Organ transplantation is one of the clearest examples of how technological advancement has enabled the realization of ancient medical ideas. The possibility of transplanting an organ from a healthy person into the body of a sick person has captured the medical imagination for many centuries. However, it was only in the second half of the twentieth century that this vision became a reality, with the first kidney transplants in the 1950s followed by pancreas, liver, and heart transplants in the 1960s. Since then, technological development has enabled more organs and tissues to be transplanted, and organ transplants have become a viable solution for a growing number of medical conditions [1].

Since the outset of the development of transplant medicine, ethical rules have been established for the supply of human organs for transplantation. Above all, such organs must be obtained through altruistic donation, i.e., given freely without any material consideration. The source of the altruistic rule in organ donation can be found in the revolution that inspired Richard Titmuss’s book The Gift Relationship [2]. Titmuss compared blood collection systems around the world and concluded that voluntary blood donation is the most effective, safe, and ethical method for collecting blood. According to Titmuss, voluntary or altruistic donations express a pure desire to help and, therefore, such donors are free from fears of fraud or falsification of medical data. Further, they contribute to social solidarity and are a buffer against trends in commercializing human relationships.

This view is the dominant paradigm when it comes to collecting human cells, tissues, and organs for therapeutic purposes. Although Titmuss’s book is outdated in many ways, the paradigm he proposed still prevails as the ethical boundary when it comes to organ transplantation. For Titmuss, an individual’s altruistic behavior is the driving force behind the mechanism of organ donation. Altruistic individuals create a norm of volunteering and donating that, in turn, increases social solidarity. The state should create “opportunities for altruism” for individuals, such as, for example, the opportunity to donate blood or organs for transplantation. The aggregated altruistic behavior of individuals crystalizes into a social norm, contributes to social solidarity, and, in a virtuous circle, leads to an increase in altruistic behaviors. This position forms the basis for policies for collecting organs for transplantation and underpins advocacy systems for encouraging organ donation around the world. The assumption is that altruism constitutes an extant force in society and can be mobilized as a solid base for organ collection policies.

Generally, deceased organ procurement schemes follow “opt-in” or “opt-out” models. In opt-in or informed consent models, organs are procured from deceased people who carried organ donor cards or any other form of personal statement of their will to donate their organs after death. These models are the current policy in Israel and in the US, as well as in other countries. In an opt-out system, organs are procured under the presumption that an individual consents to become an organ donor after death, unless that person has explicitly opted out of the system. Such a model is more widespread in Europe, with the UK, France, and Switzerland joining Spain, Germany, Austria, and other nations in their opt-out donation policies. There is an indication in most research that opt-out models yield more donations [3]. In Israel, the current policy is opt-in [4].

The impact of religion on organ donation is positive [5,6]. However, there is controversy within orthodox Judaism regarding deceased organ donations after brain death [7]. Islam also has a rather supportive stance towards organ donations [8], but research indicates a that religious stance toward organ donation is inseparable from cultural and social standing [9].

This paper examines the assumption that altruism is associated with organ donation in Israel and helps to shed light on the complexity of this concept. The paper also highlights the need for a broad cultural and social context if the complex interplay between social structures and organ donation is to be understood.

Altruism is defined as behavior aimed at helping others [10]; it may promote prosocial behavior that is sensitive to the other people’s actual needs [11]. The behavior is carried out even when the helper does not expect any benefit or return, or when the behavior may endanger the helper to some extent [12]. On an extreme level, altruism can manifest itself in conscious self-sacrifice for the sake of others. Altruism is also defined as the social motive for doing good [13].

Various scales for measuring altruism are described in the literature. For example, the “dictator game” examined altruistic charitable donation through a survey or experiment [14,15,16]. Sliwak developed the Altruism-Nonaltruism (A-N) Questionnaire, which contains ten stories, each with six answers that reflect the various degrees of intensity of a person’s altruistic attitude [17]. Another method measures the orientation to altruistic values through self-rating on an altruistic value questionnaire, focusing on concepts such as fairness, world peace, and social justice [18].

The most common scale for measuring altruistic behavior is Rushton’s Self-Report Altruism (SRA) scale. Rushton et al. [19] developed a set of 20 statements to measure the level of helping or altruistic personality traits. For example, “I have helped push a stranger’s car out of the snow”; “I have given directions to a stranger”; “I have given money to a charity”; “I have given money to a stranger who needed it”; “I have donated goods or clothes to a charity”; “I have donated blood”; “I have helped carry a stranger’s belongings (books, parcels, etc.)”. Respondents were asked to mark how often they had participated in each behavior, ranging from never (1) to very often (5). Rushton’s scale [19] been translated and validated in many languages and cultures, including Mandarin [20], Hindi [21], Spanish [22], Indonesian [23], Turkish [24], Dutch [25], and Hebrew [26].

