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The Anthropology of Organ Transplantation


Charlotte Ikels
Department of Anthropology, Case Western Reserve University, Cleveland, Ohio 44106-7123; email: cxi@case.edu

Annu. Rev. Anthropol. 2013.42:89-102. Downloaded from www.annualreviews.org by Princeton University Library on 12/05/13. For personal use only.

Annu. Rev. Anthropol. 2013. 42:89102 The Annual Review of Anthropology is online at anthro.annualreviews.org This articles doi: 10.1146/annurev-anthro-092611-145938 Copyright c 2013 by Annual Reviews. All rights reserved

Keywords
technological imperative, transplant tourism, organ donation, embodiment, brain death

Abstract
Anthropology has been involved with the eld of organ transplantation almost since its inception. As a rapidly growing subeld within biomedicine, transplantation has been analyzed as one more example of the technological imperative: the development and application of new procedures and techniques that bring, in their wake, major changes in how humans relate to their bodies. Anthropologists have been especially interested in the psychological adjustment of organ recipients as they come to terms with the sacrices or deaths that were necessary to provide them with organs and as they respond to the presence of an outsider in their bodies. Critical medical anthropologists have focused more on donor issues, raising ethical questions about transplant tourism and the commodication of organs and challenging the universal validity of brain death as the death of a person.

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INTRODUCTION
As of early May 2013, the ofcial waiting list at the Organ Procurement and Transplantation Network (OPTN), the national registry maintained by the United Network for Organ Sharing (UNOS) for those seeking an organ transplant in the United States, stood at 118,170. This gure, however, is misleading. The number of active candidates, those who could at a moments notice present themselves at the hospital operating room for a transplant, was some 42,000 fewer (see http://optn.transplant.hrsa.gov). Candidates currently too ill to be eligible for a transplant and those who have not yet met all eligibility requirements are included in the higher gure. Yet whenever the topic of organ donation is raised in the media, it is the higher gure that is used. By so doing, the media (and transplant professionals) hope to garner sympathy for the candidates and support for organ donation by emphasizing the huge gap between organ supply and demand. Anthropologists (and, even earlier, sociologists) have long questioned this apparent gap. Although generally voicing support for the practice of organ transplantation, they have been worried by the ever loosening of the criteria for wait-listing and the associated intensifying of the search for usable organs from deceased (extended criteria) donors, such as the elderly, those who have had cancer, or those who are infected with cytomegalovirus. Critical medical anthropologists have also been concerned about the potential exploitation of vulnerable populationsthe braindead, the irreversibly comatose, or those in a permanent vegetative stateas analytic philosophers propose revising, by narrowing, the concept of personhood. They worry too about the impact that the expanding quest for living donors may have on the poor and otherwise marginal populations. This review of anthropology and organ transplantation traces the ambivalent relationship between anthropologists and the transplant community, understood here to include those professionals engaged in procurement as well as those treating renal failure (nephrologists) and surgeons (urologists) carrying out transplants and their allied staff (e.g., nurses, technicians, social workers, clergy). The writings of medical anthropologists reveal skepticism about the true nature of the organ gap, the positive portrayal of posttransplant life, and the nature of the long-term impact on living donors. This skepticism has led anthropologists to conduct ethnographic studies of organ recipients posttransplant experiences and, subsequently, to study the neglected experiences of donors and donor families. In a more supportive vein, anthropologists have also offered their expertise on issues raised by members of the transplant community. Such issues include questions about ethnic/racial disparities in rates of donation in the United States, cultural barriers to the wider adoption of the concept of brain death, international variations in the relative proportion of living to cadaveric transplants, and public receptivity to compensation for donation. An inherent tension runs through much of this research as anthropologists frequently require the assistance or permission of members of the transplant community to access study populations. Yet in their publications anthropologists are often critical of the biomedical enterprise of which transplantation is one of the most lucrative specialties. Furthermore, as indicated above, anthropologists have also viewed bioethicists as problematic not only in their approach to personhood but also in their emphasis on autonomy, treated as an abstract principle independent of cultural context and deployed by some to promote a market in organs. Anthropologists have vigorously contested this argumentation with rich ethnographic data demonstrating that context matters. Everyone, from the live or braindead donor to the organ transplantation team members to hospital-based ethicists, lives in complex webs of social relationships, judgment, and support or taboo, all inuencing outcomes.

