As Paul Brodwin (2000c) has argued, the intensity of ethical debates surrounding radical biotechnologies is evident in the levels of anxiety they generate, and organ transfer is no exception. Among the strongest ideological underpinnings of transplant medicine is the adamant denial of body com-modification. The collective horror Americans share for the utilitarian use of human bodies is apparent in our folklore. Negative associations link the reuse of body parts with Hollywood's original rendering of Frankenstein's monster. A persistent theme within futuristic Anglophone fiction is the routine and frequently clandestine medical or industrial use of human bodies to sustain society and feed individual or corporate greed. Classics include Harry Harrison's Make Room! Make Room! (1964; the basis for the film Soylent Green, in which the general populace is fed recycled humans without its knowledge); Robin Cook's Coma (1977; in which healthy people are drugged and held in comatose states until their organs can be removed for sale); and the darkly comical rendering found in Monty Python's the Meaning of Life (wherein procurement officials arrive at a man's home and assert their rights to retrieve his organs while he is still very much alive, all because he has signed his donor card). The corporate preying on the body stands as a symbolic form of necrophagy—or what Youngner has dubbed “nonoral cannibalism”—where a chilling utilitarian ethos drives villains to harvest body parts without guilt (Youngner 1996: 35; for similar language, see Fox 1993; Lindenbaum 2004; Scheper-Hughes 1998b). In these tales only sensitive heroes can still recognize the humanity of captured or discarded souls.
What such fictional stories (and parodies) reveal is that body commodification—especially within the highly celebrated arena of organ transplantation—quickly erodes an already shaky public investment in medical trust. In response to such deep concerns, the transplant industry has generated an elaborate array of powerful euphemistic devices that obscure the commodification of cadaveric donors and their parts.
Precious Things
The most elaborate and pervasive rhetoric involves the shrouding of body commodification in the language of a gift economy. This language is evident in early bureaucratized form in the wording of NOTA, or the 1984 National Organ Transplant Act. Today the language of the gift permeates nearly all discussions of organ transfer, which is defined as a very particular kind of social giving in America. Most important, organs are nearly always described as “gifts of life,” a turn of phrase that has long been used within the blood industry (and especially by the American Red Cross) and now in reference to ova donation (Ragone 1999). Both realms differ from organ transfer in that they are marked by histories of direct agency-to-donor monetary compensation. In the specific context of cadaveric donation, the vast majority of organs are offered by donors' surviving kin to anonymous strangers; procurement specialists help negotiate the transfer of these body parts to surgeons, who will then transplant them in their own ailing patients. Without question, much money is exchanged, but payments made by insurance companies, individual patients, transplant hospitals, and procurement agencies are typically described as covering technical, transportation, and other support services, rather than being linked directly to the cost of the organ itself. An important shared understanding within transplant circles is that taboos surround discussions of the financial worth of organs. Furthermore, strict moral sanctions insist that donor kin should receive no direct payment for a gift offered as an ultimate form of altruistic sacrifice.
Nevertheless, I have seen on rare occasions itemized price sheets for various organs. In one hospital where I conducted research, staff regularly distributed detailed price information directly to potential recipients so that they would know the enormous costs entailed in acquiring a kidney, heart, lung, or liver. Staff saw no reason to be secretive about this. Nevertheless, because such procedures are rare, they emerge as subversive acts. Perhaps more obvious is the fact that a transplant unit defines a tremendously prestigious program for any hospital, both assuming a high community profile and generating significant income for surgeons and for the institution itself. Procurement offices, too, though nonprofit firms, operate on impressive annual budgets dispensed by UNOS. Inherent tension underlying the daily struggle to maintain transplantation's credibility arises from the fact that transplantation is as lucrative as it is medically miraculous. One dominant solution to this conundrum involves the deliberate and ceaseless denial of even the more obvious forms of body commodification.
Cadaveric donation further complicates this configuration. Whereas a vast percentage of kidney transplants in this country involve living pairs of relatives, friends, or colleagues, in nearly all cadaveric cases the donor is an anonymous stranger to the respective set of organ recipients. In those situations where living donor and kidney recipient know one another, both parties understand the kidney as being a special kind of gift to which no monetary value can be assigned.9 This initial shared understanding eventually may become a source of either increased mutual love or insurmountable conflict. As Renee Fox and Judith Swazey explain, the “tyranny of the gift” springs from the sense that the giving of so precious a thing—a part of oneself—can never be fully reciprocated (1992:39-42). A different configuration arises in the context of anonymous cadaveric donation, where recipients are generally told only the age of their donors, their family status, the region of the country from which they came, and sometimes their cause of death. Recipients find it difficult to shake the sense that someone else had to die so that they could live, their anxieties exacerbated if they imagine how close kin—typically the donor's spouse, offspring, or parents—must have suffered when faced with the donor's sudden and unexpected death.
As a result, donated cadaveric organs simultaneously emerge as interchangeable parts, as precious gifts, and as harboring the transmigrated souls of the dead. Whereas transplant recipients are encouraged by hospital staff to depersonalize their new organs and speak of them in terms that can sometimes even approximate car repair, procurement staff regularly tell donor kin that transplantation enables the donor's essence to persist in others who are thereby offered a second chance at life. These competing messages offer evidence of what I refer to as a form of ideological disjunction, a pervasive characteristic of transplant ideology that inevitably drives professionals to become powerful gatekeepers who work aggressively to prevent communication between recipients and donor kin (Sharp 1994). Whereas these professionals may deliver contradictory messages to different people about the symbolic nature of transplanted organs, all parties are nevertheless united in the revulsion they feel for blatant forms of body commodification.
As Robert Coombs and his colleagues have illustrated, within hospital contexts, and especially in emergency wards, one encounters a rich array of medical slang, where death and dying patients define prominent foci. Indeed, organ transfer generates a specialized category of insider slang: common labels applied to patients include GPO (good [for] parts only), organ donor (a motorcycle rider or an accident victim with little chance of survival), and bone (bone marrow transplant) (Coombs et al. 1993). Within transplant wards and procurement offices, and during celebratory organ transplant events, one encounters an even richer panoply of symbolic expressions that specifically obscure references to death, human suffering, and body commodification. Donors' bodies, for instance, are frequently transformed metaphorically and visually into an array of greenery, including trees and flowers, a set of images that play off the idea that organs are transplanted in or grafted on to new bodies. Context also proves crucial for determining the appropriateness of various terms. For instance, those awaiting transplants are readily referred to as “patients” by all hospital staff, whereas potential donors, whether declared brain dead or not, are rapidly dehumanized. Procurement staff may even correct one another's language if someone refers to potential donors as “patients” or even as living individuals. Donor kin, however, insist on humanizing and personifying their loved ones throughout donation and procurement: personal names are always used, and a label such as “donor” is abhorrent.
Competing forms of euphemistic wordplay also serve to mystify the procurement process. Surgeons frequently employ the expression “organ harvesting,”