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Altruism has a long history both as a moral ideal and an ethical practice; it has developed into an area of signiﬁcant interest in the domain of bioethics. This research paper examines the historical background of altruism as a philosophical concept, the varying deﬁnitions of altruism, its signiﬁcance to bioethical debate and inquiry, and the moral duties of health care professionals. A conceptual analysis of altruism is supported by a discussion of contemporary cases in health care where altruism plays a pivotal role. Speciﬁc attention is given to the importance of altruism in research participation and organ donation and the response of health professionals to epidemics and disasters. Altruism as a bioethical concept has global implications, particularly when attempting to understand the many factors that underpin the caring response of health professionals and the general public to the complex health needs of others.
The concept of altruism has a global scope within the domain of bioethical debate and inquiry. A discussion of the complexity of altruism and its role in modern health care allows a more detailed understanding of the global response to health epidemics and disasters, while also enabling a clearer perception of the moral duties of health care professionals. There has been much debate surrounding the varying deﬁnitions of altruism and the ethical implications of the normative role it plays in bioethical debate in health care. Despite the conceptual confusion surrounding discussions of the role and meaning of altruism, its ethical importance for research participation, organ donation, the doctor-patient relationship, and the ongoing response to global health emergencies remains clear. Two questions guide and animate the following discussion:
- What is the importance of altruism for bioethics?
- What are the limits of altruism in the context of the role of health professionals?
These questions pertain to the nature and the limits of altruism as an ethical concept, prompting a closer examination of altruism in terms of its historical background, how it has been deﬁned and understood, and the importance of the value of altruism in the domain of bioethical inquiry.
History And Development
The notion of altruism had its beginnings in the writing of Auguste Comte (1798–1857), whose philosophy contained a system of positive knowledge that was applicable to the natural world as well as the social world of human relationships. Comte held that altruistic instincts are part of human nature and that our “benevolent feelings” are developed by our relations with other people in the social world (Comte, in Lenzer 1975, pp. 407–408). Comte set up a distinction between the human tendency to concerns of self-interest and an outward directed concern for others, claiming that the central problem for human life was “.. .the subordination of egoism to altruism” (Comte, in Lenzer 1975, p. 400). As the philosopher Thomas Nagel states, “Altruism itself depends on a recognition of the reality of other persons, and on the equivalent capacity to regard oneself as merely one individual among many” (Nagel 1978, p. 3).
Altruism In Medicine
Medicine emerged as a profession in the nineteenth century, but its beginnings can be discerned earlier, when distinct professional identities with special skills were both recognized and in high demand. In the medical profession, the specialization of knowledge led to tensions between practitioners that were managed in part through the development of an organized medical ethics; interestingly, the doctor-patient relationship was originally mentioned in the eighteenth century in order to prevent doctors taking each other’s patients. Conﬂict within the profession became a central concern of medical ethics in the nineteenth century, with codes of ethics sometimes leading to dissonance. While medical ethics was strongly focused upon the relationships between practitioners, this did not rule out a concern for ethical principles of patient care.
For a brief period in the 1950s, medicine became truly prestigious, the authority of doctors was largely unquestioned, and the public had a great deal of trust in the competency of doctors. Changes occurred in 1960s USA, where the medical profession declined in authority and the trust of the general public; a situation that could partly be associated with uncertainty about scientiﬁc medicine, the possibilities of alternative therapies, and nonmedical resources. Medicine has a human as well as a scientiﬁc dimension, hence the traditions of science and medicine have different historical underpinnings: science is “value free” and concerned with generalizations, while medicine has a deep-rooted hierarchy of values and focuses on individuals (Cassell 1986, p. 186).
One of the best contemporary examples of the differing views on altruism in the context of the profession on medicine is the 2002 Journal of Medical Ethics special symposium “Heroes – or Just Doing Their Job?” In a commentary on the contributions of Glannon and Ross and McKay to this symposium, McLean underlines the importance of the context for the understanding of the meaning of altruism in a changing world; the meaning changes as the context changes such that in some contexts it is easier for a health professional to be altruistic than in others (McLean 2002, p. 74). The perspectives held by McKay and Glannon and Ross have a particular context highlighted by McLean. They responded to a difﬁcult time in medicine in the UK in the beginning of this century, when the morality of medicine and doctors was questioned (McLean 2002, p. 74). McLean draws the conclusion that it is more difﬁcult for doctors to practice altruism in the current context of many constraints, drawing attention to the everyday altruism of patients in teaching hospitals who allow medical and nursing and midwifery students, to examine them for the beneﬁt of future patients (McLean 2002, p. 74).
