Human Organ Donation: Gift or Graft?

Published in the Opinion page of the Chicago Tribune, May 12, 2000; of The Saint Louis Post-Dispatch, July 18, 2000; and of The Baltimore Sun July 27, 2000. It was also reprinted in a textbook by Lee Odell and Susan M. Katz entitled Writing in a Visual Age, Bedford/Saint Martin's, 2006.

A few days ago, while making rounds at a local hospital, I chanced upon the pictures of two children tacked to a bulletin board in the ICU. One photo showed a despondent, jaundiced infant with a huge, fluid-filled belly and limp, unsettled limbs stretched out in every direction. The other showed a pink, healthy baby beaming as he grasped his foot with his right hand and a toy with his left, as if trying to decide which to chew on first. Only after reading the note next to the photos did I realize that both were images of the same child. His mother sent the pictures with a moving letter thanking the hospital staff for their role in obtaining a suitable donor liver for her son, born with a fatal deformity of the bile ducts. “Thank you for giving our son back to us”, she wrote. A liver transplant was their only hope, and in this case, the benefit was nothing short of spectacular, clearly a gift of life.

Tissue obtained from humans – both living and dead – has proved to be life-saving and life-enhancing for persons with a broad range of medical problems. Despite campaigns to improve public and professional awareness of the benefits of donation, the sharp upswing in demand for human organs for transplantation has not been accompanied by a corresponding increase in supply. While solutions – of both the carrot and the stick variety – have been offered to reverse the donor dearth, none has proven particularly successful, and the unmet demand for organs has fostered commercialization and, occasionally, exploitation of donors and their families. Pennsylvania, for example, recently became the first state to offer relatives of deceased, prospective donors financial incentives to give up the bodies of their loved ones. Documentation of paid or coerced donations from the poor of developing countries and citizens of totalitarian regimes is on the rise. Sordid reports abound of abortion clinics feeding a lucrative black market in fetal tissue.

In the affluent west, “market-based” organ procurement ranks among the more creative approaches that have been proposed, but is little more than a euphemism for buying and selling of body parts. Prospective “organ vendors” could “opt-in” to an organ or tissue “futures market”. After their deaths, their estates would share in the substantial financial benefits currently enjoyed by a few for-profit tissue brokers. The concept of "rewarded gifting" -- an oblique, contradictory term concocted to blunt the funny aftertaste that comes from knowing you’ve just put your innards up for sale – is unlikely to gain wide acceptance.

Before organ transplantation was possible, laws regarding disposition of a dead person’s body made it clear that executors of an estate could not make it an item of commerce. The reason? The body was not considered “property” in the legal sense, and therefore not a part of the person’s estate. As transplantation developed into a therapeutic medical procedure, living organs from dead donors acquired value, and laws were adapted to fit the new reality. Under the Uniform Anatomical Gift Act, which regulates procurement and distribution of human organs for medical purposes, it is still illegal to sell the dead body or its parts, but not to give them away. So some non-profit procurement groups pitch donation to surviving family members, appealing to their altruism, then charge hefty processing fees to for-profit distributors. At times, the same people run both operations. The problem is that these organizations deliberately blur the distinction between giving and selling.

In his insightful book, “The Gift: Imagination and the Erotic Life of Property”, Lewis Hyde points to the existence of two “economies” operating in human relations. One is the “market economy”, where commodities are valued, bought and sold in a calculated exchange. The other is the “gift economy” where goods are given freely without calculation. Gifts can not be purchased or traded, only bestowed on one person by another. Gifts are not capital. Rather than foster competitive self-interest and social fragmentation, they create and strengthen bonds between individuals. We all like to give and receive gifts because they express values that money can’t buy: the esteem of one person or group for another; the desire that others may experience good fortune and happiness, and share in the prosperity of the giver. Gifts are a material expression of good will, of love. They unite rather than divide. In a sense, the practice of organ transplantation today occupies the intersection of these two economies: one man’s gift becomes another man’s capital.

On the one hand, the costs incurred by harvesting, processing and transporting organs should in justice be covered, and some would argue that a reasonable profit may legitimately be made in the process. On the other hand, the organ itself, the generosity of the donor’s family and the life that is prolonged are values that resist an economic paradigm. According to Hyde, “Transactions that involve life itself seem to constitute the primary case in which we feel called upon to distinguish the right of bestowal from the right of sale”. The mother of the child in the photos came to understand that life is the ultimate gift. It is bestowed, not taken, made or earned, and it is a gift of incalculable value.

The industrial age we are quickly leaving behind was characterized by the conflict of capital and labor. As the new era of biotechnology begins, the new dialectic may well be defined by the dichotomy of commodity and gift. Advances in biotechnology that allow us to manipulate human life force us to continue to put a price tags on the priceless, to confuse gift and commodity, persons and property. The tension created by these contrasting values – already evident in the debates on the patenting of human genes, the use of human stem cells and fetal tissue for the treatment of disease – may introduce original and unexpected notions of value and wealth. In time, we may well discover that we have much to gain by giving away what never really belonged to us.


Robert said...

Joe, fantastic blog. Great points. This is going to affect many people. Establish links so that you come up on Google. Look also at Alan Shewmon's stuff on brain death and let me know what you think. Fr. Bob

Anonymous said...

Do the hospitals and procurement groups profit? If this is to be an altruistic exchange, should any, none or all profit?