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CRITIQUES OF BIOMEDICINE OR THE TECHNOLOGICAL IMPERATIVE


Critiques of biomedicine (and the transplant enterprise) fall into two categories: critiques of the technological imperative and critiques of the assumption of the universality of the practice of biomedicine, i.e., the assumption that the practice of biomedicine is all science and no culture and, therefore, is the same (or should be) everywhere (e.g., Marshall & Koenig 2004). Fox (1959), along with her collaborator Swazey (Fox & Swazey 1978, 1992), Plough (1986), and Koenig (1988) were among the rst writers to sound the alarm about the technological imperative, an alarm that anthropologists have continued to sound down the years (Kaufman et al. 2006, Maynard 2006, Sharp 2006a). These writers point out that in seeking to advance medicine and improve treatment, physician-researchers travel along the experimental-therapeutic continuum. In the earliest experimental stage, they themselves wonder whether the experiment is worth the cost to the patient. Then if the preliminary trials prove successful, the drug, device, or intervention is introduced to more and more patients until what was once experimental becomes standard treatment. The culture of biomedicine and the larger public culture both embrace the idea that there is a technological x to every illness and that every patient should be offered the latest treatment regardless of circumstances. Kaufman et al. (2006) argue that the mere availability of a treatment begins to make its application seem inevitable. Thus, in their US study Kaufman et al. argue that people over the age of 70 felt that they had a mandate to live and that it was expectable that adult children or even their own similarly aged spouses would donate a kidney. Kaufman (2005) maintains that the inability or unwillingness of individuals and/or family members to acknowledge that life is nite lies behind the failure to resist these interventions. Kidneys remain the most frequently transplanted organs. Although kidney failure (formally end stage renal disease, ESRD) and kidney transplantation are phenomena that occur the world over, they are not everywhere identical. The disease itself varies in the predominance of its causes, its prevalence, and its outcomes, depending on the treatment modalities available and the patients ability to access them. Dialysis facilities to lter the blood and transplant centers may be in short supply, too expensive, or too far for most individuals to utilize. One can readily comprehend these kinds of differences across borders (Crowley-Matoka & Lock 2006). Less appreciated is the fact that procurement strategies and even surgical technique can vary across borders. Hogle (1995, 1996, 1999) was one of the earliest anthropologists to pursue explicitly cross-cultural comparisons of these practices. Having already completed a study of organ procurement in the United States, she turned her attention to organ procurement in Germany. Hogle notes differences in the process of donor evaluation such that Germans, for example, paid little attention to the social history of the donor compared with Americans. In the handling and preparation of organs being retrieved for transplant, Germans took far longer to evaluate the organs and did so prioritizing their own sense of the organs, hefting, palpating, and trimming them in a craftsman-like fashion, whereas Americans relied on numbers to determine the quality of the organs. Hogle also notes differences in German strategies to promote organ donation; memories of Nazi-era medical experimentation make it difcult to talk of donating your body so that others might live or of making sure that organs dont go to waste. In 1997 Germans resisted a European trend of adopting presumed consent by requiring that family members permission must always be sought regarding donation of bodily materials.

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THE EXPERIENCES OF ORGAN RECIPIENTS


With the exception of people with ESRD who can turn to dialysis to maintain life, people with failing hearts, livers, lungs, and other solid organs have no choice but a transplant to remain alive. Their
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plight motivates transplant professionals to broaden the criteria of organs qualied for transplant; inspires researchers to experiment with xenotransplantation, articial organs, and self-generating organs (grown in labs from cells situated on scaffolding); and drives families to travel the world looking for suitable donors. Some of these practices (e.g., utilizing executed prisoners as donors, allowing commercial transactions between donors and recipients, and transplant tourism) violate international professional codes and/or local moral values. Anthropologists have been particularly exercised by the blatant exploitation that frequently accompanies all three of these practices.

