Altruism and incentives – can they co-exist?

Last week, the Human Tissue Authority publicised the remarkable news that the annual number of ‘altruistic living organ donors’ – people offering to give one of their kidneys to someone they don’t know and will probably never meet – has increased threefold, to 104 people from a previous high of 38. One such donor, Maggie Harris, who donated one of her kidneys six years ago, was invited in a BBC interview to explain how she came to make what many of us would regard as a momentous decision.

Matter-of-factly, she explained that she’d “always been lucky” to be healthy, that she “had more kidneys than she needed” since one well-functioning kidney is sufficient, and that “it was time to offload one”. While she would not refuse if the recipient were ever to wish to make contact, she herself felt no need for any kind of contact or relationship with the person who had benefited so greatly from her act – she had simply given in order to save a life.

Maggie Harris’s story of generosity is a notable example of the kind of altruism that we discussed in our 2011 report Human bodies: donation for medicine and research – a person acting out of a desire to benefit others in a less fortunate position, even at some cost to themselves. Her reference to her own ‘luck’ in having good health brings echoes of the Council’s emphasis in its report on the value of solidarity: one important reason for maintaining an altruistic base to donation is because this focus on giving in order to benefit others reinforces a communal and collective approach to the donation of organs and other bodily material, just as we have a communal and collective approach to healthcare in general in the UK, in the form of the NHS. Such an approach to donation places a high value on the generosity and compassion of donors, and also reminds us that we are all potential recipients.

As we argue in our report, though, the value of altruism and its contribution to a solidarity-based approach to donation is not, in itself, incompatible with some forms of financial recompense for donors. We suggest that there are a number of ways (‘altruist-focused interventions’) in which altruistically-minded people may be prompted to donate: these range from advertising to increase awareness of the need for donors, to providing full reimbursement of expenses incurred in donation, to ‘token’ rewards such as lottery tickets or health checks. Such interventions are ethically unproblematic – indeed some, such as reimbursing expenses, may be ethically requisite, in order to enable individuals’ altruistic intentions to be carried through in practice. As Ms Harris, a teacher, pointed out in her BBC interview: why should employers be expected to bear the costs of six weeks’ sick leave, when it is the NHS that benefits financially from the donation? “No supply teacher paid by the NHS – no kidney!” However, what about incentives that go beyond the simple reimbursement of expenses, to include, for example, ‘compensation’ for inconvenience or discomfort, or a straightforward ‘reward’  to motivate people to donate for the benefit of others?

In our report we characterised such incentives as ‘non-altruist-focused interventions’ – forms of encouragement that may indeed co-exist with altruistic motivation, but which may also spur people to donate who would otherwise never have considered doing so. Are these unethical? Our answer to this was that it all depends. Does the incentive encourage the potential donor to do something detrimental to their own welfare, or the welfare of others affected by the donor’s decision? Does it pose a potential threat to the common good (for example by undermining an existing culture of altruism), or to professional values? And how strong is the evidence in each case? Using these criteria, we very firmly rejected the idea of financial reward beyond reimbursement of actual expenses for living organ donors – but we concluded that meeting the costs of funerals for those who decided in advance that they would donate their organs after death was ethically acceptable. Such an incentive certainly has financial value – but would benefit donors’ relatives rather than themselves (hence compatible with a general climate of altruism), and would be highly unlikely to threaten the welfare of either the deceased person or their family. As Ms Harris pointed out, every person who receives a donated organ and comes off dialysis saves the NHS nearly £30,000 a year. If offering to pay for donors’ funerals might increase willingness to donate after death, and hence both save lives and enable the money saved to be spent elsewhere in the NHS – might it be worth a try?

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