Introduction

“Over 1000 people have already volunteered to donate their kidney to a stranger in need. What about you?“ This Facebook post by the Israeli organization for procuring living organ donors, “Matnat Chaim”, (Gift of Life) has attracted much attention on social media and led many to contact the organization and to learn more about the process of becoming a living organ donor. This manner of soliciting volunteers to become living organ donors is not exceptional or unique to Israel. Yet, its success is extraordinary compared to anywhere else in the world. This paper explores this success in relation to theories on altruism and solidarity in sociological thought and calls for a nuanced understanding of the linkage between these two classical concepts.

What motivates someone to volunteer to donate one of his kidneys to a stranger? Whereas much effort was invested in exploring the social factors that determine the willingness to sign organ donor cards and to consent to post-mortem donations, the reasons that drive a living person to voluntarily undergo a nephrectomy and to donate one of his or her kidneys to a stranger, have remained largely unpacked. Nonetheless, the scope of such donations, defined as non-directed donations or living anonymous donoations, is on the rise. This type of organ donation can be defined as a kidney donation of a living person to someone with whom the donor has no prior acquaintance, a stranger of some sort. In the US the percentage of such donations increased from only 1% of all living organ donations in 2002 to 7% in 2020Footnote 1. Israel is a worldwide leader in non-directed living donations, with a rate of 67% out of all living kidney donations in 2020 being procured from living volunteers who do not know their recipientsFootnote 2. Against the backdrop of the exacerbating shortage in organs for transplantations, the solution to the question of living non-directed donations seems important not only in terms of policy, but also sociologically interesting and ethically challenging.

In this paper I wish to explore the trend of living non-directed donations in Israel by exploring the narratives, worldviews, and socio-demographic profile of these donors. Following the donation stories unravels an alternative to the liberal understanding of the altruism-solidarity nexus in sociological thought and bioethics. Following Mizrachi (2016, 2017), I am introducing here narratives outside the liberal framing of ‘an ethical organ donation’. The paper is structured as follows: I will start by introducing the altruism-solidarity question in sociological thought with an emphasis on its import to biomedicine. I will then present the challenges that non-directed organ donations pose to the ethics of organ donations. The following sections unfold central features of non-directed donations in Israel by focusing on statistical data, the donors’ reflections, and press coverage. The final part discusses non-directed donations as related to non-liberal designs of the altruism-solidarity nexus and suggests the concepts of the stranger, collective identity, and relatedness, to understand the emergent themes found in the research.

The Altruism - Solidarity question in sociological thought and its import to biomedicine

The altruism-solidarity question asks about the source of pro-social behavior: is it a result of normative structure of solidarity acted upon individuals or is it the product of altruistic actors, whose acts accumulate to form patterns of solidarity between group members? In fact, this question is in fact a variant of the problem of social order and stands at the basis of liberal thought. (MacIntyre 1967, Wuthnow, 1993. Mangone 2020). A central tenet of liberal thought frames social questions as a problem of agency: how actors, individuals, subjects act within structural constrains (Abbott, 2016)? Accordingly, liberal interpretations to the altruism-solidarity question adopts a methodological individualism standpoint which asks how to encourage a pro-social behavior? Is it sourced out from a structure of solidarity or from individualistic acts of altruism?

Coined by one of the discipline’s founders, August Comte, altruism was conceptualized as criticizing the materialistic and utilitarian aspect of human behavior in market societies of 19th century industrial France. Against the self-centered behavior of his time, Comte suggested that a futuristic and progressive society will be characterized by a “religion of humanity” where altruism (literally, other-oriented behavior) rather than utilitarianism and egotism will guide human behavior (Comte 1895, 1851-4). It is Durkheim who linked altruism with solidarity as two inseparable sociological concepts: “Wherever there are societies, there is altruism, because there is solidarity”, he writes in The Division of Labor in Societies (2014 [1893]in Steiner 2017), and refers to “pre-contractual solidarity” that enables social accordance that are sine qua non to contractual interactions. To him, and contrary to liberal theories of social contracts, no contract could have been carried out without the existence of an already given, mutual understanding of social bonding (Follert, 2020). Interestingly, in his study on religion, Durkheim understands the renunciation of self-satisfaction on behalf of the faith holder, and the commitment to religion’s set of restrictions, sacrifices and even pain, as symbols of giving away part of oneself in favor of a higher cause which is, according to him, a sublimation of the idea of the social. (Durkheim, 2008 [1912]) But Durkheim’s ideas on altruism and solidarity are tautological: solidarity begets altruism that in turn reinforces solidarity.