Cassell (1986, pp. 185–186), writing on bioethics two decades earlier, sees the changing context as a result of the increasingly close and evolving relationship between medicine and science accompanied by changing conceptions of what it means to be a doctor in terms of how to balance the human side of the profession with the scientiﬁc ideals that underpin modern medicine. Doctors do not only treat disease but persons as a whole, requiring an art of practicing medicine that demands an individual capacity to deal with the conﬂicts raised by the human aspect of their profession (Cassell 1986, p. 190).
Altruism remains important for the doctorpatient relationship, in that patients must trust the knowledge of the doctors who are treating them, while doctors accept responsibility for that trust, utilizing their skills to treat disease and acting altruistically for the best interests of their patients (Cassell 1986, pp. 203–204). From a different perspective, Downie observes that altruism is in a different moral category from duty; while doctors as professional health care practitioners are duty bound to observe the rules and standards of their profession, this is distinct from altruism, which is outside “duty” (Downie 2002, p. 75). Downie argues that doctors are not altruistic in their performance of professional duties but can be altruistic in the “context” of their duties, that is, acting outside their obligations or duties but in relation to the public position they hold (Downie 2002, p. 75).
Glannon and Ross (2002, p. 68) take a similar view, arguing that the doctor-patient relationship embodies ethical obligations on the part of doctors, who are bound by the principle of beneﬁcence and must work to support and ensure the best interests of patients. This “framework of obligation” is compatible with beneﬁcence, yet it does not align with altruism understood as something over and above duty or obligation (Glannon and Ross 2002, p. 68). For Glannon and Ross, while altruism is always optional and beyond “duty,” there are cases where medical professionals act altruistically within their roles: doctors who place themselves at considerable risk to treat patients in dangerous parts of the world or who extend extra assistance to patients outside the professional framework of duty or obligation (Glannon and Ross 2002, p. 68). Thus, health professionals who exercise their skills during global epidemics or disasters demonstrate a mixture of both beneﬁcence and altruism; they are doing more than their mere duty. McKay (2002, p. 70) maintains that the standards set by the profession of medicine itself is such that the commitment of the medical practitioner to their profession reﬂects a commitment to a higher moral standard than society in general. On McKay’s view, the duties of the medical professional are “supererogatory” and the “open-ended” nature of the commitment that doctors freely make can be understood as “supererogatory” in itself (McKay 2002, p. 72).
Doctors are not the only medical professionals to whom the notion of altruism is important, as there is an emphasis on the notions of compassion and care in the professional duties of nurses. Compassion is one of the key professional values identiﬁed by the ICN International Code of Ethics for Nurses and one that has been traced to Florence Nightingale’s Christian inﬂuenced ideals and the particular way in which she interpreted these ideals into the profession of nursing. Before the 1800s, nursing was associated with the religiously and domestically based duties of women, who provided care to the sick within families and the wider community. From the nineteenth to the mid-twentieth century, nursing was regarded as a vocation, often linked to nurses being trained by religious orders, such as the Institution of Deaconesses in Kaiserswerth, where Nightingale was a student. There has been a strong association between Nightingale and nursing reform, but the early reform movement was in effect before Nightingale’s nursing activities during the Crimean War. However, Nightingale made important contributions to nursing professionalism, including promoting its respectability as an occupation for ordinary women and by emphasizing the importance of the “caring qualities associated with women.”
