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Why donate a kidney to a stranger? The history of living nondirected kidney donation, so-called altruistic or Good Samaritan donation, is notable for its associated skepticism if not outright rejection. Since its possibility, transplantation institutes have been concerned over the motives of individuals who present to their clinics with the wish to donate a kidney to a stranger. Are these motives pure? Might there be ulterior motives or secondary gain? Or might these motives be pathological, derivative from a psychiatric disease or syndrome? Although attitudes toward the nondirected donor have improved, skepticism remains: Why, after all, benefit another in this way? This article begins with a case study, a subject who sat down for three interviews to speak freely about his reasons for donating a kidney nondirectedly. It then turns to the background of living kidney donation and a review of pertinent psychoanalytic theories of altruism, rescue fantasies, and the secret benefactor. It concludes with a discussion of the case and its implications for psychosocial evaluation guidelines for nondirected kidney donation. The hypothesis is that the motives behind nondirected kidney donation are likely multitudinous (altruistic and egoistic) and, sometimes, unconscious, yet the risks, despite current evaluation guidelines, may be no greater for that.