Essay- Marketing Mix

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Help Me Help You! Employing the Marketing Mix to Alleviate Experiences of Donor Sacrifice

Tonya Williams Bradford and Naja Williams Boyd

Abstract Nonprofit organizations often rely on individuals to execute their mission of addressing unmet societal needs. Indeed, one of the most significant challenges facing such organizations is that of enlisting individuals to provide support through the volunteering of time or donation of money. To address this challenge, prior studies have examined how promotional messages can be leveraged to motivate individuals to support the missions of nonprofit organizations. Yet promotional messages are only one aspect of the marketing mix that may be employed. The present study examines how donor-based nonprofit organizations can employ the marketing mix—product, price, promotion, place, process, and people—to influence the experiences of sacrifice associated with donation. The authors do so through an ethnographic study of individuals participating in living organ donation. First, they identify the manifestation of sacrifice in donation. Next, they define three complementary and interactive types of sacrifice: psychic, pecuniary, and physical. Then, they articulate how the marketing mix can be employed to mitigate experiences of sacrifice that emerge through the donation process. The authors conclude by discussing implications for marketing practice and identifying additional research opportunities for sacrifice in the realm of donation.

Keywords charitable giving, marketing mix, organ donors, place, price, product, promotion, sacrifice

Nonprofit organizations contribute $985.4 billion to the U.S.

economy (McKeever 2018) and serve the public interest by

providing a wide array of crucial services, goods, and

resources—from food and shelter to body parts. Organizations

tend to employ the promotion element of the marketing mix to

persuade individuals to donate; however, there may be oppor-

tunities to use additional elements. The greatest challenge such

organizations have in executing their missions is that of secur-

ing sufficient donations from individuals (Bendapudi, Singh,

and Bendapudi 1996; Winterich, Mittal, and Aquino 2017). All

types of donations from individuals entail sacrifice, yet those

who provide anatomical parts in support of health care treat-

ments make undisputed sacrifice. Because not all donations are

born of the same degree or type of sacrifice, it is necessary to

understand sacrifice in relation to donation so that organiza-

tions can better overcome this obstacle when recruiting donors.

Thus, the question guiding this research is, How can organiza-

tions use marketing-mix variables to reduce experiences of

sacrifice in donation?

Studies on consumer shopping behavior have focused pri-

marily on the monetary sacrifice made to obtain value imparted

by organizations through the marketing mix (Gupta and Kim

2010; Howard and Kerin 2006; Jindal et al. 2020); in contrast,

the charitable giving literature has focused on promotion to

increase the number of donors and size of donations (Fajardo,

Townsend, and Bolander 2018; Liu and Aaker 2008; Reed et al.

2016; Winterich, Mittal, and Aquino 2013, 2017). Although

there is recognition that the elements of the marketing mix

influence shopping behaviors (Jindal et al. 2020), there is little

insight into how marketing-mix elements—product, promo-

tion, price, place, process, or people—may be employed to

support charitable giving. While promotion to attract donors

is certainly important, it is likely insufficient to convey the full

complement of donations needed. Consider, for example, the

variance in degree of sacrifice sought. For some organizations,

little effort is required (e.g., church usher, PTA member, Meals

on Wheels driver); for others, the sacrifice is more extensive

(e.g., Make-A-Wish granter, foster parent, organ donor). The

present study examines living organ donation, a process in

Tonya Williams Bradford is Assistant Professor of Marketing, Paul Merage

School of Business, University of California Irvine, USA (email: tonya

[email protected]). Naja Williams Boyd (email: [email protected]).

Journal of Marketing 2020, Vol. 84(3) 68-85

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sagepub.com/journals-permissions DOI: 10.1177/0022242920912272

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which one undergoes elective surgery to remove an organ for

transplantation into another person. Given that any kind of

organ donation represents an extreme form of sacrifice, the

transplantation phenomenon serves as an excellent focal point

for examining the sacrificial burdens involved in donation and

opportunities to overcome them through the marketing mix.

This research suggests that different elements of the mar-

keting mix may be used to address sacrifice related to donating

behavior. Our findings suggest that a combination of

marketing-mix elements may reduce experiences of sacrifice

and thereby increase donation behaviors. This research contri-

butes to literature recognizing that consumer reluctance to

donate must be overcome (Fajardo, Townsend, and Bolander

2018; Liu and Aaker 2008; Reed et al. 2016; Winterich, Mittal,

and Aquino 2017). This reluctance has been addressed by prior

research, which has emphasized that promotional messages

may be used to procure necessary donations. This study

extends scholarship on donation by leading our inquiry beyond

that of promotion. Specifically, we describe how sacrifice man-

ifests in the donation process and identify roles for the market-

ing mix to overcome potential reluctance to make such

sacrifices. Relevant to an examination of marketing mix are

such variables as product, price, place, process, people, and

promotion.

In addition, this research contributes an understanding of

anatomical parts as a particular type of possession separate

from money, time, or other objects. While the donation of

anatomical parts has been explored in the social sciences

(Sharp 2006; Strathern 2012; Titmuss 1997), it is not a focus

of marketing literature, though the market for such parts is

significant and growing. This research also contributes an

understanding of how nonprofits may attract organ donors by

more intentionally and systemically overcoming concerns of

potential donors. Where prior research has considered dona-

tions of money, which can be replenished (Lee and Bradford

2015; Liu and Aaker 2008); possessions for which individuals

have sentimental attachments (Winterich, Mittal, and Aquino

2017); or time, for which all individuals have the same irre-

placeable amount each day (Reed et al. 2016), this research

investigates the growing market of anatomical parts for

transplantation.

In addition, this study offers practical applications by sug-

gesting how marketing-mix elements can be employed to over-

come the barriers that may hinder individuals from donating.

By better understanding how individuals may experience sacri-

fice through donation, we provide insights and tools for non-

profit managers focusing on how to use the marketing mix to

encourage donation and thereby increase supply to meet

demand.

To contextualize this study, we begin with a succinct review

of the marketing and social science research on donation and

sacrifice. We then present our methodology, including an over-

view of living organ donation within the U.S.-based transplan-

tation market. We close with our findings, followed by a

discussion of implications for practice and theory.

Theoretical Background

Nonprofit organizations deliver services to their clients made

possible through donations from individuals (Bendapudi,

Singh, and Bendapudi 1996; Winterich, Mittal, and Aquino

2017). These donations are depicted as gifts of “life” or “hope”

that support others in need (Sherry 1983). Such donations are

most often provided by individuals who intentionally offer

their support without receiving tangible rewards (Gershon and

Cryder 2018; Peloza and Hassay 2007; Titmuss 1997; Wilson

2000; Wymer and Samu 2002). These donations can be cate-

gorized as gifts to society that encompass the sacrifice of for-

gone opportunities (Larsen and Watson 2001; Mauss 1967;

Strathern 2012). It is worth noting that these contributions are

substantively distinct from contributions made to obtain some

benefit for the self, such as with “pay what you want” pricing

approaches (Christopher and Machado 2019). More specifi-

cally, contributions to nonprofit organizations are most often

provided to deliver a benefit to others. Next, we provide a brief

review of the marketing literature on donation and sacrifice.

Donation

Marketing and consumer researchers have primarily examined

how the promotion element of the marketing mix can be

employed to attract donors and increase donations. Studies

provide insight into how messages may influence potential

donors, turning a lens on the relative importance of the help

sought (Fisher and Ackerman 1998), the role of individual

identity (Bradford and Lee 2013; Reed, Aquino, and Levy

2007), the motives for participating (Wilson 2000; Winterich,

Mittal, and Aquino 2013), or the impact on the donor (Fisher

and Ackerman 1998; Winterich, Mittal, and Aquino 2013). The

focus of those studies has been to identify and understand

conditions by which appeals may arouse sufficient interest for

individuals to donate to an organization. Although promotion

has a role in transforming individuals into donors, prior

research does not illuminate how coupling other marketing-

mix elements together with promotion may influence donation.

Awareness of opportunities is an important factor in secur-

ing donations, particularly in the case of organ donations

(Healy 2006; Waldby and Mitchell 2006), and leads many

organizations to focus on promotion. Knowledge acquisition

is certainly a contributing factor for those who choose to donate

anatomical parts, yet additional requirements are necessary to

transform them into donors. For example, even after passing

the first hurdle of developing a desire to donate, potential

donors must still qualify to participate (Bradford 2019; Titmuss

1997). Thus, it is necessary to investigate the donation experi-

ence to better understand the marketing mix’s role in attracting

and securing donors.

Donations to organizations have been viewed as gifts to

society (Bradford 2013; Strathern 2012; Titmuss 1997). Like

other types of gifts, these are born of sacrifice (Mauss 1967;

Sherry 1983). Importantly, not all donations involve the same

degree of sacrifice, as individuals possess several resources

Bradford and Boyd 69

they may gift as donations. There are monetary gifts, which are

viewed as replenishable and fungible. There are gifts of time,

something qualitatively different from money in that time may

not be stored or replaced (Fisher and Ackerman 1998; Hol-

brook and Lehmann 1981). Other possessions that may be

donated have value in the degree and source of individuals’

attachment to them (Belk 1990; Winterich, Mittal, and Aquino

2017). Lacking in this conversation is an understanding of how

the marketing mix can address the types or degrees of sacrifice

that may be associated with the donation of possessions.

