Pergamon Soc. Sci. Med. Vol. 45, No. 1, pp.

137-147, 1997
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U N D E R S T A N D I N G DONORS' MOTIVATIONS: A STUDY

OF UNRELATED BONE MARROW DONORS

G A L E N E. S W I T Z E R , ~'2. M A R Y A M A N D A D E W , 2"3"4V I C T O R I A
A. B U T T E R W O R T H , 2 R O B E R T A G. S I M M O N S 2'~ and M I N D Y S C H I M M E L 6
'Department of Medicine, 2Department of Psychiatry, 3Department of Psychology, 4Department of
Epidemiology, ~Department of Sociology, University of Pittsburgh, Pittsburgh, U.S.A. and
6JDC-Brookdale Institute of Gerontology and Human Development, Jerusalem, Israel

Abstract--Medical advances in bone marrow transplantation techniques and immunosuppressive medi-

cations have dramatically increased the number of such transplants performed each year, and conse-
quently, the demand for bone marrow from unrelated donors. Although physiological aspects of bone
marrow donation have been thoroughly investigated, very few studies have examined psychosocial fac-
tors that may impact individuals' donation decisions and outcomes. To examine one particular set of
donor psychosocial issues, this study investigated motives for bone marrow donation among 343 unre-
lated bone marrow donors who donated through the National Marrow Donor Program. Six distinct
types of donor motives were identified from open-ended questionnaire responses. Donors most fre-
quently reported motives reflecting some awareness of both the costs (to themselves) and potential ben-
efits (to themselves and the recipient) of donation. A desire to act in accordance with social or religious
precepts, expected positive feelings about donating, empathy for the recipient, and the simple desire to
help another person were also commonly cited reasons for donating. Among a series of donor back-
ground characteristics, donors' gender was the variable most strongly associated with motive type;
women were most likely to cite expected positive feelings, empathy, and the desire to help someone.
Central study findings indicated that donor motives predicted donors reactions to donation even after
the effects of donor background characteristics (including gender) were controlled. Donors who
reported exchange motives (weighing costs and benefits) and donors who reported simple (or idealized)
helping motives experienced the donation as less positive in terms of higher predonation ambivalence
and negative postdonation psychological reactions than did remaining donors. Donors who reported
positive feeling and empathy motives had the most positive donation reactions in terms of lower
ambivalence, and feeling like better persons postdonation. These findings add substantially to the body
of work concerning medical volunteerism generally, and also have important practical implications for
the recruitment and education of potential bone marrow donors. © 1997 Elsevier Science Ltd

Key words--bone marrow donation, altruism

INTRODUCTION Our ongoing interest in living organ donation in

Since the National M a r r o w D o n o r Registry was
established nearly a decade ago, the number of indi-
viduals who have volunteered to donate bone mar-
row to unrelated strangers has grown exponentially.
Each month, approximately 30000 persons join the
National Marrow D o n o r Program ( N M D P ) which
now numbers over 2 million (National Marrow
D o n o r Program, 1996). Despite the fact that medi-
cal innovations have elevated bone marrow trans-
plantation from an experimental procedure to one
that is routinely used for some blood-related dis-
eases, and despite increased awareness and accep-
tance of unrelated donation among members of the
general public, few studies have systematically
investigated psychosocial issues surrounding the
decision to become a bone marrow donor.
*Author for correspondence: 3811 O'Hara Street,
Pittsburgh, PA 15213, U.S.A.
g e n e r a l - - a n d bone marrow donation in particular
(Butterworth et al., 1992; Butterworth et al., 1993;
Simmons et al., 1993; Switzer et al., under review;
Switzer et aL, in press: Switzer et al., in press;
Switzer et al., 1996)--has led us in this current
study to investigate one critical aspect of the donor
decision process: donor motivation. Specifically, we
set out to (a) describe the motives of unrelated
bone marrow donors, (b) examine the association
of donor background characteristics (e.g., sex, age,
religion) with motives for donation, and (c) examine
the relationship of predonation factors, including
donor motives, to psychosocial and physical out-
comes of the donation process.
In many ways, bone marrow donation is similar
to other types of medical volunteerism such as kid-
ney and blood donation which have enjoyed more
research attention, especially with regard to donor
motivation. In the following section, we briefly dis-
cuss motives for medical volunteerism in general

