It can be argued that living altruistic donors should remain anonymous and should not express preferences in the selection of organ recipients. This study aimed to describe the views of transplant physicians in France and Québec regarding these issues. A total of 27 French and 19 Québec renal transplant physicians took part in individual, semi-directed interviews. Almost all of the physicians agreed that anonymity is mandatory in living altruistic donation (LAD). Regarding the issue of directed donation, most of the French physicians (78%) were opposed to any form of the practice, compared to only a third of their Québec colleagues (32%). We found that these positions were embedded in their respective cultural, legal and social contexts. These results afford a better understanding of these complex issues in two different cultural contexts, and will be useful in the development of international guidelines for LAD.