The most important theoretical problem for understanding the role of altruism in bioethics is how to deﬁne it. There are many dimensions to the deﬁnitions of altruism offered in the bioethical and philosophical literature, from the idea that altruism embodies a motivation to act for the sake of others (Jansen 2009, p. 27) to the notion that altruism requires action for the beneﬁt of others without ulterior motives for self-gain (Nagel 1978, p. 79). While it is important to emphasize the notion of altruism as embodying concern for others over self-interest, there is much philosophical debate around the necessity of selﬂessness and what this means for the possibility of altruism in everyday life. The egoist view, best represented by the writing of Thomas Hobbes, holds that even when acting for the good of others, human beings always pursue their own “long-term” interests. Yet, from a more Aristotelian perspective, altruism can be compatible with self-interest, in the sense that the best outcome for one’s self, as a member of common humanity, is ensured through action that beneﬁts others. Nagel argues for altruistic agents with a strong sense of self who also act for the sake of others (Nagel 1978, p. 88). For Nagel, altruistic action is not underpinned by subjective choice but by objective values that are discoverable through the human capacity to see ourselves from two points of view: the “personal” and the “impersonal” (Nagel 1978, p. 144). Altruism is founded upon recognition of a common world, what Nagel discusses in terms of a general understanding of the existence and reality of other people, an achievement that is undermined when individuals ignore the impersonal point of view and stay solely within a purely personal perspective (Nagel 1978, pp. 144–145). Medical practitioners are expected to place the interests of patients before personal interest. Altruism in the profession of medicine has been connected with the ways in which health care professionals take up their responsibilities toward patients, placing care for patients before their own interests.
There are many aspects of health care that can be better understood through a more nuanced view of altruism set in a particular context, such as the issues surrounding organ donation, research participation (Jansen 2009), and the response to global epidemics and health emergencies (Kinsman 2012). The ethical implications of altruism in these health care domains will be the focus of attention in the next section.
The Importance Of Altruism In The Health Care Profession
Altruism may be regarded as an ideal of the medical profession rather than a requirement. As part of what makes a good “physician,” Cassell recognizes that the doctor-patient relationship embodies responsibility through the trust given by patients to doctors; doctors act altruistically when they represent their patients, taking action toward the goals that their patients would have aimed for if they could (Cassell 1986, p. 201; p. 204). Bioethicists who have discussed concepts of altruism agree that the motives of health professionals and volunteers matter and that it is ethically relevant that they help others from their regard for the needs of others, not their own, while also recognizing that the needs of others can only be met if personal needs are ﬁrst taken care of (Kinsman 2012; Jansen 2009).
From the perspective of practicing nurses, Hem et al. (2014, pp. 796–797) argue for a concept of mature care based on reciprocity, embodying an understanding of the relationship between nurse and patient that occupies a middle ground between altruism and egoism. On this account, altruistic care embodies the notion of balance between the needs of another and one’s own needs; nurses have a sense of self and care for their patients within particular contexts that are subject to change (Hem et al. 2014, pp. 798–799).
Kinsman (2012) concurs, noting the complexity of the motivations of health professionals in his discussion of the Ugandan Ebola outbreak of 2000–2001. Kinsman argues that the fear associated with the nature of Ebola led to two generalized responses toward those affected by the disease: altruism and stigma (Kinsman 2012, p. 2). He also accepts the notion that altruistic motivations can exist alongside secondary concerns of self-interest: health professionals responded to the epidemic from selﬂess humanitarian impulses; at the same time, they also had to take care of themselves so as not to become infected by the virus (Kinsman 2012, pp. 8–15).
Altruism In Research Participation
Many aspects of health care practice such as blood and organ donation and research participation depend on the altruistic motivations of patients and the general public. In the domain of research participation, Udo Schuklenk discusses the HIV/AIDS virus and the ethical considerations involved in providing terminally ill patients access to experimental drug trials, with questions being raised about the balance between the interests of future patients and the interests of the current patients; (Schuklenk 2012, pp. 446–447). As the desire to access experimental drugs that are otherwise unavailable forms part of the individuals’ motivation, there is a question about the possible exploitation of vulnerable individuals in the sense that the drugs may not work and their possibility of longer survival could be undermined. Jansen discusses the ethical relevance of altruistic motivations of people participating in research projects, distinguishing between primary and subsidiary altruistic motivation. Primary altruistic motivation indicates that research subjects who enroll in clinical trials are motivated solely from a desire to help others, whereas individuals with subsidiary altruistic motivation genuinely want to beneﬁt others but with a view to gaining some therapeutic beneﬁts for themselves (Jansen 2009, p. 27).
Jansen argues that there are both weaker and stronger varieties of subsidiary altruistic motivation and that for a research participant to be characterized as genuinely altruistic, it is necessary for them to have a primary altruistic motivation or a strong subsidiary altruistic motivation (Jansen 2009, p. 28). Jansen’s analysis is highly nuanced, but a key argument is that despite the issues around identifying the presence of altruism in the motivations of research participants, altruistic motivations could help to minimize the possibility of exploitation in clinical research (Jansen 2009, pp. 29–34). Also important in the context of altruistic motivation are patients who participate in the voluntary education of student doctors in teaching hospitals, ensuring the future beneﬁt of medical professionals and future patients (Glannon and Ross 2002, p. 68).