In order to disentangle this circle, Mauss suggested that solidarity, the basic module of social order according to this school of thought, is constituted out of gift-exchange. (Mauss, 2002 [1925]) Gift–giving is a form of disinterested act that forms social bonding and fosters solidarity. The idea of the gift and the debt of an equivocal valuable return, serve as a paradigmatic umbrella for theories on the formation of social and political life. It can be found in the thought of Levi-Strauss that conflated Mauss’s insights on exchange and Durkheim’s work on religion to decipher the structure of kinship (Levi-Strauss 1967). It can also be found in Polanyi (1940) monumental account on “The Great Transformation”, as a reversed mirror image to the distortions of the modern self-regulated market. The anthropology of the gift is a pivotal development in entangling the altruism-solidarity question; gifting is the linking practice connecting acts of generosity with a normative social order (Godelier, 1999).

An interesting turn in the study of altruism and society took place in the US. Sociologist Pitirim Sorokin, a Russian immigrant, devised an original account of altruism, a post-war concept of altruism which is inspired by both Eastern and Western cultures, that aimed at encouraging love and care for others in order to nurture stable and functioning societies (Sorokin, 2002 [1954], 1964). His idea of “creative altruism” emphasizes his solution to the altruism-solidarity question: altruistic acts are the building blocks of solidarity. Sorokin’s insights on altruism cannot be divorced from his anti-communist approach, his admiration of Russian romanticism and his mission to present a counter account of sociology, “positive sociology” to the continental critical tradition. Perhaps unknowingly, other accounts of altruism by later generations American social scientists followed Sorokin’s solution for the altruism-solidarity nexus and studied voluntarism and altruistic-like behavior as questions in middle range theories that applied concepts such as reputation, social networks and norms as the external factors impacting altruism, voluntarism and other pro-social behaviors (see for comprehensive overview: Simpson & Willer 2015, Jeffries et al. 2006, Simmons, 1991, Pillavin and Charng 1990).

The introduction of the altruism-solidarity question to the realm of biomedicine was made by Richard Titmuss, one of the architects of the British welfare policy, whose book “The Gift Relationship: From Human Blood to Social Policy”, conflated Mauss, Levi-Strauss and Sorokin into a theory that championed voluntarism as the moral and most effective way for collecting blood donations (Titmuss 1970). Titmuss advanced a three-tier interrelated thesis on altruism and solidarity: (a) altruism exists. (b) it exists to the extent and to the required volume that can sustain a certain policy of welfare, and (c) altruism and voluntarism can serve as buffers against processes of commodification and atomization of society. Titmuss formulated his argument based on Mauss and Levi Strauss accounts of archaic societies and added a strong emphasis on the liberal notion of the volunteering individual which is of course a poor fit to the societies that Mauss and Levi Strauss studied.

Titmuss’s work became paradigmatic. It helped changed the American blood collection system to one based on voluntarism and served as the scheme for the political economy of body parts, tissues, and cells in biomedicine (Oakley and Ashton 1997). It also became the blueprint for liberal thought in bioethics. The idea that body parts cannot be sold but only donated is so entrenched nowadays, that advocating for the right to sell body parts raises a debate at the very least or is totally prohibited. Furthermore, the introduction of the gift discourse to the supply of body parts is totally complete by now and has become an idiom for organ donation by itself. The “Gift of Life” became a synonym to organ donation and the name of numerous organ procurement agencies around the world (like the one discussed below). It reflects the notion of the ultimate giving, the altruistic act of surrendering one of your organs to save the life of another person.

Titmuss’s model follows the liberal imagining of society: social structure is an aggregate of autonomous individuals, whose voluntarism is acted upon a rather abstracted notion of society. Whereas his notions about the individual’s motives and the “opportunities for altruism” that should be initiated by the state are well addressed in his composition, it is unclear what are the limits of community to which the individual is committed? Implicit, and perhaps for Titmuss even self-evident, is the notion that society is bounded within the nation-state. Is solidarity for Titmuss is bounded within the political framing of citizenship? This question is left unanswered directly, but it seems that his methodology of following systems of blood collection in different countries, provides an affirmative answer. Titmuss model, therefore, is a reflection of a liberal model where solidarity is attained by acts of individuals that recognized themselves as members in the body politics of the nation-state.

Critics of Titmuss model argue that he was “weak on the nature of power in complex industrial societies, tended to over-estimate value consensus and too crudely assumed that paid/voluntary donation was the crucial factor explaining the efficiency of different systems” (Oakley and Ashton 1997:8, see also Pinker 2006). Notwithstanding these critics, that mainly debated Titmuss model as a theory of the welfare state, in bioethics the Titmuss model of voluntarism was widely and uncritically accepted (for example: Waldby & Mitchell 2006). When adopted as an ethical framing for technologies of body parts transfer, it reproduces the liberal individualistic epistemology of pro-social behavior.

