organ transplantation in a globalised world

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Organ transplantation in a globalisedworldMegan Crowley-Matoka a & Margaret Lock ba VA Center for Health Equity Research and Promotion,Departments of Medicine and Anthropology , University ofPittsburgh , USAb Department of Social Studies of Medicine and Department ofAnthropology , McGill University , CanadaPublished online: 23 Jan 2007.

To cite this article: Megan Crowley-Matoka & Margaret Lock (2006) Organ transplantation ina globalised world, Mortality: Promoting the interdisciplinary study of death and dying, 11:2,166-181, DOI: 10.1080/13576270600615310

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Organ transplantation in a globalised world

MEGAN CROWLEY-MATOKA1 & MARGARET LOCK2

1VA Center for Health Equity Research and Promotion, Departments of Medicine and

Anthropology, University of Pittsburgh, USA, and 2Department of Social Studies of Medicine

and Department of Anthropology, McGill University, Canada

ABSTRACT Organ donation and transplantation, now practiced in many places around the world,

provoke fundamental questions of both meaning and social justice. Drawing on ethnographic research in

North America, Japan, Mexico, Europe, and India, this paper offers a comparative view of how

transplantation is practiced and experienced in different settings, focusing on variation across three key

issues consistently raised by transplantation: (1) the (re)definition of death, (2) conceptions of body,

self, and identity; and (3) the commodification of human body parts. Exploring this cross-cultural

variation provides critical resources for continuing to grapple with the ever-evolving questions of practice

and meaning raised by transplantation, as we debate transplantation as it is, could, and should be.

KEYWORDS: cadaveric; commodification; cultural; globalised world; organ transplantation

Introduction

Organ transplantation has long exerted a powerful pull on both the scholarly and

the popular imagination. The act of moving body parts from one person to another

provokes numerous questions about subjective meaning for donors and recipients,

bioethics, and medical practice wherever it is introduced. In part this is so because

transplantation calls into question normative, culturally agreed-upon categories

about what constitutes life and death, self and other, gift and commodity. At the

same time, transplantation invariably poses thorny questions of social justice, as

decisions about where organs come from, to whom they should go, and how

society should distribute this scarce resource, must be made. It is perhaps not

surprising therefore, that culture, and cultural difference is so often evoked in

discussions of organ transplantation. This stands in stark contrast with the way

many other forms of high-tech biomedicine are often simply assumed to

‘‘translate’’ seamlessly into different settings, such that cultural difference rarely

becomes part of discussions about cardiac catheterisation, or the use of magnetic

resonance imaging (MRI) technology, for instance. While such assumptions about

any form of biotechnology are themselves seriously flawed, as scholarship in

Correspondence: Megan Crowley-Matoka, Center for Health Equity Research and Promotion,

VA Pittsburgh Healthcare System, University Drive Cm (151-C), Building 28, Pittsburgh,

PA 15240-1000, USA. Tel: 4126886000 ext. 815193. Fax: 4126886527. E-mail: [email protected]

Mortality, Vol. 11, No. 2, May 2006

1357-6275 (print) ISSN 1469-9885 (online)/06/020166-16 � 2006 Taylor & Francis

DOI: 10.1080/13576270600615310

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anthropology and science and technology studies has amply demonstrated, in the

case of organ transplantation it has long been accepted that the ‘‘question of

culture’’ is central.

Organ donation and transplantation are currently practiced in many places

around the world, and even the most casual consumer of popular media is exposed

to various representations of transplantation in different settings. Such popular

accounts range from celebratory images of scientific progress and lives saved

through transplantation, to nightmare visions of the international black market in

human organs. It is worthwhile, however, to move beyond this often-sensational

imagery, to take a more nuanced look at how the donation and transplantation of

human organs is practiced and experienced in different contexts. Ethnography,

the signature research method of anthropology, is uniquely suited to providing

such a nuanced perspective, for it draws upon long-term immersion in a cultural

setting and combines participant observation with in-depth interviewing to explore

questions of social organisation, cultural meaning, moral values, and power

relations as they shape human experience. A substantial body of ethnographic

work on organ donation and transplantation in various places around the world

now exists, providing particular insight into the social life of this biotechnology in

North America, Japan, Mexico, Europe, and India (see, for example, Cohen,

1998, 2002, 2005; Crowley-Matoka, 2005, in press; Fox & Swazey, 1974, 1992;

Hogle, 1995; Lock, 2002; Scheper-Hughes, 2000, 2004; Sharp, 2006). Taken

together, this work can illuminate comparisons of both the perceived promise

and perils of transplantation, reminding us that the shape and meaning of

transplantation in any one setting is always only one possible version of how this

biomedical technology is, could, or should be.