The Gift of Life


Borrowing from the works of Mauss (1967) on exchange and Titmuss (1971) on blood donation, Fox & Swazey (1978) and Simmons et al. (1977) were perhaps the rst social science writers on organ transplantation to employ the concept of the gift in their analyses of the relationship thought to exist between a donor (or donor family) and a recipient. Although many writers (e.g., Ben-David 2005, Lock 2002, Ohnuki-Tierney 1994, Siminoff & Chillag 1999, Simpson 2004) have pointed out the limitations of the gift analogy, especially in the case of deceased donation (e.g., there is no reciprocitya transplant is a one-way transaction; there is no pre- nor posttransplant established relationship between giver and receiver; donor families do not conceptualize the act of donation as a gift but as a way to memorialize their deceased loved one), the language of the gift remains very important as a discursive weapon in the ght against organ commodication ( Joralemon 1995, 2001). In the earliest years of kidney transplantation in the United States (the 1950s and 1960s), most transplants occurred between living blood-related donors because matching was critical to graft survival. At this time, donors and recipients were necessarily known to each other, and although concerned about intrafamilial dynamics consequent to donation (the tyranny of the gift), transplant staff presented donors and recipients together in the media when celebrating a successful transplant. With the shift to deceased (cadaveric) donors, transplant staff began to require anonymity of both donors and recipients and to supervise any contact between them by, for example, serving as the locus of contact and editing (censoring) thank you letters sent by recipients to donor families. Sharp (2006b) reports that staff feared that donor families may become upset by the reminder of their loss (most cadaveric donations are made under extremely stressful conditions) and/or may develop a pathological attachment to the recipient (and vice versa) as a kind of kin. Less often voiced but also a factor was staff concern that donor families might pressure recipients for favors or money.

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Becoming a Transplant Candidate


The decision to seek a transplant is not an easy one. Kidney transplantation is generally favored over dialysis by insurers because over the long term (three or more years) it is less expensive. Patients too may come to realize the benets of transplantation as they tire of dietary and liquid restrictions, the constant need to be within two or three days of a dialysis machine (unless on peritoneal dialysis), and the wearing out of blood vessels for needle access. Being approved for a transplant is by no means automatic; depending on the country, would-be candidates must meet medical, economic, personality, and even social criteria (Gordon 2000, Schmidt & Lim 2004). Once an ESRD patient decides to try for a transplant, he or she is faced with another decision: whether to attempt to recruit a living donor from among family members or close intimates or to join a national waiting list and wait for a matching deceased donor. This choice is also available to patients seeking liver or lung transplants: Liver and lung lobes and even a single lung can
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be removed from living donors (as, more recently, can a partial pancreas and partial intestine). This increasing dismemberment of the body has led to revulsion among some researchers. Fox & Swazey (1992) could no longer tolerate working in the transplant eld, observing people dehumanized as assemblages of spare parts. Others speak of the insatiable search for transplantable organs (Sharp 2000), neo-cannibalism (Scheper-Hughes 2002), and the ravenous appetites of transplant personnel (Marshall & Daar 2000). Most candidates hesitate to ask relatives directly for an organ but are willing to accept if an offer is made voluntarily, but some are adamant that they will not accept what they judge to be too risky a sacrice by their relative, especially if an alternative is available (Gordon 2001a,b; Hamdy 2008b, 2012; Marshall & Daar 1998). Starting in the 1980s with the widespread usage of more powerful drugs to suppress the immune system and thus prevent organ rejection, meticulous matching became less important in donor selection. As a result, the eld of potential donors expanded well beyond relatives or closely matched cadavers to embrace essentially the entire world and produced the phenomenon of transplant tourism (to be discussed further below). Both Moniruzzaman (2010, 2012), working in Bangladesh, and Scheper-Hughes (2008), interviewing in Israel, found recipients who refused to put their own family members at risk but did not hesitate to put others at risk by buying a kidney because organs were available. In China the alternative of using organs from executed prisoners kept donation from living persons to a miniscule 5% (Ikels 1997b). When, in 2007, legal and administrative reforms led to a precipitous drop in executions and in the apparent willingness of prisoners to donate, the absolute number of living donations began to rise, climbing to 20% by 2010 (Ikels 2012).

Exchanging One Illness for Another


In the United States, transplant recipients frequently celebrate the anniversary of the day of their transplant as their second birthday (Sharp 2006b). They have snatched life from death (or from the burdens of dialysis), but they are not cured in the sense of restored to a pristine state of health. The diabetes or high blood pressure that may have led to organ failure remains a problem. In addition, recipients now must take powerful drugs to suppress their immune system to guard against the ever-present threat of organ rejection. This suppression, however, makes the recipient more vulnerable to infections and to the growth of cancers. Should signs of rejection appear, transplant staff frequently blame the recipient for failing to comply with the medication regimen. Yet as Gordon (2006), Gordon et al. (2008), and Sharp (1999) argue, the signicant nancial costs of posttransplant care come as a surprise to many recipients. Although kidney transplants in the United States are usually covered by Medicare, recipients are responsible for a substantial co-pay for posttransplant medications for the rst three years and fully responsible after three years unless they also have private insurance or nancial assistance. Another surprise for recipients is that obtaining employment after a transplant is not as common as they were led to expect, a problem Crowley-Matoka (2005) also found in Mexico. Others, who are still employed, nd they cannot leave their jobs for fear of losing insurance coverage. To make ends meet, recipients cut back on medication or participated in informal markets to obtain medication from other recipients at a lower pricea case of winning the (short-term) battle but losing the (long-term) war.

