by Dr Bonnie Venter, University of Bristol, and Dr Liam Davis, University of Liverpool
When living kidney donors or surrogates come forward, we expect them to be motivated by altruism. Essentially, we want these individuals to selflessly help others without expecting anything in return. In recent years, the importance of altruism as the guiding value for living kidney donation (LKD) and surrogacy has been reaffirmed. The Nuffield Council for Bioethics, in their report, Human Bodies: Donation for Medicine and Research (2011), recommended that altruism remain the central value in the donation of bodily materials, and professional guidance describes altruism as the basis for organ donation. The same was echoed in 2023 when the Law Commissions of England, Wales and Scotland considered surrogacy for legal reform and underscored that surrogacy ought to remain an altruistic act.
Altruism, however, has been and continues to be open to criticism. It is not clearly defined in policy; is often applied inconsistently in practice; and is used as a means to shape the regulation of organ donation and surrogacy. Recognising this issue, we applied for funding from the Institute of Medical Ethics to host a roundtable in June 2025 at the University of Bristol.
The roundtable brought together a range of professional (researchers, clinicians, lawyers) and lived experience experts (donors, recipients, surrogates or intended parents). A written summary of the roundtable is available in BioNews, and in this post we delve into a bit more detail about the key themes from the day. The sketch notes used throughout this blog also helpfully capture the essence of the talks.
The aim of the roundtable was to i) discuss the role of altruism in LKD and surrogacy; ii) determine how altruism is applied respectively in LKD and surrogacy, both in clinical and legal practice, and whether any parallels exist; and iii) understand how LKDs and surrogates’ experiences of these practices are shaped by the clinical and legal expectation to act altruistically. It is this last focus specifically that piqued our interest in the topic, as we were working from the position that there is a disconnect between law, practice, and lived experience. Following the roundtable, we were able to discern the following key themes:
1. Defining altruism
As a core principle in LKD and surrogacy, one would assume that altruism is easily defined. Yet, the various talks demonstrated that there is no consensus on what ‘altruism’ is or should be. Key elements of common definitions of altruism were scrutinised, leading us to question what it truly means to act selflessly or to not expect anything in return. How ‘pure’ altruism must be was also considered, and more importantly the consequences of having an unrealistic expectation of ‘purity’. It was widely accepted that both practices would allow one to benefit socially from their act, in other words to feel good about donating or being a surrogate, but the lines seemed more blurred when reimbursement or payment were discussed. Whilst these academic debates added value to the discussion, the lived experience panel reminded us to not over-theorise the issue and to stay grounded in the realities of those involved.
2. Money, money, money
The conventional understanding of altruism, both in LKD and surrogacy, reinforces a binary view of donors’ and surrogates’ motives – they are either seen as acting purely altruistically or as driven by some kind of expectation of a reward. As such, much of the roundtable discussion centred on whether ‘payment’ detracts from altruistic motivation (or otherwise compromises ‘altruism’) and how ‘reasonable expenses incurred’ should be interpreted for both activities. It was clear that surrogacy leaves more room to negotiate these expenses due to parental orders, which transfer legal parenthood in surrogacy arrangements to the intended parents, being granted after the child is already born. At this point, the child’s welfare is the court’s paramount consideration. By contrast, strict boundaries are drawn around the expenses associated with living donation, leaving minimal flexibility. Donors and surrogates expressed a sense of discomfort when discussing money, noting that they did not want to be seen as ‘extorting the system’ or ‘just doing it for the money’.
3. How do those with lived experience view altruism?
As stated earlier, our interest in this work was rooted in whether there was a disconnect between law, practice, and lived experience. Venter’s doctoral research (Towards an Understanding of the Legal and Experiential Dimensions of the LKD Pathway) already demonstrated that it is not possible, nor practicable, to reduce individuals’ unique reasons for donating to a single motivator. We assumed that the same might ring true for surrogates. The roundtable could not, nor was intended, to answer this question, but it did offer several valuable insights. One was that a surrogate emphasised that she had ‘never labelled what we [surrogates] do as altruistic’ and that she had rather used altruism often as a ‘defence’ when questioned about her motives. When considering the public narrative, there seemed to be an agreement that terms like ‘hero’, ‘angel’ and ‘gift’ did not necessarily resonate with all and that these rhetorics could be dialled down. Finally, we also reflected on the relationship between altruism and others involved with the donation or surrogacy journey. It was noted that more can be done to enable others, such as family members, to support altruistic acts (for example, allowing expense claims for their involvement). Importantly, we were also reminded that, while the law focuses on assessing altruism at a single point in time, altruism’s impact in daily life is often not so linear. For instance, organ recipients may feel a lasting pressure to take care of the organ and themselves in a way that aligns with the donor’s and society’s expectations.
Where to from here?
The roundtable shone a bright light on the complexities that arise when altruism is placed at the centre of regulating LKD and surrogacy. These issues take on an added significance when viewed against the background of an ongoing shortage of donors and surrogates. The breadth of discussions and questions – far greater than we anticipated – revealed that there is much that needs to be considered. Yet, the ideal starting point seems to be to rethink what altruism means and the role it plays in donation and surrogacy.
Acknowledgements: We would sincerely like to thank all members of the roundtable who contributed their time, insights and experience to this work. We are also especially grateful to Jim Rogers, the sketch note artist, who captured the discussions so thoughtfully. A huge thank you also to our research assistant, Annie Sheldon. Finally, thanks to the Institute of Medical Ethics for providing the funding to enable all of this to happen.