Many studies use altruism as a predictor of organ donation. Khalaila [26] used Rushton’s SRA scale [19] and found that Israeli students’ willingness to donate organs was positively related to their altruism level, their positive attitudes toward organ donation, and their organ donor registration. However, the students’ knowledge level had no impact on their willingness to donate. Further, while students who identified as Christian were more willing to donate organs than students of other religions in Israel, religiosity was negatively associated with behavioral intentions regarding organ donation. Milaniak et al. [17] examined the role of empathy and altruism in organ donation decision-making among 111 nursing and paramedic students, using the Sliwak Altruism scale. They found that altruism levels were associated with post-mortem organ donation and the willingness to sign a donor card.

In a meta-analysis that included 27 studies (most of them based on semi-structured interviews and focus groups), altruistic motivation to help others emerged as the most-identified motivator for becoming an organ donor. Altruistic motivation to help another person, while knowing that the organs help another person improve their quality of life and longevity, was a driving force behind the consent to donate organs. Other factors included a sense of solidarity with society and a belief that organ donation is used for beneficial purposes with patients [27].

Given the deficiency in the number of organs and, therefore, long waiting times for transplantation (eight years on average in Israel and five years the US), policymakers face the challenge of raising organ donations [28]. Because organ supply depends on public motivation to donate, the roles of altruism and attitudes regarding organ donation are essential when considering the unavailability of organs for transplantation. However, little is known about the impact of these factors on the general population’s willingness to donate in Israel. Previous research performed in Israel was conducted among college students [26], whereas the current research was conducted among the general population. Another study in Israel examined the knowledge and preferences of Israel’s Jewish population regarding the organ allocation policy [28] rather than willingness to donate. An examination of the association between altruism and attitudes would assist in identifying groups in the population that do not tend to sign an organ donation card and in developing culture-adapted interventions and educational programs to increase awareness of organ donation.