In the realm of organ donations, the emphasis remained mainly the different ways that the concept of altruism can be expanded within the boundaries of non-materialistic rewards so that more people would become organ donors. These efforts were both theoretical (“reciprocal altruism” for instance, see Fehr & Schmidt 2006), and also at the level of policy making that suggested a basket of non-materialistic rewards, such as public recognition and gratitude to celebrate the altruist donor (Jasper et al., 2004). “The altruistic donor” is imagined as an agent whose preferences are situated in a rather limited sphere of the liberal bourgeoisie imagination, i.e. is the reward materialistic or not.

The ethical challenge of living anonymous organ donation

Living anonymous donations touch upon the very heart of the altruism question. Whereas organ donations are often described as altruistic acts, it is only in such instances that actual physical sacrifice and bodily risk is undertaken for the sake of a stranger. There is no actual physical sacrifice in signing donor cards and consenting to a post-mortem donation. Organ donations between family members are often loaded with a set of expectations and commitments between the parties involved that separate them from the aspect of non-rewards of pure altruist acts. Without disqualifying post-mortem or intra-familial donations as non-altruistic, it seems that volunteering to become the living organ donor of an unknown stranger can serve as the ultimate manifestation of supererogation and altruism.

Such donations lie uncomfortably within the liberal ethical framing of organ donations. The feature of donating to a stranger, of the non-directed donation, combines the ethics of post-mortem donation, where one’s donation is targeted to the patient at the top of the waiting list, with both parties are unrelated and anonymous at the time of the donation. Conversely, living organ donations are accepted when certain relatedness between the donor and the recipient is confirmed. This relatedness was traditionally based on genetic proximity which facilitates the reception of the graft, but due to advances in transplantation medicine it is possible now to expand the circle of living organ donors outside the genetic circle and to enable non genetically related individuals to become organ donors. Living anonymous donations are a radical extension of this expanding pool.

While living anonymous donations are approved in the USA, Canada, Iran, Saudi Arabia, Israel, the UK, the Netherlands, Hong Kong and Switzerland, they are prohibited in countries such as Spain, France, Italy or Poland. This inconsistency reflects the ethical challenge they pose to the existent ethics of organ donations. They encounter what Mizrachi (2016) following Ricoeur calls “hermeneutics of suspicion”. Thus, for instance, Henderson et al., (2003) question the motives of such donors as those of “lunatics or saints”, emphasizing the radicality of such donations. In fact, Henderson et al. found in their study, that living anonymous donors have strong system of belief and faith in their act and narrate it according to these spiritual beliefs (see also Massey et al., 2010).

The motivation and consent of living anonymous donors are a central ethical concern. In general, the consent of living donors is confirmed and re-confirmed in different registers of inspection and a “get out” option at any stage. The process of becoming a living anonymous donor is even more intricate (Jendrisak et al., 2006; Kranenburg et al., 2008) and is tailored to confirm, not only the donor’s health and physical eligibility but also personal motives so that the donor’s consent to donate to a stranger can be accepted as altruistic.

Hilhorst et al., (2005a, b) warn against biases of discrimination and social injustice when implementing such donations. They note that “In societies where both race and religion have created deep conflicts, the fear of discrimination can be real indeed.“ Yet they add that “not all preferences regarding donation are based on dubious beliefs that exclude and humiliate. They can reflect a sincere and altruistic wish to help particular others”. The ethical challenge for transplant centers is therefore twofold: to detect the thin line separating exclusionary motivations (“I do not want my kidney to be transplanted in a person from a specific origin/religion/ethnicity etc), from expressing a preference regarding the respective donor (I want it to be a child/woman/first medical priority etc). The following challenge is then to decide whether to disqualify exclusionary donations or to approve them, and by so doing reduce the waiting time for deceased donations to all patients.

This set of challenges is best illustrated in the Israeli case of Matnat Chaim. Applicants who wish to donate one of their kidneys to a stranger fill a form, where they find a clause titled “preferences”. This section allows them to generally specify to whom they would prefer to donate their kidney. The outcome is that almost all donations are targeted to Jewish patients. This led one critique to denounce the organization and its donors as “racists”, and to emphasize what can be seen as exclusionary dimension (Epstein, 2017). Conversely, another study into the motivations of Matnat Chaim donors revealed the altruism of these donors (Kurleto et al., 2020).

In the following I tackle this ethical challenge by empirically exploring the donation narratives of the donors themselves. Whereas the ethical discussion is often constructed upon an either-or logic (altruism or utilitarianism, inclusionary/discriminatory), exploring the stories of the donors themselves surfaces a more convoluted discourse, where negations and contradictions can cohabitate and present a more nuanced moral economy. Voicing the donors’ narratives will help avoid the pre-judging ready-made categories of the either/or logic that are often used in bioethical debates.