A brief story drawn from recent ethnographic research on kidney transplantation

in Mexico helps to illustrate the sorts of questions and contrasts a comparative

approach can produce (Crowley-Matoka, 2005; in press). The story involves the

case of a young boy, the son of a Mexican father and a German mother, in need of

a kidney transplant. The boy was initially diagnosed with kidney failure in an

urban Mexican hospital, and was then taken by his (fairly affluent) parents to

Germany for additional consultations. In both places, the parents were told that a

transplant offered the best chance for their son in terms of both survival and

quality of life. In Mexico, the family was informed that a live donor transplant was

the only truly viable option, given that very few organs were locally available from

brain dead donors. In Germany, however, physicians advised a cadaveric

transplant, based on that country’s (relatively) higher rates of cadaveric donations

and general reluctance to use living donors. After much consideration, the parents

chose to go through with a live donor transplant, using the German mother as the

donor. This decision was driven largely by the slightly higher survival advantages

of live donor transplants. Once this decision had been reached, German

physicians advised the couple that it would be better to return to Mexico for

the transplant. The mother’s German family was horrified and angered by her

decision, and stridently opposed the donation; it seemed inconceivable to them

that she would risk herself when another option existed. The mother, however,

Organ transplantation in a globalised world 167

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was determined to do everything she could to give her son the best chance possible

and rejected their pleas that she reconsider. The family returned to Mexico and

the transplant was carried out successfully in a private hospital.

For the Mexican transplant professionals involved in this case, the mother’s

decision to donate reflected the fact that she had become ‘‘more Mexican’’ in

her thinking and in her relationship to her (nuclear) family, because she was

willing to potentially sacrifice herself in order to save her son. Her German

family’s horror at her decision, in contrast, was viewed as a product of a colder,

more individualistic ethos, thought to be characteristic of Northern European,

North American, and other post-industrial societies. In relating the story, these

Mexican transplant professionals expressed clear pride in what they perceived as

their acknowledged expertise in live donor transplantation. This was a pride that

was acutely sensitive to the way in which the family’s return to Mexico for the

transplant reversed typical assumptions about where centres of high-tech

biomedicine typically lie.

The comparisons produced by this family’s movement between Mexico and

Germany provide several useful points for reflection. First, of course, is simply the

difference in what is regarded as the most available, and most appropriate, source of

organs for kidney transplantation in each setting: live donors in Mexico versus

brain dead donors in Germany. That is, ideas about what constitutes ‘‘the norm’’ in

transplant practice are neither natural nor inevitable, but may vary considerably

across different settings. Also highlighted in this family’s story are very different

ideas about bodily risk, family relationships, and the rights and responsibilities we

have both in our own bodies and to the bodies of others, with the mother’s donation

to her son being read as inappropriate risk in one setting, and ‘‘only natural’’ in

another. Such ‘‘cultural’’ ideas, however, cannot stand as essentialised explana-

tions of difference on their own, but rather, are themselves related to a complex set

of factors. Such factors include, for instance, the infrastructure of healthcare; the

existence of tertiary-level hospitals (or lack thereof) have enormous impact on

whether brain dead potential donors are even available. Also critical is the

sociopolitical history of relationships between individuals, families, and the state.

The history of Nazi medical experimentation, for example, provides a very parti-

cular backdrop against which the use of human bodies for transplantation is

organised and interpreted in Germany (Hogle, 1999). Finally, the young boy’s

story reminds us that people, ideas, and biomedical technologies are increasingly

mobile in today’s world, a fact that makes all the more pressing the need to explore

the variation that emerges when transplantation is practiced in different cultural

and geographic spaces.

The following sections explore this variation, focusing on three key issues

consistently raised by transplantation wherever it is practiced: (1) the (re)defini-

tion of death, (2) conceptions of body, self, and identity; and (3) the com-

modification of human body parts. Casting a wide cross-cultural net, this

exploration will draw primarily on examples from existing social scientific research

on transplantation in North America, Europe, Japan, Mexico, and India. Before

turning to these key themes of interest, however, some additional reflection on the

168 Megan Crowley-Matoka & Margaret Lock

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concept of ‘‘culture’’ will help to frame the comparative approach employed here,

and ground the ethnographic material that follows.

Revisiting the culture concept

Comparative research into the development and implementation of organ

transplantation around the world graphically shows how local values, politics,

medical and commercial interests, as well as religious prohibitions, contribute to

variation in the local forms taken by this technology. It is often assumed that these

differences can be fully accounted for in terms of ‘‘culture,’’ yet all too often

embedded within this assumption are a set of common misconceptions about just

what is meant by this term. One such assumption is the idea that culture

comprises a set of non-rational beliefs that serve to inhibit the adoption of

scientifically-grounded knowledge and practices into certain societies. In this view,

culture is something characteristic of other societies, and science (including

biomedicine) is set off as entirely independent of culture. Yet a large body of

literature has shown that worldwide the sciences are infused at every level with

values and assumptions (see, for example, Kaufert & O’Neil, 1993; Lock, 1993,

2002; Young, 1995). In other words, the ways in which science is practiced and

experienced are no less subject to culture than other areas of social life such as

religion or kinship. Thus, there is no culture-free version of science that can be

taken as a gold standard, and transplantation practices in North America and

northern Europe represent neither the norm nor the ideal against which others can

be judged.