137
138 Galen E. Switzer et al.
before we move to more specifically consider bone
marrow donation.
Medical volunteerism
The importance of investigating motivation in the
context of organ and bone marrow donation often
has been noted in reviews of the donation literature,
although systematic attempts to assess motives have
been rare (Andrykowski, 1994; Andrykowski,
1994). The frequent failure of researchers studying
donor issues to empirically assess donor motives
seems surprising given the demonstrated relation-
ship of donor motives to donor outcomes in such
settings. For example, research with blood donors
has shown that donors' motivations a r e r e l a t e d to
longer-term donation and donor satisfaction
(Callero and Piliavin, 1983; Callero et al., 1987;
Piliavin, 1990; Piliavin and Callero, 1991).
Although some outcomes such as long-term active
participation may not be a central concern for cer-
tain types of organ or tissue donation, understand-
ing how donors' self-evaluations, evaluations of the
donation process, and psychological and physical
difficulty with donation may be affected by their
reasons for donating seems critical.
Donors are likely to be motivated by a variety of
intrinsic factors (e.g., acting in accordance with reli-
gious convictions), and extrinsic factors (e.g., social
pressures) that may operate simultaneously to
inspire and/or dissuade the donor. Furthermore, it
is probable that the particular combination of moti-
vational forces differs depending on whether or not
the donor is related to the recipient. Members of
the medical profession and transplantation research-
ers have assumed that family members or emotional
partners are naturally motivated by the prospect of
saving the life of a loved one. In contrast to this
view of related donors' motivations, expressions of
willingness to donate to a stranger have often been
viewed as unusual or even as pathological (Fellner
and Schwartz, 1971). In the early years of kidney
transplantation, for example, individuals who con-
tacted transplant centers and volunteered to donate
a kidney to a stranger were regarded with distrust
and suspicion by transplant physicians (Hamburger
and Crosnier, 1968). However, in an investigation
of public attitudes toward kidney donation, Fellner
and Schwartz (1971) found that 54% of metropoli-
tan residents expressed willingness to donate a kid-
ney to an unrelated stranger. They concluded that
attitudes toward unrelated organ donation were
much more favorable than the medical community
previously had anticipated.
*Newer medical procedures including stem cell donation
that may eventually replace the traditional surgical
procedure for harvesting bone m a r r o w involve a pro-
cedure that is almost identical to whole blood and
apheresis donation.
The availability of cadaveric and living related
organs--coupled with concerns that any system of
unrelated living organ donation could be abused--
has restricted the number of unrelated solid organ
transplants performed in the U.S. However, unre-
lated donors do provide a substantial amount of
bone marrow for transplantation (Silberman et al.,
1994). Bone marrow donation bears similarities
both to blood donation (in that it involves a less
invasive medical procedure of a physical material
that is easily regenerated)* and to solid organ do-
nation (in that it involves surgery under general
anesthesia to assist a specific patient). Blood donor
motivations have been examined in detail by sev-
eral researchers and are relevant to bone marrow
donation because of similarities in the donation
procedures and because bone marrow donors have
often been recruited directly from blood donor
lists.
The first studies of motivations for blood do-
nation were conducted in the same decade as the
first studies of motivations for kidney donation,
and reached similar conclusions; altruistic/humani-
tarian motives for donating were most commonly
reported (Oswalt, 1977; Simmons et al., 1977;
Simmons et al., 1987). A more recent study examin-
ing temporal changes in blood donor motivation
determined that first-time donors were often motiv-
ated to donate by less altruistic forces such as exter-
nal social pressures (e.g., obligations to a group),
but that if donation continued, these donors devel-
oped an internal "donor self-image" (Callero et al.,
1987; Piliavin and Callero, 1991; Callero, 1985;
Callero et al., 1987; Charng et al., 1988; Gardner
and Cacioppo, 1995; Royse and Doochin, 1995).
Increased commitment to blood donation and cor-
responding changes in self-image are thus produced
in small incremental steps as donation continues; in-
dividuals begin to see themselves as "the kind of
person who donates." A similar process of increas-
ing commitment and changes in self-identity may be
operating for bone marrow donors. Such donors
are often recruited to the registry in conditions that
may involve high levels of social pressure, but sub-
sequently make a series of small incremental
decisions leading to actual donation (Stroncek et
aL, 1989).
Finally, there is some evidence that one's self-
image as a "medical donor" may generalize across
donation types. For example, studies of bone mar-
row donor recruitment from blood donor registries
have found that frequent blood donors are 3-12
times more likely to join the bone marrow registry
than less frequent blood donors (Beatty et al., 1989;
Briggs et al., 1986; Cacioppo and Gardner, 1993;
Sarason et al., 1993).
Unrelated bone marrow donation
Unrelated bone marrow donors volunteer to
engage in an act which is time consuming, painful,
 Donation motives
and frequently frightening, to help someone they
have never met. Prospective donors who are part of
the national registry are matched with individuals
who need a bone marrow transplant (most often to
treat leukemia, aplastic anemia, or some other form
of cancer or blood disorder) but who can not ident-
ify a related donor. Donors consent to undergo
general or spinal anesthesia for 1-2 hours while
bone marrow is aspirated from the illiac crest of the
pelvis through small incisions in the donor's lower
back. Following donation, donors may experience
anesthesia--related side-effects such as sore throat,
nausea, headaches, vomiting, or temporary numb-
ness in the legs. Although long-term physical costs
to donors are likely to be small because bone mar-
row regenerates, donors often spend a day or two
at home recovering and report feeling the lingering
effects of donation for up to a few weeks.
Unrelated bone marrow donation is a particularly
interesting form of medical volunteerism because it
involves costs and benefits that are higher than
those of blood donation, but potentially lower than
those involved in the donation of nonregenerating
organs (e.g., kidney, liver lobe, lung lobe) to a rela-
tive. In addition to time missed from work and
home activities, the inconvenience of rearranging
one's schedule, and anxiety induced by the medical
procedure, the costs of bone marrow donation
include physical discomfort and the small possibility
of severe life-threatening complications (estimated
as about 1 in 400; [Bortin and Buckner, 1983]) or
even anesthesia-related death (1 in 10000; [Hirsh,
