Strange Harvest. Lesley A. Sharp
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concern to transplant and procurement professionals is the constant demand from superiors to increase the number of successful outcomes. A team of transplant surgeons can qualify for transplant unit status under hospital and UNOS guidelines only by performing a minimum number of surgeries per year; even greater numbers are required to merit additional funds and staffing necessary for experimental research. Throughout the nation, hospitals proclaim their success through the actual number of transplant surgeries they perform, and certain organs, such as hearts and livers, bear more cultural capital than do others, such as kidneys. Procurement specialists in turn are under great pressure to increase their number of successful donations. It is not enough, however, simply to identify donors or acquire consent; only the actual number of organs transplanted in the end matters. As frustrated procurement staff explain, how can they predetermine the quantity of organs they acquire when the supply is beyond their control? Such demands inevitably facilitate the rapid dehumanization of patients and undermine staff morale. Under the worst circumstances, sloppy work or employee corruption may result.18
Such developments clearly generate serious dilemmas. As organ transplantation shifts to the corporate model, organ transfer is driven increasingly by market forces that discourage health professionals' compassionate and courageous acts. This in turn affects the social value of the potential donor, who may be transformed even more rapidly from a dying patient to a body capable of supplying society with highly coveted, reusable parts.
The Paradoxical Premises of Organ Transfer
In the preceding discussion, I do not mean to imply that the world of organ transfer is jaded and callous. Without exception, all participants who have assisted me with my research care deeply about the well-being of hospitalized patients, regardless of whether they are potential donors or organ recipients. Nevertheless, as transplant and procurement professionals succumb to demands for more donations, they risk undermining even further an already shaky public trust in American medical practices. Organ transfer is especially vulnerable because it must always struggle against public perceptions that this highly specialized branch of medicine preys on the bodies of dying patients. Nevertheless, the current demands associated with organ transfer may drive professionals to overlook the moral dangers of their work. To underscore the complexity of such dangers, I wish to conclude with a review of how the paradoxes just described intersect with one another and define an ethos inherent in organ transfer in America, one that guides the thoughts and actions of both professional and lay participants.
For half a century, although transplant medicine has borne the aura of the miraculous, its success has been dependent on a highly technocratic approach to healing. As noted, transplantation is driven by increasingly sophisticated diagnostic, surgical, pharmaceutical, and ultimately life-sustaining technologies that potentially dehumanize both transplant patients and potential donors as little more than medicalized cyborgs. From a purely utilitarian perspective, transplant medicine is extraordinarily expensive by virtue of its technological dependency. Although veiled in a complex array of euphemistic constructions, organ transfer and, in turn, the donor body are sites of lucrative medical practices sustained by an ever-expanding demand for technological expertise.
Set against this “technological imperative” (Davis-Floyd 1994) of transplant medicine, the donor body emerges as a site mired in contradictions. Among the most troubling is the denial of the dehumanizing force of organ transfer. Whereas a host of tissues is readily bought and sold, long-standing legislation, spearheaded by the National Organ Transplant Act of 1984, renders it illegal specifically to market transplantable organs. In response, organ transfer relies heavily on euphemistic terms that deny body commodification: organs are not bought or sold but donated; through transactions steeped in the language of a gift economy, organs are gifts offered to needy patients through great acts of kindness by anonymous Samaritans. Nevertheless, transplant patients (or, most frequently, their insurers) pay enormous sums for their surgeries; and procurement offices, though nonprofit in status, are hardly driven by volunteer labor. The symbolic rhetoric of organ transfer insists that transplantable human organs are extraordinarily precious things, yet their value is understood in radically different ways by different categories of involved parties. Whereas official rhetoric insists that organs are gifts of life, some still consider them as little more than replaceable parts, and others view them as harboring the lost souls of the dead. This array of competing constructions arises in response to the contradictory messages professionals supply to recipients versus donor kin. This ultimately leads professionals to block communication between these two sets of parties because their encounters would uncover the depth of ideological disjunction intrinsic to their work.
An even more troubling aspect of organ transfer's ideological underpinnings involves the necessity of embracing brain death criteria as evidence of absolute death. Organ transfer as a medical reality is bolstered by life-sustaining technologies, for without the respiratory ventilator, for instance, hospital and procurement staff could not maintain potential donors prior to and during the surgical removal of their organs. All involved parties must accept that these donor-patients are dead, even though they are warm to the touch, breathe (albeit with technological assistance), and can move. As we shall see, publicly expressed acceptance among all sets of involved parties may be contradicted by their more private musings over brain death criteria.
The growing anxiety over organ scarcity problematizes the assumed miraculous qualities of this unusual gift economy of death. As noted, responses now under serious consideration call largely for financial incentives for organ donation, a development that only further commodifies organs and the donor body, reducing these “precious things” to little more than coveted goods that can be acquired for a price from surviving kin. This bald-faced approach threatens the very stability of the gift economy, the linchpin of organ transfer's success to date. Other radical solutions undermine the sanctity of the medical imperative to do no harm through the NHBD protocol, or through radical forms of mechanical and xenographic experimentation. In essence, then, the miracle of transplantation may quickly dissolve into a dollar-driven medical nightmare.
Finally, the ever-increasing corporate structure of organ transfer—driven by the pairing of medical success and organ scarcity anxiety—marks the further dehumanization of its practices. Procurement and transplant professionals alike express deep frustration over demands from their superiors that they acquire, transfer, and transplant more organs every year. In some centers, staff are now confronted with monthly and annual quotas, and their inability to meet these puts their own jobs at risk. Of even greater concern are the dangers associated with corporate greed: one need only consider the science fiction tales that loom in the collective American consciousness to grasp the tenuousness of public faith in organ transfer as a medical miracle.
Anthropology and Bioethics
Against this set of paradoxical premises and accompanying anxieties, bio-ethicists provide an important and growing set of critical voices. Of particular interest to me is the manner in which their own critiques have shifted over the course of the last decade in tandem with growing concerns in transplant medicine. Commentaries in the early 1990s frequently bore the tone of the playful gadfly, notably expressed, for instance, in Arthur Caplan's book title If I Were a Rich Man Could I Buy a Pancreas? (1992). Most ethicists assumed a relativist stance, seeking primarily to expose conflicts inherent in competing positions, thus encouraging open debate among involved parties. Yet another dominant approach involved labeling or categorizing various arguments: for instance, ethicists deliberated whether calls for further commodification fit utilitarian or patient autonomy paradigms. Within the past three or so years, however, I have observed that ethicists have become more brazen in their critiques, a shift generated in large part by current proposals that so blatantly commodify the body. Thus, Caplan himself is quoted in the Wall Street Journal as stating that the market demand in human body parts “has created a kind of eBay of the body.”19 Likewise, Jeffrey Kahn acknowledges that the euphemistic language of organ transfer is merely “a semantic difference…. What's really being sold isn't the time and energy, but the material itself” (Saranow 2003).
In response, bioethicists and anthropologists can form a compelling partnership; of special interest to me are the moments of disjunction exposed by a merging of ethical and ethnographic thinking.20 As anthropologists have long known, human