ALTRUISM OR SOLIDARITY? THE MOTIVES FOR ORGAN DONATION
AND TWO PROPOSALS
Proposals for increasing organ donation are often rejected as incompatible with
altruistic motivation on the part of donors. This article questions, on conceptual
grounds, whether most organ donors really are altruistic. If we distinguish between
altruism and solidarity – a more restricted form of other-concern, limited to members
of a particular group – then most organ donors exhibit solidarity, rather than
altruism. If organ donation really must be altruistic, then we have reasons to worry
about the motives of existing donors. However, I argue that altruism is not necessary,
because organ donation supplies important goods, whatever the motivation, and we
can reject certain dubious motivations, such as financial profit, without insisting on
altruism.
Once solidaristic donation is accepted, certain reforms for increasing donation
rates seem permissible. This article considers two proposals. Firstly, it has been
suggested that registered donors should receive priority for transplants. While this
proposal appears based on a solidaristic norm of reciprocity, it is argued that such a
scheme would be undesirable, since non-donors may contribute to society in other
ways. The second proposal is that donors should be able to direct their organs
towards recipients that they feel solidarity with. This is often held to be inconsistent
with altruistic motivation, but most donation is not entirely undirected in the first
place (for instance, donor organs usually go to co-nationals). While allowing directed
donation would create a number of practical problems, such as preventing
discrimination, there appears to be no reason in principle to reject it.
It is frequently assumed that organ donation should be an altruistic act. This
provides reason to resist policies that might increase donation rates where they
threaten altruism, for instance proposals to pay donors.1 This article questions this
common supposition, by distinguishing between altruism and solidarity. Much actual
donation, it will be argued, may be motivated by solidarity rather than altruism. We
therefore face a dilemma: either we maintain that organ donation ought to be
altruistic, in which case we must concede that many existing cases of donation are
suspect, or we admit that donation need not be altruistic after all.
Accepting that donation need not be altruistic, opens the door to a number of
policy interventions intended to increase donation that might otherwise have been
rejected. I conclude by considering two reforms that might increase donation: first,
allowing priority to registered donors and, second, allowing directed donation. The
insistence on altruism often leads to such policy proposals being swiftly dismissed
but, I argue, they may be seen as expressions of solidarity. If this is a permissible
motive for donation, then we should give more consideration to such policies.
1
See, for example, R. Titmuss. 1970. The Gift Relationship: From Human Blood to Social Policy.
London: Allen and Unwin; P. Singer. Altruism and Commerce: A Defense of Titmuss against Arrow.
Philos Public Aff 1973; 2: 312-320 (though Titmuss is specifically concerned with blood, rather than
organs).
As I was putting the finishing touches to this paper, controversy erupted over the issue of payments in
the UK due to S. Rabbitt Roff, ‘We Should Consider Paying Kidney Donors’, Br Med J 2011;
343:d4867 [doi:10.1136/bmj.d4867]. See the quoted remarks of Dr Tony Calland in British
Broadcasting Corporation (BBC). 2011. Kidney Donors Payments ‘Would Save Lives’. London: BBC.
Available at: http://www.bbc.co.uk/news/uk-scotland-tayside-central-14379215 [accessed 3 Aug
2011].
ALTRUISM AND SOLIDARITY
We must, first of all, distinguish altruism and solidarity, both of which are
contested terms. While reference is often made to the importance of altruism in
debates over organ donation, there is little consensus on its meaning. Indeed, many
simply appeal to the importance of altruism, without offering any explicit definition
of what they understand by the term. Altruism has, however, been the subject of
sustained attention elsewhere.2
Thomas Nagel suggests that altruism should be understood “not [as] mere abject
self-sacrifice, but merely a willingness to act in consideration of the interests of other
persons, without the need of ulterior motives.”3 He adds that genuine altruism should
not depend on any desires of the agent. If one helps others only because one wants to,
that is not genuine altruism. The demandingness of altruism is also evident in a
discussion by Cillian McBride and Jonathan Seglow who connect altruism to
supererogation (acting beyond the call of duty).4 Note that if we have a duty to donate
our organs (at least posthumously) then donations cannot be altruistic in this sense.5
2
For a variety of perspectives on altruism, see the papers collected in J. Mansbridge, ed. 1990. Beyond
Self-Interest. Chicago: University of Chicago Press; and J. Seglow, ed. 2004. The Ethics of Altruism.
London: Frank Cass.