A second common misconception views culture as totalising, conflating the

nation state with a culture and assuming that all people living in a specific country

have a culture in common. Yet in today’s globalised world, where borders and

boundaries can no longer be easily demarcated and populations are increasingly

mobile, the notion of essentialised cultural differences among people becomes

more difficult to uphold. Moreover, unequal relations of power, as well as the

commingling of different language and cultural groups within any given society,

ensure that there is always variation not only between different societies, but withinthem as well. In the context of organ transplantation, official law and policy may

well reflect dominant societal values in any given setting, yet it is not necessarily

the case that all groups within that society agree with or even abide by those

dictates. Thus, for example, despite the fact that most people in the West are

adamantly opposed to organ selling, this does not stop desperately ill patients from

going to other countries to buy organs.

In turning to the comparative examples of transplantation practices and

experiences explored below, it is important to keep a broad and flexible

understanding of culture in mind. In drawing illustrations from different settings

of the various forms and meanings associated with transplantation and its related

practices, great care must be taken to avoid either essentialising or exoticising the

cultural contexts these illustrations (always only partially) represent. Care must

also be taken to avoid assuming that any one of them represents the best, most


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logical, or most rational way to organise and experience transplantation. Rather,

sorting through the range of possibilities opened up by a cross-cultural approach is

intended to increase the resources we have available for grappling with the still-

evolving questions raised by the practice of transplantation.

Recurrent issues in transplantation

The following sections explore three key issues consistently raised by transplanta-

tion wherever it is practiced. Surveying across different settings, of course,

prevents doing full justice to the rich complexity of each cultural context, and the

examples provided must be taken as merely a shorthand introduction to the social

worlds they represent. What is lost in depth, however, is at least partially balanced

by the breadth of comparison this approach enables, allowing insight into the

many possibilities for how transplantation is, and could be, practiced and

experienced.

Redefining death

The term brain death refers to the clinical state in which a patient’s brain has

ceased to function, yet heartbeat and respiration continues with the support of

medical technologies. The brain death concept was codified in 1968 by a

committee at the Harvard Medical School, primarily in response to the

development of the ventilator which could mechanically maintain respiration

and heartbeat for an indefinite length of time, coupled with the growing

recognition of the need for transplantable organs (Ad Hoc Committee of the

Harvard Medical School to Examine the Definition of Death, 1968; Lock, 2002).

Changing the definition of death from a heartbeat/respiration based definition to

one based on brain function allowed some patients previously considered alive to

be labeled dead, and hence made it medically and ethically acceptable to consider

these deceased persons as potential sources of viable organs for transplantation.

Although live donor organs also play an important role in organ transplantation

in many places, the brain death concept and the dead donor organs it produces are

inextricably linked to the rapid spread of this medical technology. Yet while the

term brain death is widely used in medical practice around the world, cross-

cultural research has revealed that the meanings with which it is imbued and the

actions which it authorises are not everywhere the same. In fact, the diagnosis of

brain death is not always taken to mean the death of a person, in the way that the

Harvard Committee originally intended, nor even necessarily the end of all hope

of recovery. Ethnographic examples from North America, Japan, and Mexico

suggest the range of variation in reactions to the brain death concept in different

settings.

Representing one end of what might be considered the spectrum of responses,

in North America the brain death concept was adopted over time into routine

medical practice, provoking little overt resistance among either medical profes-

sionals or the general public. To the degree that the issue of brain death has


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surfaced at all in the popular media in this setting, the overwhelming focus has

been on life-affirming stories of organ recipients who benefited from the

application of this diagnosis. At first glance, such a generally smooth acceptance

suggests that this is simply a straightforward matter of rational, scientific decision

making, implying that brain death is a purely medical issue with no room for

dissension or need for discussion. Moreover, various scholars have noted that the

practice of altruistic organ donation made possible by the brain death concept fits

comfortably with long-standing traditions of charity in North American culture

(see, for example, Lock, 2002; Ohnuki-Tierney, 1994). Yet despite the absence of

much organised resistance or prolonged debate over brain death in North

America, there is evidence even here of underlying discomforts and uncertainties

with the brain death concept. Some have argued, for instance, that the failure of

numerous public education efforts to substantially increase organ donation rates

in the USA suggests a tacit rejection of the brain death concept (Joralemon, 1995).

