*Coupling and Deviating of Altruism-Voluntariness Relationship in Organ Transplantation DOI: http://dx.doi.org/10.5772/intechopen.95895*

have featured individual 'case studies', which are sometimes called 'stories of hope' that tell the story of people awaiting a transplant and describing their situation and highlight the benefits a transplant can provide. The use of case studies aims to motivate and address people to take action to help others and create empathy by making the human impact of organ deficiency clearer.

The empathic-altruism hypothesis, widely described and proven in the psychological literature, suggests that empathic anxiety for another can lead to altruistic motivation to improve the well-being of the other [15].

Traditionally, altruism refers to a situation where one takes action for the benefit of another even when self-sacrifice is required. Therefore, altruism shows up with actions since goodwill and good thoughts are alone not enough. One goal of this action should include helping another person. If the well-being of the other person is an unintentional or secondary result of an action that one takes to improve one's own well-being, this action is not altruistic. Altruism does not change according to circumstances. Considering these characteristics, altruistic people are those who have a feeling of caring/considering other people.

There is no widely accepted classification of the types of altruism; however, two types of altruism, normative and hedonistic, are mentioned in some studies. While **normative altruism** can emerge through moral intuition, non-moral social rules, or logic, **hedonistic altruism** emphasizes that the individual finds a value in their perception of the situation where other individuals' distress decreases, they are better off, or they are happier [16].

**Ethical altruism** is based on the principle that altruism is a virtue, even an obligation. Some might argue that people are always generous and altruistic. This view may apply to a sole advocate of ethical altruism. At this point, the person expressing opinion actually advocates **psychological altruism**. It is worth noting the consequences of **pure altruism**-related behaviors based on the fact that everyone accepts the assumption of desiring very little for themselves and very much for others by one's voluntary sacrifice of their own pleasure to give pleasure to others. All those who behave in this way should not have thoughts for themselves as the giver, nor for others as the recipient, when considered not only as the waiver but as the acceptor of what has been renounced. A sense of compassion that is worrisome for others, willingly self-victimizing to benefit others, cannot be achieved without thinking that those who victimize themselves by giving something to others expect a benefit from it [17].

**Moral altruism** is based on rewarding the altruistic and punishing those who are not altruistic [18].

**Kin altruism** is defined as the situation where an individual jeopardizes their own safety to increase the survival chance of other people with genetic or blood ties in the same family [19].

Generally, the living donor is an adult family member whose first-degree relative has terminal stage renal disease. Their experience provides them with insight into the challenges of kidney disease and transplantation. Individuals, motivated by altruism when they choose to donate kidneys after thinking for a long time about risks and benefits, can be emotionally unsettled, and even if they believe they are acting with a desire to help, their ability to act autonomously and without coercion may be endangered.

When the priority of the family concerning organ donation is considered in the blood tie theory, the emergence of altruistic behavior is explained by kin relationships. The individual behaves more altruistically towards their close relatives who carry the same genes, such as mother vs. child, and siblings vs. siblings, compared to other individuals. As the blood ties decrease, the desire to tolerate harm for altruistic behavior or the likelihood of the emergence of altruistic behavior decreases.

The reason for this is that human beings have gone through a psychological evolution process in a way that motivates them to spare even their lives in order for their own genes to be permanent. Thus, a person who has close relations to an altruistic individual can survive through the behavior of this altruistic relative.

**Partial altruism**, which means the individual shares their assets with others, also constitutes an example of altruism approaches, especially in organ transplantation. While doing a favor to others, the person may have sometimes thought of obtaining financial gains from this behavior.

Living donors without a genetic link are increasingly used worldwide, and various approaches support the application. Donors who are not genetically linked to the recipient and who are emotionally connected to the patient and motivated by a desire to help, without an expectation of any material gains can be examples of partial altruism. Many psychological studies show people behave more altruistically towards their friends who have strong emotional bonds with compared to others even though they have no kin relationship. In a meta-analysis investigating factors related to organ donation [20], it was found that education, religion, knowledge, attitude, social influence, altruism, and family positively affected organ donation and that fear of death and the fear of organ donation negatively impacted it.

Pro-social behavior has been suggested by some social scientists as the opposite of anti-social behavior and has been defined as a behavior done with autonomous and free will that benefits others. According to Batson, there are two types of prosocial behavior: egocentric and other-centered. In egocentric pro-social behavior, the person expects to be rewarded or escape from any negativity for the positive behavior to another, while in other-centered pro-social behavior, the only goal of the person is to be helpful to the person to whom the positive behavior is directed, and there is no personal expectation in return for this behavior [21]. While this type of behavior is specified as altruistic behavior, one of the best examples of this is organ donation after death. A person cannot benefit from donating their organs after death.

In a study on the phenomenon of altruistic behavior, titled "An investigation on epistemological problems", Yeşilkaya approaches the subject with a three-color classification. The view claiming that altruism is based on the expectation of gaining a benefit from the person or the community that receives the sacrifice is characterized by the "black" metaphor, and the view claiming that this kind of sacrifice is made without expecting any return from any source is characterized by the "white" metaphor. However, when the research on this subject is examined, a third, "gray", understanding, which makes the epistemological blurriness that already exists more thought-provoking, stands out. The study points out that this hybrid approach, which makes the subject relatively more complicated, differs completely from the "black" view in terms of from whom or where to expect the return of altruistic behavior, but reveals clearer boundaries than the "white" view. As a matter of fact, although this understanding accepts that altruistic behavior is realized with an expectation, it is seen that the addressee of this expectation is based on the understanding that it is not the person or the community that receives the sacrifice but a completely different motivator and a different source of power. In other words, according to the "gray" view, it is accepted that there is an expectation that motivates the individual to act altruistically as in the "black" view, and it is essential not to expect a return from the person who is the subject of the sacrifice as emphasized by the "white" view. That is, the person acts voluntarily [22].

Some critical points can be mentioned when talking about altruism. Some studies have shown that personality is not effective in attitudes towards organ donation, but altruistic nature affects attitudes towards it [23].

People who volunteer to be a living donor with a completely altruistic attitude, without expecting anything in return, make a great sacrifice. Whether the approach of donors is really altruistic in organ transplantation requires a good ethical evaluation.