Sacrifice

In the marketing literature, the concept of sacrifice is focused

primarily on price—what consumers give up to obtain value

(D’Angelo, Diehl, and Cavanaugh 2019; Gao, Zhang, and Mit-

tal 2017; Zeithaml 1988). Beyond money, research identifies

consumer sacrifice as the expending of energy, effort, or time

(Baker, Grewal, and Voss 2002; Bender 1964; Bradford and

Sherry 2013; Gupta and Kim 2010; McGrath, Sherry, and Levy

1993). The degree of sacrifice, conveyed by price, may serve as

information to consumers (Dodds, Monroe, and Grewal 1991;

Gao, Zhang, and Mittal 2017), inform perceptions of alterna-

tive offerings, or provide indicators of offering quality (Suri,

Kohli, and Monroe 2007; Völckner 2008). In addition to the

sacrifice one may make to obtain an offering, there is the sacri-

fice that manifests as a consequence of forgoing other options

(Larsen and Watson 2001; Völckner 2008). While individuals

may feel minimally burdened by the particular form of sacrifice

made, some sacrifices may be deemed too great, thereby reduc-

ing a consumer’s willingness to purchase an offering (Belk and

Coon 1993; Dodds, Monroe, and Grewal 1991). While price is

often equated with sacrifice in the market, there also is recog-

nition within the literature that consumers make sacrifices

beyond price to attain desired outcomes.

Extra-economic sacrifices are found in investments of time,

effort, or energy (Areni, Kiecker, and Palan 1998; Belk and

Coon 1993; Fernandez and Lastovicka 2011; Gupta and Kim

2010; Zeithaml 1988). Time is a limited and perishable

resource. It is most often viewed as that which may be mon-

etized and is perceived as a cost (Baker, Grewal, and Voss

2002; Giebelhausen, Robinson, and Cronin 2011; Zeithaml

1988), considered in relationship to search and intended patron-

age (Baker, Grewal, and Voss 2002; Grewal, Monroe, and

Krishnan 1998), or viewed as a precursor to attaining desired

offerings (Bradford, Grier, and Henderson 2012; Howard and

Kerin 2006). As a type of sacrifice, time is often described in

conjunction with effort. Sacrifices of effort are depicted as

labor or inconveniences necessary to attain benefits (McGrath,

Sherry, and Levy 1993; Otnes, Lowrey, and Kim 1993). Effort

is evident in the cocreation of market-derived experiences

where consumers are active participants (Celsi, Rose, and

Leigh 1993; Epp and Price 2011; Scott, Cayla, and Cova

2017; Tumbat and Belk 2011). Sacrifices of effort may include

that of choice when individuals opt to provide gifts in response

to specific recipient requests (Bradford and Sherry 2013; Low-

rey, Otnes, and Ruth 2004; Wolfinbarger 1990).

Sacrifices of energy are described as psychic or emotional

expenditures encompassing the contemplation associated with

a consumption opportunity (Areni, Kiecker, and Palan 1998;

Aydinli, Bertini, and Lambrecht 2014; Baker, Grewal, and

Voss 2002; Belk 1996). While a primary focus in the literature

is on monetary sacrifice for value that is conveyed through the

marketing mix, it is necessary to examine how the marketing

mix can be used to address sacrifice experienced by donors.

Although time and effort may emanate from the embodied self,

sacrifice of the physical self is less often contemplated. None-

theless, Fernandez and Lastovicka (2011) examine the employ-

ment of physical and mental energy to transform a previously

used object; Marcoux (2009) considers the physical nature of

effort involved in providing relocation assistance; and Klein,

Lowrey, and Otnes (2015) recognize the physical peril individ-

uals accepted when they secretly shared additional food with

other inmates in Nazi concentration camps. Together, those

findings illustrate that monetary sacrifice alone may be insuffi-

cient for some forms of consumption and that promotions are

likely insufficient to overcome sacrifices beyond those of

awareness.

Methodology

The purpose of this study is to understand the nature of sacrifice

in donation so as to guide organizations in overcoming obsta-

cles to obtain donations. Because living organ donation indis-

putably involves great sacrifice, it provides a clear context in

which to understand sacrifice in relation to donation. Further-

more, an organ must be donated voluntarily and may only be

offered as a gift in the United States (National Organ Trans-

plantation Act of 1984; Uniform Anatomical Gift Act of

1968 1 ). Next, we provide an overview of the phenomenon

followed by a discussion of data collection and analysis.

Phenomenon of living organ donation

Living organ donation is orchestrated by medical personnel and

associated transplant centers within the transplantation market.

Whereas early transplants relied on organs from deceased indi-

viduals, living organ donation is increasing as health care inno-

vations provide opportunities for transplanting organs from

living, genetically unrelated individuals (Bradford 2013; Roth-

man, Rozario, and Rothman 2007). Nonetheless, with demand

for organs outpacing supply, living organ donors are increas-

ingly sought. Without a transplant, individuals experiencing

organ failure may undergo various treatments that sustain life,

though often at diminished quality. All clinical costs associated

with donation are funded by participating organizations (e.g.,

organ procurement organizations, insurers, transplant centers

1 See https://www.uniformlaws.org /committees/community-home?

CommunityKey¼015e18ad-4806-4dff-b011-8e1ebc0d1d0f (accessed March 5, 2020).

70 Journal of Marketing 84(3)

within hospitals) and are coordinated by a transplant team

(Waldby and Mitchell 2006).

Individuals may donate one kidney, a portion of their liver, a

lung, or part of their intestine. We study the experiences of

living kidney donation, as they are the most frequent type. The

organ donation process is complex, requiring physiological and

psychological clearances of donors. Living donors may be

directed, meaning they donate to a known other (e.g., loved

one, colleague), or nondirected, thereby donating to an

unknown other. Nondirected donors provide an organ to the

next individual on the transplant list with whom they are a

match, or to support a donor chain. No matter the recipient,

the donation process is the same.

This process begins with education and culminates with

surgery. The organ donation and transplantation process

includes informing potential donors about the steps to qualify

and the consequences of participation. Once they choose to

participate in the process, individuals are assessed for their

overall fitness. Qualification begins with procuring an exten-

sive medical history, which provides for an assessment of over-

all health as well as evidence of current and potential (physical

or mental) disease. Next is tissue and blood testing to assess the

viability of a match to a recipient. When an individual is iden-

tified as a clinical match to a recipient, and it is determined that

removing the organ is not likely to be detrimental to the donor,

surgery is scheduled.

Kidney transplants occur across two surgeries. First is the

nephrectomy, removal of the kidney from the donor, a surgery

that typically lasts four hours. Next is the transplantation, the

insertion of the donated kidney into a recipient, which lasts

approximately three hours. Surgery leaves a donor with an

immediate and significant degradation of bodily functionality,

coupled with the physical trauma of the procedure. Donors are

hospitalized on average between two and four days after the

procedure, followed by a recovery period at home of two to six

weeks. Recipients often emerge from surgery feeling well due

to the immediate functionality provided by the transplanted

kidney. Both parties are required to participate in follow-up

tests to monitor their respective kidney function, though the

requirements differ.

Data collection

Because the present study focuses on the experience of living

donation, we deemed ethnography to be the most appropriate

research method. Given that the process to become a living

organ donor is quite extensive, a larger number of people begin

the screening process than actually donate. This is due to any

number of reasons, including a prospective donor’s current or

projected health, willingness to proceed through various clin-

ical tests, or decision to terminate the process. To better under-

stand sacrifice within living donation, this study thus examines

only those individuals who completed the living kidney dona-

tion process.

Prior to beginning this study, the authors themselves parti-

cipated in organ transplantation. The second author made her

need known, as advised by her physician. The first author

volunteered to be tested and ultimately became the second

author’s donor. The process, from the precipitating event

through recovery, transpired over a period of nine months.

Each author recovered without incident. Throughout this pro-

cess, field notes were captured.

Study participants were solicited through clinicians, online

living organ donor support forums, and snowball sampling,

with varying outcomes. They included individuals from differ-

ent regions in the United States who participated in both

directed and nondirected donations. Each author has a relation-

ship with a nephrologist (kidney physician) with whom they

shared the intention of this study. Those physicians were asked

to share study information with their patients as they saw fit.

The physician provided those patients who expressed an inter-

est in participating in this study with the authors’ contact infor-

mation. Within online donor forums, the first author posted

notices inviting willing participants to initiate contact through

a social media platform, direct message, or email. In both

recruiting approaches, more individuals expressed interest in

participating in the study than actually followed through to

participate in interviews. No compensation was provided to

individuals who participated in this study.

Our sample includes 20 individuals representing diversity in

race, age, sex, sexual orientation, elapsed time since donation,

donor and recipient outcomes, type of donation (i.e., directed,

nondirected, or donor chain), and location (see Table 1). The

participants include eight nondirected donors and six individ-

uals who had complications or became aware of their recipi-

ents’ complications. Although statistics indicate that the

majority of donors continue to be in good health postdonation,

some suffer donation-related complications. Our participants’

clinical outcomes range from expected recoveries to varying

degrees of acute or chronic physical and emotional disease.

Most, but not all, recipients had resumed a healthy lifestyle

free of dialysis.

We collected ethnographic data through semidirected phe-

nomenological interviews, participant observation in living

donation, and online donor forums. We downloaded the posts

of individuals identified in online forums, which often provided

an archived timeline of their experience, and these served as

projective tasks within interviews. Given our own experiences,

we quickly established rapport with study participants.