More explicitly, Lock’s work among North American intensivists, the medical

professionals who work most closely with brain dead patients, has revealed that

many do not really equate brain death with the end of human life, although they

are confident that it is an irreversible condition (Lock, 2002). And recent public

survey data suggest that even those among the general population who support

organ donation may think of brain death as a ‘‘good as dead’’ condition, rather

than truly dead (Crowley-Matoka & Arnold, 2004; Siminoff, Burant, & Youngner,

2004). Yet, at least for the moment, such doubts are not generally publicly

acknowledged, and procurement of organs from the brain dead remains a largely

unchallenged part of routine medical practice in North America.

Standing at the other end of our imagined spectrum is Japan, a highly indus-

trialised, modern, and largely secular society where brain death has nonetheless

been the subject of protracted public debate over the past three decades. Analogous

to the issue of abortion in the USA, brain death has become the central bioethical

controversy in Japan, generating heated legal battles, numerous scholarly treatises,

and countless public opinion surveys in the search for some sort of societal

consensus. Of central concern in these debates is the question of whether brain

death can be considered the end of human life, with considerable unease about a

form of death identifiable only by doctors. In contrast with the North American

focus on organ recipients, Japanese debates have centred largely on the vulnerability

of potential organ donors to utilitarian treatment. As a result, cadaveric organ

donation was illegal in Japan until 1997, and is still far from routine. And although

Japanese society seems to be moving slowly toward acceptance of the brain death

concept, an ongoing ambivalence is suggested by the contradictory state of current

law. At the moment, brain dead patients in Japan are considered dead only when

they have declared in writing that they wish to be an organ donor and a close

relative has cosigned the advance directive; otherwise they may not be removed

from the ventilator until their hearts stop beating or the family wishes it.

Ethnographic research has identified a complex web of factors at work in producing

this very different response to the re-definition of death (Lock, 2002). Among these

factors is the scandal-ridden first Japanese heart transplant, in which doubts were


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raised about whether the donor was truly brain dead and whether the recipient’s

own heart had been sufficiently impaired to warrant the risk of transplantation. The

lengthy, well-publicised legal investigation that ensued in this case was clearly

influential in shaping the course of the debate in Japan, yet cannot alone be held

responsible for fueling Japanese resistance to the routinisation of the brain death

concept. Rather, this paralysing scandal may be seen as itself symptomatic of a

nexus of attitudes, beliefs, and social relations in Japan that mitigate against the

relatively conflict-free acceptance seen in North America. Among these are a

generalised mistrust of medical specialists (as opposed to the family doctor), and

wariness toward the quick adoption of Western medical practices that raise difficult

ethical questions. In addition, death in Japan has long been thought of as a process

recognised by family consensus. This renders the concept of brain death, in which

death is defined as a discrete event about which medical professionals stand as the

ultimate arbiter, at uncomfortable odds with Japanese custom. Also at issue is the

finely developed system of reciprocal gift-giving characteristic of Japanese social

relations, within which the idea of receiving an altruistically donated organ with no

expectation or even possibility of reciprocation may be thought of as incurring an

unbearable debt. Together, these various dimensions of Japanese culture and

society have fostered an approach to brain death that has been both cautious and

contentious. While understanding this response in its own context is critical, the

Japanese case is useful also for what it highlights about responses elsewhere, forcing

us to ask, for instance, not just why the Japanese are so uncomfortable with

surrendering the determination of death to physicians, but also why North

Americans seem so comparatively comfortable doing so.

Although we can think of the North American and Japanese examples as two

ends of a spectrum, ranging from general acceptance to widespread rejection of

the brain death concept, these of course do not encompass the full range of

possibility. A brief exploration of the situation in Mexico provides yet another lens

of possibility through which to examine brain death, revealing the effect of both

cultural beliefs and political economic factors. Organ donations from brain dead

donors are currently relatively rare in Mexico, and thus transplant programmes are

largely dependent upon living donors, with the result that kidneys are the only

solid organs routinely transplanted. Reasons for low rates of cadaveric organ

donation are complex, and include religious beliefs such as lay Catholic

interpretations of resurrection as requiring an intact body. A belief in miracles

as an ever-present possibility also makes some Mexicans, among them both

patient families and medical staff, reluctant to accept a diagnosis of brain death as

truly spelling the end of all hope for recovery. Yet while such traditionally cultural

barriers to accepting brain death and organ donation exist in Mexico,

ethnographic research reveals that most at issue is not rejection of the brain

death concept per se, but rather dimensions of the political economy of healthcare

which make the diagnosis and support of brain dead patients not only difficult to

put into practice, but, for some, difficult to trust as well (Crowley-Matoka,

in press). There are substantial infrastructural limitations that make identifying

and maintaining brain dead patients in Mexico challenging. These include, in


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particular, the scarcity of tertiary-level hospitals, ventilators, and medical staff with

expertise in diagnosing and managing brain death. Further complicating matters is

the deep-rooted skepticism, bred by the long history of corrupt single-party rule in

