Altruism has played a central role in transplantation medicine throughout the history of the field. Even today, altruism is still considered to be an essential moral concept in the field of organ transplantation. A large number of medical associations and organ procurement institutions—such as the United Network for Organ Sharing (UNOS), the American Society of Transplantation (AST), The World Medical Association (WMA) and The German Organ Transplantation Foundation (DSO)—emphasize that altruism is morally appropriate, which constitutes the basis for the choice of donating organs. Also the Nuffield Council on Bioethics emphasized once again the special role of altruism for the donation of human parts in their report Human bodies: donation for medicine and research (2011), even when they outlined altruism in a particularly broad sense.¹

The fact that altruism is one of the leading ethical principles in transplantation medicine goes along with at least two deep-seated moral intuitions: Firstly, the idea that the human body and its parts have a particular value, and secondly, that each and every individual has control over his or her own body. The latter refers to every human being’s ability to decide how to lead his or her life and shape his or her own body, a fact that should apply even after one’s own death. The idea that every human being has basic bodily rights that we ought to respect caters to this. The second intuition is related to the fact that organs do not constitute a product in the traditional sense of the word, in that they can neither be created nor produced. Thus, it is considered unacceptable that both the access and the distribution of organs are organized in the same sense as trading markets. Due to the special status of organs, one cannot manage their use in a market paradigm context in which conventional products are sold and purchased. In contrast to a market paradigm , the field of organ transplantation prefers a system of giving.² Thus, organ donation is seen as an act of giving, as long as it implies the gift of life. Such an act is voluntary and solely a result of good will and is considered to be altruistic due to the lack of personal gain. Despite the fact that organ donation seems to be regarded as an altruistic act, recently, a number of doubts and points of criticism about this assumption have been discussed.³

In this chapter, I will examine to what extent altruism arguments are likely to increase the willingness to donate organs. The working hypothesis is that altruism arguments are unsuitable for this purpose. In order to demonstrate this, I will first deal with the concept of altruism. In a second step, I will look into the motivational nature of altruistic actions and present this as a problem in the face of organ shortage. Due to the ethical and political challenge to tackle organ shortage—which means making the survival of seriously ill patients possible or to improve their quality of life —we urgently need binding measures. In a third step, I will suggest that not altruism but solidarity is the key word in promoting organ donation. For that purpose, I will argue that a model based on the value of solidarity is suitable to justify other policy interventions that might increase donation rates. Finally, I would like to draw attention to the meaning of justice (as fairness) for the success of these actions.

Before searching for an acceptable definition of the concept, it may be wise to make an important distinction when speaking of altruism. This concept can be understood as a motivation to act in a certain (altruistic) way, but it may also refer to an (altruistic) outcome or result regardless of whether the motivation was also altruistic. In this chapter, I solely address the motivational understanding of altruism, inasmuch as that is the meaning that is considered to be essential in the field of organ transplantation.

Altruism is a term that goes all the way back to the early Stoics and is prevalent in Judeo-Christian tradition, as well.⁴ However, it was August Comte who shaped the specific modern and secular notion of altruism⁵ (“vivre pour autrui” [Schischkoff 1991, p.17]). In philosophy as well as in bioethics , different approaches have been proposed to outline whether altruism refers to a rational,⁶ an emotional,⁷ or an evolutionary⁸ concept. Although one can find varying notions of altruism in literature, there is a general consensus on the fact that altruism is a motivated action that is performed for the benefit of somebody else’s wellbeing. Altruism is therefore contrary to the term egoism , in that whereas selfish acts are an expression of exaggerated self-love, altruistic actions aim at benefiting the wellbeing of others: “altruism, in ethics, a theory of conduct that regards the good of others as the end of moral action” (Altruism Encyclopædia Britannica 2013). Altruistic actions are characterized by a genuine concern for others in an objective and impartial way⁹ and their wellbeing. In addition to the central place of the other in altruistic actions, a lack of self-interest also seems to be an essential constituent of altruism. This lack of self-interest means that the altruistic agent does something for the benefit of another person without expecting any kind of reward; it is about an act of selflessness or even self-sacrifice. The altruist acts without expecting to benefit from the action in any way, whereas the egoist is not capable of such selflessness .

Regarding altruism as a motivation for altruistic actions generally entails the presumption that altruism is a genuine disposition. If deeds are done for the benefit of others, but are motivated by an external force that one does not regard as compulsory, then these are, strictly speaking, not altruistic actions. Altruistic acts that are not guided by an altruistic principle, such as norms expected by society or the denial thereof, do not arise from internalized values that have altruism as their basis. In order to call an act altruistic, it must have the ultimate goal of benefiting the wellbeing of others, but must also entail a certain amount of selflessness or at least a lack of concern for self-interests. This means that for the agent an altruistic act can have more risks and costs than benefits in pursuing the wellbeing of another person.

Seeing organ donation as an act of giving implies that this act cannot be coerced in order to be considered an altruistically motivated action. With regard to post-mortem organ donation, the existence of informed consent is the ethically legitimizing reason for the removal of organs. A person who gives informed consent to organ removal makes it possible for another person to potentially benefit from this decision. The individual’s willingness to donate constitutes a good and selfless act.

Regarding post-mortem organ donation as an altruistic act causes a problem for transplantation medicine. As long as there is an enormous gap between the supply of available organs and the demand for them, one may legitimately infer a moral obligation to solve the organ shortage crisis. This obligation concerns both the individuals’ moral decisions on organ donation as well as the decisions on the matter in the form of public health policy.

The model of altruistic giving has not yet led to an increase in the willingness to donate. Since altruistic acts are always selfless or even acts of self-sacrifice, they cannot be brought about by force or coercion. The voluntary nature of organ donation should be put to the test using autonomous consent. Given the ethical and political challenges of solving the organ shortage crisis, which would mean improving or even saving the lives of many seriously ill patients, there is a need for regulatory measures that go beyond the model of altruistic giving. For this purpose, the altruism argument does not suffice; we must call for stronger and more convincing reasons to increase donation at both an individual and a general level.

First, it should be stressed that a right to receive donor organs does not arise from the moral obligation to donate. It is important to remember that rights and obligations do not always go hand in hand.¹⁰