Methodology

Socio-demographic data on Matnat Chaim donors was obtained from the organization itself. The organization compiled data records on their donors that was handed to me with the donor’s names anonymized. The record contains data on 230 donors from 2011 to 2020 which constitutes about 22% of the total donors that were procured by the organization in that period. Missing values in several categories slightly reduced the records in some categories, but the dataset provided rich and important information regarding gender, age, religiosity, and residence. Most of the data related to donors who donated from Jan. 2016 to Feb. 2020. The dataset was provided by the organization during July 2020.

The organization also supplied materials such as its application form and brochures. An interview with the organization’s founder, the late Rabbi Heber, was conducted in May 2019. A content analysis of newspapers articles from the daily print and online press in Hebrew from 2010 to 2020 was also conducted. Online articles were collected using keywords such as “Matnat Chaim”, “Organ Donation”, and “Altruism”. Print press was collected through public library coded archives using the same keywords. The secular papers “Yedioth Ahronoth”, “Maariv”, “HaAretz”, and “Israel Hayom” were selected together with the Haredi papers “Yated Ne’eman”, “Hapeles”, and “BaKehila”. In addition, 55 donation stories of Matnat Chaim donors were obtained from the organization’s own publications (website and printed materials).

The demographic analysis yielded a descriptive statistical picture of who the donors are. Qualitative data was analyzed according to a grounded theory methodology and thematic analysis (Charmaz, 2014; Chapman et al., 2015). The qualitative data was analyzed in three stages: a thorough and comprehensive reading of the data; detecting recurring themes, codes, and categories in a second reading of the data; refining and defining the generated themes, codes, and symbols in relation to the research question, i.e. what motivates a person to become an anonymous organ donor.

The methodology sets limitations to the following analysis and interpretation. The quantitative data refers only to 22% of all the organization’s donor population. Yet, there is no existent quantitative analysis of this growing donor population, and as the data refers to donors throughout 2011 to 2020, it can be considered representative. The donors’ personal stories were collected from formal Matnat Chaim publications and may be biased and filtered to reflect the public image of the organization. Nonetheless, they do convey a picture of the donors’ system of beliefs and motivations to donate.

Findings

The Matnat Chaim Organization

Matnat Chaim is an Israeli non-profit organization that matches individuals who wish to donate one of their kidneys with patients in need. The organization was founded in 2009 by the late rabbi Yeshayahu Heber, a kidney recipient who was frustrated by the lengthening waiting time for transplants in Israel and decided that founding an organization, that would procure volunteers, to become living kidney donors would be his life mission. Since then and up to July 2022, Matnat Chaim has procured over 1200 volunteers who donated one of their kidneys to patients with whom they had no prior acquaintance. Heber started his initiative by appealing to his close circle, the ultra-orthodox Jewish community. Since then, the ultra-orthodox and modern-orthodox communities have become the main pools from which the organization procures its volunteers.

In its mission statement, the organization declares that it operates according to Israeli and international lawFootnote 3. Notwithstanding, its modus operandi stands at odds with accepted protocols of living anonymous donation, as the donors are allowed to select their recipients’ general characteristics. In fact, the organization takes pride in opting selection, stating in their ethics guidelines that:

“It is the donor’s right to favor someone who is close to him… Some prefer to donate a kidney to a young person; some people want to contribute specifically to a man or to a woman. There are those who wish to donate to Jewish patients, and some have asked to donate to an Arab or a Palestinian patient. Some will make a point of preferring a patient who is careful to maintain his or her health, such as a non-smoker. We have encountered dozens of other personal preferences, according to the subjective choices of each donor. As stated, our working assumption is that choosing the donor according to independent criteria is a legitimate choice, like giving charity according to the donor’s inclination. A kidney donation is truly a ‘gift of life’, and it is a donor’s right to give his gift, a functioning kidney, to whomever he chooses”.Footnote 4

The preferences clause in the application form was added, according to R. Heber, to match donors with recipients that come from the same ways of life “that brought them to be organ donors in the first place”Footnote 5. Quantitative data on the donors’ socio-demographic profile demonstrates the extent to which the donors come from specific segment of Israeli society i.e. the religious sector (Table 1).

Table 1 Distribution of Matnat Chaim donors by age, religiosity, gender and residence
Full size table

The data portrays a rather specific profile of Matnat Chaim donors. First, the organization has managed to procure only Jewish donors. The Jewish orthodox sector comprises 90% of the donors. Both sectors, ultra- and modern- orthodox, are over-represented in relation to the general Israeli Jewish population. For comparison, The Israeli Central Bureau of Statistics reported on 2018 that the Jewish society in Israel is composed of 45% secular, 25% traditional, 16% very religious, and 14% who identify as ultra-orthodoxFootnote 6, an almost opposite profile of Matnat Chaim’s donors.