Mexico, with which many Mexicans view both medical professionals and the

(largely state-run) healthcare institutions where they work. In such an environ-

ment, fears among both patient families and medical staff about the inappropriate

diagnosis of brain death and the potential for profiteering from donated organs are

not uncommon and form an additional barrier to the routine adoption and

implementation of the brain death concept. In contrast to the North American and

Japanese examples explored above, the Mexican case raises slightly different

questions, for here the issue is less whether brain death is accepted as death (or

not), but rather whether the infrastructure upon which the brain death concept

depends is in place. Thus, the comparative view from Mexico highlights the

conditions required for procurement of organs from brain dead patients, calling

attention to the considerable societal resources that must be invested before brain

death can even become a topic of debate.

Body, self, identity

The act of taking organs from one person and putting them into another evokes a

whole range of questions related to conceptions of body, self, and identity. In one

register, the practice of transplantation seems to rest upon an objectified,

mechanistic vision of the body born out of the much-problematised Cartesian split

between mind and body, subject and object. This is, of course, a vision

characteristic of biomedicine and post-Enlightenment Western thought more

generally. Carrying this logic to its ultimate conclusion, organ transplantation can

be seen as analogous to the replacement of faulty parts in an engine, a

straightforward switching out of objectified bodily material with no implications

for identity, for the self of either organ recipient or organ donor. Yet in another

register, the movement of organs between people may have profound implications

for identity, creating possibilities for the merging of selves through the integration

of bodily flesh. This is the logic that drives much of the rhetoric used to encourage

organ donation, for instance, animating the notion of ‘‘living on through another

person,’’ and representing a very different conception of the relationship between

body and self. Anthropologists have long explored the rich cross-cultural variation

in beliefs about the body and notions of self-identity (Csordas, 1994; Turner,

1984), and similarly historians and philosophers have documented changes

through time (Porter, 1997; Taylor, 1989). Thus it is hardly surprising that the

implications of transplantation for body and self are interpreted and experienced

quite differently across diverse settings. The examples below, drawn from research

in the USA, Germany, and Mexico, explore some of this variation and offer

insight into how people in different places make sense of the implications of

transplantation for their bodies and lives.

Official language and policy used in USA transplant programmes clearly

promotes a mechanistic vision of the human body, a vision in which organs are


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simply anonymous, interchangeable parts. Organ recipients (particularly those

who receive organs from brain dead donors) are strongly encouraged by transplant

professionals to think of their donated organs in this highly objectified way and to

reject the idea that anything of the self of the donor inheres in the organ and can be

transmitted to the recipient. In fact, recipients who do identify with, or even

simply dwell on, the identity and characteristics of their organ donors may be

pathologised by transplant professionals, who have coined the term Frankenstein

syndrome to describe what they generally deem to be an unhealthy and irrational

fixation (Sharp, 1995). Yet while organ recipients are being pushed to think of

organs as emptied of all personal identity, a very different sort of language and

imagery is often used to motivate organ donation. Families of brain dead patients

are often explicitly encouraged by organ donation professionals to think of organ

donation as offering a redemptive chance for their loved one to live on in the body

of another. Indeed, much of the promotional literature designed to encourage

organ donation draws upon imagery in which human organs are explicitly

animated or humanised, these lively and symbolically-laden versions of organs are

certainly presented as more than just parts (Fox & Swazey, 1974; Sharp, 2001,

in press). The rhetoric of connection and continuity between donor and recipient

only goes so far, however, and donor families historically have been discouraged,

or even outright prohibited, from establishing contact and any sort of ongoing

relationship with the recipient(s) of their loved one’s organs. Regardless of the

interpretations and interactions sanctioned by transplant professionals, however,

recent research reveals that both organ recipients and donor families in the USA

often make sense of the merging of bodies that takes place in transplantation in

ways that draw on very different understandings of the relationships between

body, self, and identity (Sharp, 2006, in press). Organ recipients often report

powerful feelings of identification with their donors, describing new attitudes,

tastes, personality traits, and bodily habits believed to have been acquired from the

donor along with the implanted organ. For their part, donor families also often

resist the official interpretations thrust upon them, sometimes seeking out the

recipients of their loved ones’ organs through a variety of creative means, despite

the opposition of transplant professionals. In some cases, this contact forms the

basis of an ongoing relationship, with donor family members and recipients

adopting the language and forms of family relatedness to express their sense of

connectedness to one another. This strong sense of connection experienced by

many organ recipients and donor families has even motivated the formation of

advocacy groups that have begun to pressure (with some success) for changes to

official policies regarding contact between them. Thus, in the USA context, we see

multiple conceptions of the relationship between body and self at work in the

experiences of those articulated with the transplant endeavor (see also Lock, 2002,

for Canada). Yet it is important to note that in keeping with the reverence for

scientific rationality so characteristic of American culture, some such conceptions

(the body as object) enjoy official sanction and form part of the public face of

transplantation in this setting, while others (the body as imbued with some sense

of transferable self) form a more quietly held, private discourse.


