Psychosomatics 41:407-411, October 2000
© 2000 The Academy of Psychosomatic Medicine
Religious Altruism and Organ Donation
David J. Dixon, M.D., M.A., F.R.C.P.C, and
Susan E. Abbey, M.D., F.R.C.P.C.
Received October 28, 1999; revised January 11, 2000; accepted March 16, 2000. From the Department of Psychiatry, Toronto General Hospital & University of Toronto. Address reprint requests to Dr. Dixon, Department of Psychiatry, 8 EN-212, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, Ontario M5G 2C4.
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ABSTRACT
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Clinicians performing psychiatric assessments of potential organ donors must consider the motivations behind an act that is—strictly in terms of its physiological implications—entirely altruistic. The authors present two case reports in which proposed kidney donors conceptualized their offers exclusively in terms of their religious beliefs and not in terms of kinship or emotional intimacy with the intended recipients. The negative reactions of some clinicians to the offers reveal the readiness with which religious beliefs can be pathologized and the way in which biological relationships can unduly restrict the clinical understanding of healthy altruism.
Key Words: Religion
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INTRODUCTION
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For most physicians and medical ethicists, the living- related donor (LRD) has become an acceptable organ source for renal transplantation. The use of the living-unrelated donor (LURD), however, remains controversial.1–4 Many medical centers restrict LURDs to spouses only. Even then, the spousal donor must often meet standards of psychological health more rigorous than those thought necessary for the blood relation.1,5,6 Moreover, nonspousal LURDs apparently cause such concern about pathological motivations as to be permitted (if at all) only in the context of long-term, emotionally intimate relationships.1 In other words, the altruism of the kidney donor can be expressed in only one of two circumstances: readily in terms of biological relationships and quite guardedly in terms of emotional relationships that lack blood kinship.
The following case reports challenge the conventional understanding of acceptable and psychologically "healthy" altruism in renal transplantation. Although there is literature considering the place of organ transplant in various religions, there has not been, to our knowledge, case reports in which religiously based altruism appears to be the organ donor's sole motivation.
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Case Report
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Ms. B., a 42-year-old woman employed as a secretary, was the prospective donor for a fellow church member whom she had recently come to know. Ms. B. was married and lived with her two children, ages 19 and 21; her husband lived overseas. If her offer to donate was approved, Ms. B. planned to join her husband after the postoperative convalescence. Ms. B. cited two experiences as essential in her decision to donate. First, an accident 14 years ago—which resulted in extensive injuries to both feet and necessitated several years of physiotherapy—sensitized Ms. B. to those who struggle with chronic disabilities and illnesses. Second, Ms. B.'s membership in an evangelical church over the previous 2 years had involved her in several charitable enterprises and introduced her to proactive expressions of religious altruism.
Ms. B. met the potential recipient, Mr. C., at church. She learned about his chronic renal failure, the health effects of dialysis, and the possibility of transplantation being the definitive treatment option. Ms. B. regarded Mr. C. as a "humble man of God" who, in her opinion, would do justice to the gift of a donated organ by continuing to lead a virtuous life. Prompted by both her sensitivity to the chronically ill and her religiously inspired and sustained sense of charity, Ms. B. began to consider the possibility of donating her kidney to Mr. C. After several weeks of prayer and in-depth discussions with her husband, children, and fellow parishioners, Ms. B. decided to present herself to the transplant team for evaluation.
Ms. B. did not see the donation as a means to change her relationship with Mr. C. Other than working together on some church-related matters, they had little contact. Furthermore, because Ms. B. planned to join her husband after her recovery, she emphasized that there would be little opportunity for her even to see Mr. C. again.
With regard to the basic issues around informed consent, Ms. B. conveyed an excellent understanding of the surgical procedure, the convalescent period, the risks to her own health, and the possibility of graft failure. She had no present concerns of a psychiatric nature. Past psychiatric history included a brief admission for depression 4 years earlier. Fluoxetine had effectively resolved the mood symptoms. Ms. B. had no history of suicide attempts. She had had ongoing psychotherapy with a general practitioner/therapist for the past 10 years, initially focusing on marital discord. As this problem lessened (and Ms. B. subsequently divorced her first husband), the frequency of sessions had diminished to only 3 or 4 a year. Past medical history was significant for several operations including a fibromyectomy, hysterectomy, tonsillectomy, two procedures on the gastrointestional tract, and two cosmetic surgeries (breast reduction and rhinoplasty).
Developmental history revealed that Ms. B. suffered several incidents of sexual abuse between the ages of 3 and 8, physical abuse from her father as a teenager, and further physical abuse in her twenties during her first marriage. Ms. B. also described difficulties managing her own anger and aggression, though she emphasized that these had resolved with the aid of therapy and prayer.
