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Altruism and the Volunteer: Psychological Benefits from Participating as a Research Subject

Seelig, Beth J.*; Dobelle, William H.

Point of View

Psychiatric assessment of potential volunteers for hazardous biomedical experimentation should include an assessment of the motivations underlying the altruistic action of volunteering. Screening goals include evaluation of informed consent as well as screening out experimental subjects who would be likely to be psychologically harmed by participation. This discussion of psychological issues to be considered, beyond those of informed consent and screening for severe psychopathology, originated in the psychiatric screening of the small group of original volunteers for the “Dobelle eye” Artificial Vision Project. These individuals entered the project over 20 years ago at a time when they could expect no tangible benefit from participation. Superficially altruistic behavior, such as volunteering for this project, serves multiple psychological functions and in a given clinical case, the determinants are often complex. A spectrum of altruistic behavior is suggested, based on interviews with these original subjects as well as from extensive evaluation of patients studied in the setting of psychoanalytic treatment with one of the authors (B.J.S.). We suggest that adaptive altruism can explain the finding that some volunteers gained actual psychological benefit from their participation. This unanticipated finding, that participating in research as an experimental subject can result in lasting improvement in self-esteem, is discussed. Suggestions are made for increasing the likelihood of such benefit. Ethical ramifications are addressed.

From *Emory University Psychoanalytic Institute, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia; †The Institut Dobelle AG, Zurich, Switzerland, and The Dobelle Institute Inc. at the Columbia-Presbyterian Medical Center, New York, New York.

Submitted for consideration July 2000; accepted for publication in revised form July 2000.

Reprint requests: Beth J. Seelig, MD, Emory University Psychoanalytic Institute, Emory West, 1256 Briarcliff Road, NE, Suite 154, Atlanta, GA 30306.

hat motivates someone to volunteer for hazardous experimentation? It seems easy to answer that question when there is a potential therapeutic benefit or financial reward to be gained from participation in a study. Another possible motivation, a “sense of adventure,” was postulated by Altman 1 in his discussion of the history of self-experimentation by physicians. When there is no probable direct tangible benefit to be gained by volunteering, and especially if the experiment is dangerous, a more thorough scrutiny of the basis of such an altruistic action is essential. Additionally, rigorous examination of the ethical ramifications of permitting another person to participate as a volunteer must take place.

In the 1970s, it seemed that the development of a useful visual prosthesis involving direct implantation of an array of electrodes on the occipital cortex was far in the future. The initial volunteers for the “Dobelle eye”2 experiment were not expected to gain any useful vision as a result of their participation in the project. As a consequence, the ethical obligation to be certain of the adequacy of the informed consent to the procedure and to do rigorous psychiatric screening was even greater than if the surgical procedure brought with it a likelihood of limited vision. In fact, the ethical question had to be seriously considered; should an otherwise healthy blind individual ever submit to a craniotomy without any actual physical necessity, such as a brain tumor? Did the possible future benefit to mankind of developing a potentially useful visual prosthesis justify requesting volunteers? Psychiatric screening was essential to ensure not only that genuinely informed consent was being obtained, but also that the volunteers selected were not likely to be psychologically damaged, even in ways they themselves did not anticipate, by participating. The interview data from the small group of early volunteers was presented almost 20 years ago. 3 At that time, it was already evident that the volunteers were not psychologically damaged by participation. In fact, they expressed great pride and satisfaction about their role as volunteers. This unexpected finding, that taking the physical risk of volunteering for the experiment could result in the psychological benefit of enhanced self-esteem, provided the impetus for the re-examination of the psychology of altruism summarized here. This study on the complex issues involved in human altruism owes a great debt to the blind volunteers who allowed probing of their brains and their minds for the good of future generations of humanity.

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Altruism and the Volunteer

A Sociobiologic Approach to Altruism and Volunteering.