We began interviews by asking individuals to describe how

they became a living organ donor. Accounts shared in response

to the initial question were probed using emic terms to facilitate

interview continuity. In addition to learning of each unique

circumstance, we asked individuals to describe how they

learned of the need, made the choice to donate, and experi-

enced testing, surgery, and recovery. They were also asked to

describe the process, who was involved in the process, the

emotional and physiological outcomes for themselves and the

recipient (when known), and the timing of the transplant. Inter-

views ranged in duration from one to four hours, with an aver-

age of 90 minutes and some follow-up exchanges on social

media and email. Data were collected by phone and through

Bradford and Boyd 71

face-to-face meetings at the convenience of participants. Inter-

views were audiotaped and transcribed.

Data analysis

Interview transcripts and field notes provide the basis for our

analysis and interpretation. Data analysis began with a review

of the donation process as described by donors. This review

revealed that the donation process was the same for all parti-

cipants regardless of center type, testing protocol, or surgical

method, thus allowing for comparison across phases in the

process. Next, codes were generated from readings of the

anthropology, theology, market, and consumer research on

donation (e.g., time, money, effort). Those initial codes were

supplemented with emic terms (e.g., wait, goal, endure) from

the initial analysis of the transcripts and field notes.

Analysis continued with each transcript being coded. Next,

transcripts were analyzed across each phase of the donation

process: learning about the opportunity, making the choice to

participate, qualifying (i.e., determining the degree of match),

and fulfilling the commitment to volunteer (i.e., surgery,

recovery, and donor outcomes). In addition, we analyzed tran-

scripts across outcomes in terms of meeting expectations

(e.g., successful outcome), exceeding expectations (e.g., eas-

ier, faster), or falling below expectations (e.g., poor outcomes

for the self or the recipient). Thus, two types of analyses—

diachronic (i.e., across the process) and synchronic (i.e.,

within similar phases or outcomes of the process)—were per-

formed (Arnould and Wallendorf 1994; Strauss and Corbin

1998; Thompson 1997).

We identified emergent themes through an iterative process

comprising analysis of the transcripts, the coded data, and the

literature (Strauss and Corbin 1998). Data collection and anal-

ysis continued until saturation was attained. We conducted

member checking in follow-up discussions and emails with

four participants.

Findings

We codify the living organ donation process in three key

phases: deliberate, decide, and donate. Through our partici-

pants’ experiences, we find that the marketing mix is the

Table 1. Overview of Study Participants.

Pseudonym Sex Age

(Years) Type of Donor Donor Outcomes Recipient Recipient Outcomes

Alison Female 40s Nondirected As expected Stranger; different race As expected Derrick Male 50s Directed As expected Wife As expected Erica Female 30s Nondirected

(paired kidney program)

As expected Mother As expected

Franklin Male 70s Nondirected As expected Stranger; met after 15 months

As expected

Gregory Male 60s Directed Chronic pain Colleague’s daughter As expected Hannah Female 50s Directed As expected Neighbor; developed

relationship with extended family

Kidney died; recipient went on dialysis

Isaac Male 40s Directed As expected Professor; reconnected via Facebook

As expected

Jacob Male 50s Directed Surgical complications, financial complications

Coworker; different ethnicity

As expected

Kenneth Male 40s Nondirected (donor chain)

As expected Stranger As expected

Lizbeth Female 40s Directed As expected Brother As expected Meredith Female 50s Directed As expected Son As expected Nancy Female 50s Directed Depression, kidney disease Friend Continues to have health

challenges due to chronic disease

Octavia Female 40s Directed As expected Mother As expected Penelope Female 40s Directed Initial complications due to

previous surgery; recovery as expected

Brother As expected

Quintessa Female 30s Directed As expected Husband As expected Reginald Male 50s Directed As expected Brother As expected Sadie Female 60s Directed As expected Husband Less than half normal activity

resumed Tabitha Female 20s Directed As expected Cousin As expected Victoria Female 50s Directed As expected Niece As expected Wilma Female 50s Directed As expected Brother As expected

72 Journal of Marketing 84(3)

primary means by which organizations may support the dona-

tion process and, in particular, mitigate donor sacrifice that

emerges as individuals become donors who offer their posses-

sions for the benefit of others. We identify roles for six

marketing-mix elements that aim to manage sacrifice experi-

ences: product, promotion, place, price, process, and people.

Furthermore, we identify three complementary and interactive

types of sacrifice: psychic, which reflects the employment of

mental or emotional energies; physical, which encompasses

investments of components and functioning of the bodily self

as well as modifications to behaviors; and pecuniary, which

comprises investments of possessions, time, or money. We find

the each of the three types of sacrifice may emerge during any

of the phases within donation (see Table 2).

In line with this categorization, we find that there may be

opportunities for organizations to address the types of sacrifice

that may evince across any one of the three phases of the

donation process. While both individuals and organizations

participate in each of the phases in the process, the degree of

relative influence varies, such that the deliberation phase is

more heavily influenced by the individual and the donation

phase by the organization. Next, we depict participant experi-

ences through data excerpts to illuminate relationships between

sacrifice and the marketing mix within each phase of the pro-

cess. Although the phases are presented as discrete units, the

experience is more of a continuum in that data may encompass

aspects of more than one phase.

Deliberate

The first phase in the process is one of deliberation, in which

organizations prominently employ promotion to raise aware-

ness of the donation opportunity. For many donor-reliant orga-

nizations, the product and process are entwined in delivering

the intended outcomes and associated benefits. Here, too, we

find that organizations may benefit when they more fully depict

the product as comprising both the donation and the transplan-

tation. Through our informant experiences, we identify roles

for the product and the process that, together, provide donors

with opportunities to contemplate the benefits and risks of

participating (for themselves and for the recipient). The parti-

cipants in our study come to learn of this particular volunteer

opportunity in a variety of ways, from observing a loved one’s

decline in health to encountering promotional (and public rela-

tions) messages. Regardless of the means through which

individuals learn of the donation opportunity, they necessarily

employ psychic sacrifice to better understand the requirements

and implications of participation in the process.

One informant, Gregory, initially learned of living organ

donation through a story on National Public Radio’s This

American Life program. He describes how that story prompted

him to consider participating as a living organ donor, though he

was not moved to act until he received a request for help. While

promotion stirred his interest in the product, it was insufficient

to motivate action to participate. He learned, through a group

email, that his colleague’s daughter was diagnosed with end-

stage renal disease and was a candidate for transplantation.

Though he did not know the daughter, he describes feeling

compelled to offer to become her donor:

I received an email from [a colleague] on a Sunday morning that

his daughter had just gone onto the transplant list. . . . It was a

request [saying] that she needed a kidney—he was letting other

people know. And [the email] stated her blood type, and it was

mine. I spent about an hour wrestling with it, looking for a justifi-

able reason not to volunteer. And finding none, I decided that I

would volunteer to be tested. (Gregory)

The information from his colleague, coupled with knowl-

edge garnered from a donor story in the media, compelled

Gregory to donate. He describes learning of the opportunity

to act along with the awareness of the product and process as

integral to awakening his calling. Gregory’s acknowledgment

of his calling encompasses psychic sacrifices with respect to

relinquishing a sense of control over the choice to participate.

His sacrifice of choice was not due to any external forces but,

rather, an alignment of his choice with his calling.

Within the deliberation phase, individuals acquire additional

knowledge about the process by which the donation will be

used to deliver the product and associated benefits for the non-

profit’s client. For most of our informants, the initial informa-

tion requests are related to the specifics of donation in terms of

what they contribute to the product and the process. That often

begins with a desire to understand the requirements necessary

to participate:

I called [a transplant center in my city] just to see if I was even a

candidate. . . . I was going to be 61 in February, and I thought quite

possibly I would be too old. They said that because of my age I

would be considered a marginal donor in their system. I called

[another transplant center] where the surgery was to be performed

Table 2. Definitions of Sacrifice as Experienced Across the Three Phases of the Donation Process.

Psychic Pecuniary Physical

Deliberate Mental effort to consider the option Expenditures associated with exploring the opportunity

Behaviors or actions exerted to assess opportunity

Decide Mental energy to weigh benefits and concerns of selection

Expenses related to choosing to pursue an opportunity

Behaviors or actions employed to choose an opportunity

Donate Recognition that a choice removes other possible choices

Costs incurred with making the contribution

Being present to provide contribution

Bradford and Boyd 73

and they said, according to their system, I was fine. So, I began the

long evaluation process. (Gregory)

Across transplant centers, the product—retrieving a donated

organ and transplanting it into one in need—is the same. Gre-

gory pursued the donation opportunity in the face of mobility

challenges, legal blindness, and the concern that he may be too

old to participate. In fact, when he presented himself to a local

center as a donor, he was rejected due to age. While it is

uncommon for individuals to comparison shop for a transplant

center, there are several instances in our data in which individ-

uals found aspects of a center’s process or people to more

readily mitigate sacrifices posed by the donation. Thus, indi-

viduals might find one center to be more attractive than

another, which may influence where or how they choose to

participate.