The data conveys a profile of a Matnat Chaim typical donor as mostly a male, in his forties that lives in a relatively small community. Two points of interest are to be stressed: first, the gender gap here is the reverse of the one in living kidney donation between family members where it is mothers, sisters, and daughters, who make up the majority of donors (Rogers, 2022, Steinman 2006). In fact, in Israel the gap in family donations is precisely the opposite: 67% female and 33% male (Boas et al., 2012). Second, most of the donors come from small towns. 57% live in localities with less than 50,000 populations. 38% of them come from small communities under 5000 populations, with 76% of them coming from settlements in the occupied territories (the total Jewish population in the occupied territories is around 450,000, which is about 5% of the total Israeli population, and 6.5% of the total Jewish population of Israel).

“Charity begins at Home” – making sense of selecting a Jewish person as a recipient

The qualitative data conveys a fuller picture of the sense that Matnat Chaim’s donors attach to their donation acts. In a magazine paper article on a conference of Matnat Chaim’s donors, the reporter asks the donors: “if the goal is saving life, why the conditioning and the selection?“ she is answered by one of them:

“I am firstly taking care of my own people’s problems. Charity begins at home. If I am doing this big step and give something from myself I want to give it to someone from my own people. It is natural and it is my right” (Stern 2016).

When asked about the preferences clause, R. Heber replied:

“Moshe was not willing to donate a kidney to someone who might stone him. I find this to be legitimate. It is his right to prefer whoever he wants. Some say to me: I want to donate to a young person. Others say quite the opposite = I want to give to someone with the fewest chances to receive a (post-mortem) donation. Some wish to donate to observant Jews. Some to Jews in general with no further conditioning” (Rat 2014).

The ethical concern of discrimination is well observed by the donors and is not swept under the rug. As a response, they articulate their own concepts of donation ethics. Relating to this issue, reporter Rat observes:

“The donors find it hard to answer whether they would have donated their kidney to non-Jew as well. Shapira volunteers to explain this in the name of everyone else: ‘one person can say, I am willing to give to my brother, and also to my cousin, and also to a cousin of the cousin and to anyone from my people. I mean to expand my family boundaries to include anyone from my own people. I am also willing to donate to an Arab but only if some relative of this Arab would donate to a Jew in return. I mean that I am ready to risk my life so that someone from my extended family, that means my people, will live. I don’t care if this will be achieved by a direct or indirect donation” (Rat 2014).

The idea of the extended family discloses a layer of meaning, which places the preference to donate to a Jew beyond notions of exclusion and discrimination. Relatedness is drawn here extensively as a normative assumption about caring for your own family first. When relating to the option of donating a kidney to an Arab patient, the idea is not negated but rather is harnessed again to the benefit of the extended family.

This is a normative rationale of a defensive minority which characterized the Jewish experience of living under foreign, often hostile, rule. This norm is still hegemonic even under a sovereign Jewish state and touches a deep underlying sentiment of belongingness. Thus, throughout the donors’ stories, the idiom “a Jewish person” - in the idiomic forms of “helping a Jew” or “a Jew in a desperate need”, etc. – repeats time and again, resembling exilic Hassidic fables on good deeds and acts of solidarity between Jews. Thus, for example when Y. was found as a non-match for a certain recipient, he continued the process: “All I saw in that moment, was the enormous privilege to give life to a Jewish person. My only request was to donate only to a Jew”Footnote 7. Or in another story: “I wanted to save a soul from Israel (a reference to the Jewish community, not the state of Israel, H.B) – it did not matter to me the exact name of the recipient”.Footnote 8

The anonymity here is a façade. Although the donation is non-directed to anyone specific and a stranger will receive the organs, in the donors’ eyes the recipient is not really a stranger. Their belonging to the Jewish community (with less distinction on the recipient’s level of religiosity) suffices to include him or her in the imagined extended family of eligible organ recipients. What does the identity category “Jewish” means? Does it carry with it an exclusionary or inclusionary aspect? Another donor’s confession clarifies this:

“A kidney is a wonderful expression of our old sages’ saying ‘all Israel are responsible for one another’ and Rabbi Jonathan Eybeschutz (18th century rabbi) has a wonderful explanation for this saying: ‘A person has a long beard but has a neighbor that, Heaven forbid, shaves his face with a razor. The person with a long beard should feel that he has only half a beard and half of his face is shaven, for ‘all Israel are responsible for one another’ and all of us are in fact different organs of the whole Jewish people (Klal Israel)”Footnote 9.

