death occur? Do all parties concur? Is it at the moment when a neurologist declares a patient brain dead, or during surgery when a donor's organs are removed? Is death lodged in the brain, the body, a soul, or a combination of these or other possible sites? Fourth, do brain death and organ donation confirm, confound, or enhance cultural understandings of personhood and social worth? Where does the donor-as-person dwell before, during, and after the surgical removal of transplantable organs? What issues are at stake when donors' identities remain anonymous? Finally, does it make sense to ask who owns the donor body and its parts? Can anyone claim rights to the donor's transplanted organs? If so, following transplantation, do organs belong exclusively to their recipients? If others lay claim, at what point should they relinquish their hold?
These overlapping philosophical, ethical, and cultural dilemmas shape this investigation as a whole. At one level, such questions define the parameters for debates considered regularly by medical ethicists. My purpose, however, is neither to offer definitive answers nor even to negotiate conflicts so that a compromise might be reached that would satisfy both the emotional and the practical demands of involved parties. Rather, from an anthropological standpoint, I view such debates as generating valuable data that ultimately expose troubled yet culturally driven concerns about organ transfer in this country. Such concerns are also linked to larger problems that plague medical practice more generally, especially regarding the medical versus social worth of patients; the social significance of the hospital death; the importance of altruism and kindness in medical contexts; and perplexing questions about death and proper forms of mourning. Thus, my work is most heavily invested in exploring the subject and tenor of these debates to broaden medical policy discussions and to stimulate frank and open public consideration of the social value of organ transfer.
As I will explain here and illustrate in subsequent chapters, transplantation rests on a paradoxical set of ideological or moral premises that guide medical conduct, professional public outreach efforts, and dominant lay understandings of death, the body, and gift giving. The tenuous nature of the assumptions driving organ transfer also contributes to the current transplant crisis in America. In this regard, transplant ideology relies on the following set of premises: (1) the concept of transplantation as a medical miracle; (2) the denial of transplantation as a form of body commodification; (3) the perception of transplantable organs as precious things; (4) the dependence on brain death criteria for generating transplantable parts; (5) the assertion that organs of human origin are becoming increasingly scarce in our society and require radical solutions; (6) an insistence that the melding of disparate bodies is part of a natural progression in a medical realm predicated on technological expertise; and, finally, (7) the imperative that compassion and trust remain central to the care of dying patients, even when a new corporate style of medicine demands an increasing number of transplantable organs. I will now consider the paradoxical nature of each of these premises.
The Miracle of Technocratic Medicine
Transplantation is regularly hailed as one of the great miracles of modern science. As such, it might very well be viewed as the quintessential example of millennial medicine, for we have remained in awe of its accomplishments since the mid-twentieth century and into the twenty-first. In one sense, labeling transplantation as miraculous is justified: it is truly astonishing that surgeons can save lives by replacing failing organs in their patients with those taken from other humans' bodies. Nevertheless, this passion for the miraculous can obstruct our view of a problematic underside.
The social construction specifically of transplant surgery as a miraculous procedure draws on the successful development of an elaborate array of sophisticated technologies intrinsic to American medicine. For instance, medical progress in this country is frequently tracked along timelines that trace the experimental design and implementation of a host of complex machines (for a recent example, see Maeder and Ross 2002). A quick glance at the history of visual technologies alone underscores this remarkable progress, as one moves, say, from the X-ray to the sonogram, CAT scan (or CT scan, for computed axial tomography imaging), magnetic resonance imagery (MRI), and fiber-optic devices.6 Of great relevance to organ transfer's success is the development of “life support” devices, a history marked by the development of the iron lung (invented in 1929 and in common use by the 1940s to sustain polio victims) to the routinized hospital use of the respiratory ventilator, the latter now essential to sustaining brain dead organ donors prior to and during procurement surgery. Other crucial technologies range from hemodialysis to heart-lung bypass devices. Pharmaceuticals represent yet another important thrust of medical success that renders posttransplant survival possible. Among the most significant developments involved the creation in the 1980s of the powerful immunosuppressant cyclosporine, which prevents the body from rejecting an organ of foreign origin. Cyclosporine and other immunosuppressants, paired with powerful steroids, are the mainstay of daily transplant survival for many patients.7 This array of technological developments has enabled organ transplantation to make phenomenal strides, so that it now epitomizes medical possibility within the collective American imagination.
The miracle of transplant surgery also underscores the impressive capabilities of mainstream cosmopolitan medicine in this country. For one, American medicine is overwhelmingly allopathic: in other words, it assumes a heavily biomedical approach to the human body and to suffering. In the healing encounter the patient is generally approached as an individual and, thus, as a discrete entity, where treatment is possible without considering the significance of a larger social milieu. This is because the body itself is viewed as a sophisticated organism whose splendor stems from its physiological complexity. The biomedical model is wed to the rationale of disease theory; as such, a progression from diagnosis to treatment and cure is essential to the paradigm. Allopathic practices can be highly invasive, driven by an overwhelming concern for the body's inner workings (marked, for example, by the displacement of general practitioners by internists in recent decades). As a result, the surgical ability to alter, remove, and replace body parts ranks among biomedicine's most impressive accomplishments to date. Through such practices the human body is rapidly transformed into a highly medicalized system of interdependent parts and processes.
Transplantation signifies the zenith of medical skill, albeit for a small minority it heralds the dangers of technological medicine run amok (Illich 1976). More generally, mainstream American medicine is wed to a technocratic model, argues Robbie Davis-Floyd (1994), relying increasingly on specialized diagnostic methods, technical procedures, mechanical implants, and a vast array of potent pharmaceuticals as a means to alter, cure, and improve the human body. At the high end of technocratic medicine, patients may emerge as little more than medically manipulated cyborgs, hooked up to an array of machines, their functions sustained by powerful drug regimens (Davis-Floyd and Dumit 1998; Downey, Dumit, and Traweek 1997; C. Gray 1995).
The United States is hardly unique here; it does, however, offer an unavoidable benchmark for comparison. Technocratic practices are part and parcel of capitalist medicine in this country. More so than in any other nation, American medical decisions are driven by private insurance responses to market trends, where high-end technologies are increasingly vilified in discussions on the rising cost of medicine (Neumann and Weinstein 1991:1). Health care costs in the United States totaled $1.3 trillion in 2000, jumping 6.9 percent from the previous year (Alliance for Health Reform 2003), and by 2002, these accounted for fourteen cents of every dollar spent in this country (PBS 2002). American consumers are drawn to technological innovation, too, a fact facilitated by legal marketing strategies, such as direct-to-consumer advertising of pharmaceuticals (Hogle 2001, 2002). Against these developments, transplantation defines a multibillion-dollar industry in America, and more transplants are performed in the United States each year than in any other country. In 1997, for instance, a national total of 20,297 transplant surgeries fell only 194 short of the 20,491 for all of Europe (ITCS 1997; UNOS 2003b).8 The technocratic approach to healing—as epitomized by organ transfer, and even more so by transplant surgery—is a medical fact of life in America.
The Commodification of Human Body Parts
Transplantation's ascent to iconic status as a miraculous medical