Embodiment and Subjectivity


Whereas the physiological consequences of harboring anothers organ in ones own body have been of obvious interest to the transplant community, anthropologists have been interested more in its
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impact on the recipients subjectivity. Drawing on the works of Bourdieu (1977), Csordas (1990, 1994), Haraway (1991), Merleau-Ponty (1962), and Scheper-Hughes & Lock (1987), anthropologists have sought to understand how the organ, initially experienced as Other, is incorporated into the recipients sense of self. This process is considered particularly fraught as biomedicine regards the body as a solid, bounded entity (and, correspondingly, Western philosophers regard it as housing an autonomous individualsee below). Anthropologists utilize this bodily image when investigating the question of incorporation, perhaps because their focus has been on recipients who share the biomedical perspective on the body. Yet anthropologists are very much aware that the body is conceptualized differently in other cultures, posing, one would assume, a different kind of challenge to organ recipients. Langford (2002), for example, points out that practitioners of Ayurveda (the major professional indigenous medicine of India) see the body as open and porous: engaged in a continuous interchange with the social and natural environment (p. 11). Similarly, Lamb (2000) notes how elderly women in a North Indian village, as part of their preparation for death, are expected to cut attachments to people, places, and things by drying out their bodies so as to minimize the exchange of body uids and particles that otherwise would tie them together. Among the Suya, an Amazon basin population, incorporation of the white mans power could be accomplished by pharmaceutical injections (Scheper-Hughes & Ferreira 2003). This Suya concept made kidney incorporation also include absorbing the power of the particular white man from whom it had come. The notion of kinship among the Suya is not centered around lineages but around the sharing of intimate bodily substances including milk, blood, urine, sweat, feces, vaginal secretions, spit, pus, and semen. A substance group is a kind of extended family based on birth, marriage, afliation, alliance, and proximity (p. 147). Thus, everyone in a recipients substance group acquired some of this white mans power, although the particular kidney transplant occurred in only one body by biomedical standards. Cultures also differ in the physical or symbolic signicance attached to particular organs (Scheper-Hughes & Lock 1987), and such differences, logically, could affect recipient responses following transplantation. Unlike a kidney, which does its job quietly, a newly transplanted heart is difcult not to notice. In addition, in many cultures the heart is seen as the locus of feeling, so it becomes understandable that heart transplants awaken very strong emotions in recipients. A quite different illustration comes from China. In traditional Chinese medicine, the kidney acts as the storehouse of original qi (cosmic energy or vital force present at the time of birth) and of reproductive potential. The loss of a kidney means much more in Chinese societies than elsewhere, and living donation is, therefore, regarded as a much more serious undertaking (Ikels 1997a,b). Whether this particular view of the kidney also affects the recipients experience has not yet been explored. Studies of organ recipients psychological reactions to their transplants reveal diverse responses. The initial and dominant reaction, regardless of whether the organ came from a living or a deceased donor, is often profound gratitude (tempered by guilt that someone had to suffer or die to make the transplant possible) along with a sense of stewardship of the organ (Shimazono 2008). In his study in Bangladesh, Moniruzzaman (2010) found such gratitude, however eeting, even among recipients who had purchased their kidneys. Another reaction is to attribute changes in dietary or activity preferences to the new organ, as if at a cellular level the organ retained memories of its original bearers preferences (Manderson 2011). However, unlike almost all other anthropologists who write on this topic, rather than attributing these changes to cultural notions of kinship or psychological factors, Manderson notes that posttransplant medications and steroids (as well as the ability to expand ones diet after years on dialysis) can account for dietary shifts. Simply having energy restored can also account for changes in interests and activities. In his study of liver recipients in China, Yu (2011) reported surprise and disappointment with the quality of posttransplant life, guilt over the short- and long-term costs associated with the transplant, and
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psychological distress associated with the sense of the Otherness of the organ (one recipient even required an exorcism before becoming comfortable with her new liver). As indicated above, recipients views about the nature of the organwhether it is nothing more than a machine part or an animate or spiritual extension of its donorshape how the organ is incorporated into the self (Sharp 1995). About half of Sharps recipients (2006b) (all of whom had deceased donors) fell into each category. Those who adopted the perspective of the transplant community in the United States and viewed the organs as replaceable parts felt little challenge to their sense of self. Those who focused on the organ as an extension of the donor, however, frequently felt that they had become as kin to the donors family, like blood relatives, because they shared a common substance. They were especially likely to seek contact with the donor family despite transplant center bans against contact.