The sense of solidarity as stemming from of a sense of sameness and shared responsibility comes out strongly in this story. The expression “All Israel are responsible for one another” has a strong normative register and can explain the sense of mutual commitment to a fellow Jewish person in need, and in its historical context it refers to a political state where responsibility lies within the community members. Together with “charity begins at home”, these two expressions explicitly mark the strong in-group sentiments that drive these donors to offer themselves as donors to individuals they do not personally know but have a forceful and substantial commitment to their social grouping.

Recursive Altruism in Small Communities

As mentioned above, most of the donors come from small towns and localities. This plays a crucial role in the motivation to become a living anonymous donor. 76% of the donors who come from localities with less than 5,000 population, live in remote settlements in the occupied territories. “A fierce competition between the settlements on the number of altruist donors” cries the title of an item on settlers-donors:

“Kidney donation has become a real sport up to a competition between Itamar and Yitzhar settlements. The hashtag ‘Only in Itamar’ reveals this: ‘today the first donor from Itamar enters surgery. The competition begins’ was recently posted on social media. Jonathan Goldin, the donor from Itamar explains: It’s not really a competition, Itzhar leads with ten donors and we have just three’, but he does not lose hope and reveals that three more from Itamar are in the process of donation. Once a person donates, it becomes a thing. People come to him and ask questions, see that it is something that can be done”. Footnote 10

Altruism has a recursive feature. It is contagious, especially in small communities such as Itamar (pop. 1,270), or Itzhar (pop. 1,730), where anonymity is limited and gemeinschaft life renders altruism a repetitive behavior, almost a norm, or social expectation. This is well observed by the reporter of an Israeli popular paper in her magazine story on living anonymous donors in the settlement of Beit Hagai (pop. 670), located south of Hebron: “This is a small, quiet and modest settlement (…) named after the initials of three Yeshiva students that were murdered in Hebron in 1980. 110 families, 670 residents. 9 of them are altruistic donors who donated one of their kidneys to a stranger” (Eldad 2020:39). One of the donors explains: “I told myself: if others can do it, why can’t I? It comes from an unexplained desire to do something substantial” (ibid.). Another donor explicitly describes the recursive element: “one brings another, a friend brings another friend. It’s contagious. We hear stories about donors and donations and want to join in” (ibid.).

The modus operandi of Matnat Chaim aims at fostering awareness of living anonymous organ donation by addressing the communal sense of members in congregation, or small localities. Its brochures and publications are distributed in synagogues and are attached as supplements to local papers of the orthodox and religious sectors. “For three year I’ve being hearing stories about living organ donations through the brochures of Matnat Chaim. I told myself secretly that a day will come when I too will donate”.Footnote 11

Focusing the efforts on well-defined social groups with clear communal boundaries leads not only to procurement of volunteers, but also to the process of recursive altruism, where the radical act of volunteering to become a living donor becomes a story that has a contagious effect:

“Although I initially thought to keep my donation private, as many donors do, I changed my mind when I remembered that my original inspiration to donate came from reading someone else’s story. Perhaps someone – even just one person – will read or hear about my donation and be inspired to find out whether donation might be right for him or her?! Every living donation saves a life and shortens the waiting list for everyone just a little more”.Footnote 12

The role of a small community in fostering kidney donations as a normative conduct is clearly stated in the following story:

“During the process, I have been asked over and over to explain why on earth I am doing this. In my answer I generally mention my community, Merav (a religious kibbutz, 723 pop.), a place where so many people are involved in doing good, both on a communal and a personal level, that I have been inspired to find my own way of giving back.“Footnote 13

Whether a settlement in the occupied territories, or a kibbutz, the themes of recursive altruism and small communities go hand in hand. In such places the exceptional is transforming into the acceptable, almost the normal. In places where anonymity is limited, the notion of extended family gains momentum and normative power. In such places living organ donors become a model to be followed. It is important to note that donors that come from big cities, like Jerusalem or Haifa, live in very defined ultra-orthodox neighborhoods that maintain the same characteristics as described here regarding small communities.

The role of religion

The religious Jewish aspect strikes as the organization’s conspicuous aspect. In its publications it is stated that " All activities of Matnat Chaim are conducted in accordance with Jewish law (Halacha), the Torah and Jewish ethics, from which the organization draws its sense of mission and obligation”Footnote 14. Approvals from leading rabbis of the ultra-orthodox community back the organization’s vision of procuring living anonymous donors.

