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Bioethics

On Altruistic Living Kidney Donation

Kidney specialist Mahendra Govani recommends a particular variety of evolved ethical behaviour.

During the recorded and unrecorded evolutionary march towards happiness, the ultimate goal, humanity has mastered many mountains, walked through a variety of valleys, and tumbled into dozens of dreadful ditches. However, one can argue that in the arena of social and ethical development we have lagged far behind. Here, I will address the problems caused by the shortage of organs. A very small but significant portion of the population gains happiness through various altruistic actions, including the heroic act of kidney donation.

Immanuel Kant’s classic ethical work is Foundations for the Metaphysics of Morals (1785). Kant’s moral formulae are derived from a duty to humanity and pure reason. They are tough acts to follow. There are also many criticisms of his theory. However, in the arena of altruistic kidney donation, the grounds for criticism of his principles is shaky at best.

In terms of Kant’s moral system, the altruist donates a kidney or undergoes a series of tests 1) according to a maxim eg that ‘it is good to donate organs when possible’ willing at the same time that this maxim should become a universal law. 2) He treats humanity as an end and not as means - by acting on the basis of seeing the value of another person’s life. 3) Finally, his will prescribes this altruism as a universal law. Egoists will argue that there has to be some selfish motive behind this apparent altruistic action. If no material gain is involved, then there has to be some sort of immaterial gain (respect, affection, satisfaction etc). This is a non-falsifiable argument - it is impossible to prove or disprove. The purist may want to call this behaviour ‘enlightened self-interest’. Whatever one wants to call it, no one will argue against the fact that a significant number of quality life-years are added to an individual’s life with a minimal risk to the donor. I think it is an act of heroic altruism and deserves enormous respect from society and the medical community.

It is unfortunate that society considers these virtuous men and women eccentric at best. In the USA, we need only approximately 200,000 people (less than 0.2% of the adult population) to be these eccentric adults and solve the shortage of kidneys (assuming that 3 out of 4 will fail the medical tests). Looking at the whole spectrum of humanity from one extreme to the other, statistics show that more than 1% of the adult population is ‘violent egoist’. Assuming that there is no skewed distribution, we should have a similar proportion of ‘heroic altruists’. Are we, as a society, suppressing balancing virtuous acts by too much suspicion? Simply by nature of their virtue, most of these men and women will be modest or even bashful, with some eccentricities. I think society and the medical community has a responsibility to encourage these virtuous creatures to express their pure love for humanity, instead of spending valuable time doubting their motives obsessively and considering the sale of living kidneys - merchandising which treats humanity as a means and not as an end.

This would delight Immanuel Kant and Auguste Comte in their graves. Comte was the French founder of Positivism, and he coined the word ‘altruism’. In his words altruism is “the definitive formula of human morality, giving direct sanction exclusively to our instincts of benevolence, the common source of happiness and duty.” It is a virtue of temperament - a unification of courage, good will and charity.

I was personally involved in detailed evaluation of two altruistic donors. Meetings with these donors were some of the greatest experiences of my life.

Finally, I’d like to cite an essay on ‘Virtue’ from Voltaire’s Philosophical Dictionary(translated by Theodore Besterman) for the benefit of all the egoists, skeptics and cynics:

“What is virtue? Doing good to one’s neighbor. Can I call virtue anything other than what does me good? I am poor, you are liberal; I am in danger, you come to my help; I am deceived, you tell me the truth; I am neglected, you console me; I am ignorant, you instruct me: I do not find it difficult to call you virtuous...

“But come, should we really acknowledge as virtues only those that are useful to our fellow man? Well, how can I acknowledge others? We live in society, so there is no true good for us but what is good for society. A solitary is sober and pious; he wears a hair-shirt: very well, he is a saint. But I shall not call him virtuous until he has performed some virtuous act from which other men have benefited. So long as he is alone he is neither beneficent nor maleficent: he is nothing to us... Virtue between men is commerce of beneficence. No account should be taken of any man who had no part in this commerce. If this saint were in the world he would no doubt do good in it; but so long as he is not, the world will be right not to call him virtuous: he will be beneficial to himself, and not to us.”

I am sure Voltaire would consider altruistic kidney donation a virtuous act, and deplore organ commerce vehemently.

As a society let us not throw stones at these heroic altruists, and allow them to climb the moral mountains unhindered. Let all of us strive to perform some acts of conventional altruism, if not of heroic altruism. This would be a major conscious step forward in ethical evolution. By approving the regulated commercial sale of organs, we will be going in the wrong direction. Surely, there are arguments for it. But all those arguments, in a larger sense are for short-term gains, and treat humanity as a means rather than an end.

Mahendra Govani is Associate Professor of Clinical Medicine at the Indiana University Medical Center, Indianapolis.