Organ Donation And Altruism
Organ donation (and more recently live organ donation) has placed altruism at the center of the bioethical debate. In nonliving organ donation, there are concerns raised about how the altruism of donation is couched in the language of a “gift relationship,” with the possibility that the degree of sacriﬁce is not adequately captured by this terminology. The inadequacy of this term could be partly attributable to the relationship between gifts and consumerism and the impression that gifts are an extra rather than a necessity.
Altruism has been utilized in policies that aim to create or elicit altruism in society, and according to Hagai Boas (2011, p. 1379), nonliving organ donation has long been underpinned by a framework of altruism, understood in terms of a nondirect gift given to society in trust.
The Duties Of An Altruistic Health Professional In The Case Of Global Epidemics
To understand the scope and limits of altruistic acts of health professionals and ordinary individuals, it is necessary to understand what altruism means in today’s global health care settings, particularly in relation to widespread epidemics of infectious diseases. The West African Ebola epidemic was brought to the attention of the World Health Organization, and by early August, the WHO declared the epidemic to be “a public health emergency of international concern” (WHO, August 8, 2014). The outbreak began in Guinea in December 2013, and its transmission involved the African countries of Guinea, Liberia, Nigeria, and Sierra Leone (WHO, August 8, 2014). Von Bredow and Harkenbroch reported in The Observer newspaper on October 5, 2014, that Liberia, one of the countries affected by the Ebola virus, had a total of 51 doctors in 2010 and many of them died of the disease. Within Guinea, Sierra Leone, and Liberia, many health care workers from the local population succumbed and died from the disease, with problems in infection control making health care facilities highly risky and dangerous places for both patients and carers alike (MSF 2015, p. 7).
A shortage of medical staff points to related problems of lack of physical resources and stafﬁng, of hospitals, and of knowledge and education of the disease. Ebola triggers a high level of fear in the general public and among health care workers because of the associated symptoms and the high possibility of mortality, and this can undermine efforts to recruit volunteers and to obtain sufﬁcient resources to ﬁght the disease (MSF 2015, p. 11). A Doctors Without Borders (MSF) report released in 2015 was critical of the world’s response to the Ebola virus, particularly noting a “lack of leadership” from the World Health Organization and the initial reluctance of the governments of Guinea and Sierra Leone (MSF 2015, p. 9). It was noted that the slow response of these countries could not provide the help needed in a timely manner that would have prevented the rapid spread of disease a year earlier (MSF 2015, p. 9). The MSF report was also critical of the focus of altruism during a globally signiﬁcant epidemic: cases of Ebola diagnosed outside of Africa gained international attention and prompted a change to the international response to Ebola (MSF 2015, p. 11). The concern was for the small number of doctors and nurses, those closest to us, infected by the virus, rather than for the large numbers of people suffering and dying in Liberia, Guinea, and Sierra Leone.
Limits To The Altruism Of Health Professionals During Epidemics
There are limits to altruism, no matter how willing health professionals are to engage in acts of it. The MSF report drew attention to the problems of ensuring enough volunteers and specialized staff to fully deal with the Ebola epidemic, emphasizing the altruistic actions of national health workers, who at a high personal cost continued to deal with the outbreak on the ground (MSF 2015, p. 9). In Liberia in particular, ethical issues arose in the context of the limits of altruism; MSF had to make a decision whether to take over Ebola management centers in the country when they were already at capacity dealing with the outbreaks in Sierra Leone and Guinea (MSF 2015, pp. 9–10). The risks were considered and the decision informed by altruism: MSF would take over the coordination of the centers in Liberia, intensively training over 1000 people to assist (MSF 2015, p. 10). MSF acknowledged the limits of altruism by stating that no matter how hard they tried, the scale of the crisis was so large that not all lives could be saved by their interventions (MSF 2015, p. 10).