The fact that a decisive majority of donors come from strong religious background is interesting especially against the strong opposition of ultra-orthodox circles to deceased organ donation. The opposition results from rejecting the definition of brain-death (or respiratory-brain death, as it defined in the Israeli law), as a valid death definition. It is specifically their religious background that drive them into living anonymous donation and prevents them from signing on organ donor cards:

“during the period when I realized that I cannot sign a donor card, my wife told me on a colleague of her from work who is about to donate a kidney. I felt as I have found the solution for not signing an organ donor card”.Footnote 15 Or in the case of a donor that carries an unofficial donor card issued by rabbis that condition the deceased donation with a rabbinical supervision: “If I am willing to donate organs after my death, what about when I am living? Commandments (mitzvot) are after all commanded upon a Jew during lifetime? (…)”Footnote 16

The religious fervor and the cultural cosmology of observant ultra-orthodox Jews envelops the donors’ stories. Their donation narratives are replete with religious significance: “I told myself: all this story is after all based on the willingness to give, and we can find this in the personalities of our great three fathers: Abraham, Yitzhak and Jacob (…) God has granted us two healthy kidneys so that I could donate one to a Jew with two misfunctioning kidneys”Footnote 17. A Chabad Hassid wanted to be the 770th donor, which is the house address of the Lubavitch Rebbe, the leader, and has a symbolic meaning. Other donors’ stories are replete with Jewish old sages’ sayings and writings on benevolence, charity, kindness and giving.

The centrality of orthodox Jewish identity is also palpable in the ways Matnat Chaim addresses its audience. It has different publications for different strands of orthodox Jews: modern and ultra-orthodox. Thus, the publication for ultra-orthodox communities will not feature pictures of women donors and tells the stories of Yeshiva students and rabbis that donated a kidney, with an emphasis on familiar features of ultra-orthodox daily routine such as Yeshiva studies, leading rabbis, expressions and idioms that come with the cultural background of leading an ultra-orthodox lifestyle. On Rosh Hashana of 2019, the organization issued a special edition of a brochure for the many ultra-orthodox that travel to Uman for Breslov traditional festivitiesFootnote 18. The brochure celebrated the story of Breslov donors that donate through Matnat Chaim. The organization’s general line of publication addresses modern orthodox circles. These brochures are periodically published during the high holidays or ahead of Passover. They include donation stories of modern-orthodox donors from both genders, and have references to the approval not only of rabbis but also of the general Israeli press.

Discussion

Is it possible to discern between acts of solidarity and the social atmosphere of deep diversity in which these acts are embedded? I wish to approach this ethical dilemma by focusing on three sociological concepts that entangled this quandary, and by suggesting a new grammar for the altruism-solidarity question which digresses from the liberal conventions. In the following I will refer to the concepts of “the stranger”, “collective identity”, and “relatedness”, and will argue that Matnat Chaim donors evince an ethics of relatedness that is deeply rooted in bounded solidarity. Such a form of solidarity is approached with suspicion in liberal bioethics and yet plays a significant role in the moral economy of these donors. This moral economy charges new meanings that challenge conventional transplantation ethics.

Central to Titmuss’s model is the concept of “the stranger”. The stranger, as Simmel taught us (2008), is not a total outsider but rather “an element of the group itself”. It is this “other” that defines the latin root “altro” (other) in altruism: an other-oriented behavior to someone who does not share our close social circles and yet is always out there. The stranger is always a point of reference. For Titmuss, social policy is all about our acts towards strangers who constitute society. In his view, the stranger is “outside the reciprocal rights and obligations of family and kinship (Titmuss, 1997:279), and thus pertains to the social realms. His project therefore is mainly “concerned with ‘stranger’ relationships” (ibid). But as aforementioned, the liberal imagination here leaves the notion of the stranger rather vague, and is weak in unpacking the sociology of strangers, that is the premise that strangeness and similarities are located on a continuum with changing dispositions in regard to different factors and contexts.

Matnat Chaim donors provide a look into the dynamics of this continuum between the stranger and the inside group member. The preferences option enables donor to select potential recipients in different degrees of social distance. The general trend of donating to Jews under the justification of “charity begins at home” draws circles that expand the pool of patients to those considered as members of the group, the “home” where charity begins, and stop at the stranger – the Palestinian - who as per the Simmelian definition, constitutes the other, which stands as a constant threat.

Collective identity is a central component in the motives of Matnat Chaim donors. The data suggests that one feature of this identity relates to their level of religiosity. It can be argued that another key feature of their identity is their national component; as seen above, they see themselves as agents of a collective national project. The construction of collective identities is, to a large extent, a project of setting the dispositions of the in-group and the outgroup members. Eisenstadt (1998) and Shils (1975) suggest that such construction is in fact “the construction of solidarity (that) entails (…) above all the structuring of the entitlements of the members of the collectivity as against outsiders” (Eisenstadt, 1998:231). According to Shils (1975), the construction of collective identity is impacted by three codes: primordial, civic and the sacred. These codes are the organizing axes for drawing social boundaries and entitlements along the continuum between insiders and outsiders. The primordial code relates to kinship, territory, race, language and the like; the civic code is about implicit and explicit norms, mores and traditional rules of conduct; and the sacred or transcendental code is connected with the realm of the sublime, which is beyond nature and physical reality. This third code can be God but also a belief in Reason and rationality. Eisenstadt emphasizes that these codes are ideal type and can cohabitate within one collective and veer between place and time.