When individuals learn about donation opportunities

through intimate relationships, as is the case with a spouse or

siblings, they may experience a strong desire to donate even

before fully understanding the product, process, or its impact

on them. That desire also has the potential to stir psychic sacri-

fice as individuals pursue a known product with little informa-

tion about the process around it. Wilma’s brother was in need

of a kidney, yet she had little understanding of what would be

required of her. The transplant center personnel began educat-

ing Wilma from their first conversation when she requested

information on how to become her brother’s donor:

I just called [the center], and [the transplant coordinator] sent me

out my package and we went from there . . . . I think [my brother

and sister-in-law] wanted to control [the process]. I think they just

found out that [the transplant center] wasn’t going to let them

control it anyway. Their blind selection of a donor was to protect

both ends, both the recipient and the donor. I felt very . . . taken care

of, very considered. They were always looking out for me. They

said, “You can stop this process any time you want. Even if you’re

a perfect donor and you get the heebie-jeebies, it’s okay, you can

stop it.” . . . I knew at any time I could say no and so, therefore, I

didn’t feel like I wanted to say no. . . . They were very kind, they

were very helpful, very professional . . . . We do feel like we’ve

been on a ride and I think it’s not just me, ’cause I’m the donor. But

it’s the whole family—my dad, my brother Bill—just all of us feel

like this has been a long process. (Wilma)

As Wilma’s knowledge increased, so did her comfort with

donation. From the initial stages of the process, the people

responsible for facilitating the process to deliver the product

conveyed the ways in which they would help Wilma navigate

and support her through the process. The people and their focus

on Wilma’s well-being helped mitigate experiences of psychic

sacrifices even before they emerged.

Promotion focuses predominantly on why one should

donate, not on how messaging can help attenuate the psychic

sacrifices individuals may make as they navigate relationships

affected by donation. For example, an individual’s decision

whether to donate an organ can have major relational impacts

within their network of family, friends, supporters, and nay-

sayers due to the potential health risks and uncertain recovery

period involved. Consider the experience of Gregory, who ter-

minated his relationship with his longtime partner when she

questioned his desire to donate. In addition to supporting poten-

tial donors, it is crucial for the process and promotion to attend

to the support network of those donors. An example is found in

Wilma’s experience, in which she describes how the people in

the center focused on communicating the process and her role

within it to deliver the product as support for her as well as to

alleviate her family’s trepidation. Then there is Nancy, who

incurred travel costs because she felt the need to communicate

to her family in person regarding her intention to donate. The

people in Nancy’s center were less helpful in supporting her

desire to understand the process in detail, which resulted in her

incurring financial costs. Perhaps if the people and process

were more supportive, Nancy would have been able to avoid

pecuniary sacrifices in support of her donation.

The process tends to focus on the potential donor, with some

inquiries about their support system. This approach in organ

donation is derived from laws that prohibit the sharing of med-

ical information with people other than the patient. While leg-

ally compliant, such an approach often leaves potential donors

lacking in assistance as they attempt to encourage their support

system to come on board. Consider another informant, Ken-

neth, who described his wife’s dismay as he aimed to initiate a

kidney transplant donor chain. A donor chain is possible when

donor–recipient pairs who are not clinical matches participate

as part of a group of donors and recipients, where each donor

contributes to another recipient such that at least two trans-

plants result (Bradford 2013). Kenneth knew he had an oppor-

tunity to positively affect many lives through participation in

the chain, as his donation would make subsequent transplants

possible. He explains that he put his marriage at risk as a result

of his decision to donate:

I was part of the biggest chain that has been so far. . . . I knew that I

was starting it. . . . I’m married and my wife told me she was going

to leave me if I did it. I said, okay, and she didn’t [leave me]. But I

wasn’t going to let that stop me because she’s worried or whatever.

I wasn’t going to let that stop the benefit that it was going to be to

other people, I didn’t think that was right . . . . She never came

around . . . . I think it still kind of bugs her that I went against what

she wanted. Almost in a way, it’s like I had an affair or something.

(Kenneth)

Potential donors often invest mental energy when contem-

plating becoming an organ donor and speaking to their close

circle about it. The possibility that their health could be nega-

tively affected may well produce personal stresses and, as was

true for Kenneth, stress within their close relationships. Ken-

neth was driven to contribute what he perceived as the immea-

surable good that would emanate from his cumulative psychic

and physical sacrifices, and therefore he excluded his wife from

a life-altering decision. He draws parallels between his kidney

donation and an affair, a state of emotional and/or physical

74 Journal of Marketing 84(3)

perfidy. Reconciling this requires him to sacrifice his wife’s

opinion and support, which are of great value in a peaceful

marital union. Yet Kenneth, akin to many of our study partici-

pants, describes positive aspects that emerge through donation.

The codification of those experiences would serve organiza-

tions in the development of promotions and process compo-

nents to support potential donors and their support systems, as

well as infuse opportunities within the process and the people

supporting it to celebrate such experiences.

The experiences of the previous informants underline how

promotion, designed as it is to disseminate knowledge to poten-

tial donors about the opportunity to donate, is insufficient in

addressing the various types of psychic sacrifice that emerge

through the donation process. The process contemplates the

clinical needs of an individual, yet organizational managers

should consider and prepare for the types of psychic sacrifices

donors make, from contemplating the opportunity, informing

loved ones of their decision, and navigating support throughout

transplantation, including the postdonation phase. There are a

variety of products for which marketers commonly address

potential fears (e.g., “safe when used as intended”). Because

messaging around organ donation does not typically address

the various sacrifices that manifest, there is a large window of

opportunity for tailoring the marketing mix to address this

deficiency.

The integration of promotion, product, and process also

provides opportunities for organizations to support potential

donors as they contemplate engaging in donation. Another

participant, Sadie, learned of her husband’s need for a trans-

plant when accompanying him to a doctor’s visit. During that

discussion, she learned about and was motivated to consider

becoming her husband’s living organ donor:

When you live with someone and all of a sudden you see them

losing weight, you see them walking around like a zombie having

no energy. . . . He was doing the peritoneal dialysis, and he had to

hook himself to the machine every night by eight o’clock . . . . The

reason [the medical team] did this for him was because he liked to

play golf. They were trying to make it so that he could maintain his

lifestyle . . . . He was on dialysis for six months, but it was an awful

six months . . . . When I went with him [for a checkup], the nephrol-

ogist informed me that a lot of wives are giving their husbands

kidneys . . . . I thought, “Well, I have one foot in the grave and one

on a banana peel. I can do this!” (Sadie)

The same medical team that proffered in-home dialysis to

address her husband’s renal failure also offered organ donation

as an alternative. The physician shared the benefits of living

organ donation and also began to introduce information to

enable Sadie to ponder such an option. Even though it was a

more complex offering than dialysis, she welcomed an oppor-

tunity to take a more active role in improving her husband’s

health. When discussing it as a family, their son offered to

donate instead of Sadie. She declined his offer as he was

recently married, had a newborn, and had just started a new

career. Thus, she enacted psychic sacrifice in her assessment of

the opportunity, the relative risk to the possible donors (i.e.,

herself vs. her son), the potential impact to her own health, and

the hope to enjoy a more spontaneous and active life than that

which dialysis accommodated. These sacrifices are not

accounted for within the process, leaving donors to manage

them on their own when organizations can anticipate such

experiences and should proactively address them.

The deliberation phase is likely inspired, in some part, by the

promotional element of the marketing mix. However, it is insuf-

ficient to address the multifaceted experiences of psychic sacri-

fice individuals bring to the deliberation phase. Prior research

has found that psychic sacrifice may be enacted in response to

promotional messaging. For example, a recent University of

Pittsburgh Medical Center (UPMC) television commercial

depicts a line of individuals slowly making their way through

an ominous tunnel with the voiceover: “At UPMC, living donor

transplants put you first so you won’t die waiting.” Similarly, the

National Kidney Foundation initiated the promotion

“#BigAskBigGive,” which provides individuals with guidance

on how to talk with others about becoming a living donor. Pro-

motional materials serve to inform, persuade, and invite action

by individuals to consider participating in a process to deliver a

specific product. Similar to for-profit organizations, which must

align promotions with other aspects of the marketing mix, it is

necessary for donor-reliant nonprofits to consider how other

aspects of the marketing mix can be employed to address psy-

chic sacrifices that may emerge in the deliberation phase of

donation. Potential donors experience psychic sacrifice in con-

templating what it means to undergo an elective surgery where

the result is to remove functionality from their physical self and

provide that functionality to another. Psychic sacrifices also

serve as precursors for other types of sacrifices to manifest.

Importantly, the mitigation of psychic sacrifices through a

clearly and compassionately positioned and communicated

product and process may provide encouragement to individuals

to proceed to the decision and donation phases of the process—

phases that likely require additional forms of sacrifice for which

donors will seek support.

Decide

Individuals undergo the decision phase of the process as they

review the donation opportunity and determine their plans.

While organ donation for transplantation, as a product, consists

of a similar set of criteria and testing protocols across transplant

centers and a consistent set of surgical procedures, there are

some differences. These differences reflect each organization’s

approach to organ donation—specifically, the approaches of

those with distinct roles associated with the entirety of the

transplantation process. As individuals decide whether to

donate, they assess not only the opportunity but also the orga-

nization. Thus, the decision to donate may be influenced by

aspects of the product, the process to deliver it, the people who

enable its delivery, and the place where the donation will occur.

Where psychic sacrifice allows individuals to move forward

with sincere contemplation, the decision phase finds

Bradford and Boyd 75

individuals facing psychic, pecuniary, and physical sacrifices.

Organizations have opportunities to mitigate these sacrifices,

thereby likely contributing to the experience of donors and

perhaps increasing the likelihood that individuals will choose

to become donors.