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Offering intriguing contrast with the USA, Hogle’s research in Germany reveals

organ transplant and donation professionals drawing on very different conceptions

of body and identity as they engage in the work of moving organs from one person

to another (Hogle, 1996, 1999). Rather than viewing organs as homogenous,

wholly interchangeable parts, the people who work to obtain and implant human

organs in Germany are more likely to stress the particularity of each individual

organ, a particularity that is related to the individual identity and quality of the

donor. Great attention is paid to preserving donated organs in as fresh and natural

a state as possible in this setting, with the goal of interfering as little as possible

with the unique qualities of the individual organ before it is transplanted into a

recipient. Thus, rather than splitting off body from self, the self not only persists in

the bodily parts, but imbues them with greater (or lesser) value. In part this

approach is surely shaped by the still acutely-felt history of National Socialism in

Germany, for anything that evokes the rationalised use of human bodies toward a

greater social good resonates uneasily with the logic underpinning the whole

system of human experimentation and extermination under the Nazis. Against this

backdrop, the pains now taken to preserve and honour the humanity and

individuality in each donated organ make a particular sociohistorical sense. This

history is not the only factor at work here, however, for also at issue are centuries-

old concepts of continuing animation in dead bodies, of the persistence of some

form of life and personhood not just in the body itself, but in all of its parts. These

ideas, traceable back to the early Germanic territories, find modern-day

expression in popular theories of cellular memory which posit the preservation

of personal identity all the way down to the level of individual cells. Such long-

standing notions about the relationship between body and self seem also to inflect

the practices and attitudes of German transplant professionals as they go about

their daily work of shepherding human organs from one body to another. While

further research is needed into how organ recipients and donor families in

Germany make sense of their experiences, it is clear that at least professional

discourses in this setting proceed from conceptions of body and self as deeply

interconnected and fundamentally inseparable.

Yet another possibility for how the relations between body and self may be

understood in transplantation can be found in Mexico, where, as described above,

the vast majority of organs for transplantation come from living donors. More

specifically, these organs most typically come from living related donors. This

material reality is shaped in part by the lack of available cadaveric organs

(discussed above), and by the cultural and political economic importance of large,

extended families in the Mexican context. Thus, in contrast with settings where

cadaveric donation is the norm, in Mexico organ recipients are most likely to be

involved in ongoing, intimate relationships with their organ donors. In this

context, the organs that move between donor and recipient are less likely to be

represented as merely interchangeable, identity-free parts, but rather are often

experienced as an extension of the shared bodily substances that characterise

family relations more generally (Crowley-Matoka, 2005, in press). This

experience is particularly acute when organs move between parents (most


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typically mothers) and children, and is captured in the commonly heard logic of ‘‘I

gave my son life once, why wouldn’t I do it again,’’ or, conversely, ‘‘My mother

gave me life, why wouldn’t I do the same for her if I can?’’ Thus, in this context,

organs exchanged in transplantation are often experienced neither as objectified

parts, nor as wholly other, they contain the self of the donor, yet are also always

already connected to the self of the recipient through familial relatedness. For their

part, transplant professionals in Mexico to some degree foster and even depend

upon these understandings of organs as, in some sense, a shared family resource,

for they are acutely aware that the transplant enterprise in Mexico could not

survive without willing living donors. Thus, these professionals often find

themselves switching back and forth between the more mechanistic imagery and

language characteristic of global scientific discourse in transplantation, and a

language that imbues transplanted organs with familial identity in various ways.

Ultimately, the Mexican context thus reveals yet another possibility for the

configuration of body and self in transplantation, one that is produced by both the

local realities of the organ supply and the shape of social relations in that setting.

Commodification of human body parts

The specter of bought-and-sold body parts is a nearly inescapable one in the realm

of transplantation, recurring in journalistic exposes, scholarly analyses, and pop

culture horror movies alike. The sensationalistic treatment often given this issue,

however, misses much of the complexity both of the concept of commodification

itself and of the highly variable ways in which human bodies are, or may be,

commodified in the context of transplantation. In its original meaning a

commodity was understood as something of use, advantage, or value; in

contemporary society this implies more often than not that these items will have

monetary value, though this is not necessarily so. Moreover, the ‘commodity

candidacy’ of things must be understood as complex, culturally-determined and

fluid, forming part of ongoing and always-partial social processes (Appadurai,

1986). Despite much current rhetoric implying that the commodification of

human bodies is a new problem, the application of market values to human bodies

has a long and often-torturous history, one that includes slave, sex, and wage

labor, to name just a few examples, while human body parts have also been

commodified for centuries as religious relics, talismans, and medications, among

other uses (Sharp, 2000). Only relatively recently, however, has the human body

garnered significant commercial value as a source of spare parts and therapeutic

tools (Hogle, 1996). The forms and consequences of this value, however, are not

everywhere the same and the commodification of human organs is organised in

distinct ways in different parts of the world, as illustrated below in examples drawn

from India, Mexico, the USA, and Spain.