It seems that in their altruistic acts, Matnat Chaim’s donors promote two codes, that produce two types of strangers. One type of a stranger is the unorthodox Jew. The phrase “All Israel are responsible for each other” denotes a primordial code of collective identity in which it is ancestral belonging, with no importance to level of religiosity, that loops all Jews together in one collective identity. In this sense, these donations are not anonymous donation but rather nondirected to someone specific, but rather to the idea of collective identity.

The second code is the modernist axis of nation building and defining its boundaries. The strangers that are not entitled for their donations are perceived as clear or potential enemies. When Titmuss asks in his book “Who is my stranger?“ and insists that altruism is always directed towards an abstracted stranger, he assumes an abstract anonymous stranger. In contrast, Matnat Chaim donors are pre-occupied in constructing and maintaining the strangers, the outsiders, in a constant process of identity-making. Here we meet their second type of strangers: The Palestinian Arab in need of a transplant. Here the strangers are not seen in their distress. I see the donors’ reluctance from donating organs to the first in line, as connected to the civic code of collective identity. Whereas the civic code of liberal societies is tied to an abstracted notion of a citizen, the the donors’ strangers are very specific. In fact, the donors’ donation stories can be read as rites of identity-making, and as such they pertain to the civic code of Shils and Eisenstadt typology: the code of setting the rules of living together.

Thus, Matnat Chaim donors promote an ethics of relatedness that expands beyond the concept of the nuclear family and denotes a broader net of mutual commitments and obligations. This form of interdependence and of “thick kinship” sets the ethics of these donors that pose an alternative to the notion of altruism as helping a universal and abstracted other. The responsibility for the welfare of other Jews, irrespective of their religiosity levels, can be traced back to the code of collective Jewish identity in exilic time. The sociological and historical feature of Jewish identity as a self-sufficient, self-contained, and self-reliant group. This feature is still very dominant within the groups from which Matnat Chaim donors come. The high level of religiosity of these groups and the fact that they mostly live in small gemeinschaft towns and dwellings contribute even further to fundamentals of altruism as rooted in specific social structure that is not in line with the individualistic modern way of life. In these communities, the answer to the altruism- solidarity enigma is clear: it is the social structure that encourages altruistic acts. It is in these social contexts that altruism can be rendered recursive and contagious.

Conclusions

It is hard to disentangle the acts of life-saving organ donations from their social and political determinants. Taken together, the concepts of the stranger, collective identity and relatedness are charged with specific meaning in the context of Israeli society today and serve as the setting upon which these life-saving acts of organ donations need to be understood.

Furthermore, the Israeli case of Matnat Chaim provides an answer to the altruism-solidarity question which does not conform with liberal ontology of bioethics. Whereas in liberal imagination, altruism is about helping an abstract stranger and, solidarity is about similarity between members in a given group, the story of Matnat Chaim proves the sociological notion of strangers within us. While liberal thought sees altruism and solidarity as two seemingly opposite ontologies, the story of Matnat Chaim tells about their meeting points that are produced in the process of identity-making, constructing different types of strangers, providing entitlements for groups members, and excluding outsiders. In this process what seems as altruistic acts can be understood as sporadic rites of identity claims that, when institutionalized, become a normative pattern that sets orders of entitlements. The story of Matnat Chaim tells the case of how these acts foster and fostered by a bounded framing of specific collective identity. Yet, dominant to the acts of donations are the social contexts of the donors’ collective identity. In this respect, it is their bounded solidarity that begets altruism.

Matnat Chaim saves many lives. It represents an avant-garde model of organ donations which challenges the liberal assumptions on altruism and solidarity in the ethics of organ donations in particular and in bioethics in general. It joins other examples of Israeli exceptional understanding of bioethics that transgresses liberal bioethics (Boas et al., 2018; Raz, 2009; Hashiloni-Dolev, 2015). In that respect, Israel serves as an important case for bioethics. From a liberal point of view, the practice of Matnat Chaim defies the axiom of equity and equality of the liberal grammar. The discriminatory themes and preferences patterns that may lead some of Matnat Chaim donors, reflect – as Hilhorst et al., (2005a, b) note, a more general social structure of a conflictual, disrupted society, with a decisive religious and national split between Jews and Arabs in Israel. Having said that, a person can choose to whom does he or she wants to donate a kidney and to specify certain characteristics just like any other philanthropic act. The solidarity model of Matnat Chaim can operate next to the state organ procurement agencies, which should not diverge from banning conditioning or preferences on post-mortem organ donations.