The opportunities for donor-reliant organizations to employ

product, process, and people aspects of the marketing mix

become more impactful as individuals assess the opportunity

to make their decision. One informant, Penelope, donated to

her brother after he survived a failed transplant from a deceased

donor. She and her family were angst-ridden by his tenuous

health and recount being summoned to the hospital because his

physicians were uncertain if he would live. She aimed to better

understand the impact of donation as part of the product, as

well as the implications of participating on her lived

experience:

[The transplant center] had a reception for donors and recipients, a

little cookie and cake thing where people who had [volunteered to

donate] talk to those of us who are going to do it. [They] talk about

their experience. That was great because I got to see people who

had done it . . . . I was getting nervous. I was excited because I was

going to help my brother but I was still nervous. That was my first

surgery ever. (Penelope)

In Penelope’s case, the organization provided individuals

considering where to donate an opportunity to learn about the

experience from former donors. Sponsoring this event also

provides an opportunity for the organization to help donors

manage experiences of psychic sacrifice as they weigh saving

another’s life while risking their own. By expanding the pro-

cess to include additional people, the organization has oppor-

tunities to provide additional support to potential donors and

perhaps improve their decision process.

The contributions of an organization’s people in the deci-

sion phase are crucial to the process and to the donor’s per-

ceptions of it. Individuals who choose to donate, as well as

their friends and family, may question the extent to which

organizations recognize the depth of sacrifices required to

do so. Wilma and her husband wanted to learn how people

in the organization, and in particular the surgeon, viewed the

process:

My husband asked a question, “What does that feel like once you

take that kidney out of there and you take it over to the other

person? How do you feel about it? . . . Do you kind of feel like

God? Like you’re saving this person’s life?” [The surgeon] said,

“Well, I am the physician who takes out the kidney. My patient is

the donor. And, the donor comes in healthy. . . . I am very particular

about my job, because in the whole hospital, I’m the only person

with patients who come in healthy and go out impaired.” And I

thought, “Wow! He understands.” . . . I felt relieved or assured by

him saying that. I knew that he understood the gravity of the

donation. (Wilma)

Individuals considering donation recognize that transplan-

tation provides significant benefits for both the recipient and

the organization. However, potential donors are acutely

aware that those benefits emerge through their sacrifices.

As Wilma shared, individuals may encounter compassion

in those who play roles in the provisioning of transplanta-

tion or in their initial contact with the organization. Such

experiences facilitated by organizations through the people

and processes that support the product allow individuals to

receive validation of their sacrifices and enable their will-

ingness to contribute the sacrifices required to fulfill the

donation.

With a decision to donate made, individuals begin the qua-

lification phase. Potential donors are provided a detailed

description of the process, including an overview of the criteria

required for participation, the testing sequence, and the possi-

ble consequences of participation. The choice to donate is

fraught with uncertainty, as it does not mean that an individual

will be accepted as a donor. As such, individuals have different

approaches to sharing their intentions with others. The first

author described angst when contemplating with whom to

share:

I want to tell [my friend] about my plans [to donate]. She might

think I’m crazy. I can’t hear anything negative about [donating].

It’s enough that [the transplant coordinator] said I could die! But

what if [the transplant center] rejects me? How will I explain that?

(Field notes)

It is commonplace for individuals to share important hap-

penings in their lives with others. The desire for acceptance of

one’s decision and support for it is common among the parti-

cipants in our study, and many seek out such support in online

donor forums.

The experience of qualification feels more extensive than

how it is presented to potential donors. Participants generally

express astonishment at the degree of testing required:

I thought it was just a blood test. I learned I had more

tests to take . . . . I thought, “Oh Lord, this is going to be

impossible!” . . . Everything was going along and [the transplant

coordinator] came back and said we are an identical match! . . . I

think one of the difficult things is we don’t know how to ask a

sibling to donate. It’s a sacrifice. (Reginald)

The transplant coordinator orchestrates progression through

the qualification phase based on clinical results from a series of

escalating tests (e.g., blood tests to CT scan). These tests may

be the first opportunity for individuals to experience the place

where their donation will occur and, as such, leaves an indelible

impression. One of our informants, Nancy, was deciding

whether to conduct her tests at the local transplant center or

the one where she was a potential match to a recipient. Ulti-

mately, she felt it necessary to meet the people who would

orchestrate and conduct her donation. She organized a visit

incurring travel, accommodation, and vacation time costs to

travel from one state to another in the Western part of the

United States:

76 Journal of Marketing 84(3)

I did online research . . . . The transplant center sent me a [video]

and I read the literature that they gave me . . . . I decided to go to

[the next state over] where the transplant happened—I wanted to

do the blood matching there. . . . I wanted to meet the people . . . . I

read the possible adverse effects like pneumonia, blood clots, and

death. I felt comfortable, but I still wanted to know more . . . . When

I came to the appointment with the transplant surgeon, who’s actu-

ally a cardio surgeon, he’s not even a nephrologist! . . . I had lots

and lots of questions. I wanted to know what was going to happen

during the surgery and he just kind of waved me off and said, “Oh

you don’t need to know that; let’s not worry about that. We’ll take

the kidney out of your old caesarean scar. You won’t have any new

scars and the rest of it we won’t worry about.” He just wouldn’t

give any more information and I even asked, “Are there any other

living donors? Is there somebody I could talk to?” . . . They said,

“Oh no, we don’t do that.” (Nancy)

As individuals proceed through the process, their aware-

ness of the impending surgery and its associated risks

becomes more of a reality. Where Penelope describes an

opportunity to interact with former donors, Nancy was not

allowed to do so. Thus, process contributed to Penelope’s

reduction in experiences of sacrifice by enabling her to see

former donors, yet it accumulated additional sacrifices for

Nancy. Furthermore, where Wilma’s experience of sacrifice

was attenuated by the health care staff, for Nancy it was not.

Although these donors continued through the process, there

are opportunities for organizations to mitigate experiences of

sacrifice through marketing-mix elements that may also

enhance the overall donation experience.

An increasing awareness of the associated risks provides

insights into the various sacrifices these individuals undergo.

There are two that seem to be most angst producing: (1) the

possibility of death and (2) the possibility of being rejected. In

Nancy’s visit, it becomes evident that although the product is

similar, there were opportunities to employ alternatives for the

communication of the process as well as interactions with

transplantation staff to address her experiences of sacrifice

related to her well-being and, ultimately, her life. Other parti-

cipants spoke of the angst experienced as they pondered

whether they would meet the criteria to donate. Participants

stated that they have sufficient information about the process

from the promotional and product materials as it relates to

reasons why they may not be accepted as donors, or the rare

but possible outcome of death. Yet their confidence in the

process is influenced and experience of sacrifice altered when

they are exposed to the people within it.

Throughout the process, individuals often seek some affir-

mation that everything will work out satisfactorily. That is

often evident in how individuals pursue the qualification pro-

cess. For Nancy, it entailed travel to the transplant center to

gather first-hand knowledge of the overall process and people

within it. For others, like the first author, there are sacrifices

made to ensure success with each step throughout qualification

with the hopes of increasing the probability of acceptance. For

example, the first author was required to complete the 24-hour

urine volume test four times, as the results were different than

expected by clinicians:

Seriously? I drink a lot of water—the two jugs [of urine] are all

mine! Off to get the new jugs and another [urine collection] hat . . . .

I don’t like the jugs at the [local clinic] so I will get them from the

[local] transplant hospital—it’s a drive, but anything is better than

redoing this test! (Field notes)

Testing often requires that individuals rearrange their lives

to accommodate travel, clinical appointments, and testing

procedures. As with the surgery costs, tests are covered by

the recipient’s insurance. However, some of these activities

necessitate the expenditure of money (e.g., copay, gas, park-

ing). In addition, the tests themselves typically require that

individuals provide access to their body and bodily products

to assess fitness for organ donation. Thus, testing to qualify

may lead to psychic, pecuniary, and physical sacrifices. These

sacrifices emerge during a fragile time in the process when

individuals are anxiously awaiting to hear whether they can

progress to the next phase of testing until they are accepted as

donors.

The nexus between place, people, and process in the deci-

sion phase represents an ideal point at which marketers can

influence the donation experience. At this juncture, there is

an escalation of commitment evident as individuals proceed

from consideration to making a decision to actively pursuing

the final phase of donation. Alison, a nondirected donor,

wanted to donate in response to a story she heard on NPR. She

is a busy mom with a career who wanted to donate on her terms.

She identified a convenient location for her donation and pre-

pared a schedule that negotiated necessary donation-related

time commitments with the demands of her life. Alison

describes her experiences of sacrifice and how the organization

employed people throughout the process to attenuate antici-

pated anxiety as she passed from one level of clearance to the

next round of testing:

You kind of felt like you were on the show Survivor. Every time

[the transplant coordinator] would email or call me, I would be

like, “Was our blood a match?” Every time you had to have that

blood draw, you were praying that you still were on the island!

That you weren’t going to get the call, “Sorry, you’ve been

rejected. You can’t donate.” . . . Every time I knew I passed the

next test, I was like, “Yes! Okay! One step closer!” (Alison)

The presentation of the self for extractions of fluids and

tissues serves to prepare individuals for ever-increasing phys-

ical sacrifices culminating with the nephrectomy. The relation-

ship the transplant coordinator builds with the potential donor

is key. The commitment to the process is commonly expressed

because individuals anticipate progressing through to the dona-

tion stage. Ideally, the transplant coordinator supports this

anticipation with commendations as potential donors undergo

sequential tests and celebrations when they advance through

stages in the process.