3
T. Nagel. 1970. The Possibility of Altruism. Oxford: Clarendon Press: 79.
4
C. McBride and J. Seglow. Introduction: Egoism, Altruism, and Impartiality. Res Publica 2003; 9:
213-222: 215-6.
5
A duty to donate is suggested by D. Peters. A Unified Approach to Organ Donor Recruitment, Organ
Procurement, and Distribution. J Law Health 1988-9; 3: 157-87; P. Chouhan & H. Draper. Modified
Mandated Choice for Organ Procurement. J Med Ethics 2003; 29: 157-62; B. Saunders. Normative
Consent and Opt-Out Donation. J Med Ethics 2010; 36: 84-87.
Solidarity has also been more extensively theorised in other literatures, such as
discussions over national identity, but is now receiving increasing attention in
bioethics. Solidarity has been proposed as a guiding principle for genomic research. 6
It has also been argued that the Universal Declaration on Bioethics and Human
Rights is implicitly solidaristic.7
Again, the meaning of solidarity is contested, but common themes emerge. David
Heyd describes solidarity as “sympathy mediated by a belief in a common project.”8 It
is, he notes, inherently partial, since we feel solidarity only for members of a certain
in-group, such as our nation.9 Ori Lev, similarly, proposes that the core sense of
solidarity is captured by the ideas of integration, commitment to a common good,
empathy, and trust.10 Adam Cureton argues that solidarity may manifest intrinsically
valuable relationships, without being valuable in all circumstances, for instance
among Nazis.11
6
R. Hoedemaekers, B. Gordijn & M. Pijnenburg. Solidarity and Justice as Guiding Principles in
Genomic Research. Bioethics 2007; 21: 342-350.
7
D. Gunson. Solidarity and the Universal Declaration on Bioethics and Human Rights. J Med Philos
2009; 34: 241-260.
8
D. Heyd. Justice and Solidarity: The Contractarian Case against Global Justice. J Soc Philos 2007;
38: 112-130: 120.
9
Gunson, op. cit. note 7, pp. 245-6 rightly observes that we can feel solidarity with groups to which we
do not ourselves belong, but this does not undermine the point that we feel solidarity only for a certain
group.
10
O. Lev. Will Biomedical Enhancements Undermine Solidarity, Responsibility, Equality and
Autonomy? Bioethics 2001; 25: 177-184: 178.
11
A. Cureton. Solidarity and Social Moral Rules. Ethic Theory Moral Prac. Forthcoming. DOI
10.1007/s10677-011-9313-8. Published online 4 Nov 2011.
Having briefly characterized altruism and solidarity, it remains to ask whether
these are two distinct phenomena or, rather, two terms referring to the same thing. It
has been suggested that solidarity can be understood as a form of altruism.12 Most
authors, however, distinguish the two. Solidarity is usually understood to involve
feelings of group identity or some common project, which is sometimes taken as a
prerequisite for the demands of social justice to apply.13 Thus, it seems that altruism is
broader in scope but weaker in its motivational force, whereas solidarity is a more
powerful motivation because it invokes feelings of attachment that we do not share
with everyone.
It could be argued that solidarity is a restricted form of altruism, confined to a
particular in-group. Such restricted concern, however, seems not to be genuine
altruism. True, scholars sometimes speak of ‘reciprocal altruism’ or ‘kin altruism’.14
These phenomena are not wholly disinterested though. Where apparently ‘altruistic’
behaviour is conditional on others reciprocating, this is no more than extended selfinterest: you scratch my back and I’ll scratch yours. Nor is so-called ‘kin altruism’
entirely selfless. When parents risk their own safety to protect their children, this
serves the propagation of their genes. Note that Richard Dawkins connects this limited
altruism with selfish genes.15
12
Hoedemaekers et al., op. cit. note 6, p. 343.
13
Heyd, op. cit. note 8; Y. Tamir. 1993. Liberal Nationalism. Princeton: Princeton University Press:
117-137; D. Miller. 1995. On Nationality. Oxford: Oxford University Press: 17-47; M. Canovan. 1996.
Nationhood and Political Theory. Cheltenham: Edward Elgar: 27-36.
14
M. Ashton, et al. Kin Altruism, Reciprocal Altruism, and the Big Five Personality Factors. Evol Hum
Behav 1998; 19: 243-255.