When we advocate altruism, we generally think that we are advocating something good. This may be true, but it is important to ask for whom is the good intended? If there is no obvious, direct potential benefit to the volunteer from volunteering, when are we justified in requesting participation in our project? In this discussion, the role of financial incentives for volunteering will not be discussed, as the complex ethical issues involved in offering financial inducements to volunteers are beyond the scope of this study.

Asking an individual to volunteer for an experiment involves inducing the prospective volunteer to agree to do something that will be of benefit to others. Therefore, the ethical burden on the research team is great. It can certainly be ethical to ask someone to volunteer if full disclosure about the risks of the experimental procedure is provided. However, it is essential that the prospective volunteer not be manipulated into acquiescing. Unfortunately, there have been instances in which prospective volunteers have actually been duped. This was the case in the infamous Tuskegee untreated syphilis study. 4

In “The Problem of Altruism - Freudian-Darwinian Solutions,” Badcock 5 examines altruistic behavior from a perspective that combines Darwinian sociobiology with psychoanalysis. He divides altruism into three forms: reciprocal, kin, and induced altruism. Kin altruism preserves genetically related others at the expense of the individual. Reciprocal altruism takes place when each of two individuals performs an action beneficial to the other. Thus, reciprocal altruism benefits both parties, and kin altruism promotes the survival of the species, at times at the expense of the individual altruist. In the context of biomedical research, relative efficacy studies of proven treatments provide examples of reciprocal altruism. The subject gets free treatment and monitoring, and the researcher gets data.

Badcock’s third subtype of altruism is induced altruism. Induced altruism is the most problematic form of altruism. He states that induced altruism takes place, “whenever one organism promotes the fitness of another at its own expense and without reciprocal benefit to itself or benefit to its genesinduced altruism describes selfishness from the point of view of the exploited party” (p.121). Thus, induced altruism benefits the individual who induces the altruistic behavior in another, and/or a third party. The central feature of induced altruistic behavior is that the altruistic individual acts in a manner to benefit another, often without having freely decided to do so.

Badcock points out that there is a significant benefit to the person who manages to avoid being consciously aware of the self-serving aspects of the desire to induce altruism in others, while avoiding being actually altruistic oneself. At the same time, it is beneficial to recognize others’ disguised efforts to induce one to behave altruistically. His ideas are very useful in understanding subtle aspects of the conscious and especially the unconscious exercise of power among members of a close knit human group. These concepts also have application to the evaluation of a research proposal involving human subjects, especially if there are no obvious physical benefits to the prospective volunteer.

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A Psychoanalytic Approach to Understanding the Altruistic Volunteer.

The ideas summarized in this section are set forth in greater detail in an earlier study, “Normal and Pathological Altruism” by Seelig and Rosof, 6 in which the interrelations among altruism, masochism, and narcissism are presented. In the psychoanalytic literature, since the time of Anna Freud, altruism had been regarded as almost synonymous with masochism. She applied the term, “altruistic surrender”7 to a subtype of altruistic behavior ethnologists would consider to be a form of kin altruism, in which an individual furthers the good of another (a proxy) while unable, for neurotic reasons, to achieve that good herself. This form of altruism has generally been regarded as evidence of masochistic psychopathology.

Seelig and Rosof have revisited the psychodynamic basis for altruism and divided altruistic behavior into four categories. Type I altruism, also referred to as proto-altruism, is the instinctively based, species preserving behavior of animals and humans. Type II altruism is the ability to experience conflict-free pleasure in fostering the success and/or pleasure of another. Type II altruism develops out of Type I and co-exists with it. Type II altruism can also be regarded as an autonomous ego function. 8 This form of altruism includes the “ideal” parental altruism, in which a parent enjoys fostering the child’s achievement of the child’s own goals. Type III altruism is altruism that is drawn into conflict. It has pathologic elements. For example, if a parent has a psychological need to have a child who achieves certain career goals, the child may feel forced to gratify the parent by becoming the sort of adult the parent wants. In this case, the parental “altruism” is actually a technique to induce altruism in the child. The parent generally believes he or she is altruistic and the child, while behaving altruistically toward the parent, is strongly conflicted. Type III altruistic behavior can be highly adaptive, while still serving defensive purposes. Pleasing one’s parent in one’s career choice can result in achieving a successful career with much gratification, despite the fact that the original choice was, at least in part, an act of induced altruism. Although Type III altruism is often adaptive, Type IV altruism, or pseudo-altruism is maladaptive, or adaptive in only a severely pathologic way. It involves significant constriction in the ability to obtain gratification directly. Examples of Type IV altruism can be found in many joyless self-denying martyrs who have severe masochistic and narcissistic character pathology. Type IV altruists have a compulsive need to sacrifice themselves and take care of others. Often there is an absence of pleasure in the sacrificial care-taking behavior. There also may be dramatic exhibitions of suffering which aim, generally unconsciously, at coercing others. These patients are often very seriously depressed.