Bradford and Boyd 77

The decision phase encompasses the full complement of

sacrifices, but psychic sacrifices in particular usher in oppor-

tunities for additional experiences of sacrifice as individuals

move through different phases. Key to the donation is the inte-

gration of process and people (surgeons, counselors, etc.)

within place to deliver on the transplantation product. Further-

more, while incurred costs are pecuniary sacrifices, organiza-

tions provide a variety of alternatives to help individuals

assuage or avoid incremental costs. Doing so likely requires

additional donor confidence in the team communicating and

managing the process. Within for-profit offerings, sacrifices

associated with price may signal desirable attributes (Zeithaml

1988). However, incurred costs within donation tend to reflect

a need for organizations to communicate more with potential

donors such in order to mitigate such costs. Within the decision

phase, donor sacrifices may be managed through a combination

of marketing-mix elements to support donors as they make a

crucial decision.

Donate

The donation phase is reached when an organization’s efforts to

secure donors materializes. This phase culminates with the

creation of a product (a donated organ for transplant) that pro-

vides valued benefits to clients. For those attracted to donate,

organizations orchestrate the delivery of the product benefits

through place, which houses the requisite people and processes.

This phase of living organ donation then concludes with the

emergence of the most critical sacrifice: the nephrectomy.

While organizations cannot eliminate the totality of sacrifices

associated with this phase, they can—through the careful spe-

cification of the product including roles for donation and

thoughtful facilitation of product delivery through place, peo-

ple, and processes—attenuate experiences of sacrifice.

As the people within organizations prepare donors for sur-

gery to complete the donation, there is an opportunity to con-

tribute to donor confidence and comfort in order to reduce

experiences of sacrifice. Increasing comfort with the part of

the process that encompasses the details of surgery is a crucial

component of the experience. One informant, Victoria, donated

to her niece. Once credentialed as a donor, she recounts how

she aimed to gather as much information as possible to better

understand how her kidney would be removed:

I’m one of those people that goes and does as much research as

possible. As soon as they told me I was a match, I’m like, “Okay,

what’s the surgery going to be like?” I actually found on YouTube

a video of the actual surgery so I sat and watched that . . . . The

surgeon actually has to slide their hand [into the abdomen] to

retrieve the kidney . . . . It wasn’t long after that I was meeting the

surgeons. I met the one gentleman who came in and the first thing I

looked at—his hands were huge! I was just like, “Oh my gosh, are

you my surgeon?” He says, “No actually, I’m going to do the

transplant [into the recipient].” I’m like, ‘Oh good!’ He kind of

looked at me funny, and I said, “Your hands are huge!” Shortly

after that, I met my surgeon. It was a woman and she has these

beautiful, little, tiny hands! (Victoria)

In the deliberation phase, donors are most often concerned

with factors related to transplant center successes. After decid-

ing to pursue donation and being accepted to donate, individ-

uals often turn their focus to the surgical process that results in

donation. Like Victoria, donors express concern with recovery

and factors that may influence it, including the size of the

incision or degree to which organs are displaced. Though trans-

plant centers do not assign surgeons based on hand size (or

personality, or specialty area), it is crucial to understand the

importance of people within the process. Organizations should

have an awareness of what factors may increase perceived

donor sacrifice and how they can proactively manage them.

Once in the donation phase, sentiments about completing

the process become more salient. Hannah, a hospice nurse who

describes herself as one who avoids “medical stuff,” describes

how interaction with her surgeon reduced her concerns with

donation:

I just love [my surgeon], there was something about him. And

surgeons are usually so detached and so task-based. He was just

a lovely man. We talked about different ways he could do the

surgery. I said, “Well, I’m going to be asleep so I want you to

be comfortable with how you’re doing this.” . . . He did end up

doing the open [nephrectomy]. I have a six-inch scar . . . . And then

he asked me, “This is a nice thing you’re doing. Is there something

we can do for you?” I said, “Well this is going to sound a little

strange, but I would love to have a picture of my kidney going to

him . . . ” He just looked at me and said, “Bring a camera!” So we

got a disposable camera and I have pictures of my kidney in the

metal bowl with him working on it and [the other] surgeon coming

to get [the kidney]. (Hannah)

The organ donation and transplantation process involves peo-

ple at every stage who take on crucial roles. For example, donors

most frequently describe the transplant coordinator as an orient-

ing figure in the process. Another central figure is the surgeon,

whom people assume to be competent, albeit stereotypically

impersonal. As surgeons show compassion toward donors and

the sacrifices they experience through surgery and recovery, the

donors feel cared for within the process. Conversely, recall

Nancy’s encounter where she felt the surgeon was dismissive

toward her inquiries. Hannah’s and Nancy’s experiences under-

score that just as health professionals can enable the progression

of the process in a manner where donor sacrifices are managed,

they can also amplify experiences of sacrifice.

The nephrectomy, the most obvious physical sacrifice by

donors, occurs during a surgical procedure with donors fully

anesthetized. Physical sacrifice is thus experienced primarily

through the recovery process. Penelope describes a postsurgical

recovery experience that is common among living organ donors:

When I came out of surgery, I felt like I had been run over by ten

trucks. One after the other! They just kept running me over. One

after the other. I was a mess, just a mess. But deep down, I was

78 Journal of Marketing 84(3)

happy because I could hear them telling me that my brother was

fine . . . . You can’t look at the moment of surgery. You have to

look at the end result. (Penelope)

The transplant team provides an overview of all aspects of

the process, including recovery. Recovery, both immediately

after surgery and extending weeks afterward toward the goal of

regaining full strength, is particularly challenging for donors

given their high levels of health prior to donation. Recovery

often requires that individuals refrain from several activities,

including work, for anywhere from two to six weeks. The

totality of sacrifices necessary by individuals to contribute to

transplantation is most often deemed worthy, as exemplified by

Penelope. The recovery portion of the donation process focuses

primarily on clinical outcomes. While important, there are

opportunities for organizations to support donors in the experi-

ences of both physical sacrifice and psychic sacrifice as they

strive to fully recover, in addition to pecuniary sacrifice

through lost income and incurred costs.

For most donors, the process ends once they obtain medical

clearance to resume their regular activities. For the organization,

the process comes to a close approximately six weeks after

surgery with the postsurgical lab work. Although the likelihood

of negative outcomes is low for kidney donors, when they do

occur, a timely and appropriately compassionate response by the

organization is important. Recall Nancy, who traveled to

another state to donate her organ. During postsurgery recovery,

she experienced unexpected outcomes that were not explained

or anticipated by the clinicians or found in her research:

The transplant was successful. They had told me in advance that

I’d probably stay in the hospital six days because I had so far to

travel to go home . . . . Before I was discharged, I noticed that I had

lost feeling in my one leg, in my one upper thigh of my left leg. I

mentioned it to the doctor and they said, “It will disappear in six

months.” So, I literally marked on my calendar for the six months.

And, the pain did not go away—it was intensifying. I wrote [the

transplant center] and insisted that they examine me again. And,

they confirmed that I had neurological damage in that leg. (Nancy)

Throughout the process, individuals are made aware of pos-

sible complications. While some complications from organ

donation are resolved within the first year of surgery through

additional clinical intervention (e.g., hernia repair) or lifestyle

adjustments (e.g., fluid intake to address abnormal lab metrics),

other complications may extend much longer (field notes). As

with Nancy, Gregory experienced complications:

It was in my exit interview, six days after surgery when I was

released to come home, the same surgeon who operated on me

said that it would probably be six to eight weeks before I would

be out of the woods entirely . . . . At 8 weeks when I asked for a

refill of pain medication, actually 8 weeks and 1 day, they said they

had trouble with providing any pain medication after 8 weeks, and

at 12 weeks when . . . the surgeon called me, I was surprised that he

did, but a Saturday night he called me, and he said he had never had

a patient who 12 weeks out was still in pain . . . . They never offered

anything in terms of solution . . . . It felt to me like my internal

organs were out of their normal position . . . . I asked if I could

receive water therapy and [the surgeon] approved that. I asked if

he would approve myofascial release work which I had learned

about and I thought could help with what I was told was the scars

were forming and the nerve tissue was probably entangled in the

scars and myofascial release might work, and he denied that, he

said no he wouldn’t approve that. [He was] quite dismissive; as if I

was saying, you know there’s a witch doctor down the street.

(Gregory)

These experiences are similar to those of some donors who

continue to be challenged as a result of surgical complications

that may require accommodation for an extended period of

time. Thus, it is important that health care providers equip

themselves to manage donor experiences that encompass a

range of outcomes, including those of prolonged and unex-

pected sacrifice.

Although the process includes tests to assess mental and

physical fitness and risks for donation, there are negative out-

comes. As with Nancy and Gregory, medical complications

that yield physical sacrifices are most often treated as excep-

tions to the process and may result in encounters with people

who are not equipped to manage them within the context of the

donation experience. Beyond physical complications, individ-

uals may experience additional psychic sacrifices after dona-

tion. Consider Lizbeth, who donated to her brother with whom

she had a standoffish relationship. Throughout the process, she

describes feeling angst and frustration that she would have to

donate to keep peace with her parents and brother. As a reluc-

tant donor, she describes her experience:

Donors, even donors who wanted to do this, feel like after, that “I

was just a kidney walking in there with arms and legs attached.”

You’ll find a lot of donors feel neglected and abandoned. . . . I

called the doctor and now they don’t want to talk to me. Now that

I gave up the organ, now I’m not important to them. [It’s] kind of

like a girl who goes out with a guy and he said, “I love you! I love

you!” and she sleeps with him. Then afterwards, he doesn’t call

her. Like that feeling of, “I gave something that was precious to me

and now you don’t even appreciate it.” (Lizbeth)

Even years after the transplant and with great health, Liz-

beth harbors resentment that neither the process nor the people

within it did much to care for her emotionally and physically.