15
R. Dawkins. 1989. The Selfish Gene. Revised edition. Oxford: Oxford University Press.
It might be objected that the contrast here proposed between altruism and
solidarity is too stark. Rather than seeing solidarity as something other than altruism,
we could interpret as exhibiting some limited form of altruism, even while falling
short of full altruism. If altruism comes in degrees, then we can classify many actions
as exhibiting at least partial altruism. But this does not solve the problems facing us.
While the question of whether organ donation is or should be altruistic may be
trivialized, we instead face the question of how altruistic donors are or should be.
If low levels of altruism are sufficient, then it is not obvious that the requirement
of altruism precludes measures like payment for organs. If appeal to altruism is meant
to exclude such proposals, then much higher degrees of altruism are required. But, if
the standards of altruism are set so high, then merely solidaristic behaviour seems to
fall short of such an ideal, since its scope is limited to a narrow group with whom the
agent feels some affinity.
I shall, in what follows, contrast altruism and solidarity. If you prefer to think of
solidarity as a limited form of altruism, then read all subsequent references to altruism
as full altruism. The essential point is that solidarity falls short of (full) altruism,
because it is restricted to members of a particular group.
IS ORGAN DONATION ALTRUISTIC?
Having distinguished altruism and solidarity, it seems that most organ donations
are not (fully) altruistic. Many may be motivated by solidarity or other feelings.
Of course, whether donation is altruistic depends on how altruism is understood.
As we have seen, altruism is sometimes associated with supererogation, which would
mean that organ donation could not be altruistic if we are under a duty to donate our
organs. Similarly, on Nagel’s understanding, altruism requires us to be motivated
simply by consideration of others’ interests, and not by our own desires. Thus,
someone who donated her organs because she wanted to help others would not count
as altruistic in Nagel’s sense.
Maybe many organ donors are altruistic in some broader sense, but there are
reasons to doubt that they are altruistic in our present, narrower sense of the term.
Altruism is often understood to involve some measure of self-sacrifice, but it is not
clear that organ donors sacrifice anything significant. Living donors may offer an
organ because it makes them feel good about themselves or to save a loved one. In
either case, it could be argued that they are at least as well off after the gift as before.
Moreover, since people’s organs are of little use to them after they are dead,
posthumous donors seem to sacrifice little or nothing. Perhaps some people, for
instance those whose religious beliefs require that their bodies be buried intact, would
be required to make a great sacrifice if their organs were taken. 16 Such people,
however, usually invoke this sacrifice to justify their refusal to donate, rather than to
emphasize the altruism of their donation. Most of those who do donate lose little, if
anything, by their donation. This provides one reason to question whether donation is
really altruistic.
Further, if we accept the distinction drawn above, between group-focused
solidarity and impartial altruism, then most donations fall short of altruism because
the good is restricted to fellow members of a solidaristic community, such as a nation.
Organs rarely go to the neediest people globally. Rather, states operate national
systems of organ donation and allocation. Thus, when a given individual donates her
16
B. Saunders. Normative Consent and Organ Donation: A Vindication. J Med Ethics 2011; 37: 632-
633.
organs, they will usually go to fellow citizens, with whom she shares some common
bonds. Some donors may have their altruistic wishes frustrated by this, but others may
wish only to give to their fellow nationals, and thus be acting solidaristically rather
than altruistically.
Some question whether a national health service, where resources are spent on
fellow citizens before more needy foreigners, is morally defensible.17 This is not my
present concern. My point is simply that most organ donations benefit fellow citizens,
with whom we feel solidarity, so need not exhibit (full) altruism.
MUST DONATION BE ALTRUISTIC?
If organ donation must, as often supposed, be altruistic then the findings of the
previous section would be unsettling. But that most organ donation is not in fact
altruistic need not be a problem.
I have argued elsewhere that, even if altruistic donations would be preferable, this
does not give us reason to refuse donations simply because we are unsure of the
donor’s motives.18 Altruism is good, certainly, but so are organs and, even if we
cannot increase levels of the former, we ought nonetheless to seek to increase the
supply of the latter. Provided that measures to increase organ donation do not reduce
altruism, we still have sufficient reason to endorse them.
Too much weight has been placed on the alleged requirement of altruism. While it
might be better if donors were altruistically motivated, this should not be an absolute
17
I. Brassington. 2007. Public Health: Why an NHS is Morally Indefensible. Exeter: Imprint
Academic.
18
B. Saunders. Opt-Out Organ Donation without Presumptions. J Med Ethics 2012; 38: 69-72.
necessity. Organs are good because they can be used to save lives, or spare
unnecessary suffering, and this instrumental use is not diminished by the way that
those organs are acquired.