Religion had always played an important part in her life. She recalled that as a youth she would interpret her Roman Catholic faith as demanding of self-punishment for wrongdoing. For example, she would sometimes walk with her shoes filled with pebbles as a means of physical penance. However, Ms. B. did not regard her offer to donate as a similar expression of penitence. That is to say, the bodily "injury" she would endure—a concomitant of any surgical procedure—was not seen as "actually" an act of penance only masquerading as an act of altruism. Ms. B. explained that her offer to donate had been given considerable thought, had been discussed at length with church members, and had been prayed about. At the end of this process she concluded that penance was not a factor in her motivation.
On mental status examination, Ms. B. presented as a vivacious, articulate woman who maintained an affability and good humor throughout three separate evaluations, with the last being in front of the psychiatry transplant team. Of particular note, Ms. B. understood the importance of the assessments in light of the unusual circumstances, cooperated with the team in allowing the collection of collateral information, and did not react defensively when the transplant team proposed alternative hypotheses about her offer. She did not convey a sense of excessive or anxious investment in undergoing the transplant procedure. Indeed, Ms. B. stated that if her offer were refused, she would feel disappointment for Mr. C. but would not embark on a mission to find another worthy recipient for her kidney.
In assessing Ms. B.'s offer, the most troubling concern was the possibility of factitious disorder. The combination of an abusive upbringing and marriage, the difficulties with anger management, the attempts in youth to expiate guilt through self-punishment, and the history of multiple surgeries together introduced the worry that Ms. B.—for reasons outside her conscious awareness—was deliberately orchestrating a situation that would cause her significant physical injury as an end in itself. Possible reasons included the venting of aggressive impulses or the dissipating of guilt through injury and pain. Yet both the family physician and the psychotherapist, each of whom had known Ms. B. for several years, were convinced that her offer was a manifestation of sincerely felt, and religiously based, charitable impulses. They also felt the previous surgeries were prompted by legitimate medical and cosmetic concerns. The doctors' opinions resonated with the nondefensive and thoughtful manner Ms. B. conveyed in each of the three assessment interviews.
The transplant team's reaction to Ms. B. forms a salient part of the case report. For some of the transplant staff, the idea of a nonpathological motivation for the offer bordered on the incredible. One member of the psychiatry team, on hearing Ms. B. explain her charitable impulses as being modeled on Jesus' self-giving love, remarked that the interpretation was "psychotic." Another member categorically discounted Ms. B.'s own explanation of her religious development and concluded that she was "trying to give away body parts because of her Roman Catholic guilt." Both agreed, however, that they would have had no objection if Ms. B. had proposed donating to a sibling or parent, even if that familial relationship were emotionally distant. Indeed, even the more muted protests of other staff revolved around the whole concept of an unrestricted altruism. For these clinicians, the concern was less that Ms. B.'s developmental history suggested a pathological motivation and more that an offer to donate outside a biologically or emotionally intimate relationship was itself a priori evidence of pathology. With that preconception as a starting point, the details of Ms. B.'s history could then be marshaled forth simply to give the assumption further support.
Nonetheless, after two assessments by the first author, one by the second, and much discussion with the team, it was recommended that the transplant proceed. Both Ms. B. and Mr. C. subsequently did well and reported positive feelings about having gone through with the transplant.
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Case Report
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Mr. G. was a 35-year-old evangelical minister, married, with a 13-month-old daughter. He came forward as a potential LURD for a 42-year-old man whom the transplant team initially thought a close friend of the minister but was revealed by the psychiatric assessment to have a much more distant relationship. Mr. G.'s wife was very supportive of the offer, but a brother expressed concerns to the transplant coordinator that Mr. G. had "always been prone to getting involved in off-the-wall schemes." The coordinator, however, noted that Mr. G. was "sincere and articulate," and that "there was nothing odd about him." Mr. G. was referred for a psychiatric assessment as part of the standard workup for LURDs.