India offers the most commonly known example of bodily commodification in

transplantation, due largely to the numerous exposes that have appeared in both

popular media and scholarly accounts of the sale of living donor kidneys in that

country. For a period of time, the market in kidneys operated quasi-legally in


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India, and although organ selling was made officially illegal in 1994, recent reports

suggest that the buying and selling of body parts continues under more clandestine

guise (Cohen, 1998, 2002, 2005; Marshall & Daar, 2000; Scheper-Hughes, 2000,

2004). Organ brokers operate as middle-men in India, recruiting desperately poor

organ sellers, lining up desperately ill organ buyers, and retaining much of the

profit for themselves. Ethnographic research reveals that organ sellers are typically

searching for a way out of crushing debt, although the exploitative practices of

organ brokers mean that most find that their financial situation fails to improve,

and may even worsen, after selling an organ (Cohen 1998; Goyal, Mehta,

Schneiderman, & Seghal, 2002). Organ buyers, for their part, often choose to use

their greater economic privilege to protect their own family members from the risk

of donating a kidney. In both cases, however, poor long-term health outcomes for

both buyers and sellers of kidneys suggest that the risks incurred may be

considerable in a setting where both profit motives and the shroud of illegality

work to undermine the availability and quality of medical care before and after the

donation and transplant (ibid; Scheper-Hughes, 2004). The widely circulating

image of India as an organs bazaar has had a powerfully stigmatising effect on

that country’s national identity. This is an effect with consequences not just in

this setting, however, for with India standing as the most notorious (and most

blatant) example of a market in body parts, other forms of bodily commodification

in transplantation at work elsewhere in the world have perhaps gone less

remarked.

In Mexico, as described above, kidneys for transplant most typically come

from living related donors, rather than the living unrelated donors more

common in India. Yet the existence of family relationships does not preclude

market values of various kinds from entering into the exchange between organ

donor and recipient (Crowley-Matoka, in press). In many cases, of course, the

offer of a kidney to a family member in need is a nearly automatic one,

prompted by the combination of emotional ties and mutual dependency that

makes up the web of family relations. In other cases, however, the decision to

donate a kidney is born of a brutal calculus in which one family member is

driven to provide a kidney to another to safeguard the economic survival of the

family as a whole. Not surprisingly, in a setting where formal sector jobs still

most often go to men, women are particularly vulnerable, and wives sometimes

describe their decision to donate to a husband in straightforward terms of

economic dependency. In still other cases, organ recipients are frank about

offering family members something tangible in return for a donated kidney; a

car, real estate, or even travel may be held out to potential donors in the spirit of

both enticement and simple fair-minded reciprocity. These sorts of familial

exchanges, of course, are not the sort of bodily commodification generally held

up as most worrisome, yet clearly there is danger of exploitation here as well.

Further complicating the picture, Mexico also provides examples of non-related

living donation in which associations that began as a straightforward exchange

between relative strangers (a kidney for land use, for example) can evolve into

something somewhat unexpected, as ongoing social relations between organ


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seller and organ buyer may grow over time into fictive, but deeply-felt, kinship

ties. Ultimately, attending to the mixing up of human bodies and market values

in the Mexican context demonstrates the multiple and fluid nature of the

possibilities for bodily commodification in transplantation.

The USA offers yet another vision of how bodies may be commodified in

transplantation, for despite vehement opposition to organ sales, transplantation in

the USA is big business, with nearly everyone but the donors or donor families

profiting from the organ donation and transplant enterprise. Both medical

professionals and medical centres garner prestige and considerable financial gain

from transplantation, pharmaceutical companies earn huge profits from the

medications upon which transplant recipients depend to survive, and even non-

profit organ procurement organisations wield substantial budgets (Fox & Swazey,

1992; Sharp, 2006). Although organs cannot be legally bought and sold in the

USA, cadaveric organs are assigned prices in this setting, based on the costs of

procuring, preserving, and transporting the organs. Some transplant recipients are

even shown price lists for organs as a way of impressing upon them the

preciousness of what they have received. It should also be noted that the business

model of USA transplant programmes (at least in part) drives the constant push to

expand the boundaries of those considered eligible for transplantation, such that

patients are now accepted for transplantation at older ages, in sicker states, and

even with multiple prior transplants. As we and many others have also pointed out,

as these boundaries are widened, the demand for organs is expanded as well, thus

widening the gap between supply and demand and helping to create the much-

touted organ shortage (Fox & Swazey, 1992; Koenig, 2003; Sharp, 2006).