While transplant organizations are in need of donors’ organs, it

is critical those donors are fully cared for in a manner that does

not leave them feeling abandoned or exploited. It is thus

imperative that organizations develop a supportive process

staffed with compassionate people to mitigate sacrifices by

individuals with less than ideal emotional or physical out-

comes, a process that may well also enhance the product by

heightening appeal to potential donors.

Nonprofits typically focus on messaging that promotes their

product, which in the case of organ donation organizations

translates as engendering a desire among potential donors to

sacrifice an organ for a person in need. The experiences of

Bradford and Boyd 79

donors participating in the present study reflect the kinds of

sacrifices that are common within the organ donor community

and emphasize that such sacrifices need to be addressed by

organ donor organizations. By pursuing mitigation strategies

in the form of various marketing-mix elements, organizations

can convey a cohesive value proposition in their quest to pro-

cure donors, one that speaks directly to the sacrifices that often

accompany the donation of an organ.

Discussion

This study of living organ donation contributes to the literature

by describing how elements of the marketing mix may be

employed to attenuate donor experiences of sacrifice. Prior

research has focused on how promotional messages may be

employed to make individuals aware of donation opportunities

and to overcome reluctance on the part of potential donors.

While the aims of these promotions are crucial, we suggest

how the marketing mix can be employed to mitigate concerns

about the sacrifices often experienced by individuals as they

advance through the donation process feeling valued as integral

participants. As part of that strategy, we identify roles for the

marketing mix—product, price, place, process, people, and

promotion—that extend consideration beyond that of promo-

tion. Thus, this research contributes an understanding of how

organizations can more intentionally and systemically over-

come potential donors’ concerns and thereby increase the pop-

ulation of donors.

Managerial implications

Nonprofits contribute significant value to society together with

support from the individuals who contribute to them. Securing

donations is a primary challenge and focus for the delivery of

these organizations’ missions (Bendapudi, Singh, and Benda-

pudi 1996; Winterich, Mittal, and Aquino 2017). These find-

ings are of particular interest to managers of nonprofit

organizations who rely on individuals to offer contributions

born of sacrifice that enable those organizations to deliver on

their missions. Although these findings emerged from a partic-

ular type of donation, they are relevant to organizations that

depend on contributions born of sacrifice, such as those seeking

families to host foreign exchange students, those striving to

facilitate the adoption of children who are difficult to place,

those providing hospice support to individuals and their fami-

lies during end-of-life transitions, or those offering compassio-

nate care to individuals in crisis (e.g., sexual assault, domestic

abuse, suicidal tendencies). These findings provide insight into

how organizations can secure contributions, a necessary com-

ponent of supply, to meet demand.

Prior research primarily has focused on how nonprofit orga-

nizations may employ promotional messaging to inspire con-

tributions from individuals. We agree that promotion is

certainly necessary, yet the present findings provide evidence

suggesting that managers may be better served in meeting their

missions by considering how to effectively employ the entirety

of the marketing mix to attract individuals for available dona-

tion opportunities. We suggest that managers consider the com-

posite of sacrifices required from individuals as they proceed

through each phase of donation, and that managers employ the

marketing mix to proactively and compassionately address the

various types of sacrifice that emerge.

We identify actions for managers to employ the marketing

mix—product, place, price, promotion, people, and process—

in addressing each of the three types of sacrifice identified in

the donation process (see Table 3). In addition to those specific

actions identified, there are some general considerations for

organizations. Product is reflected most clearly in a nonprofit

organization’s mission statement and manifests in the offering

to which the donation supports. Place focuses on how disparate

entities are integrated to support an individual’s escalation of

commitment from interested to committed as well as the deliv-

ery of the offering. Price is the component that conveys the

costs incurred by donors to provide the contributions. Promo-

tion is most often found in messages educating and persuading

potential donors by conveying their importance to delivery of

the offering. An organization’s people are an important factor

in delivering the entirety of the process and serve as a guide for

donors throughout the process.

The process component reflects the steps required for indi-

viduals to transform from potential to actual donors, and it is

the manifestation of the donation. The process we define is

composed of three phases. In the deliberation phase of the

process, individuals considering the opportunity are more

involved in moving the process forward with some input from

the organization. Within the decision phase, there is a balance

of influence between individuals and organizations. As indi-

viduals move through to the donation phase, the balance of

influence shifts toward the organization. Thus, an awareness

of the process and perceptions of the organization to which

individuals are contributing is also important. To an extent,

donors are invited “backstage” (Goffman 1959) as they con-

tribute to the creation of offerings for others. As such, it is

imperative that organizations understand what they are asking

of donors and how donors may experience sacrifice. Further-

more, it is important for donors to experience a degree of

success, particularly when they are not able to readily observe

the outcomes of their donations. Therefore, it is important that

the processes to which donors contribute provide them with

satisfaction that may be in some ways commensurate with the

sacrifices they make to participate.

Importantly, process and people influence each phase of the

donation experience and should be audited regularly to ensure

that the interfaces between them and each phase, as well as the

other marketing-mix components, are integrated. Furthermore,

it may be helpful for managers to examine the milestones

within a donation experience by assessing the extent to which

those milestones are critical transition points for an individual

to continue with the process of becoming a donor. Prior

research has suggested that recognition may not be impactful

to those who already contribute to nonprofit organizations

(Winterich, Mittal, and Aquino 2013). However, it may be that

80 Journal of Marketing 84(3)

when the process to become a donor is more involved, it may

be useful for organizations to provide motivation that inspires

individuals to continue through the process.

The integration of each of the six marketing-mix elements is

more likely to result in an environment in which individuals feel

their donations are valued and respected. Each marketing-mix

Table 3. Marketing and Organizational Considerations and Actions to Alleviate Sacrifices and Attract Organ Donors.

Marketing-Mix Element

Type of Sacrifice

Psychic Pecuniary Physical

A: Marketing Considerations and Messaging to Alleviate Sacrifices and Attract Organ Donors

Product Offering created from

donation

Delineate donor attributes (e.g., blood type, health metrics) required for the transplantation offering.

Identify potential costs associated with securing supply and ensure expedient reimbursement to donors.

Specify donor consequences of donation beyond transplant outcome and include adequate follow-up to assess progress toward intended outcomes.

Promotion Education about offering

and persuasion to donate

Share impact of donation for recipients and community.

Communicate that participating as a donor is cash neutral, and proactively include reimbursement process.

Employ donor testimonials on the range of bodily impacts throughout the process and describe relevant support.

Place Environment for product

sourcing, creation, and delivery

Provide a virtual tour of the process and the locations for each phase.

Facilitate access to direct billing for testing or immediate reimbursement for out of pocket expenses.

Assess organizational readiness prior to donor arrival to ensure designated space and adequate environment preparation.

Price Incurred costs to participate

Explain how transplant costs are covered by recipient insurance; explain how donor contribution enables the process.

Eliminate costs incurred for donation proactively; ancillary costs related to donation should be promptly reimbursed.

Provide materials to ensure donor comfort throughout donation and recovery free of charge.

Process Steps to source inputs for,

create and deliver offering

Deliver training for donor communication to ensure the steps proceed in a respectful and compassionate manner before, during, and after the transplant.

Identify steps most likely to create costs (e.g., lab tests, transport to hospital, hotel stays while testing) and offer support (e.g., direct bill lab orders; prepaid hotel or transport) to donors.

Recognize the most likely physical and behavioral post-surgical challenges for donors; provide support to prepare and follow up with donors sufficiently.

People Individuals tasked with steps

within the process

Provide necessary information and decision authority to process managers as they support donors within the process.

Ensure that participants who are facilitating the process have the capability to approve costs and facilitate reimbursements.

Equip participants to support donor physical and behavioral challenges with actionable, compassionate plans.

B: Organizational Considerations and Actions to Alleviate Experiences of Sacrifice

Product Offering created from

donation

Delineate impact of donation to organization mission and society.

Reduce cash outlays and reimburse quickly.

Connect challenge to impact of donation.

Promotion Education about offering

and persuasion to donate

Communicate individual and cumulative benefits of donation.

Identify possible out of pocket expenses and note how they will be compensated.

Identify physical and behavioral requirements to participate and engage former donors to communicate “do-ability.”

Place Environment for product

sourcing, creation, and delivery

Create virtual tours and provide maps to facilitate navigation.

Identify and mitigate potential costs incurred by donors.

Provide comfortable workspace for donor contribution.

Price Incurred costs to participate

Explain how costs related to service creation and delivery are covered; connect donor contribution to delivery of client benefits.

Eliminate costs to participate as a donor; document the process for what may be reimbursed and how.

Provide all materials necessary to support donation.

Process Steps to source inputs for,

create and deliver offering

Provide training to successfully support donors with respect and compassion.

Review steps to identify where costs may emerge and proactively manage them.

Recognize steps that may provide donors with physical difficulties and simplify.

People Individuals tasked with steps

within the process

Ensure that participants have adequate compassion in their roles supporting donors to meet the organizational mission.

Provide decision-making authority to participants who support donors incurring costs and reimbursement processes.

Equip participants with tools and resources to provide donors with necessary support to donate successfully.

Bradford and Boyd 81

element should be aligned to engender the desired response to

the organization: that of converting an individual into a volun-

teer. A great deal of marketing research focuses on the types of

messages or individual characteristics that are more likely to

yield larger contributions for nonprofits. In the present research,

we instead focus on how the marketing mix can be engaged to

prepare individuals to engage in a donation opportunity. We find

that marketing-mix elements mitigate sacrifice, which serves to

engage individuals in the donation task and thereby increases the

likelihood that they will continue. For organizations where

donation may continue, the enactment of such sacrifices is likely

to engender loyalty and continuity.