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THE EXPERIENCES OF ORGAN DONORS AND DONOR FAMILIES


Some of the questions and concerns of donors and donor families are the same or the reciprocals of those of recipients. Where recipients pondered whether to ask a relative to become a living donor, those relatives had to decide whether to donate. Following a deceased donation, donor kin frequently found satisfaction in knowing that parts of their loved one were still alive and, like recipients, believed that they had established a kinship bond with the recipient, especially so in the case of a heart transplant. Because, despite overlap, the issues pursued by anthropologists studying living donors and those studying deceased donors and their kin are different, the two types of donation are discussed separately.

Living Donors: Autonomy, Exploitation, Transplant Tourism


From the earliest years of transplantation, researchers, including transplant personnel, have expressed concerns about the well-being of donors. The Hippocratic injunction, rst do no harm, presented a potential ethical roadblock to subjecting individuals to surgery that was neither necessary nor personally benecial. Bioethicists helped to remove this roadblock via two justications: (a) the assurance of voluntary informed consent to the procedure by the autonomous donor; and (b) the presumed psychological benets to the donor of altruistically helping save (or improve the quality of ) a life, initially the life of a blood relative, then that of an emotionally related person, and nally even that of a stranger. Anthropologists and other social scientists have taken issue primarily with the rst justication, pointing out that for many donors the decision to donate is instantaneous, not the product of rational deliberation of the pluses and minuses of donation, but more of a visceral response that this is what relatives do for one another. Should a decision based on a gut reaction be considered an informed decision? What is rational informed consent from an anthropological perspective? Most anthropological research has focused on the limitations of the concept of autonomy, one of the anchoring principles of American bioethics but perhaps not the best guide for understanding individual or family decision-making. In many societies, decisions that involve family members are not freely made by the individuals concerned, even when they are adults. Rather, seniors make decisions for juniors, males make decisions for females, and/or the collective rather than the individual makes decisions for the good of the whole. Under these circumstances autonomy is neither practiced nor valued. The most expendable member (the nonwage earner, the unmarriageable sister, or the soon-to-be married-out daughter) is likely to be put forward. Gender imbalance in donation within the familyfemales disproportionately serving as donors to males and/or males disproportionately failing to serve as donors to femalesis widespread (Ikels 1997a,
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Moazam 2006). Moazams study of a transplant center (the Institute) in Pakistan revealed that the largely female staff in the pretransplant clinic (with the support of the male head of the Institute) were so determined to prevent female exploitation that they bullied and badgered families with several sons to have the sons tested for a match when a daughter was presented as the prospective donor. She also pointed out that the paternalistic practice of medicine is the norm in Pakistan and that the families so badgered did not take offense. The Institute was proud to be the only center in Pakistan with an equitable gender ratio in donation. Also of concern to researchers has been the lack of information provided to donors prior to their surgery. Whereas the short-term risks of the surgery and the immediate postsurgery period are usually clearly spelled out, the long-term risks are often not (Crowley-Matoka et al. 2004, Joralemon & Fujinaga 1996). Donors spoke of feeling dropped by the transplant team as soon as their organ had been removed because there was little to no follow-up. Internationally, anthropologists have been concerned that the presentation of organ donation as nearly risk-free, at least in the case of kidneys, has been based on outcomes in high-tech hospitals in developed countries. Should there be postoperative complications or infections, donors usually have ready access to care through insurance. The risks to donors in developing countries can be very different, and the situation is complicated by the issue of transplant tourism (Scheper-Hughes 2002). Lower standards of sanitation and hygiene increase the risk of infection, and the shortage of health care facilities and lack of insurance coverage pose serious problems to Third World donors (Moniruzzaman 2010). Of all the transplant-related research conducted by anthropologists, transplant tourism is the topic with the greatest visibility to the public. This visibility is due largely to the efforts of ScheperHughes, who in 1999, along with her colleague Lawrence Cohen, founded Organs Watch at the University of California, Berkeley, to document the extent of the international organ trade (Scheper-Hughes 2001). Originally investigating the rumors of organ stealing that were rampant in South America in the late 1980s and early 1990s, Scheper-Hughes (1996) at rst interpreted the rumors as not literally true but as metaphoric ways to express the sense of vulnerability felt by the poor. At the time, she even linked the rumors to the democratization that she felt allowed people to express the sense of violation they had felt under the military or, in the case of South Africa, apartheid. However, subsequent investigations, driven perhaps by revelations of mutilated bodies and confessions by participants, offered support for the rumors; i.e., under the military in Brazil and Argentina, dissidents and suspected Communists were disappeared as were their children (thus the kidnapping/organ-stealing stories) (Scheper-Hughes 2000). As part of the Bellagio Task Force on Transplantation, Bodily Integrity, and the International Trafc in Organs organized in September 1995 by David Rothman, professor of social medicine and history at Columbia University, Scheper-Hughes (1998) undertook an investigation of transplant tourism involving Brazil and South Africa, whereas Cohen focused on India. The research later expanded to Argentina, Israel, Turkey, Moldova, the Philippines, and even the United States. Not surprisingly, what they discovered was frightening and scandalous: well-known surgeons operating with impunity, knowingly using purchased organs in violation of international transplant ethics; misrepresentation and exploitation by brokers of living donor/sellers, and living donor/sellers mostly worse off after donation than they were before (Cohen 1999; Scheper-Hughes 2000, 2002, 2003a,b, 2005, 2008). To carry out her research, Scheper-Hughes employed some unorthodox research methods (approved by her institutional review board) and cooperated, including initiating contact, with various governmental authorities to alert them to the abuses occurring in their countries (2004). She has justied her undercover and journalistic methodology as necessary, given the illegal nature of the activities she was investigating. Unfortunately the fact that she did not stay in any one place long enough to gain a full picture of the local transplant scene, that she was perceived as
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either an investigative journalist or other member of the media by her interviewees, that she was unable to interview any kind of random sample of donor/sellers, and that her language is deliberately provocative have undercut her message indicating that donor/sellers are manipulated and exploited. Other anthropologists, however, have been able to carry out longer-term research, and their ndings echo hers. Both Cohen (1999) working in India and Moniruzzaman (2010, 2012) working in Bangladesh conrm deception of donor/sellers, minimal nancial benets (debts paid off or dowries funded only to be followed by more debt), and poor physical outcomes. Donor/sellers lamented their long-term loss of energy and inability to carry out farm work. All three of these anthropologists are strongly opposed to proposals to develop organ markets (see below).