Mr. G. explained that his decision to donate a kidney evolved quickly and was in line with his spiritual convictions. The potential recipient was the husband of one of his parishioners. Mr. G. had presided at the couple's wedding and, in fact, first met the recipient at the wedding rehearsal. The idea of donating the kidney first occurred to Mr. G. during the rehearsal, and then, in his own words, "the conviction just grew." Although the potential recipient's wife and her family had been long-standing congregants, Mr. G. did not have a particularly close relationship with any of them. Nonetheless, Mr. G. and his wife continued to consider the idea, and eventually, with prayer, both concluded that God wanted the offer to be made. The tissue typing match, which was unusually good, was taken as "a further sign of God opening the door" to the donation. "If God hadn't wanted me to proceed," explained Mr. G., "then the match would not be so good." Both he and his wife had thought through several practical concerns—relating to the distance from the transplant center, job demands, and the lack of employee benefits—and made appropriate arrangements. With regard to his own family, Mr. G. thought it unlikely his daughter would ever need a kidney, and his wife emphasized that she would donate hers if this was ever required. Mr. G. had reconciled himself to the possibility of graft failure, noting that he would take comfort in the knowledge of having done what he "was supposed to do." He had no doubts about the recipient's ability to care for the kidney.
Mr. G.'s only concern was the "potentially impersonal aspect" of the transplant procedure. He expressed "annoyance, dismay, maybe even deep inner resentment at the way that business and science have become devoid of ethics." "I am reluctant," Mr. G. said, "to hand myself over to an institution where I am just a slab of meat, and they are joking about the weather outside rather than focusing on the mystery of the body and the sanctity of the transplant experience."
Developmental history revealed that Mr. G. had grown up, to use his words, "in a very dysfunctional family" and had experienced significant difficulties in his mid-teens with polysubstance abuse. His family was Roman Catholic, but he was "the black sheep." Mr. G. said that a "conversion experience," following a period of depression and suicidal ideation, "brought Jesus" into his life. He subsequently enrolled in Bible college and then pursued the ministry. Mr. G. met his wife through a Christian group for young adults. He described his marriage as a happy one. His family had become closer over the years, and he recognized their concern about the proposed donation. Mr. G.'s mother claimed that the stress of his surgery would "kill her," and, as noted, a brother had expressed worries to the transplant team. In contrast, Mr. G.'s father and other siblings offered Mr. G. and his wife both instrumental and emotional support. Past psychiatric history was limited to some short-term counseling at the Bible college and a brief contact with a community mental health clinic. Medical history was significant only for an appendectomy.
Mental status examination revealed a pleasant, well- groomed, and robust man who appeared quite sincere. Mr. G. indicated that he was "pleased" with the psychiatric assessment: he saw it as evidence of the transplant program "caring" for him and being cautious about his mental health. Mr. G. related his story in an articulate manner and had clearly thought through the relevant issues.
Some members of the transplant team felt strongly that Mr. G.'s offer should be rejected. The fact that the minister did not have a familial or long-standing emotional relationship with the recipient was the paramount concern—one that was not obviated by Mr. G.'s faith-based explanations of his motivation. Such trepidation notwithstanding, the psychiatric recommendation was that the transplant should proceed. Four years later the recipient continues to do well. In a follow-up study of donors, Mr. G. reported no regrets and felt very positively about his having been a kidney donor.
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DISCUSSION
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The living donor complicates the standard ethical dichotomy between autonomy and paternalism.7,8 A narrow paternalistic interpretation of the traditional "do no harm" edict mitigates against the use of any living donor. Most clinicians reject this narrow view. But even that rejection is usually limited to donor-recipient relationships based on biological kinship or less frequently on emotional intimacy.4 Inflicting physiological harm, in other words, is ethically permissible if the result is the improved health of the "victim's" relative, spouse, or extremely close friend. Such harm ought not to be permitted, however, if the intended beneficiary is unrelated or emotionally remote. In those cases, protective paternalism should apparently trump donor autonomy.
A corollary to these guidelines is that there is no a priori sanction against donating to an emotionally distant recipient, as long as the recipient is biologically related to the donor.6 The implication is that altruism based on "blood" is healthier than altruism based on broader humanitarian foundations. Bone marrow transplantation offers an interesting point of comparison.8,9 It is not uncommon for a bone marrow donor to be a stranger to the recipient. The altruism motivating such donations is usually regarded quite positively, even though the donation falls outside a donor-recipient relationship of biological or emotional intimacy. That these donations are accepted as psychologically healthy—as opposed to kidneys from emotionally distant LURDs—stems from the reduced health risks faced by the marrow donor vis-à-vis the kidney donor. Only if the risk is minimal is it considered acceptable to express altruistic concern to a stranger. If the expression of altruistic concern involves more serious risks, such as those of major surgery, then the beneficiary of that concern ought to be family. Thus, healthy altruism is seen to have definite limits, and those limits are defined by a kind of biological tribalism: the greater acts of benevolence should be reserved, it seems, only for those in the same familial gene pool.
