.m.saunders{at}soton.ac.uk

Abstract

It has traditionally been assumed that organ donation must be altruistic, though the necessity of altruistic motivations has recently been questioned. Few, however, have questioned whether altruism is always a good motive. This paper considers the possibility that excessive altruism, or self-abnegation, may be intrinsically bad. How this may be so is illustrated with reference to Tom Hurka’s account of the value of attitudes, which suggests that disproportionate love of one’s own good—either excessive or deficient—is intrinsically bad. Whether or not we accept the details of this account, recognising that altruistic motivations may be intrinsically bad has important implications for organ procurement. One possible response is to say that we should take further measures to ensure that donors have good motives—that they are altruistic is no longer enough. An alternative is to say that, since altruistic donation need not be intrinsically good, we have less reason to object to other motivations.

  • donation/procurement of organs/tissues
  • philosophical ethics

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Organ donation saves lives, but this instrumental benefit is realised whether organs are obtained through altruistic donation or through other means, such as a market or theft. Nonetheless, it is commonly held that all donations should be altruistic, even though this means fewer organs may be available. For instance, Neidich et al state that ‘altruism should be the guiding motivation for all [organ] donations’.1

Whether altruism—in any sense—is necessary for morally legitimate organ donation has already been much debated. Some think that this requirement should be weakened in order to increase the supply of donor organs.2 3 These authors think that at least some non-altruistic motivations are morally unproblematic. While we may still wish to exclude some morally problematic motivations, we may want to be open to receiving organs from donors whose motivations are not altruistic or at least not purely altruistic.

Less attention has been paid to whether altruism is sufficient to make a donation morally legitimate. However, surgeons have sometimes been wary of taking organs from living donors who volunteer to donate to strangers, even when assured that there is no payment or coercion.4 5 This may represent an alternative concern regarding the donor’s motives. It may be thought that some donors’ motives are morally troubling because they place too little value on their own good. Let us call this attitude self-abnegation.

It may seem strange to suggest that self-abnegation could be a moral vice, for we are accustomed to thinking that most people should be more altruistic and less selfish. However, Aristotle held that all moral virtues are a mean between two vices, one of excess and one of deficiency.6–8 Courage, for instance, he saw not as a willingness to face any danger, but as a proper balance between the vice of cowardice and the opposite vice of recklessness or foolhardiness. Someone who is too ready to rush headlong into danger is not courageous, but reckless. This is not virtue, but vice.

Similarly, we may think that the virtue of altruism lies between selfishness (excessive self-concern) and self-abnegation (deficient self-concern). While it is probably true that most people ought to be less selfish, if someone shows little or no concern for her own well-being, this too could be morally troublesome. This might explain worries about the motives of some altruistic donors; we may fear that they are ‘too altruistic’ or not sufficiently concerned with their own good.

It might, however, be thought that this worry is incoherent. If altruism is good, then how can there be too much of a good thing? This paper’s first aim is to explain how self-abnegation is bad, by appeal to Tom Hurka’s theory of value.9 Hurka thinks that concern for the good of others is a higher-order good, but so is concern for one’s own good. Excessive concern for others, relative to oneself, represents an imbalance in one’s attitudes that may be bad. The paper’s second aim is to suggest some implications that this may have for organ donation.

Preliminary qualifications

Some caveats are necessary, before I proceed. First, the phrase ‘altruistic donation’ is used in different ways. Often it refers specifically to non-directed (living) donations.10 This invites confusion because all donation is supposed to be altruistic.

Since my concern is with excessive altruism, the argument is likely to apply primarily to these cases of non-directed living donations. As these are relatively rare, this limits its scope. However, the argument is still significant because living donations are often considered preferable to cadaveric donations due to better outcomes.11 The argument may bear on whether we ought to seek to increase living donations. Further, finding that even altruistic donations may exhibit morally suspect motives may lead us to be more open to donations from other motives. This may have implications for posthumous donations too.