Deceased Donors and Their Kin: Whole Brain Death and Beyond
The creation in 1968 of the so-called Harvard Criteria for the Determination of Brain Death solved two problems at once: rst, how to justify terminating ventilator support for the irreversibly comatose, and second, how to increase the supply of transplantable organs. Although Lock (2002) asserts that, compared with Japan, the adoption and acceptance of brain death as (a kind of ) real death in the United States was relatively straightforward and did not generate much public agitation, its application in a given case is often quite disturbing to the relatives of the newly deceased ( Joralemon 2002). Even medical personnel are disconcerted by a warm, breathing (albeit mechanically assisted) body that moments ago they were treating as a patient but now, certied as dead, they must refer to as a corpse or neo-mort, though not in front of the family (Sharp 2006b). Sharp has been unusually attentive to linguistic and metaphorical shifts in the transplant eld, noting that organ procurement organizations (OPOs) in the United States have shifted their emphasis in the phrase gift of life from gift to life. She refers to this trend as the greening of the donor, symbolized by OPO name changes, all manner of plant life motifs in donor recruitment drives, and tree planting at public donor memorial services, an effort to move the donor family quickly out of the shadow of death and to encourage donation as a way to promote life. Most technologically advanced countries quickly followed suit and accepted the concept of brain death, but not Japan, which held out until 1997 and even then limited its application to people who had already indicated they wished to become organ donors and had their familys support (Lock 2002). Hardacre (1994), Lock (1996, 1999, 2002), Lock & Honde (1991), and Ohnuki-Tierney (1997) have all offered explanations for the reluctance of the Japanese medical and religious communities as well as the public to accept the concept of brain death. For example, Japanese are said to value sentiments over rationality as the essence of the person. Therefore, death of the organ associated with rationality (the brain) does not equate with death of the person. Reluctance to accept brain death has also been attributed to specic historical events. Memories of Japanese medical experimentation in wartime China reduced public trust in the medical profession. In 1968, Dr. Wada who performed the rst heart transplant in Japan was thought to have killed both the donor (a man who had nearly drowned but was not dead when he was transported from the treating hospital to Dr. Wadas hospital) and the recipient, who required heart valve surgery but unexpectedly wound up with a transplant and survived only 83 days (Lock 2002). This case continues to shadow public discussion of heart transplantation, even though it occurred at a time of great international experimentation. Events have also played a role in the rather sudden revision of Japans brain death legislation in July 2009, which took effect in 2010. Under the new regulations, only those who have actively refused to become donors ahead of time will not be considered as potential donors, though family member agreement continues to be necessary. The media have noted that interest in revising the law probably gained momentum after the World Health Organization proposed in 2007 a restriction on patients seeking transplants abroad.
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Germany (Lock & Nguyen 2010) and China (Ikels 2012) have actively refused Japanese patients for transplants. Hamdy (2012) points out that the concept of brain death and the practice of deceased donation are regarded variously across the Islamic world. In Saudi Arabia, Jordan, Kuwait, and Iran, for example, deceased donation has been (and remains) permitted, whereas Egypt did not accept brain death until 2010. However, even where declaration of brain death is legal, medical personnel are still extremely reluctant to declare dead someone whose heart is still beating, and the general public is even more reluctant to donate a questionably deceased loved ones organs. Budiani (2007) and Hamdy (2008a, 2012) in the case of Egypt, Sanal (2004, 2011) in the case of Turkey, and Tober (2007) in the case of Iran all point out how this reluctance should not simply be assumed to be the result of religious conservatism. In their detailed ethnographic studies, these anthropologists draw attention to the broader political and economic circumstances that contribute to a much greater acceptance of living donation in all three of these countries and particularly of unofcial tolerance of illegal payment to (unrelated) living donors. Both Tober (2007) and Sanal (2004) emphasize the importance of customary law, in which payment for bodily injury or exchange among participants in private networks was widely practiced. Sharp (2006b) found that once family members agree to donate the organs of a loved one their perception of the organ (as spare part or container of the donors vital or spiritual essence) affects how they want to relate to the recipients. Although most donor families do not seek contact with recipients, they have resented the transplant communitys insistence on donor anonymity. Well into the 1990s, UNOS and regional OPOs conducted annual memorial services for donors collectively with no names allowed (or if names were allowed, dates of death were not) to prevent recipients from guring out who their donor might have been and initiating contact with the family. For families, keeping the donors name visible is a way of honoring his or her life and the gift. Sharp (2001, 2006b) describes the many subversive actions donor family organizations took to make the names visible.

