Review: The role of altruism in living organ donation and surrogacy

What does 'altruism' mean? How does it manifest within the law and policy of living organ donation and surrogacy? Are there any similarities and differences? These are just some of the questions we considered at a roundtable discussion held in June 2025 at the University of Bristol, bringing together professionals (including researchers, lawyers and clinicians) and people with lived experience (as a donor or recipient, or a surrogate or intended parent).

The roundtable was funded by the Institute of Medical Ethics. In our application, we said we wanted to interrogate the role of 'altruism' within organ donation and surrogacy because, while altruism underpins both practices, it is differentially regulated and enforced. This leads to a disconnect between law and practice and, as the different panels highlighted, illustrates that 'altruism' may not always reflect lived experience.

The day consisted of a keynote presentation and four panels: leading researchers; clinical experiences; regulatory insights; and lived experience.

The keynote presentation, delivered by Professor Jackie Leach Scully, University of New South Wales, Australia, currently visiting the University of Bristol, set up a general framework of altruism including its various understandings. She also outlined key similarities and differences between organ donation and surrogacy, particularly in terms of the end results (an organ versus a baby), motivations, timescales, and outside involvement. Professor Leach Scully raised the question, what can appropriately be considered a 'gift'? Could organs, or a baby, be considered a 'gift'? She emphasised the importance of understanding the role and meaning of altruism within both practices, especially as this impacts their regulation – a key theme to be considered throughout the day.

The first panel comprised leading researchers in law and philosophy. Dr Andreas Albertsen, associate professor at Aarhus University, Denmark, gave a philosophically-informed account of organ donation. He outlined the role and limits of altruism within (living) organ donation, making a plea to acknowledge the constraints of focusing too much on acting 'altruistically'. Spencer Clarke, senior lawyer at the Law Commission of England and Wales, then gave a brief overview of the 2023 surrogacy law reform Report's recommendations regarding 'permitted' and 'prohibited' payments. Finally, Professor Kirsty Horsey, Loughborough University, spoke to the current model of claiming expenses in UK surrogacy law, drawing on empirical work she conducted on how surrogates view 'expenses' and 'payments'. Dr Albertsen and Professor Horsey clearly demonstrated that a purist account of altruism does not suitably cover the numerous motivations behind organ donation and surrogacy.

The second panel focused on clinical experiences. Dr Pippa Bailey, nephrologist and associate professor in renal medicine at the University of Bristol, said she found viewing living kidney donation as an altruistic act problematic. Rather than strictly using 'altruism' as a guiding principle when assessing a living donor, she looks at their motivations more broadly. Dr Bailey also acknowledged that the different conceptions of altruism can cause difficulties, for example, adhering strictly to 'pure' altruism would exclude many potential donors. Suzanne Whitehead, a clinical psychologist, said she likewise focuses on motivations when assessing donors and noted some 'red flags', such as seeking to donate to 'correct' a past wrong.

Dr Carole Gilling-Smith, CEO, medical director and Human Fertilisation and Embryology Authority person responsible at the Agora Clinic, then outlined how the pre-conception welfare check in surrogacy acts to 'test the capacity' of an altruistic surrogacy arrangement, therefore positioning clinics as having a 'gatekeeping' function. Finally, David Pexton, head of counselling and wellbeing at SurrogacyUK, explained how his role as an implications counsellor was not to validate altruism, but to ensure that people understood the consequences of their decisions and made an informed choice. Like earlier speakers, Pexton was more concerned with a person's motivation to become a surrogate or donor, suggesting 'pure' altruism could, for example, silence valid emotional responses. This panel therefore helpfully illustrated an apparent disconnect between law and practice.

The penultimate panel focused on regulatory insights. Lisa Burnapp, associate medical director, NHS Blood and Transplant, differentiated between how altruism is often seen as 'impure' versus 'pure' by explaining that she viewed altruism as a spectrum; that is, between egoism ('about me'), reciprocity ('about us'), obligation ('about them'), and altruism ('about everyone else'). Sarah Jones, chief executive of SurrogacyUK outlined the various reasons someone might wish to be a surrogate, remarking that altruism cannot rely solely on good intentions. Altruism is not about being a saint – but about being respected and supported in decision-making. Finally, Andrew Spearman, partner at Hanne and Co Solicitors, provided a breakdown of how the courts have broadly interpreted the legal requirement that surrogates can only be reimbursed 'expenses reasonably incurred'.

The final panel of the day comprised speakers who have lived experience in organ donation and/or surrogacy: Amy Carr, Fez Awan, Sally Sheldon and Zara Shettima. Speakers discussed motivations for donating/becoming a surrogate and, once again, how a strict focus on 'altruism' did not reflect lived realities. Amy (a surrogate) said she had not previously thought much about understandings of altruism, but had used the term 'altruistic' as a defence when people mistakenly assumed she must have been motivated in some way by financial gain. Interestingly, Fez (a three-time kidney transplant recipient) reflected on how an overemphasis on altruism as the guiding value can obscure the complex realities involved in familial living organ donation.

At the end of the day, as with any good discussion, we were left with more questions than answers. One common theme was 'altruism' having no set definition, makes it hard to regulate or enforce (indeed, if we wish to uphold this ideal). But there was also a sense that focusing on altruism means that lived experience differs from legal expectations, which also differ from the public narrative. For example, donors and surrogates are typically referred to as either 'heroes' or 'angels' for their actions and perceived altruistic motivations, but might reject such terminology. We plan to explore this in future research, building on insights gained from the roundtable.

We also plan to conduct further research into altruism within organ donation and surrogacy (and more broadly within medical law and policy) to attempt to answer some of these unresolved issues – and maybe even posit new ones. At present, however, it seems altruism's role as a guiding principle is open for debate. Although the day demonstrated that altruism sometimes creates more complications and inconsistencies than it resolves, it also undeniably helps to foster a baseline of trust and common ground. That said, it might be time to begin thinking more critically about the values we attach to 'altruism' and which we wish to preserve, before considering other ways to regulate 'altruism' (whatever it means!) in practice.