1. Barr, ; Bradley, J.A.; Hamilton, D. Organ Transplantation: A Historical Perspective. In Transplantation Surgery; Hakim, N., Haberal, M., Maluf, D., Eds.; Springer Specialist Surgery Series; Springer: Cham, Switzerland, 2021. https://doi.org/10.1007/978-3-030-55244-2_1.
2. Titmuss, The Gift Relationship: From Human Blood to Social Policy; George Allen and Unwin: London, UK, 1970.
3. Madden, ; Collett, D.; Walton, P.; Empson, K.; Forsythe, J.; Ingham, A.; Morgan, K.; Murphy, P.; Neuberger, J.;Gardiner, D. The effect on consent rates for deceased organ donation in Wales after the introduction of an opt-out system. Anaesthesia 2020, 75, 1146–1152. https://doi.org/10.1111/anae.15055.
4. Boas, ; Lavi, S. Organ donation, brain death and the limits of liberal bioethics. In Bioethics and Biopolitics in Israel: Socio-Legal, Empirical and Political Analysis; Boas, H., Davidovitch, N., Filc, D., Hashiloni-Dolev, Y., Lavi, S., Eds.; Cambridge University Press: Cambridge, UK, 2018; pp. 258–277.
5. Daar, S. The body, the soul and organ donation: Beliefs of the major world religions. Nefrologia 1994, 14, 78–81.‏
6. Oliver, ; Woywodt, A.; Ahmed, A.; Saif, I. Organ donation, transplantation and religion. Nephrol. Dial. Transplant. 2011, 26, 437–444. https://doi.org/10.1093/ndt/gfq628.
7. Halevy, ; Brody, B. Brain death: Reconciling definitions, criteria, and tests. Ann. Intern. Med. 1993, 119, 519–525. https://doi.org/10.7326/0003-4819-119-6-199309150-00013.
8. Rady, Y.; Verheijde, J.L. The moral code in Islam and organ donation in Western countries: Reinterpreting religious scriptures to meet utilitarian medical objectives. Philos Ethics Hum. Med 2014, 9, 11. https://doi.org/10.1186/1747-5341-9-11.
9. Alkhawari, S.; Stimson, G.V.; Warrens, A.N. Attitudes toward transplantation in U.K. Muslim Indo-Asians in west London. Am. J. Transplant. 2005, 5, 1326–1331. https://doi.org/10.1111/j.1600-6143.2005.00814.x.
10. Meyers, G. Social Psychology, 8th ed.; McGraw-Hill: New-York, NY, USA, 2005.
11. Batson, D. Altruism in Humans; Oxford University Press: Oxford, UK, 2011.
12. de Waal, F.B. Putting the altruism back into altruism: The evolution of Annu. Rev. Psychol. 2008, 59, 279–300. https://doi.org/10.1146/annurev.psych.59.103006.093625.
13. Monday, O.I. Is altruism always sufficient for organ donation? vroom's expectancy theory, for expanding the organ donor Saudi J. Kidney Dis. Transplant. 2020, 31, 503–507.
14. Bekkers, Measuring Altruistic Behavior in Surveys: The All-or-Nothing Dictator Game. Surv. Res. Methods 2007, 1, 139–144. https://doi.org/10.18148/srm/2007.v1i3.54.
15. Carpenter, ; Connolly, C.; Myers, C.K. Altruistic behavior in a representative dictator experiment. Exp. Econ. 2008, 11, 282–298. https://doi.org/10.1007/s10683-007-9193-x.
16. Hilbig, E.; Thielmann, I.; Hepp, J.; Klein, S.A.; Zettler, I. From personality to altruistic behavior (and back): Evidence from a double-blind dictator game. J. Res. Personal. 2015, 55, 46–50. https://doi.org/10.1016/j.jrp.2014.12.004.
17. Milaniak, ; Wilczek-Rużyczka, E.; Przybyłowski, P. Role of empathy and altruism in organ donation decision-making among nursing and paramedic students. Transplant. Proc. 2018, 50, 1928–1932. https://doi.org/10.1016/j.transproceed.2018.02.153.
18. de Groot, I.M.; Steg, L. Value orientations to explain beliefs related to environmental significant behavior: How to measure egoistic, altruistic, and biospheric value orientations. Environ. Behav. 2008, 40, 330–354. 10.1177/0013916506297831.
19. Rushton, P.; Chrisjohn, R.D.; Fekken, G.C. The altruistic personality and the self-report altruism scale. Personal. Individ. Differ. 1981, 2, 293–302. https://doi.org/10.1016/0191-8869(81)90084-2.
20. Chou, L. The Rushton, Chrisjohn and Fekken Self-Report Altruism Scale: A Chinese translation. Personal. Individ. Differ. 1996, 21, 297–298. https://doi.org/10.1016/0191-8869(96)00040-2.
21. Khanna, ; Singh, P.; Rushton, J.P. Development of the Hindi version of a Self-Report Altruism Scale. Personal. Individ. Differ. 1993, 14, 267–270. https://doi.org/10.1016/0191-8869(93)90202-E.
22. Aguilar Pardo, ; Martínez Cotrina, J. Validation of the self-report altruism scale test in Colombian University Students. Ánfora 2016, 23, 17–35. https://doi.org/10.30854/anf.v23.n41.2016.139.
23. Suseno, Adapting self-report altruism scale to measure altruistic behavior of pre-service teachers in Indonesia. Int. J. Psychosoc. Rehabil. 2019, 24, 7652–7662. https://doi.org/10.37200/IJPR/V24I8/PR280777.
24. Karacan, ; Cengiz Seval, G.; Aktan, Z.; Ayli, M.; Palabiyikoglu, R. Blood donors and factors impacting the blood donation decision: Motives for donating blood in Turkish sample. Transfus. Apher. Sci. 2013, 49, 468–473. https://doi.org/10.1016/j.transci.2013.04.044.
25. Garofalo, ; Noteborn, M.; Sellbom, M.; Bogaerts, S. Factor structure and construct validity of the Levenson self-report psychopathy scale (LSRP): A replication and extension in dutch nonclinical participants. J. Personal. Assess. 2019, 101, 481–492. https://doi.org/10.1080/00223891.2018.1519830.
26. Khalaila, Religion, altruism, knowledge, and attitudes toward organ donation: A survey among a sample of Israeli college students. Med. Law 2013, 32, 115–129.
27. Newton, D. How does the general public view posthumous organ donation? A meta-synthesis of the qualitative literature. BMC Public Health 2011, 11, 791. https://doi.org/10.1186/1471-2458-11-791.
28. Elalouf,A ; Pliskin, J.S.; Kogut, T. Attitudes, knowledge, and preferences of the Israeli public regarding the allocation of donor organs for transplantation. Isr J Health Policy Res 2020, 9, 25. https://doi.org/10.1186/s13584-020-00376-3.
29. Barr, ; Bradley, J.A.; Hamilton, D. Organ Transplantation: A Historical Perspective. In Transplantation Surgery; Hakim, N., Haberal, M., Maluf, D., Eds.; Springer Specialist Surgery Series; Springer: Cham, Switzerland, 2021. https://doi.org/10.1007/978-3-030-55244-2_1.