REDUCING THE GAP BETWEEN ORGAN SUPPLY AND DEMAND


Many of the anthropologists who study organ transplantation are troubled by the constant publicity given to the length of the waiting list and to the number of people on it who die annually for lack of an organ, and they are profoundly disturbed by the relentless efforts under way to justify new ways to increase the organ supply. They argue, futilely so far, that more attention should be given to the demand side of the equation, e.g., Koenig (2003), and they have questioned the propriety of developing transplant programs at all in societies that cannot even meet the basic public health needs of their populations. But they expend the greatest amount of energy arguing against proposals to establish organ markets (Daar & Marshall 1998; Das 2000; Delmonico & Scheper-Hughes 2003; Joralemon 1995, 2000, 2001; Joralemon & Cox 2003; Marshall et al. 1996; Moniruzzaman 2010; Scheper-Hughes 2001, 2002, 2003a,b, 2005; Sharp 2000). The process and consequences of converting an object into a commodity are well-covered by Appadurai (1986). The neo-liberal idea of treating an organ as just another kind of disposable personal property that the owner has the autonomous right to sell (and others the right to buy) offends anthropologists who take a consequentialist perspective rather than a utilitarian one. According to those who have studied it, the current illegal market benets the rich at the expense of the poor, those from developed countries at the expense of those from developing ones, and, more often than not, men at the expense of women. They see no reason that legalizing sales would have very different outcomes. Nor have anthropologists supported suggestions that criteria for the determination of
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brain death be altered to generate more potential donors, e.g., by declaring persistent vegetative state a new category of brain death. How then to increase supply? Simpson (2004) points to the success Sri Lanka has had in persuading individuals and families to consent to eye and full-body donation by drawing on Buddhist notions of the spiritual signicance of the gift and of the importance of demonstrating a lack of attachment to the body and its parts and highlighting the many stories of the Buddha, in various incarnations, sacricing body parts and even his life for the benet of others (Ohnuma 2007). Copeman (2006) studied an Indian body donation society that sprang up in the 1990s as a response to Indias portrayal as an organs bazaar. Its members too draw on the story of a mythical culture hero who sacriced his bones to help the gods. The body is portrayed as too valuable to waste in cremation; instead, it should be used to advance medical knowledge. Distaste for funeral practices also motivated the Greeks in Papagaroufalis study (1999) to register as donors out of self-interest: They could not abide the thought of subjecting their bodies to traditional Greek Orthodox burial rites requiring that the body be dug up after a few years in the grave, the bones scraped clean of the esh, and deposited in an ossuary. Importantly, these three examples reveal that tradition should not be treated simply as an obstacle to donation. Indeed, it can be a resource. This review of anthropological studies of organ transplantation has focused primarily on the experiences, attitudes, and beliefs of organ recipients and secondarily on those of donors because these are the populations most frequently studied by anthropologists. People who are professionally involved in the eld of organ transplantation, however, constitute a relatively neglected study population. Given that there would be no need for organ donors or recipients without them, it is surprising that the experiences, attitudes, and beliefs of surgeons, nurses, and other transplant staff have not been researched to the same degree. To truly understand the transplant enterprise, we need to know what motivates them to enter this eld and what keeps them motivated or drives them out, what they perceive as its ethical quandaries, and how they would like to change current practice if they could.