Notably, it is this shortage that is so often used to justify the perennial proposals in

the USA for more explicitly market-driven models of organ procurement in which

donors or donor families would be offered outright payment for organs in the hope

that this would increase the organ supply.

Finally, Spain offers an additional example of how money and human body

parts may become entangled in complex ways, even in settings where the more

blatant forms of bodily commodification have long been outlawed. Spain currently

boasts the most successful cadaveric organ procurement programme in the world,

it is the only country whose waiting lists for organs are actually decreasing. The

reasons for this success are complex and require further untangling beyond

the scope of this paper, although the state’s substantial commitment to the

development and maintenance of a national organ procurement system surely

plays a role. Because Spain’s healthcare system is nationalised, the commercia-

lisation issues surrounding transplantation are distinct from those in the USA, yet

here too money enters the picture in various ways. Perhaps most striking are the

bonuses paid to those involved in procurement for each successful donation.

Although these bonuses are generally relatively small, they constitute part of the

strategy to professionalise the organ procurement process that is one of the

cornerstones of the successful Spanish model. In addition, organ procurement

professionals in Spain have the option of offering donor families reimbursement

for funeral costs in return for agreeing to donate, although many professionals


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say that they prefer not to exercise this option, either because it rings too

uncomfortably of payment for organs or because it has caused problems with

funeral homes attempting to inflate prices to take advantage of the government-

subsidised payment. And finally, it should be noted that the ‘‘Spanish model’’ for

organ procurement has itself become something of a commodity in its own right.

In stark contrast with the way transplantation practices in India have been

stigmatising, the success of Spain’s organ donation programme has become both a

major point of national pride and an export, spawning a whole series of

international training programmes, publications, and lecture circuits for Spanish

procurement professionals. Ultimately, the Spanish case helps to illuminate

the deep entanglement of money and human body parts in transplantation not

only in the settings held up as shameful cautionary tales, but in those considered

exemplary as well.

Conclusion

As organ transplantation and other biotechnological innovations continue to

further enable our ability to manipulate the human body, we must engage with the

ever-evolving social consequences of these capabilities. And as debates persist over

the shape and meaning of transplantation, knowledge gleaned from across the

broad range of human experience provides valuable resources for grappling with

transplantation as it is, should, and could be. Indeed, as the story of the young

Mexican boy in search of a kidney transplant with which we began made clear, the

variations evident in the social organisation and experience of transplantation

across different cultural settings do not exist in isolation from one another.

Although important differences clearly do exist between Germany and Mexico,

and between Japan and the USA, nevertheless patients, donors (or their parts) and

their families, as well as transplant professionals, pharmaceutical companies, and

the actual medical technologies increasingly move between various local settings.

Rejection of the brain death concept in one setting, for instance, pushes desperate

patients across the globe in search of cadaveric organs unavailable in their own

country. And efforts to outlaw the outright sale of human organs in some settings

are surely weakened by markets in living donor kidneys elsewhere in the world.

Meanwhile, innovations in the field, ranging from novel drug regimens, to

boundary-pushing surgical techniques, to new kinds of donors (be they living

donors as sources for more than just kidneys, expanded pool cadaveric donors, or

even non-human sources of organs) are constantly emerging and being rapidly

taken up around the world. The stakes in transplantation are perilously high. In

our ever-more globalised world, cultural and regional variations in what counts as

dead, in how relations between body, self, and identity are understood, and in the

particular forms of and possibilities for bodily commodification are not merely an

issue of quaint or exotic interest. Rather the cultural meanings and social

organisation that shape organ donation and transplantation in any one place may

be both profoundly connected to and enormously consequential for the existence

of this biotechnology elsewhere.


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Biographical Notes

Megan Crowley-Matoka, PhD, is Assistant Professor of Medicine and Anthropology at theUniversity of Pittsburgh and the VA Center for Health Equity Research and Promotion. Her bookProducing transplanted bodies: Life, death and value in Mexican organ transplantation is in press withDuke University Press. Her recent work focuses on issues related to the expanding arena of livingorgan donation.Margaret Lock, PhD, is the Marjorie Bronfman Professor in Social Studies in Medicine, affiliatedwith McGill University. Lock holds a number of prestigious fellowships and awards in Canada, andthe Wellcome Medal of the Royal Anthropological Society of Great Britain. A prize winning author,her monographs include East Asian medicine in urban Japan, Encounters with aging: Mythologies ofmenopause in Japan and North America and Twice dead: Organ transplants and the reinvention of death.


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organ transplantation in a globalised world

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