1982]). The potential benefits include feeling that
one has acted in accordance with deep emotional
sentiments or moral convictions, and the very tangi-
ble possibility of saving someone's life.
In the course of our discussions with bone. mar-
row donors in previous studies, it became evident
that different donors weighed the costs and benefits
of donation in very different ways and, in many
cases, seemed to be so strongly motivated to donate
that they discounted any possible negative outcomes
of the donation process altogether (Butterworth et
al., 1993; Switzer et al., in press). We therefore
became deeply interested in investigating donors'
motives in a more systematic fashion, both to
describe such motives and their demographic ante-
cedents, and to determine whether motives pre-
dicted psychosocial and physical reactions to the
donation process. For the current study, we exam-
ined these issues qualitatively--by creating a typol-
ogy of the six types of non-mutually exclusive
motives reported by this group of d o n o r s - - a n d
quantitatively--by examining the relationships
among donor background characteristics, donor
motives, and donors' reactions to the donation ex-
perience.
139
METHODS
Subjects and procedure
Potential subjects for this study were the 962 in-
dividuals from the N M D P registry who donated
bone marrow between December 1987 and
December 1991 (see Butterworth et al., 1993 for a
more complete description of donor recruitment
procedures). Although a series of psychosocial ques-
tionnaires was sent to all donors, participants for
the current study included the cohort of 343 indi-
viduals who donated marrow through the N M D P
during this timeperiod and returned predonation,
1-2 week postdonation, and one year postdonation
questionnaires. During the first few years of N M D P
operation, virtually all donors were recruited
through blood banks and thus were regular platelet
or blood donors who volunteered to join the regis-
try. Once a volunteer in the N M D P registry was
identified through laboratory blood tests as the best
potential match for a patient needing marrow, the
volunteer attended an hour-long information ses-
sion with donor center medical personnel. Before
consenting to become a bone marrow donor, all po-
tential donors were fully informed about the mar-
row collection procedure, risks and benefits of bone
marrow donation, and anesthesia options, and
often viewed a videotape which described a related
donor transplant. Shortly after giving final consent
to bone marrow donation, donors received a predo-
nation questionnaire including the measures
described below. Follow-up questionnaires were
mailed 1-2 weeks postdonation and 1 year postdo-
nation.
Longitudinally, of the 849 predonation respon-
dents, 716 (84%) subsequently returned the shortly
postdonation questionnaire. Of these 716, 343
(48%) returned the one year postdonation ques-
tionnaire producing a final panel of 343 donors
who completed all three questionnaires. To deter-
mine whether particular types of donors were
likely to be excluded from our sample because of
nonresponse to one of the study questionnaires,
the 343 donors in our study cohort were compared
to donors who returned predonation but not post-
donation questionnaires. Chi-square analyses indi-
cated that these two groups did not differ on any
of the demographic characteristics measured predo-
nation. In addition to gathering questionnaire
data, we conducted one hour in-depth telephone
interviews with every second donor of approxi-
mately the first one hundred donors. Quotations
from these 50 interviews are included below to il-
lustrate the categories of motives developed from
the full sample.
Measures
Three classes of variables were included in the
present study. First, motives were coded from open-
ended responses to the predonation questionnaire
140 Galen E. Switzer et al.
item, "In your own words, what do you feel your
reasons are for donating?" A typology was devel-
oped inductively; as open-ended responses were
reviewed they were collapsed into six distinct motive
categories which were based on Simmons' prior
work (Simmons et al., 1977). Research staff were
trained to code up to four motives for each respon-
dent based on the responses to the open-ended
question. All responses were initially coded by one
staff member and an additional twenty percent were
subsequently coded by a second staff member.
Agreement among the two ratings, corrected for
chance, was measured using Cohen's Kappa. A
kappa of .85 (p < .05) was achieved between the
two raters, indicating a strong degree of interrater
reliability. Over half (63%) of respondents reported
more than one motive. The average number of mo-
tives reported was 1.97 (sd = .96).
Second, donor background characteristics includ-
ing gender, age, religion, marital status, whether the
donor had any children, and educational level
attained were collected from predonation question-
naires. Because 99% of these donors were white,
ethnicity was not included as a variable in these
analyses.
Finally, reaction to the donation process was
measured by a total of seven outcomes gathered in
the three questionnaires (predonation: ambivalence;
shortly postdonation: physical difficulty with do-
nation, negative psychological reactions; 1 year
postdonation: negative psychological reactions, self-
esteem, feeling like a better person, concern about
recipient). The one reaction to the donation process
measure collected predonation was an additive
seven-item ambivalence scale used previously with
kidney donors (Simmons et al., 1977). (Cronbach's
alpha for the present sample was .78). It was
assumed that the formulation of donor motives
temporally preceded donors' emotional responses
(e.g., ambivalence) toward donation--thus, predo-
nation ambivalence is conceptualized as a donation
reaction potentially affected by motives.
Ambivalence items assessed doubts and worries
about donating (e.g., "I sometimes feel unsure
about donating.") and commitment to donating
(e.g. "I would really want to donate myself even if
someone else could do it.") To be consistent with
previous applications of this measure (Switzer et al.,
in press; Simmons et al., 1977), all items were
dichotomized and an index of ambivalence was
formed by summing the number of items checked
by the respondent (0 = no items endorsed: not at
all ambivalent, to 7 = all items endorsed: extremely
ambivalent).
Physical difficulty with donation and negative
psychological reactions to donation were
measured on the 1-2 week postdonation ques-
tionnaire. Physical difficulty with donation was
measured with five items asking how the donor
felt physically during and after the donation,
whether the process was more or less painful
than the donor expected, how many days
passed until the donor felt physically "back to
normal," and whether the donor had experi-
enced fatigue or lower back pain. These items
were scored along 3-point scales (e.g., fatigue:
0=not at all, 1 = a little, 2 = a lot; days
until donor felt physically normal: 0-5, 6-14,
>14 days). An overall physical difficulty scale
was created by summing the 5 items [6]. Thus,