One way to expose ‘status quo bias’ is to employ a reversal test.19 It is often
argued that certain ways of increasing donations, such as paying donors, are
undesirable, because they would reduce altruism. But if altruism is sufficiently
valuable to be worth not increasing organ supply for, then we should ask whether it
would also be worth reducing current organ supply for. We might make donation
more burdensome, to ensure that donors really are altruistic.20 I take it that few would
embrace this suggestion. But, in the absence of any reason to believe that we have
exactly the right balance between altruism and organ supply, it should be no less
reasonable than rejecting an increase in organ supply.
So far, I have argued that much donation may not really be altruistic, as often
claimed, but merely solidaristic. If we were to insist that donation must be altruistic,
this would give us reason not only to resist certain measures (such as payment for
donors) to increase donation rates, but also reason to regard many existing donations
as morally suspect. The current section, however, has argued that the importance of
altruism is often over-stated. While it might be desirable for donors to be motivated
by altruism, we need not reject other motives, including that of solidarity.
The alleged requirement for altruism is frequently invoked in order to reject
proposals such as payment for donors. Note, however, that we can (if we wish) reject
such proposals without insisting on altruism. We might simply say that donations
19
N. Bostrom & T. Ord. The Reversal Test: Eliminating Status Quo Bias in Bioethics. Ethics 2006;
116: 656-80.
20
B. Saunders, op. cit., note 18.
should be either altruistic or solidaristic, in the senses employed here, and that those
who part with organs only for payment exhibit neither altruism nor solidarity.
Alternatively, we might reject payments due to concerns about exploitation or
commodification, regardless of the donor’s motivation.
Rejecting the requirement of altruism does not, therefore, necessarily open the
door to any methods of organ procurement. But, once we abandon the requirement of
altruism, reforms that might otherwise have been rejected seem more acceptable. I
conclude by briefly considering two proposed reforms based on solidarity.
PRIORITY FOR DONORS
One way to increase donation rates might be to offer registered donors some level
of priority when it comes to the allocation of organs. That is, those in need of organs
would enjoy an advantage over others on the waiting list if they were themselves
registered donors.21 Such a scheme has been employed in Israel.22
This policy appears in conflict with a requirement of altruism, since donors
motivated by such an incentive seem more concerned with securing their own good,
rather than with a selfless concern for others. If altruism were a requirement for
donation, then such a policy seems undesirable.
21
I. Kleinman & F. Lowy. Cadaveric Organ Donation: Ethical Considerations for a New Approach.
CMAJ 1989; 141: 107-110; D. Undis. Changing Organ Allocation will Increase Organ Supply. De
Paul Law Rev 2005-6; 55: 889-896.
22
J. Lavee et al. A New Law for Allocation of Donor Organs in Israel. Lancet 2010; 375: 1131-1133.
A similar strategy has been proposed in Canada. See S.D. Shemie et al. Lifetime Probabilities of
Needing an Organ Transplant Versus Donating an Organ After Death. Am J Transplant 2011; 11:
2085-2092: 2088.
But, if solidarity is a legitimate motivation for donation, then this policy might be
grounded not in the self-interest of donors, but rather on a norm of reciprocity,
recognizing their willingness to give as well as to receive. Those who want to receive
transplants, but are not willing to donate their own organs, can be seen as free-riding
on the willingness of others to donate. Giving priority to registered donors can be
seen, therefore, not simply as an incentive appealing to their self-interest, but as
embodying the solidaristic norm that those who would receive should also be
prepared to give.
Priority for donors seems likely to increase rates of organ donation and can be
justified on grounds of solidarity, if not altruism. If I am right that this motivation is
not objectionable, then such proposals are worthy of further consideration. This does
not mean that such reforms are justified; my claim is merely that we must attend more
carefully to arguments for or against such proposals, rather than dismissing them as
inconsistent with the requirement of altruism.
As it happens, I am somewhat sceptical about the reciprocity-based justification
for such measures. It is assumed that those who would take organs must be prepared
to give organs in return, but – while it is fair to expect beneficiaries to contribute in
some fashion – no justification is offered as to why they must contribute in kind, by
giving their organs. We do not always expect beneficiaries to reciprocate in the way
that they benefited. If we did, then we may as well demand that those who receive a
transplant should also be prepared to conduct transplant surgery on others!
If we regard society as a community cooperating in pursuit of some common
good, then we must recognize that people contribute in many different ways.