Second, I am concerned with the intrinsic value of altruism, rather than its instrumental effects. Of course, misguided altruism can have bad effects. I may genuinely try to help you, yet be so ham-fisted in my attempts that I do more harm than good. Others have questioned whether public policy should seek to promote altruism as such on instrumental grounds.12 13 But, if we are primarily concerned with instrumental effects, then we may conclude that the good that a donated organ does outweighs any badness in the motives. If this is so, then it is no longer clear whether we should be concerned even about organ selling.14

Those who insist on the importance of altruism fall into two camps. Some favour altruism over payments because they think that it will lead to more donations.15 This is an empirical claim which requires investigation.16 Moreover, even if true in our current circumstances, it can support only a contingent, rather than principled, objection to organ markets. If this is the only objection to markets, then they would be morally permissible—and perhaps even obligatory—wherever they increase supply. Others, however, object to markets on principled grounds, for instance, because they think that buying and selling of body parts is inherently objectionable.17

My focus is whether the altruism itself—or, strictly, the package of attitudes of which it is a part—is good or bad, independent of its instrumental effects on the supply of organs. Further, I am not concerned with the usual cases, but only possibility that it may sometimes be bad.

Third, while I seek to show that how some cases of altruistic motivation may be bad, my argument is not comparative. That is, I do not attempt to show that such cases of self-abnegation are worse than alternative motives. My argument opens the door to the possibility that other motives are sometimes better than altruism, but I do not try to demonstrate that here.

Fourth, one might question whether donors are always in fact motivated by altruism. Empirical studies of blood donors have suggested that their motives may be better classified as benevolence, rather than altruism.18 19 The motives of living organ donors are also, at best, complicated.20 There is often reason to question whether donors are really altruistic.21–23 At best, those who derive personal satisfaction or a ‘warm glow’ (ie, some personal benefit) from donation can be said to exhibit impure altruism.24 25 While it is important to establish whether or not donors are genuinely altruistic, the finding that many are not does not disturb my present argument, which has application so long as some are altruistic—or even so long as some might be altruistic, even if none actually are.

Hurka’s theory of value

Hurka begins by assuming that each person has a good; that is, that there are things that make their life good for them. We may offer various accounts of what this good consists in. For present purposes, it is not necessary to choose between competing theories of personal good. Hurka employs a mixed welfarist-perfectionist theory but, for simplicity, I will focus only on the good of health.

Each person has a good, but we can take different attitudes to this good. One might love the good or one might hate it. Loving a good, for Hurka, can mean either desiring it, taking steps to pursue it or simply taking pleasure in it where it does obtain. Conversely, hating a good consists in the opposite reactions: desiring, pursuing or taking pleasure in its absence.

According to Hurka, ‘self-interest is the love for itself of one’s own good, and altruism the love for itself of another’s good’ (p. 287). Thus, to be altruistic is to desire, pursue or take pleasure in the good, such as health, of others. So defined, altruism need not be universal in scope, but also includes a narrower concern for others that might more appropriately be termed solidarity. If one’s attitudes are properly in proportion, however, then one will have to love the good of all others.

Following a number of early twentieth thinkers including G. E. Moore and W. D. Ross, Hurka holds that ‘if a state of affairs is intrinsically good or evil, then appropriate attitudes toward it are also intrinsically good and inappropriate attitudes intrinsically evil’ (p. 288). Furthermore, the appropriate attitude towards something good is to love it, while the appropriate attitude towards something evil is to hate it.

Assuming an agent-neutral theory of value, each person’s good is a good for all agents. I do not mean your health is good for me, as in beneficial to me (as my own health is), but it is from my perspective a good. Thus, the appropriate attitude for me to take towards your good is to love it. This does not necessarily entail that I must work towards (ie, pursue) your good, but I should at least desire it or take pleasure in it. If I wish you harm, that is an inappropriate attitude, and hence something bad.

Hurka describes our attitudes towards goods and bads as higher-level goods and bads or, respectively, virtues and vices (p. 289). My health is a lower-level good, as is yours. My love of my own health is a higher-order good, my love of your health is also a higher-order good, and likewise your love of your health and mine is a higher-order good.

Thus, altruism is a higher-level good. But self-interest is also a virtue: since my own good is good, I should love that too (p. 289). This is less intuitive, perhaps because we tend to conflate self-interest with excessive self-interest. Many people are too concerned with their own interest, to the exclusion of others. However, having the proper amount of regard for one’s own interests is good.

Proportional attitudes

We still need to distinguish between appropriate and inappropriate self-interest. The theory so far simply tells us that, where we have two goods—say, your good and my good—I should love both of them. Nothing has yet been said about how much I should love each of them. Hurka calls this the problem of division (p. 291).

An intuitively plausible answer to this problem is that degrees of love should be proportional to degrees of goodness. Thus, if X is twice as good as Y, then I should love X twice as much as Y. It should not matter if X happens to be your good, rather than my own.