scores ranged from 0 = no physical difficulty,
to 10 = high physical difficulty with donation
(Cronbach's alpha = .70).
Psychological reactions shortly postdonation
(and also measured at one year postdonation)
were measured with a four-item scale developed
for use with kidney donors (Simmons et al., 1977),
and modified slightly for use with bone marrow
donors (Switzer et al., in press). Items asked
whether donors felt like they had given something
for nothing in return (0 = disagree a lot,
1 = disagree a little, 2 = agree a little, 3 = agree a
lot; dichotomized for analysis as 0 versus all other
categories), whether they were generally happy
about having donated (0 = very happy about hav-
ing donated, 1 = a little happy, 2 = a little
unhappy, 3 = very unhappy about having
donated; dichotomized as 0 versus all other cat-
egories), how worried they were about the effects
of marrow donation on their own body
(0 = almost never, 1 = sometimes, 2 = often;
dichotomized as 0 versus all other categories), and
how worried they were about their own current
health (0 = not at all, 1 = a little, 2 = somewhat,
3 = very; dichotomized as 0 versus all other cat-
egories). Because the number of response cat-
egories per item ranged from 3-4, and because the
distribution of responses on each item was skewed,
items were dichotomized as noted above (Switzer
et al., in press; Simmons et al., 1977). The four
items were summed to form a final scale ranging
from 0 = no negative psychological reactions, to
4 = very negative psychological reactions. The in-
ternal reliability coefficient for this scale
(alpha = .44) is lower than the coefficient obtained
in previous uses of the scale (alpha = .73;
(Simmons et al., 1977). However, the four items
were all positively intercorrelated (median r =.10),
and excluding one or more items did not produce
any improvement in reliability. The low coefficient
probably reflects measurement error in large part,
and suggests that statistics using this scale will
underestimate the degree of relationship of donor
motives to psychological reactions.
The four other measures of donor reaction to the
donation process were measured one year postdona-
tion. These included measures of negative psycho-
logical reactions (discussed above), self-esteem,
feelings that one is a better person as a result of the
donation, and concern about the recipient. A nine-
 Donation motives
Table 1. Means and standard deviations for all donation reactions
Donation reaction Range
Predonation
Ambivalence 0-7
Shortly postdonation
Physical difficulty 0-10
Psychological 0-4
difficulty
One year
postdonation
Psychological 0-4
difficulty
item scale measuring self-esteem was derived from
the scale developed by Rosenberg* (Rosenberg and
Simmons, 1972; Rosenberg, 1965), (Cronbach's
alpha for this sample was .75). Donors responded
to statements about themselves (e.g. "I feel I have a
number of good qualities", "On the whole, I am
satisfied with myself,. . . . I feel I do not have much
to be proud of", "At times I think I am no good at
all") using four response categories (1 = strongly
agree, 2 = agree, 3 = disagree, and 4 = strongly
disagree). To be consistent with previous appli-
cations of the scale (Simmons et al., 1993; Switzer
et al., in press; Simmons et al., 1977) responses
were dichotomized (0 = low self-esteem, 1 = high
self-esteem) and summed to form a composite scale
ranging from 1 to 9.
The final three variables were adapted from
Simmons' studies of kidney donors (Simmons et al.,
1977). The ten-item "perception of oneself as a bet-
ter person" measured the extent to which a donor
felt like a better person due to the donation
(Cronbach's alpha =.75). Items were questions
about respondents' self-feelings when they thought
about the transplant (e.g. "When you think about
the transplant have you felt..." 1 = very proud,
2 = a little proud, 3 = not at all proud; "Donating
bone marrow makes one feel that he/she is some-
how a bigger and more worthwhile person. Do
you..." 1 = agree a lot, 2 = agree a little,
3 = disagree a little, or 4 = disagree a lot). Items
were dichotomized (0 = low "better person,"
1 = high "better person") and summed to form a
composite scale ranging from 0 to 10.
Donors' concern about the recipient at one year
postdonation was measured with a single item.
Donors were asked to respond to the statement, "I
think about the recipient..." by checking one of
nine frequencies ranging from, 1 = never to
9 = more often than once a day. Table 1 lists
means and standard deviations for all donation
reaction variables.
*Nine-item and eight-item versions of this scale have been
extensively used and validated in previous work (e.g.,
Simmons et al., 1993; Simmons et aL, 1977; Rosenberg
and Simmons, 1972). In such cases, the elimination of
one or two items from the original ten-item scale has
substantially improved the internal consistency of the
composite measure.
141
Mean SD
1.78 1.95
4.85 2.49
1.55 .80
1.40 .62
RESULTS
Describing donor motives
Our motive typology included six types of mo-
tives: empathy-related motives, exchange-related
motives, normative motives, idealized helping mo-
tives, positive feeling motives, and past experience-
based motives. Each are defined below and are
summarized. These motives are similar to those
found among other types of volunteers, both in nat-
uralistic settings--such as volunteer "buddies" for
AIDS patients (Clary and Snyder, 1991; Snyder,
1993; Clary and Orenstein, 1991; Omoto and
Snyder, 1990), 4-H volunteers (Rohs, 1986), social
service volunteers (Rubin and Thorelli, 1984),
elderly volunteers (Okun and Eisenberg, 1992), and
kidney donors (Simmons et al., 1977; Simmons et
al., 1987)--as well as in more controlled experimen-
tal studies of helping (Batson et al., 1989; Baumann
et al., 1981; Karylowski, 1982; Perry et al., 1986;
Bar-Tal, 1982; Cialdini et al., 1987). Table 2
includes donor quotations from our in-depth inter-
views and open-ended questionnaire responses illus-
trating each motive category.
Exchange-related motives were the most com-
monly reported type of motive; 45% of donors
reported such motives. Motive descriptions were
categorized as exchange-related if they stated or
implied donors' awareness of the relative costs (to
themselves) and benefits (to themselves or the mar-
row recipient) of donating. Variations of exchange
motives included statements indicating that donors
were comparing their own good fortune with the
bad fortune of the recipient and wanting to "give
something back," and statements concerning the
hope that should they or their family were in a
similar desperate situation, others would do the
same for them.
More than one-third of donors (37%) gave ideal-
ized helping motive responses. These donors seem to
have been responding "automatically" without deep
thought about the potential costs of donation or
even their own motivations to become volunteers.
Approximately one-quarter (26%) of donors cited
feeling that donating was their social obligation/
duty or that donating was morally correct or appro-
priate (normative motives). In many cases, state-
ments included in this category contained direct
142 Galen E. Switzer et al.