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Altruism and Adaptation: The Artificial Vision Project.

In the initial screening for the Artificial Vision project, prospective volunteers with severe psychopathology, including major depression and psychosis, were not permitted to participate. Additionally, masochistic individuals who were driven to sacrifice themselves were considered to be severely at risk of a poor psychological outcome and were not accepted. The motivations for volunteering that seemed least likely to result in psychological damage were the desire to benefit mankind with a realistic acceptance of risk and a sense of adventure at being able to participate in exploring a new frontier of human knowledge. The altruism of the blind volunteers for the Artificial Vision project inspired this discussion of the adaptive aspects of altruism. Participation in the Artificial Vision Project resulted in unexpected psychological benefits to the volunteers. One of these early subjects became motivated to return to school and obtained a professional degree after participating as a research subject. He felt that his participation was like being an astronaut, taking a great individual risk for the benefit of mankind as a whole.

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Discussion

Not all altruism stems from an underlying sense of defect, although the motivation for altruistic behavior may sometimes be a compensation for a feeling of defectiveness based on a physical injury. Volunteering for the Artificial Vision Project provided the opportunity for the volunteers to counteract feelings of having a defect, although it could not at that early stage even partially reverse blindness. In these cases, participation in the project turned out to be highly adaptive. It resulted in an enhanced sense of self-esteem based on the fact that participation was a valuable part of a groundbreaking research effort, and that blindness was the attribute that made the volunteers eligible to participate. Thus, the liability of blindness was partly converted into an asset. As one of the volunteers stated, even Dr. Dobelle would not have been able to do the research without his contribution and that of the other volunteers.

We all have aspirations that are impossible to achieve in our lifetimes, strivings we are physically or mentally incapable of fulfilling for reasons of endowment, opportunity, or life choices, rather than primarily intrapsychic conflict. In the case of the fully informed altruistic volunteer for biomedical experimentation, the opportunity to help humanity by volunteering can be very valuable, not only for others, but also to the volunteer. It should be clear, however, that despite the fact that the act of volunteering can be of psychological benefit to the volunteer, such benefit might prove to be the exception rather than the rule. This question represents an area that requires further investigation.

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References

1. Altman LK: Who Goes First. New York, Random House, 1986.
2. Dobelle WH: Artificial vision for the blind by connecting a television camera to the visual cortex. ASAIO J 46: 3–9, 2000.
3. Seelig BJ: Motives of Visual Prosthesis Surgical Volunteers. Proceedings of the 134th Annual Meeting of the APA: 1981.
4. Corbie-Smith G: The continuing legacy of the Tuskegee Syphilis Study: Considerations for clinical investigation. Am J Med Sci 317: 5–8, 1999.
5. Badcock CR: The Problem of Altruism. London, Basil Blackwell, 1986.
6. Seelig BJ, Rosof LS: Normal and pathological altruism. J Am Psychoanal (in press).
7. Freud A: Ego and Mechanisms of Defense. New York, Int University Press, 1976.
8. Hartman H: Ego Psychology and the Problem of Adaptation. New York, Int University Press, 1958.
Copyright © 2001 by the American Society for Artificial Internal Organs