The implications of these findings are obviously important

for organizations in need of tissue or organs to deliver on their

mission. However, these findings are also relevant to organi-

zations in need of donations generally. Consider the Center for

the Homeless, a nonprofit serving those individuals without

secure housing that is reliant on grants, fundraising, and dona-

tions. In particular, individuals donate clothing and food sup-

plies, organize various life skills workshops for adults, and staff

and equip a classroom for children. While there are various

donors who contribute resources to support operations, the cre-

ation and maintenance of a Montessori classroom at this shelter

is partially reliant on donor support. These donors contribute a

significant amount of time, talent, and money annually to main-

tain a fully functioning classroom (e.g., books, computers,

supplies) in addition to supporting training and funding for a

full-time Montessori teacher.

The Center for the Homeless generates much promotion to

increase awareness that there are homeless children in need of

support, yet these findings suggest that it may be more effective

for the center to leverage the composite of the marketing mix to

attract donations to the Montessori classroom. Promotions may

be helpful to clearly articulate the intention of providing quality

education for homeless children at the center in such a manner

that manages the psychic sacrifice individuals may experience

as they contemplate the opportunity. However, more is needed

to explain the role of this particular product, as it is nontradi-

tional in the realm of a homeless shelter as well as a school. The

product is education that serves as a bridge, aiding students in

catching up until they are once again enrolled in a school. Thus,

the product may involve specialized processes and require

additional people beyond the teacher to provide adequate edu-

cation. The place—that is, the Montessori classroom within the

center, is organized to aid children to be treated like students

who are able to learn. Thus, place includes features of a tradi-

tional classroom (e.g., textbooks, reading pods) while accom-

modating the necessarily transient and multiple-grade-level

nature of its students. As with other types of donation oppor-

tunities, there may be incurred costs for donors (e.g., back-

ground check to work with minors, art project supplies). The

marketing mix could be employed by the Montessori classroom

to attract not only donations but also volunteers. More specif-

ically, the center could more fully employ the marketing mix to

attenuate psychic sacrifice (as individuals recognize they have

limited capacity to assist homeless children), pecuniary

sacrifices to participate, or the physical sacrifice that stems

from being in an environment (e.g., smells, security, equip-

ment) different from what they typically imagine encountering.

Organizations are not static, as evident in alterations to their

operations, offerings, and positioning. As for-profit organiza-

tions alter their offerings, they often try to retain existing con-

sumers and attract new ones, recognizing that each will invest

differing psychic energies to consume the offering (Okada

2006). Similarly, nonprofit organizations could adjust their

offerings to remain relevant to those they serve, thereby main-

taining or growing their client base. For example, Habit for

Humanity could upgrade its offerings by adapting the market-

ing mix through product attributes (e.g., new houses, disaster

recovery, retail outlet), distribution (e.g., local and global

builds), market messaging (e.g., model home challenges,

Women Build Week), processes (e.g., one-time vs. long-term),

or people (e.g., retail staff, policy advocates, board members).

As they do so, it is important that they assess how those

changes affect the degree of sacrifice required for existing and

potential donors and operationalize the marketing mix to

address those sacrifices. These examples underscore the impor-

tance of understanding how the marketing mix can be

employed to mitigate sacrifice that emerges in the donation

process as well as to enhance the overall donation experience.

The deft employment of the marketing mix to extend the tenure

of donors may also accrue other benefits to organizations such

as confidence in operational projections, service stability, or

reduction in expenditures to delivery services.

The extension of donor engagement may be viewed as a

form of loyalty. Similar to brand loyalty, which has a positive

impact on a firm’s bottom line (Batra, Ahuvia, and Bagozzi

2012), it is likely that donor loyalty evident in their continued

engagement with an organization also has a positive impact on

an organization’s performance. Consider blood donation, a rel-

atively noninvasive procedure to obtain human tissue. Blood is

donated to organizations that bank it for clinical usage. Some

individuals consistently donate every eight weeks, often at the

same facility. When individuals continue to donate to an orga-

nization, it is likely that they experience less psychic (e.g.,

contemplation), physical (e.g., blood draw, testing), and

pecuniary (e.g., transport, time) sacrifice compared with their

consideration and choice of new donation opportunities (e.g.,

child advocacy). Such continuity may also reduce the number

of donors who switch their support to another organization or,

worse yet, depart the donor marketplace. When organizations

successfully communicate the value that donors help deliver to

the marketplace and stimulate desire for individuals to donate

and minimize sacrifices through the marketing mix, individuals

are likely to engage as donors.

Opportunities for future research

The present study investigates living organ donors. While there

are a growing number of living organ donors annually, the

majority of transplants occur with organs offered by deceased

donor families. Those families employ a different calculus

82 Journal of Marketing 84(3)

when considering donation of their loved one’s organs (Fox

and Swazey 2002; Healy 2006; Scott, Warren, and Ooi 2018;

Sque, Payne, and Clark 2006). Where the present research

focuses on those who make a choice to donate, further research

is warranted to assess how the marketing mix can be employed

to mitigate sacrifices for deceased donor families.

We focus on individual donors and their sacrifices. These

individuals are embedded in social networks where those rela-

tionships likely influence the donation experience. The gift-

giving literature provides insights into how the nature of social

networks may shape the process and experience (Belk and

Coon 1993; Bradford and Sherry 2013; Sherry 1983). An

examination of donors’ social networks and their influences

may provide additional insights. Recall Lizbeth and Wilma.

Lizbeth found her social network to be lacking in compassion

and support, whereas Wilma found hers to be filled with care

and consideration. Each recounted distinct experiences of the

support they sought in the marketplace, which may be related

to what was provided by their social network. Thus, there is an

opportunity to understand how and to what extent social

networks influence the donation experience providing donor-

reliant organizations opportunities to understand and ade-

quately prepare for donor support.

The current research theorizes sacrifice at the individual

consumer level. Scholars in anthropology and theology theo-

rize sacrifice at a community level in relation to social cohe-

sion. Similar to the indigenous Chukchee people, who worked

together to attain benefits for the collective (Mauss 1967), it

may be that members of contemporary societies can be inspired

to work together in support of beneficial societal outcomes. For

example, several movements requiring individuals to employ

sacrifices to attain societal benefits have gained momentum in

recent years (e.g., #BlackLivesMatter, #MeToo, Get Out The

Vote, #NeverAgain). Participation in those movements most

likely involves psychic (e.g., contemplation of consequences

of action and inaction), pecuniary (e.g., donations), and phys-

ical (e.g., protests) sacrifices. Therefore, it may be that sacri-

fices related to consumer movements may be viewed as

enhancing participant commitment. Thus, it is important to

explore how entities pursuing societal benefits (e.g., move-

ments, nonprofits, civic organizations) can employ the market-

ing mix to attract and retain participants. It may be that for

some movements, experiences of sacrifice are part of the per-

sonal benefit in addition to the societal benefits donors seek,

and thus, organizations will have to understand to what extent

and under what conditions they are to attenuate experiences of

sacrifice.

Scholars have also suggested that organ donation may be

viewed as a form of gift-giving to society (Bradford 2013;

Strathern 2012; Titmuss 1997). Such gift-giving contributes

much to the public good. Even as the marketing mix may be

employed to generate even greater degrees of gift-giving, it

must also be recognized that the same tools also may result

in less-than-ideal outcomes. For example, the Susan G. Komen

Foundation raises funds for breast cancer research and makes

grants for breast cancer screening to organizations. The

foundation effectively employed the marketing mix to inspire

donations as individuals paid to participate in three-day races

and secured additional contributions from others. In recent

years, the organization has reduced grant-making capacity due

to the decreased number of individuals willing to make dona-

tions. While monies were employed for the organization’s mis-

sion, a significant amount was used for what donors perceived

to be excessive non-mission-critical expenditures. Thus, it is

imperative that scholars also consider factors that influence the

relationship between marketing-mix elements, donor sacrifice,

and perceived organizational effectiveness.

Conclusion

Consumer sacrifice allows donor-reliant organizations to attain

their missions. We expand prior theories of sacrifice with an

explanation of its three types and how they may be managed

through the marketing mix. This explanation provides oppor-

tunities for managers to better understand how to more fully

leverage the marketing mix to inspire individuals to partner

with them by reducing experiences of sacrifice. Thus, those

seeking more effective ways to procure donations for their

organizations will benefit from understanding the nature of the

relationship between sacrifice and the employment of the mar-

keting mix to position their offerings.

Acknowledgments

The authors appreciate the insightful comments on this research from

Gokcen Coskuner-Balli, Mary C. Gilly, Eileen Fischer, Rob Kozinets,

Hope Jensen Schau, and John F. Sherry Jr. as well as from participants

in the Institute for Money, Technology, and Financial Inclusion Col-

loquia; the Southern California Consumer Culture Community Collo-

quia; and the University of San Diego Brown Bag Series. The authors

acknowledge their transplant team for excellent emotional, social, and

medical care and extend appreciation to those donors who entrusted

them with their stories. The authors are grateful for the support of

family and their loving care throughout the transplant journey. This

paper is dedicated to the authors’ beloved father, John E. Williams

(1941–2018).

Associate Editor

Craig Thompson

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, author-

ship, and/or publication of this article.

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