Strange Harvest. Lesley A. Sharp
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way to underscore the act of reaping life to assist others in need. Other professionals, however (and especially those who work with donor kin), are repulsed by this phrase because it offers an all too graphic reference to the physical destruction of the donor body. Agricultural imagery in other forms nevertheless abounds in all domains of organ transfer, marked by what I refer to as the systematic “greening of the body” (Sharp 2001), where even the most basic term transplantation inspires images of renewal and rebirth, rather than extraction, death, and decay. Thus, just as nature renews itself, so, too, does the human body, albeit through the assistance of sophisticated medical techniques. In contrast, all parties despise depictions of procurement as the mining of the body for its parts because of the horrific suggestion that this is a profit-making enterprise that preys on the bodies of the dead. Further, such commercial language simultaneously defies the purpose of NOTA, challenges the miraculous quality of body repair, and discredits the selfless love that enables grief-stricken kin to give to anonymous strangers. As we shall see, particularly pronounced is the current (though rapidly eroding) understanding that a precious gift economy drives transplantation's success, because newly acquired body parts enable organ recipients to undergo a radical transformation, often referred to as a “second life” or “rebirth.”
Bodies, Persons, and Things
Cadaveric donation inescapably places a heavy emotional toll on all concerned parties because of death's inevitable presence. Recipients, donor kin, and transplant and procurement professionals alike must make sense of transplantation as a lifesaving technique that nevertheless relies on donors' deaths and the surgical removal of their organs. For such epistemological constructions to work, all involved parties must embrace the legitimacy of brain death criteria, for head injury—be it from an auto accident, gunshot wound, or massive cerebral hemorrhage—is the overwhelming cause of organ donors' deaths in this country. Brain death is a relatively new medical construction, stemming initially from recommendations put forth in 1968 by the Ad Hoc Committee at Harvard Medical School (HMS and Beecher 1968; Ramsey 1968). The committee's recommendations shaped national policy and subsequent state-by-state legislation. Today medical historians and ethicists generally agree that the committee's actions were driven by the surgical desire for organ donors. As Stuart Youngner explains, discussions surrounding newly conceived brain death criteria “were quite rational” and were driven by two key factors: “to facilitate organ procurement and…to avoid legal concerns about turning off ventilators” (1996: 41).
Today organ transfer remains highly dependent on ventilator use (or what is referred to in other contexts as “life support”), because this now ubiquitous machine enables staff to maintain a donor in physiological stasis before, during, and after brain death is declared. Each breath of air forced into the lungs in turn stimulates the heart, which then sustains other vital organs by supplying them with a steady flow of oxygenated blood. Without the technological assistance of the ventilator, human tissue rapidly deteriorates, rendering the organs useless for transplant. When the body is denied a regular flow of oxygenated blood, a process known as warm ischemia sets in, which threatens the later graft survival of transplanted organs in recipients. Sepsis is yet another constant threat. Without medical intervention, human organs are quickly lost. In the United States various drugs are also administered to facilitate physiological stasis in the donor prior to procurement (Fox, DeVita, and Ritchie 1998; Hogle 1995b). It is important to understand that a (potential) donor remains connected to a ventilator both before and after brain death is declared, while consent is being acquired from kin, and during initial surgery stages, when the donor is anesthetized so that the organs can be removed without the body going into shock. Such practices are considered medically essential, yet they can trigger feelings of great unease among kin and professionals alike, who may struggle to accept brain death criteria as proof of absolute death (Sanner 1994; Sharp 2001; Youngner et al. 1989).
Within this ideological framework, the maintenance of brain dead donors is carefully orchestrated by a range of health professionals whose actions radically transform the organ donor into an extraordinary category of person. It is accepted as medical fact that brain dead patients will never regain consciousness, unlike cases involving patients who are comatose or in persistent vegetative states (Kaufman 2000, 2005). Further, because their level of brain damage is so severe, organ donors lack personhood as it is understood and valued in this culture; that is, brain dead patients have irretrievably lost their subjectivity and thus can no longer assert themselves in social contexts. This construction of personhood rests firmly on the medicalized assumption that the self is lodged in the brain: with severe and irreversible head trauma, we cease to be who we are, we are no longer human, and thus we cease to exist. The brain dead donor, then, is but a human shell, a body that functions physiologically but no longer thinks or senses the surrounding world. By medicolegal definition these donors are dead: whereas the ventilated brain-dead body appears to be alive to lay parties and health professionals alike, each breath taken is technologically dependent. The bodies of such donors maintain their natural coloring and remain warm to the touch, and they may even manifest what are understood as involuntary movements that result from residual nervous system activity. Such contradictions render them inherently strange.
Transplantable organs, too, are peculiar things. Because of their unusual origins, they are steeped in elaborate symbolic imagery. Their preciousness may lead to a displacement of the donor-as-person, once medical (or certainly procurement) attention is riveted on retrieving organs in time to save dying patients elsewhere. It is no wonder, then, that even after more than half a century of practice, organ transfer continues to be described simultaneously as a remarkable medical miracle, the giving of life, a legalized form of body commodification, and a medical process circumscribed by an unusual form of death.
Scarcity Anxiety
One of the great ironies of organ transfer is that its remarkable technological success has engendered a national crisis of supply and demand. Because the surgical transfer of organs strikes us as unmistakably wondrous, it has produced an ever-growing need for new surgical techniques, pharmaceuticals, and clinical subspecialties that then further perfect the medical ability to sustain life in this way. The intense desire to prolong life and cure disease has spawned as well an ever-increasing national list of patients for whom transplantation is deemed a basic medical right. Today the national list is an urgent topic of debate: heated discussions are spurred on by fears associated with the assumed shortage of transplantable organs and, thus, the dire need to increase the supply of willing donors. For more than a decade I have watched how proposals designed to enhance donation have shifted from casual, what-if scenarios to a pronounced level of alarm and even desperation. Thus, although concerns over supply and demand have always pervaded transplantation, the intensity of organ scarcity anxiety is new.
Significantly, much attention is given to the growing number of patients in need, set against either an assumed leveling or, at most, a sluggish climb in the annual number of donors. The urgency expressed in a recent story from the Boston Globe typifies current phrasing (the data and wording nearly always supplied by UNOS):
The waiting list for organs, now at about 82,000 people, keeps growing, and nothing has succeeded in significantly increasing the number of donations. Almost 60 percent of those on the list are expected to die waiting…. The transplant community has tried various initiatives…. But the gap keeps growing. Overall, the waiting list has been increasing by about 12 percent a year, while the number of brain-dead donors has been rising by under 3 percent, to about 6,000 a year. A recent study estimated that the number of potential donors each year is about 17,000. (Goldberg 2003)
The UNOS Web page has at times displayed a clock alongside an up-to-date report on the number of candidates on the national waiting list, recorded to the minute, stressing, too, that “for each person who receives a transplant, two more are added to that list.”10 As these examples illustrate, scarcity anxiety is focused squarely on the short supply of organs as transplant's great dilemma. In contrast, little is said about the responsibility the transplant industry bears in generating its own patients, a process that in turn increases the national demand for organs. Transplantation is in essence the capitalist's dream because the supply can never answer the pressing and ever-increasing social desire for these coveted goods.
When I first entered this field of research