Table 2. Six Donor Motivation Categories Illustrated with Donor Quotations

Exchange-related motives
The main thing on the bone marrow, I think, (was)a the.., information they gave when I received the pamphlet. It gave the statistics on
survival and how much it increased. I felt, oh boy, if I can do that (it's such a little thing on my part). I can't remember the exact
statistics, but it increased from (about) 20% to 70%.
My healthy marrow can prolong her life, I hope. That's the whole drive. I got something freely, and if I can give it back, let's do it.
Idealized helping motives
I feel fortunate that I am able to be a donor... I guess (I was) just glad to be able to help.
(I wanted) to try to help somebody out, give somebody a chance for a normal life.
Normative motives
There was no doubt I wouldn't do it. It's something I feel I should do. I was brought up to help others whenever possible.
Well, I guess being raised Catholic and being pro-life, it gives me a real good feeling to say I helped someone.
Positivefeeling motives
The bottom line is here I can do something that's going to make me feel pretty good about myself.
From the beginning I felt very privileged I could do this.
Empathy-related motives
I don't think I got emotional until they told me they notified her they had a donor. That's when 1 got emotional (thinking of them telling
her). I was real excited for her.... The fact that she's close to my age makes me feel more emotional.
... (the donor coordinator) told me it was a little five-year-oldboy. That decided me. I have a little five-year-oldboy at home now. I keep
looking at him and thinking, "What if it was my boy?"
Past experience-based motives
It's just the next step after giving pheresis. I started out giving blood, then pheresis, now this. If can help someone (I might as well).
I'm a science teacher and I had read about children with Combined Immunosuppression Syndrome and that really appealed.... I did it
because it was medical.
aParenthetical words or phrases within quotes indicate that the words may not be precisely those used by the respondent, although they
are quite close. Such slight inaccuracies are the inevitable result of verbatim documentation of interviews which were not tape
recorded.

references to religious tenets concerning helping
others. A n o t h e r q u a r t e r (25%) o f d o n o r s discussed
the d o n a t i o n in terms o f the good feeling it gave
t h e m to p e r f o r m this helping act (positive feeling
motives). These positive feelings often included the
expectation t h a t the d o n o r would have improved
self-esteem or feel better a b o u t him/herself after
donating. D o n o r s also reported feeling special or
privileged to be able to donate, especially w h e n
they were the only p e r s o n whose m a r r o w m a t c h e d
t h a t o f the recipient. A p p r o x i m a t e l y one-fifth o f
d o n o r s (18%) described their m o t i v a t i o n s to give
b o n e m a r r o w in terms of their feelings t o w a r d the
recipient (empathy-related motives). D o n o r s seemed
to be putting themselves in the place o f the person
w h o needed b o n e m a r r o w or t h a t d o n o r ' s family.
E m p a t h y seemed to be triggered by a variety of
stimuli including similarities between the d o n o r a n d
the recipient, similarities between the recipient a n d
s o m e o n e close to the d o n o r , or simply seeing some-
one else w h o was ill.
Finally, smaller n u m b e r s o f d o n o r s reported past
experience-based motives ( 8 % ) which included state-
m e n t s a b o u t the d o n o r ' s previous life experiences
such as participation as a b l o o d or apheresis d o n o r ,
o t h e r b a c k g r o u n d as a volunteer, or experiences
t h a t m a d e the d o n o r especially aware o f the need
for b o n e marrow. A n additional 9 % o f motives did
n o t seem to fit any o f the a b o v e categories. The
m o s t c o m m o n t h e m e a m o n g these remaining mo-
tives were statements t h a t did n o t so m u c h give
reasons for their decision as express incredulity t h a t
a n y o n e would decide otherwise. Because the pro-
p o r t i o n o f d o n o r s reporting past experience-based
motives, or motives t h a t did not fit any o f the pre-
established categories was relatively small, sub-
sequent analyses focused o n only the five m o s t
c o m m o n motive types a n d did not include motives
from these two categories.
Intercorrelations a m o n g the motive types were in-
itially calculated to determine, in part, whether our
a priori motive categories were in fact distinct mo-
tive types. Low intercorrelations a m o n g motive cat-
egories would bolster o u r claim t h a t we are
measuring a well-defined heterogeneous set of
reasons for donating. W e did find t h a t motives were
n o t highly intercorrelated; the only statistically re-
liable relationships were between exchange a n d
idealized helping motives (r = - . 1 4 ; p < .01), nor-
mative a n d idealized helping motives (r = - .21;
p < .01), a n d n o r m a t i v e a n d e m p a t h y motives
(r = - . 1 6 ; p < .01). The correlation coefficients are
all relatively small a n d negative indicating t h a t
e n d o r s e m e n t o f one o f these motive pairs slightly
decreases the likelihood t h a t the other motive o f the
pair will also be endorsed.
Association o f background characteristics with mo-
tives
Two-thirds of the sample were m e n (66%). M o r e
t h a n h a l f (65%) o f the d o n o r s were currently mar-
ried a n d h a d at least one child (64%). M o r e t h a n
9 9 % were high school graduates a n d 52% h a d com-
pleted some college. D o n o r s ' age ranged from 22 to
55 years (X = 38, sd =7.6). Forty-three percent
were Protestant, 35% were Catholic, 3 % were
Jewish, a n d 19% did n o t consider themselves part
of those religions.
Chi-square analyses were conducted in order to
determine whether d o n o r b a c k g r o u n d character-
istics were associated with specific d o n a t i o n mo-
tives. W o m e n were significantly more likely to
report e m p a t h y a n d positive feeling motives a n d
s o m e w h a t m o r e likely to report idealized helping
motives t h a n were male donors. Twenty-three per-
 Donation motives 143

