vast majority of whom are declared brain dead and are maintained on respirators in anticipation of organ procurement surgery. Donors are peculiarly liminal beings, caught somewhere between patient and cadaver status. Early in my research I was struck by the pervasiveness of language designed to depersonalize these donor-patients and, further, by the ways in which involved professional and lay parties struggled to make sense of this process while nevertheless embracing donation, procurement, and transplantation as laudable and necessary social acts. I also soon came to learn that a host of intriguing social relationships emerge among these parties in direct response to the presence of the cadaveric donor. As we shall see, even the donor body itself may be reanimated in the minds of recipients and donor kin who share the understanding that transplanted organs can retain the life essence of their donors. Organ transfer mitigates these peculiar and fascinating social relationships and associated symbolic constructions precisely because it relies on retrieving organs from donors who are considered legally and medically dead and who, at least at the outset, are anonymous to transplant recipients.
A brief contrast with other forms of organ donation will help clarify the importance of my exclusive focus on the cadaveric body. Kidneys, for instance, can be transferred legally and with relative medical ease from living kin; recent news accounts also indicate a rise in the national incidence of kidneys offered by friends and even strangers to patients in need. This sort of organ transfer is referred to as living donation and involves two tandem surgeries. An assumption that renders this medical procedure possible is the widely accepted view that it poses relatively little harm to a healthy donor, who continues to thrive because he or she retains a second kidney.3 Much has been written on living kidney donation in the United States, with pronounced interest in the long-term survival rates of donors and recipients, as well as the nature of their social relationships (see especially Fox and Swazey 1992). The United States as a research context shapes these dominant concerns, for as one moves into the global arena, the focus shifts rapidly to investigations of both legal and clandestine forms of trafficking in human body parts, with organs taken from donors who, unlike recipients, lack access to quality health care.4 My decision to limit my focus to the United States is in part a matter of scale. The United States has long stood as a world leader for organ transplants, both in terms of the innovative use of biotechnologies and because of the sheer volume of surgeries performed each year. Today many American cities can boast of at least one hospital with a transplant unit, and as other researchers have found, it can be difficult to avoid comparison with the United States when writing about transplants elsewhere (Hogle 1999; Lock 2002). I therefore leave living donation, tissue (that is, non-organ) procurement, and global trends for others to explore.
As the chapters in this book detail, highly complex social relationships arise in response to cadaveric donation. These relationships can be difficult to uncover because of the strict taboos imposed by involved health professionals, many of whom, for example, insist that donor bodies be viewed as mere corpses that generate reusable parts; that recipients should neither identify with or idealize their donors nor humanize their organs; and that surviving donor kin and recipients should not communicate with one another but instead move on with their separate lives. Nevertheless, many health professionals wrestle privately with highly medicalized constructions of donors' deaths. Further, recipients do in fact imagine a donor's identity in all sorts of ways and frequently integrate this unknown Other as an intrinsic part of their subjective sense of self. Finally, organ recipients and their donors' surviving kin may long to encounter one another, and they may go to great lengths to do so, even when blocked by transplant professionals who hold records of their respective identities, addresses, and histories.5 Among the great ironies of organ transfer in the United States is that it generates a host of new social relationships that at first may seem altogether strange to the uninitiated, yet which are in fact common and, I argue, culturally generated and thus naturalized responses to the peculiar qualities of cadaveric organ donation.
With this in mind, I am most intrigued by the manner in which medicalized definitions of death affect how involved parties think about organ donors, transplanted organs, and donors' deaths. Key to understanding cadaveric organ donation is that it relies overwhelmingly on donors who have sustained sudden, unexpected head traumas and who are declared brain dead within hospital settings (most frequently by staff neurologists in hospital ICUs). Because the shadow of death pervades this form of organ transfer, I argue that very particular and peculiar responses emerge that stand in contrast to those associated with living donation. Donor death is highly problematic: for transplants to be socially acceptable, all involved parties must embrace legal definitions of brain death as legitimate in medical, physiological, and spiritual terms. Nevertheless, careful probing reveals that there is tremendous disjunction between expressed public (or official) and private understandings of brain death criteria. For these reasons, throughout this book I will refer to cadaveric (that is, of or like a cadaver) forms of donation while avoiding the label cadaver when speaking specifically of the organ donor (that is, the donor-patient). Also, the logistics of donor care inevitably force involved parties to struggle with conflicting messages about death and suffering. This remains true regardless of whether one is a transplant specialist who works with patients on a transplant ward; a procurement professional who talks to kin about donation as a loved one lies dying in an ICU, and who may later assist, too, in the surgical procurement of organs; a patient who becomes an organ recipient through transplant surgery; or a donor's surviving kin who have granted permission so that a donor-patient's organs can be taken and transplanted in recipients elsewhere. The unusual form of death so intrinsic to organ transfer's success generates deeply personal responses, which persist long after donation, procurement, and transplantation occur. These responses may stand in stark contrast to what is currently represented in the literature as transplant dogma.
As an in-depth exploration of the ethos of organ transfer, this book is structured around conundrums or nagging questions that I will refer to as transplant paradoxes. These paradoxes spring from a set of ideological premises that guide research participants' everyday actions and speech, as well as the tenor and focus of both specialized professional publications and promotional literature on organ transfer written for general audiences. As I shall illustrate throughout, a wealth of knowledge is embedded in the ways professional and lay parties behave and talk about organ transfer in a variety of settings, including transplant wards; professionally orchestrated events such as conferences, annual commemorative celebrations, and patient support group meetings; and interviewees' private homes. I am especially sensitive to dominant narrative genres—that is, the particular ways in which participants learn how to speak of or write about their experiences with organ transfer. Most intriguing is the fact that responses offered in public venues may differ radically from the private thoughts individuals share only with trusted friends, close colleagues, and, at times, the anthropologist. Applied carefully, the methodological approaches that define ethnographic research reveal insider understandings of transplant decorum, exposing those moments when involved parties defy scripted forms of behavior, or when they question dominant ways of thinking about organ transfer. Surprisingly, these moments of disjunction are hardly rare. My ultimate goal is to uncover these paradoxical moments and then decode their significance as a means for understanding organ transfer as a dominant, albeit troubled, sociomedical process in America.
THE IDEOLOGICAL UNDERPINNINGS OF ORGAN TRANSFER
The cadaveric organ donor offers an especially rich site for exploring the paradoxical nature of organ transfer in the United States, where discussions of this unusual category of patient rapidly shift to a questioning mode. First, when considering cadaveric donors, do all parties think of and respond to them as a social category? For instance, how do donor kin, on the one hand, and hospital staff, on the other, talk about brain dead donors or behave when in their presence? What sorts of ideas about donors do transplant recipients and their surgeons, nurses, and social workers share, and where might their ideas diverge? Second, is it possible to speak of a collective understanding of the cadaveric donor body itself, or can conflicting ideas coexist? Can the donor be viewed simultaneously as a deceased loved one, a source of exchangeable parts, and the repository of an unusual kind of social gift? Third, does the presence of the organ donor clarify or confound understandings of death? And when precisely does