Donating one’s organs may be one way of contributing to society, but not the only
way. One may also contribute, for instance, through volunteering for charity or simply
by paying one’s taxes.
Suppose we have two individuals needing a transplant: one is a registered donor
but lives on benefits, while the other is not a registered donor but a higher rate tax
payer, whose earnings helped pay for the operating theatre and surgeons. It is not
obvious that the former has contributed more to the system than the latter. Solidarity
may require that all be willing to contribute towards the common good, but it sets no
restrictions on the form that this contribution must take. There is no reason to assume
that registered organ donors display greater degrees of solidarity than those who
contribute in others ways.23
We might think that the problem is simply too narrow a notion of contribution and
that an alternative system could be devised in which one’s place on the organ waiting
list depends on a variety of ways in which one has contributed. I do not think that this
is an attractive avenue to explore. While solidarity may be linked to reciprocity, it is
not to be understood as an arms-length market transaction. Solidarity is invoked to
explain why we are motivated to care for those who cannot care for themselves, even
when we cannot expect anything from them in turn.24 We care for the profoundly
handicapped, for instance, because we regard them as part of our community, even if
they cannot contribute towards it.
Schemes that would give registered donors priority in organ allocation are not,
therefore, straightforward implications of solidarity. The relation between solidarity
23
And these ways need not be financial. One might ‘contribute’ by living a healthy lifestyle that puts
less strain on the health service. If such a person needs a liver transplant, it would seem unfair to give
priority to an alcoholic, whose liver disease was self-inflicted, simply because the latter was a
registered donor.
24
Canovan, op. cit. note 13; Tamir, op. cit. note 13; Miller, op. cit. note 13.
and reciprocity is more complicated.25 While such proposals may be worthy of further
consideration, I am doubtful that they could be justified.
DIRECTED DONATION
Another possible reform is to allow directed donations, in which a potential donor
is allowed to donate their organs on the condition that the organs are received by a
member of a certain group.26 Again, such suggestions are usually opposed on the
grounds that directed donation fails to manifest the proper altruistic attitude. As
argued above though, most actual donation falls short of full altruism. Indeed, giving
one’s organs to a national organ bank can itself be seen as a form of directed donation
(though not at the discretion of the donor), since one’s organs will go to one’s fellow
citizens, rather than more needy foreigners.27
25
Though perhaps not much more complicated. Maybe all that is necessary is that others be willing to
cooperate, whether or not they can.
26
I would suggest that we allow donors to specify a priority, but not to restrict their organs absolutely.
Thus, one may insist that one’s organ will go to a white person in preference to any black people, but
not that it could never go to a black person, if there were no whites on the waiting list. But this is a
matter of practical implementation, rather than policy.
27
Note that I treat reciprocity and directed donation as separate phenomena, but directed donation can
be used to restrict donations to reciprocators, as in LifeSharers. See D.J. Undis, op. cit, note 21.
I also set aside the implications of this policy for NEAD chains. See M.A. Rees et al. A
Nonsimultaneous, Extended Altruistic-Donor Chain. N Engl J Med 2009; 360: 1096-1101 and I.
Ashlagi et al. Nonsimultaneous Chains and Dominos in Kidney-Paired Donation – Revisited. Am J
Transplant 2011; 11: 984-994. Some donors may wish to direct their organs in ways to facilitate such
chains, so as to bring about the most good, but other directions may frustrate such chains. It has been
argued that such chains raise ethical problems; see E.S. Woodle et al. Ethical Considerations for
If we recognize solidarity as an acceptable motive for organ donation, then there
seems less reason to oppose directed donation. Why should we accept donations from
those with solidaristic feelings towards their fellow citizens as a whole, but reject
those from others who would prefer to restrict their organs to some other group with
whom they share a solidaristic bond?
A common concern about directed donation is that people’s reasons for restricting
their organs to members of a particular group may often be morally suspect. We
might find that whites would prefer to restrict their organs to fellow whites, and not
blacks or other minorities, and vice versa. It may be thought that this is an area where
group solidarity shades into morally objectionable racism and ought not to be
tolerated – hence the requirement for altruism.