During epidemics, large numbers of people are in need of urgent, specialized medical and nursing care. This raises ethical concerns about how to ensure our altruistic responses to health emergencies have the most beneﬁcial outcomes, a problem that the notion of triage may be able to further illuminate. According to Veatch, the notion of triage contains a complexity of ethical principles that can be in conﬂict with tenets of the Hippocratic Oath as a “traditional ethic of medicine.” Veatch identiﬁes three categories recognized on the battleﬁelds in WW11: those with minor wounds who do not need immediate attention, those with critical injuries, and those who are so badly wounded that they are beyond hope (Veatch 2005, p. 236) Two perspectives are possible: (1) to treat those individuals or groups for whom the health professionals can do the most good, following the principle of utility, trying to do the best to promote the welfare of the greatest number of people; (2) to prioritize the treatment of those in greatest need, following the principle of justice. Veatch argues that many philosophers and many ordinary people would privilege assisting those worse off even if this lessened the quantity of overall good achieved (Veatch 2005, p. 238).
The MSF report discusses the limits that were adhered to in their response to Ebola, reﬂecting the very same ethical issues that animate the notion of triage. Rosa Crestani describes the choices as one of treating those at an earlier stage of the disease as opposed to those who were more advanced in the more infectious progression of the disease. The approach taken was to take the most patients possible (one patient per bed), to treat the sickest, to provide palliative care, and, due to lack of staff, to limit the time spent on each individual patient (MSF 2015, pp. 10–11). These issues emphasize that altruistic, well-meant intentions to assist suffering people around the globe on their own are not enough. International health professionals require large investments for their education and ongoing training; they need highly specialized knowledge as well as personal resilience in order to cope with working in isolated locations away from their families and home comforts.
Indeed, the MSF report draws attention to what is needed to adequately cope with any future outbreaks of Ebola, noting the importance of “perseverance” and “tenacity” of medical professionals, collaboration with the communities affected, improved technology, and further research and development (MSF 2015, pp. 20–21)
Do health professionals have an obligation to provide care in global disasters and epidemics if their own health might be at risk by doing so? The MSF report reﬂects the difﬁculties of the decisions to provide care in contexts that pose a high risk to health professionals. The risks posed to the safety of its employees was identiﬁed as one of MSF’s internal challenges, and it was noted that some of the precautions taken to protect staff caused distress in terms of placing limits on their capacity to provide the level and kind of care that they wished to provide (MSF 2015, p. 19). This could be interpreted in terms of recognition that there are limits to altruism and that these limits are associated closely with risk. As Downie has argued, although health professionals are necessarily bound by particular duties and obligations, altruism is in a different moral category (Downie 2002, p. 75). While this is also the view held by Glannon and Ross (2002, p. 68), the importance of altruism for medicine is recognized through their acknowledgment of the altruistic actions of health professionals who act outside their obligations.
In the ﬁrst three elements of the Code of Ethics of the International Council of Nurses (ICN) revised in 2012, nurses are directed to provide care to people who need it, particularly vulnerable populations, and doing this in a culturally appropriate manner while observing the principles of equity and social justice. The Code is short on practical detail as to how this can best be done. Even if the preamble to the Code of Ethics of the ICN supports the nurses’ refusal to participate in certain activities, this support pertains to acts that conﬂict with caring and healing. The ICN includes in the professional responsibilities of nurses the requirement to care for all patients “unrestricted by considerations of age, color, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race or social status.” The altruism of health professionals, then, must be founded on their skills, knowledge, and expertise, rather than merely on a vaguely deﬁned desire to help others expressed by ordinary individuals and groups.
Caring for the interests of others and the capacity to recognize the common good by adopting the perspective of the other are essential to any deﬁnition of altruism. A deﬁnition of altruism that could underpin bioethical enquiry might require only that one’s own interests do not take center stage and that the care of others, which is at the heart of medicine, may require sacriﬁce to one’s own interests within limits, framed by the common good that is gained from putting the interests of others ﬁrst.
Altruism plays an important role in understanding the commitment of health professionals; the contested nature of the notion of altruism in the context of the role and duties of medical professionals was discussed. It is clear that the voluntary nature of research participation, organ donation, and the altruistic motivations of health professionals, patients, and members of the public should be respected and acknowledged as crucial for the integral functioning of medicine.
The role of altruism cannot be underemphasized in the human response to health epidemics and the efforts of health professionals from around the world to countries far removed from their home societies. It is not possible to expect or demand self-sacriﬁce from health professionals or volunteers even though societies may hold expectations of particular roles of professionals in society. Altruistic professionals provide ethical health care globally, as evidenced by the response to global health epidemics and emergencies; patients and other members of the public make their contribution to this effort.
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