cent of females compared to 13% of males reported
empathy motives (Z2(1, n = 342) = 5.02, p < .05)
and 31% of females compared to 21% of males
reported positive feeling motives (~2(1,
n = 342) = 3.83, p < .05). In addition, younger
donors were more likely to base their reasons for
donating on exchange-related motives and idealized
helping motives than were older donors. Forty-eight
percent of younger donors (those under 40)
reported exchange motives, while 38% of older
donors reported exchange motives (X2(I,
n = 343) = 3.66, p = .056) and 41% of younger
donors compared to 31% of older donors reported
idealized helping motives (;(2(1, n = 343)= 3.67,
p = .055). Finally, Protestants (30%) were slightly
more likely than members of other religious groups
(22%) to report normative motives for donating
(Z2(1, n = 343) = 2.91, p = .088). Other than these
associations no other background characteristics
were associated with specific motives for donating.
Association o f background characteristics and mo-
tives with donation reactions
A series of hierarchical multiple regression analy-
ses was conducted to assess the relationship of
background characteristics and the 5 most com-
monly reported predonation motives to psychoso-
cial and physical reactions to the donation process
(see Table 3). Seven such regression equations were
constructed. For each equation, a single outcome
variable (ambivalence, physical difficulty with do-
nation, shortly postdonation negative psychological
reactions, one year postdonation negative psycho-
logical reactions, self-esteem, better person, and
concern about recipient) served as the dependent
variable. Predictor variables were entered in two
blocks: background variables (gender, age, religion,
education level, marital status, and presence of chil-
dren) were entered in the first block; motives
(exchange, idealized helping, normative, positive
feeling, empathy) were entered in the second block.
Variables were entered in separate, hierarchical
blocks because, temporally, donors' background
characteristics were likely to have preceded develop-
ment of their motives for donation, and because
our goal was to assess the effect of donation mo-
tives on outcomes while controlling for the effects
of donor background characteristics (Cialdini et al.,
1987).
The linear combination of donor background
characteristics and motives produced statistically
significant (or nearly significant in the case of
Physical Difficulty and Psychological Difficulty 1
year postdonation) R-values for the full equation
for all outcomes except donor self-esteem.
Ambivalence toward donation was predicted by
gender and education level; female donors and
donors who were more highly educated were more
likely to experience higher levels of predonation
ambivalence. Even after the effects of background
characteristics were taken into account, exchange-
related and positive feeling motives were related to
ambivalence. Donors who seemed to be weighing
the costs and benefits of donating were more likely
to experience predonation ambivalence while those
who were motivated by the expectation of positive
feelings for themselves as a result of donation were
less likely to be ambivalent.
Of the two outcomes measured shortly postdona-
tion, psychological difficulty with donation was
most strongly related to predonation background
factors and motives. The only factor that signifi-
cantly predicted physical difficulty with donation
was gender; women were much more likely to
report experiencing physical side-effects of donation
than were men. Psychological difficulty, in contrast,
was predicted by age (younger donors were more
likely to report psychological difficulty than were
older donors), and by marital status (married
donors experienced greater psychological difficulty

Table 3. Relationship of Background Characteristics and Motives to Donation Reactionsa

Ambivalence Physical Psych. difficulty Psych. difficulty Self-esteem Better person Concern about
toward donation difficulty shortly post 1 yr. post recipient