While these concerns have some force, directed donation need not be permitted or
rejected wholesale. Even if directed donation is allowed, presumably not all directions
would be permissible, if only because some (such as ‘give my organs to the person
with the fewest Jewish ancestors’) would be too difficult to implement. We might
simply prohibit the more morally troublesome instances of direction, while permitting
those that strike us as (relatively) innocent.28
Moreover, if our concern is that allowing directed donations would harm certain
minorities, who may be discriminated against in people’s directions, it should be
noted that whether this would occur is an empirical question. It is not obvious that
minorities would be harmed by directed donation. Firstly, since compatibility is one
Participation of Nondirected Living Donors in Kidney Exchange Programs. Am J Transplant 2010; 10:
1460-1467. These issues cannot be treated here.
28
Remembering, of course, that so long as the donation and allocation of organs continues to operate
on a national basis, it may never be entirely innocent. Is it really any worse if, for example, a member
of some particular religious community wishes her organs to go to another member of her faith?
criterion for allocating organs, many people’s organs already go to other members of
the same ethnic groups. Secondly, allowing directed donations may actually
encourage members of minority groups, who are reluctant to have their organs taken
for the benefit of the majority, to donate, thereby improving the prospects for others in
their group. Whether allowing directed donation would in fact harm minorities
requires empirical research in each case (since there is no reason to expect a single
answer to hold good for all societies).
Even if these studies suggest that minorities would be discriminated against by
directed donations, it is a further question whether avoiding this harm justifies the
harm arising from a smaller supply of organs. If the former harm is not great, then it is
possible that we (or, more accurately, the minorities in question) should be prepared
to bear it, for the sake of the good that increased organ donation may do.
This line of thinking can be supported by John Rawls’s influential notion of
justice as fairness. Rawls’s ‘difference principle’ holds that socio-economic
inequalities should be arranged so that they are to everyone’s advantage. 29 One way to
understand this is to say that, from a baseline of equality, it makes sense for all to
accept inequalities if everyone benefits in absolute terms. It may be better to have a
smaller slice of a larger pie, than an equal slice of a smaller pie.
A system of donation in which organs go to the most needy is egalitarian, since it
does not discriminate on the basis of race, sex, class or any other such ‘arbitrary’
factors.30 Allowing directed donation threatens to upset this equality, since members
29
J. Rawls. 1999. A Theory of Justice. Revised edition. Oxford: Oxford University Press: 53.
30
Though age might figure in determining priority for transplants. Moreover it might be worried that
some other criteria, such as compatibility, might amount to indirect discrimination. I bracket such
concerns here.
of some social groups may have greater prospects of receiving an organ than those of
other groups. Nonetheless, it may be that all individuals – even those of disfavoured
groups – will have better prospects under the latter arrangement, because such a
measure may increase the supply of organs available for everyone to such an extent
that all are more likely to receive organs than before.31
Again, I am not saying that we should allow directed donations, only that we
should give more consideration to such reforms. However, directed donation seems
more attractive than giving registered donors priority on waiting lists.
It is true that there may be a number of practical difficulties with directed
donation. Indeed, it may be so administratively complex and costly that we are better
off prohibiting it altogether, thereby avoiding the need to keep track of various
directives or to decide which are and are not legitimate. Nonetheless, even if this is
our conclusion, it is important to be clear that we do not reject directed donation on
principle (as would be the case if we focused on the lack of altruism exhibited), but
for practical reasons. There is nothing inherently wrong about wanting one’s organs to
go to those with whom one feels solidarity.
CONCLUSION
31
Moreover, it should be remembered that if one organ has a ‘whites only’ directive, giving that organ
to a white recipient may free up the undirected organ that they would have received for a black person.
We may even adjust existing allocation criteria to minimize the effects of discrimination. For instance,
if the top of our waiting list has 1) white person, 2) black person, 3) white person, and our top available
organ is undirected, but the second organ in line is ‘whites only’, then rather than give the first organ to
the first person, we might give it to the second (black) person, so that the top two on the waiting list
still receive organs.
The practical implications of my discussion are limited. I stopped short of
endorsing either priority for registered donors or directed donation, but these policies
are likely to appear more attractive to us once we recognize that most organ donation
is not, and need not, be wholly altruistic. Even if we conceive of organ donation as a
gift, rather than a duty, it is often motivated by solidarity with a particular community.
Placing too much emphasis on altruism may lead us to neglect ways in which organ
donation can be increased. We should, instead, look for reforms that tap into
widespread feelings of solidarity.
Acknowledgements
I thank Sarah Fine for sharing unpublished work on solidarity; Patricia Illingworth
for discussion of the proposal; and two anonymous reviewers for comments on a
previous version.
.
WORD COUNT: 4,989.