DISCLOSURE STATEMENT
The author is not aware of any afliations, memberships, funding, or nancial holdings that might be perceived as affecting the objectivity of this review. LITERATURE CITED
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Perspective
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Annual Review of Anthropology Volume 42, 2013

Ourselves and Others Andr e B eteille p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1 Archaeology Power and Agency in Precolonial African States J. Cameron Monroe p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 17 The Archaeology of Illegal and Illicit Economies Alexandra Hartnett and Shannon Lee Dawdy p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 37 Evidential Regimes of Forensic Archaeology Zo e Crossland p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 121 Biomolecular Archaeology Keri A. Brown and Terence A. Brown p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 159 Biological Anthropology Agency and Adaptation: New Directions in Evolutionary Anthropology Eric Alden Smith p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 103 Teeth and Human Life-History Evolution Tanya M. Smith p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 191 Comparative Reproductive Energetics of Human and Nonhuman Primates Melissa Emery Thompson p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 287 Signicance of Neandertal and Denisovan Genomes in Human Evolution John Hawks p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 433 Linguistics and Communicative Practices Ethnographic Research on Modern Business Corporations Greg Urban and Kyung-Nan Koh p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 139

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Language Management/Labor Bonnie Urciuoli and Chaise LaDousa p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 175 Jurisdiction: Grounding Law in Language Justin B. Richland p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 209 Francophonie C ecile B. Vigouroux p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 379 Evidence and Authority in Ethnographic and Linguistic Perspective Joel Kuipers p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 399 International Anthropology and Regional Studies
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Anthropologizing Afghanistan: Colonial and Postcolonial Encounters Alessandro Monsutti p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 269 Borders and the Relocation of Europe Sarah Green p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 345 Roma and Gypsy Ethnicity as a Subject of Anthropological Inquiry Michael Stewart p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 415 Sociocultural Anthropology Disability Worlds Faye Ginsburg and Rayna Rapp p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 53 Health of Indigenous Circumpolar Populations J. Josh Snodgrass p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 69 The Anthropology of Organ Transplantation Charlotte Ikels p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 89 The Anthropology of International Development David Mosse p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 227 The Nature/Culture of Genetic Facts Jonathan Marks p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 247 Globalization and Race: Structures of Inequality, New Sovereignties, and Citizenship in a Neoliberal Era Deborah A. Thomas and M. Kamari Clarke p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 305 The Politics and Poetics of Infrastructure Brian Larkin p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 327 The Anthropology of Radio Fields Lucas Bessire and Daniel Fisher p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 363

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Theme: Evidence The Archaeology of Illegal and Illicit Economies Alexandra Hartnett and Shannon Lee Dawdy p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 37 Evidential Regimes of Forensic Archaeology Zo e Crossland p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 121 Biomolecular Archaeology Keri A. Brown and Terence A. Brown p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 159 Teeth and Human Life-History Evolution Tanya M. Smith p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 191
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The Nature/Culture of Genetic Facts Jonathan Marks p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 247 Evidence and Authority in Ethnographic and Linguistic Perspective Joel Kuipers p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 399 Signicance of Neandertal and Denisovan Genomes in Human Evolution John Hawks p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 433 Indexes Cumulative Index of Contributing Authors, Volumes 3342 p p p p p p p p p p p p p p p p p p p p p p p p p p p 451 Cumulative Index of Article Titles, Volumes 3342 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 455 Errata An online log of corrections to Annual Review of Anthropology articles may be found at http://anthro.annualreviews.org/errata.shtml

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