Background
Gender .14" .24*** .01 .07 .03 -.20** .03
Age -.04 -.07 - . 16* - . 14* -.06 -.03 -.04
Religion -.03 -.01 -.01 .05 .03 .13" .06
Education .21"* .01 -.07 .03 .06 -,04 -.09
Married -.06 .05 .19* -.05 .11 -.02 -.04
Children -.03 -.07 -.04 .03 -.09 -.04 -.01
Motives
Exchange .13* -.04 ,08 .03 -.03 .02 -.08
Ideal help .11 .03 .18"* .14" -.04 .04 -.06
Normative -.08 -.02 -.05 .01 .07 -.09 .03
Pos. feeling - . 18"* -.07 -.06 -.04 -.02 .14" .11 #
Empathy .05 .03 -.01 - . I 1# -.02 .12* .22** *
Adjusted R .30*** .18# .29*** .16# .13 .24** .22*
a Numbers in the Table are standardized regression coefficients (beta values).
#p < =.10.
*p < =.05.
**p < =.01.
***p < =.001.
144 Galen E. Switzer et al.
than did unmarried donors). In addition, donors
who reported idealized helping motives were signifi-
cantly more likely to experience shortly postdona-
tion psychological difficulty than were their
counterparts who did not endorse such motives.
A pattern of results similar to that for shortly
postdonation psychological difficulty was found for
one year postdonation psychological difficulty.
Older donors and donors reporting idealized help-
ing motives again experienced less psychological dif-
ficulty than their counterparts. In addition, donors
who were motivated to donate by empathetic feel-
ings for the recipient were slightly less likely to ex-
perience psychological difficulty at one year
postdonation than were donors who did not report
such motives.
The perception that one was a better person for
having donated bone marrow was predicted by two
background characteristics and two types of mo-
tives. Men were significantly more likely to feel like
better persons for having donated than were women
and members of Protestant religions were more
likely to feel like better persons than were donors
with other religious affiliations. Donors who
reported positive feeling and empathy motives were
also more likely to feel like better persons for hav-
ing donated than were donors who did not report
such motives.
Finally, concern with the recipient was signifi-
cantly predicted by empathy-related motives; those
donors who were motivated to donate because they
could understand what the recipient was feeling
were more likely to be concerned about the reci-
pient's well-being one year postdonation. In ad-
dition, donors who reported positive feeling motives
were somewhat more likely to be concerned about
the recipient postdonation.
DISCUSSION
Donors who agree to undergo a surgical pro-
cedure to donate bone marrow to a stranger engage
in a unique and potentially life-threatening form of
helping. The fact that the number of unrelated bone
marrow transplants performed in the U.S. increases
dramatically each year makes it critical to better
understand the psychosocial processes involved in
donors' decision-making. Although researchers have
long been interested donor motives in the broader
context of living medical donation (e.g., blood do-
nation and kidney donation), motives for donating
bone marrow have not been systematically exam-
ined to date. Thus, we have undertaken an investi-
gation of donor motives in a cohort of the first
individuals to donate through the National Marrow
Donor Program. In addition to describing such mo-
tives, we have examined the relationship of donor
background characteristics to motives, as well as
the relationship of background characteristics and
motives to a set of key donation reactions. Our cen-
tral goal was to determine whether donors' self-
reported motives for donating predicted donors'
reactions to the donation process even after back-
ground characteristics were taken into account.
Although the majority of donors reported more
than one motive, motives were not highly intercor-
related. This indicates that particular groups of mo-
tives were not consistently reported together,
suggesting that a number of different psychosocial
processes rather than a single motivation may guide
this type of altruistic behavior. This interpretation
is strengthened by our findings that different motive
types were related to different sets of background
and outcome variables.
The reasons donors gave for performing such an
altruistic act varied widely. These reasons included
weighing the risks and benefits of such an oper-
ation, a simple desire to help, normative consider-
ations, the positive feelings related to performing
such an act, and feelings of empathy for the recipi-
ent or the recipient's family. Motives were coded
from an open-ended questionnaire item into a priori
motive categories based on previous work with kid-
ney donors (Simmons et al., 1977). Although inter-
rater reliability for the presence or absence of each
motive was excellent, this manner of assessing and
coding donor motives is likely to have produced
motive groupings that are somewhat less precise
than those that would have been produced with
closed-ended ordinal-level items. Ultimately, how-
ever, allowing donors to describe motives in their
own words may have yielded more valid responses
than closed-ended items would have. In addition,
the fact that several important and intuitively mean-
ingful relationships of donor motives with donation
reactions were found lends credence to the robust-
ness of these motive categories; more precise
measures could be expected to produce even stron-
ger relationships.
There were surprisingly few reliable associations
of donor background characteristics with donation
motives. Perhaps the most interesting was that
women were more likely than men to report donat-
ing because of empathic feelings for the recipient,
because they expected to feel good about donating,
and for unspecified "idealized" helping reasons.
These motives make sense in the context of the so-
cietal norms for women, which encourage--and
often impel--them to be more nurturing and caring
than men (Eagly, 1987; Eagly and Crowly, 1986;
Parsons and Bales, 1955). The incorporation of
these norms into women's daily roles may, in turn,
lead women to help others for a variety of reasons
that are consistent with such roles (e.g., empathy
for someone in need), or for the possible outcomes
of having fulfilled the role (e.g., feeling good for
having helped someone else).
The most interesting and important findings in
this study of donor motives resulted from the set of
regression analyses concerning the relationship of
 Donation motives
donor background characteristics and motives with
donation reactions. In general, men had more posi-
tive donation experiences than did women; men had
lower levels of predonation ambivalence, less physi-
cal difficulty with donation, and felt like better per-
sons following donation. This gender difference
favoring men is one that is fairly consistently