Many think that you should be prepared to make small sacrifices for the greater good of others, such as ruining your suit in order to save a child from drowning.26 Remember though that ‘love’ here need not mean ‘pursue’. I may be permitted to do more to promote my good than I do to promote yours. Thus, it does not follow that someone with two functioning kidneys has an obligation to donate one to someone with none, even though the recipient would arguably benefit more. One’s love for the good of others may be manifested simply in desiring or welcoming it. Thus, one may love someone else’s greater good more than one’s own lesser good, as proportionality requires, while still doing more to pursue the latter.

However, some people may love their own lesser good more than they love the greater good of others. Loving one’s own good too much is selfishness. Because this exhibits disproportionality in one’s attitudes towards two goods, the combination of attitudes can be bad, even if the attitudes are themselves appropriate (and therefore good). Moreover, one’s attitudes can also be disproportionate in the other direction. If I love my own good too little, compared with yours, this is self-abnegation (p. 294). This is still disproportionate, so it is also bad for the same reason.

In both cases, my attitudes are good in themselves since they involve loving goods, but disproportionate. Thus, Hurka says that excessive or deficient self-interest, though intrinsically good, is instrumentally bad, insofar as it prevents the existence of a better combination of attitudes (p. 294).

Thus far, even grossly excessive self-interest would seem to be intrinsically good, though accompanied by instrumental bad. However, Hurka also holds that ‘any disproportion in one’s division of love between two goods or evils is, as that disproportion, intrinsically evil’ (p. 296). Thus, ‘self-interested and altruistic attitudes can also be instrumentally evil in the stronger sense of making for intrinsic evil in one’s combination of attitudes as a combination and even, given a sufficient disproportion, on balance’ (p. 298).

If someone loves her own good a great deal, and the equal good of others only a little, then, though the loving of good is intrinsically valuable in each case, the evil of disproportionality may be sufficient to make her combination of attitudes intrinsically bad on the whole (p. 297). This is also true of self-abnegation: the attitudes of one whose concern for others is much greater than their concern for themselves, because disproportionate, may also be intrinsically bad.

Is self-abnegation a vice?

Again, the claim that self-abnegation, or excessive altruism, is bad may seem counter-intuitive, because much of our moral teaching focuses on fostering altruism.

Though Aristotle held all virtues to be a mean between two opposing vices, if one vice is more common or worse, he recommended that we aim to err on the other side, to increase our chances of reaching the mean. If we are naturally more prone to cowardice than recklessness, then we should strive to err on the side of recklessness, which makes it more likely that we will achieve the right balance. Similarly, since selfishness comes more easily than self-abnegation, and is generally worse, it is not surprising that many moralists have focused their efforts on the former. Self-abnegation is rarely condemned because it is either less common or less bad than selfishness.

Moreover, Hurka does not think that self-abnegation is always a vice. In the case of self-love, Hurka notes that common sense morality grants each of us an agent-relative permission to favour the pursuit of our own good (to some extent). Thus, those who need a transplant may do more to find themselves a donor than they would do for others. But Hurka denies that a similar permission extends to our attitudes (p. 301). If we both need a transplant, I should be as glad when you find a donor as when I do.

Common sense morality also grants us a permission to pursue the lesser good of others rather than our own good. Here, however, Hurka thinks that the permission extends not only to actions but also to attitudes (p. 301). Specifically, ‘If a person believes that his own pleasure is good from the point of view of other people, so that they have as much reason to care about it as about anyone else’s pleasure, and would also be good from his point of view if he chose to care about it, then his choosing not to care about it is not morally objectionable’ (p. 304).

This may characterise the ‘moral saint’—someone who is prepared to make significant sacrifices for what seem lesser gains for others. This may seem to violate the proportionality requirement, that one should love greater goods more. However, Hurka suggests there is a permitted exception when it comes to loving one’s own good less. Crucially though, such a person does not think their own good objectively less important than that of others; they simply are not so concerned with it.

Nonetheless, Hurka thinks self-abnegation can be bad where it manifests a lack of self-respect: ‘I think it would be a mistake to hold, as a purely altruistic morality would, that self-abnegation is never a moral failing. It is important to emphasize that people’s attitudes can be less than the best, and even on balance evil, because they care too little about their own good’ (p. 304).