The cases of Ms. B. and Mr. G. challenge this blood- is-thicker-than-water conception of healthy altruism. Neither donor had a biological relationship or a close emotional connection with the recipient. Religion was the framework by which the idea to donate was conceived and nurtured. As such, Ms. B. and Mr. G. forced clinicians to move beyond a mere lip-service respect for religion as a salient psychological feature. After all, here were two potential donors who provided no alternatives to which their religious motivations could be subordinated. The psychiatrist could not simply patronize the religion-based reason for donating and then emphasize in the consultation note the "real," relationship-based reason. Instead, altruism based on a belief in God—serious, risky altruism—had to be confronted and evaluated directly.
Three main trends were discerned in the unfavorable reactions provoked in some staff. First, despite recent calls for greater sensitivity to cultural and religious issues in the clinical setting,10–13 the reaction to the religious beliefs of Ms. B. and Mr. G. was, for some staff, unapologetically cynical. The notion that faith could be an effective means of working through past traumas and healing mental anguish was greeted with marked skepticism. A history of abuse, problems with anger control, the emotional sequelae of a "dysfunctional family"—all these were seen not so much as unresolvable in general but as unresolvable through the mechanisms of faith, prayer, and religious affiliation. Furthermore, if religion could not be taken seriously as a means to restore mental health, then it certainly could not be taken seriously as a means to create more mature and advanced expressions of mental health. Such views necessarily ignored a growing psychiatric literature indicating positive associations between religious practice and certain measures of mental and physical health.14,15 But it should also be noted that such views are by no means rare among mental health professionals. Psychiatry's traditional suspiciousness about all things religious may be waning, but it is still far from being a thing of the past.11,16,17
Second, the objections to Ms. B. and Mr. G. demonstrated that biology could still predominate formulations of human relationships. The unavoidable inference is that altruism means "looking after one's own." As such, cross- cultural and centuries-long religious conceptions of inclusive altruism and universal kinship can be summarily dismissed.18 Religion, in other words, becomes pathological "religiosity" for its failure to make charity dependent on genetic proximity.
Third, the reaction particularly to Ms. B. contained elements of prejudice in its most literal form. The membership of Ms. B. in a group that contains almost 1 billion people was felt sufficient to pass "prejudgments" about her personal motivations. Moreover, these conclusions could not be modified by Ms. B.'s own explanations. Because Ms. B. was once a Roman Catholic, her offer must be tainted by "Roman Catholic guilt"; because Ms. B. is now a member of an evangelical church, her offer must be part of a religious "psychosis." A disparaging caricature of the group was substituted for a rigorous assessment of the individual. To be sure, those who invoked these caricatures would undoubtedly condemn their use with regard to an individual's ethnic or cultural background. The case of Ms. B. (and to a lesser extent that of Mr. G.) suggests that certain religions, or certain denominations, may not be accorded that same respect.
Mirza et al.19 are no doubt correct in saying that "future generations of surgeons will look back on this phase of transplantation in which live donors are used as a relatively primitive time." But as long as living donation remains an essential treatment option for chronic renal failure, it is important to examine the thinking that goes into the psychiatric assessments of potential donors. Living donation may indeed be "primitive," but the understanding of donor altruism need not be as well. Referring to both LRDs and LURDs, Daar20 has asked why " do we insist on altruism and then stand in the way of its expression?" The present case reports suggest one answer: that conceptions of altruism can be unduly restricted by an overvaluing of biological kinship and an undervaluing of religious motivation. By pathologizing an altruistic act that does not restrict itself to family, ethnicity, or friendship, only the most primitive conception of human relationships is left as the standard of mental health. Such pathologizing says more about the fear and prejudice of the clinician than the mental health of the donor. Simply put, the generosity of Ms. B. and Mr. G. proved so unsettling because it presumed meaningful, caring relationships with others based on a common humanity. For some staff, it proved easier to denigrate the religious framework by which this generosity was conceived than to contemplate changes in their own blood-based understanding of human value and healthy altruism. Prejudice was easier than reassessment.
Clearly, the psychiatric evaluation of the donor must always consider the possibility of pathological motivations, and those motivations conceptualized by the donor as "religious" ought not to escape careful scrutiny. But to assert that religion should not be off-limits in the psychiatric assessment is not to assert that salacious generalizations should somehow substitute for actual knowledge about religions in general and the patient's own belief system in particular.11–14,21 Daar20 has called organ donation "perhaps the most meaningful and altruistic gesture of solidarity that a human being could choose to perform." If that statement is correct, then it seems essential for the clinician who evaluates organ donors to strive toward an enlightened understanding of that "altruistic gesture"—an understanding that duly recognizes the variety and complexity of ways in which that "solidarity" with humanity is conceived and expressed.
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ABSTRACT
INTRODUCTION