reported throughout the donation/transplantation
literature (Switzer et al., in press; Piliavin and
Cailero, 1991; Simmons et al., 1987), and may
result from women's greater willingness to express
less positive feelings or from an actual difference in
the way that bone marrow donation is experienced
by men and women. Two other groups--more edu-
cated donors and younger donors--also reported
less positive reactions in terms of greater predona-
tion ambivalence or psychological difficulty one
year postdonation.
Even after the effects of donor background
characteristics were controlled, however, there were
notable relationships of pre-donation motives to do-
nation reactions. Two types of donors, those report-
ing exchange-related motives and those reporting
idealized helping motives, seemed to experience do-
nation as less positive than donors who did not
report such motives. First, donors who indicated
that they had weighed the costs and benefits of
donating were much more likely to experience pre-
donation ambivalence than were other donors.
Although such exchange-related motives were not
directly associated with other less positive donation
reactions, other investigations involving this same
population indicate that predonation ambivalence is
itself a central predictor of other negative postdona-
tion outcomes (e.g., physical and psychological diffi-
culty; Switzer et al., 1996). Thus, a cost-benefit
analysis approach to donation may place donors
directly or indirectly at risk for a variety of less
positive donation outcomes. Second, donors report-
ing idealized helping motives were also likely to
have less positive experiences in the form of elev-
ated psychological difficulty (e.g., feeling like they
had given up something for nothing in return) both
shortly postdonation and one year postdonation. It
is possible that exchange-related motives and ideal-
ized helping motives are actually two aspects of a
single dimension--exchange donors seem to have
heightened awareness of the potential costs of do-
nation while idealized helping donors seem to be
unaware of such costs. Differing levels of sensitivity
to the potential underlying costs of donation would
explain why exchange donors experience predona-
tion ambivalence while idealized helping donors'
negative reactions (psychological difficulty) are
delayed until after the donation experience.
Two donation motives--positive feeling and
empathy--were related to positive reactions to the
donation process. Donors who said that they felt
privileged to donate or that they expected to feel
good about themselves after donation experienced
145
significantly lower levels of predonation ambiva-
lence, elevated feelings of being a better person for
having donated, and somewhat more concern about
the recipient than donors who were not motivated
by positive feelings. Although it is not necessarily
clear that concern about the recipient is a positive
reaction, the fact that this outcome is associated
with other positive outcomes (both for positive feel-
ing and empathy motives) indicates that it certainly
is not causing donors to experience the full do-
nation process less positively. As noted previously,
the fact that positive feeling motives are associated
with lower ambivalence is important because
ambivalence may lead to a variety of other negative
donation reactions. The link between positive feel-
ing motives and feeling like a better person after
donating is not surprising, and may represent, in
part, a fulfillment of donors' expectations about the
donation process. Donors with empathy motives
had somewhat less psychological difficulty at one-
year postdonation, felt like better persons for hav-
ing donated, and were significantly more concerned
about the recipient than were donors who did not
report empathy motives.
Although expecting positive feelings for oneself
and being concerned about the well-being of a reci-
pient seem to represent two divergent motivational
states--one focused internally on the potential ben-
efits of donation to oneself and one focused exter-
nally on the potential benefits to the recipient--they
do share a common element. More than any of the
other motive categories, these two motive types are
affectively rather than cognitively based. Although
the evidence presented here is preliminary, it is
possible that donors who are emotionally engaged
in the donation process may experience more posi-
tive donation outcomes than those who donate for
other reasons.
In sum, our findings demonstrate several things.
First, it is clear that unrelated bone marrow donors
agree to donate for a variety of reasons, none of
which--in contrast to some of the earliest assump-
tions about unrelated donors' motivations--seem
particularly pathological. Second, specific motives
for donation appear to be associated with donor
background characteristics. This relationship seems
especially strong for donors' gender, which was as-
sociated with three of the five motive types central
to our analysis. Finally, donors' motives are associ-
ated with their reactions to donation; at least one
motive type was associated with five of the seven
donation reactions. Specifically, two motive types
(exchange and idealized helping) were associated
with less positive donation outcomes and two
others (positive feeling and empathy) were associ-
ated with more positive donation outcomes. The
implications of these findings for the process of
donor recruitment and education are important. If
subsequent studies confirm the relationship of
donor motivation to donation outcomes, donor
146 Galen E, Switzer et al.
recruitment and continuing education strategies
could be tailored to compensate for any liabilities
invoked by certain motives, and to encourage
donors to view the donation process more compre-
hensively. F o r example, if a donor coordinator
informally assessed a donor's motives shortly before
donation and discovered that the donor was focuss-
ing narrowly on a process of weighing costs and
benefits of donating (exchange motives), the donor
coordinator could help the donor to broaden his/
her perspective to consider the potential good that
could result from donating or on feelings of empa-
thy for the recipient. We believe that the findings
from the present study both enhance our conceptual
and theoretical understanding of the process of
medical volunteerism and further our ability to
make practical suggestions for the recruitment and
education of bone marrow donors.
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Acknowledgements--This work was supported by grant
HL48883 from the National Heart, Lung, and Blood
Institute, Bethesda, MD.
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