Unlike the moral saint, this person thinks their own good of little or no objective importance. This failure even to recognise the value of their own good may lead to a variety of self-destructive behaviours, including an excessive readiness to make personal sacrifices for the benefit of others. For instance, we may think that this accurately characterises oppressed women, who are prepared to endure significant sacrifices to please their menfolk as they have internalised their own supposed worthlessness.

I take that this concern with self-abnegation enjoys some intuitive plausibility since it is shared by others.27 28 If self-abnegation, defined as an excess of altruism over self-love, can be intrinsically bad, then the motives of altruistic organ donors may be intrinsically bad.

Application to organ donation

In the case of living organ donation, the benefit to someone receiving a needed kidney is usually greater than the cost to a donor. Therefore, it is proper for the donor to place more value on the needy recipient’s good than their own lesser good. However, there is still a disproportionality if one’s love for one’s own good is even less than is warranted by it being less good. As noted, this need not be morally tainted provided one still regards one’s own good as objectively important, but may be a moral failing if someone attaches no value to her own good.

I am not claiming that these cases always exhibit self-abnegation. Empirical studies reveal that donors have various motives.29 It might be that some donors derive personal satisfaction from donating, though this would mean that their altruism is ‘impure’. Others may simply choose to prioritise the good of others, without thinking that their own good is any less important. But some may exhibit self-abnegation because, for instance, they lack self-respect. They may be willing to give their organs because they do not regard their own interests as of any importance. Thus, increased self-esteem reported by some donors may reflect a prior lack of self-esteem.

According to Hurka’s account of value, someone’s not valuing her own good is bad and disproportionate concern for others, rather than oneself, may also be bad. If we accept that altruism can be part of a bad attitude (self-abnegation), then we have reason to look critically at instances of altruistic behaviour and to ask whether the altruism they exhibit (while good in itself) is part of something that is on the whole bad.

This may explain why ‘altruistic’ (living, non-directed) donations are sometimes viewed with suspicion. Aside from the worry that the donation may not really be altruistic (eg, there may be payments taking place), there is another worry that the donor may lack sufficient concern for her own good. Further, this challenges prevailing assumptions around organ donation. It is normally assumed first that non-altruistic motives are suspect, and second that altruistic motives are morally untainted. But this second assumption may be unfounded. Sometimes altruistic donations may exhibit the vice of self-abnegation, meaning that they too might be classified as bad motives.

Conclusions

Hurka’s theory explains how it is that excessive altruism can be a bad thing, while altruism itself is good. Of course, I have not argued that we should accept Hurka’s theory. One might reject this account, though Hurka goes to considerable lengths to show it is consistent with many common sense moral intuitions (p. 286), including worries about self-abnegation.

To be sure, none of this is to deny that altruistic organ donation is, in almost all actual cases, a good thing, especially when its instrumental consequences are taken into account. Nor have I said anything about how transplant centres might distinguish between donors whose motives are good and those whose motives are morally problematic. The point is a conceptual one: altruism, taken to excess, may be part of a combination of attitudes that is intrinsically bad. This does not seem to have been sufficiently recognised in debates over the motives for donation, where it is commonly assumed that all altruism is morally innocent, despite concerns elsewhere about ‘altruistic donors’.

There are various ways that we might respond to this revelation. One is that we might be more wary about which donations we accept. If we are concerned to ensure that all donors are acting on good motives, rather than bad ones, then we may want stronger safeguards around non-directed living donations than are already in place, thereby further reducing the supply of organs.

Alternatively, if we recognise that even altruistic motives need not be good, this may make us more prepared to consider other possible motives as morally acceptable. For instance, it seems to follow from Hurka’s theory that someone motivated primarily by the good that a transplant can do for others but also welcoming their own ‘warm glow’ of satisfaction (impure altruism) may be as good as pure altruism since loving one’s own good is itself valuable. Thus, showing that altruism is not always good may give more ammunition to those who have argued that it ought not to be necessary for organ donors.

Acknowledgments

I thank Alex Gregory, Brian Ho, Simon Hope, Elselijn Kingma, and Sandra Marshall, and two anonymous referees for their comments. The final version and revisions were completed during an internally-funded sabbatical, for which I am grateful to the University of Southampton.

References

Footnotes

  • Twitter Please follow Ben Saunders @DrBenSaunders

  • Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Presented at Earlier versions of this paper were presented to the Philosophy Department, University of Stirling (February 2013) and the Health Ethics And Law group, University of Southampton (October 2015).

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