61
SAIS Review vol. XXII no. 1 (Winter–Spring 2002)
The Ends of the Body:
Commodity Fetishism and
the Global Traffic in Organs
Nancy Scheper-Hughes
Amidst the neoliberal readjustments of the new global economy,
there has been a rapid growth of “medical tourism” for transplant
surgery and other advanced biomedical and surgical procedures.
A grotesque niche market for sold organs, tissues, and other
body parts has exacerbated older divisions between North and
South, haves and have-nots, organ donors and organ recipients.
Indeed, a kind of medical apartheid has also emerged that has separated
the world into two populations—organ givers and organ re-
ceivers.
Over the past 30 years, organ transplantation—especially kidney
transplantation—has become a common procedure in hospitals
and clinics throughout the world. The spread of transplant
technologies has created a global scarcity of viable organs. At the
same time the spirit of a triumphant global and “democratic” capitalism
has released a voracious appetite for “fresh” bodies from
which organs can be procured. The confluence in the flows of immigrant
workers and itinerant kidney sellers who fall prey to sophisticated
but unscrupulous transnational organ brokers is a
subtext in the recent history of globalization. Today’s organ proNancy
Scheper-Hughes is a Professor of anthropology at the University of
California, Berkely, where she directs the doctoral program in Medicine,
Science, and the Body. She is the cofounder and Director of Organs Watch,
a medical human rights organization based at the university that monitors
the international traffic in human organs. The research on which this article
is based was funded by a generous grant from the Open Society Institute
with matching funds from the University of California, Berkeley. The article
is based on a chapter from her forthcoming book, The Ends of the Body: the
Global Traffic in Human Organs (New York: Farrar, Strauss & Giroux).
62 SAIS Review WINTER–SPRING 2002
curement transactions are a blend of altruism and commerce; of
science and superstition; of gifting, barter, and theft; and of
voluntarism and coercion.
International Organ Markets, Bioethics, and Social Justice
The problem with markets is that they reduce everything—including
human beings, their labor, and their reproductive capacity—
to the status of commodities that can be bought, sold, traded, and
stolen. Nowhere is this more dramatically illustrated than in the
market for human organs and
tissues. The concepts of the integrity
of the body and human
dignity have given way to ideas
of the divisible body and detachable
organs as commodities.
The new field of bioethics
has largely capitulated to the
dominant market ethos.1
Conventional
medical ethics obscures
the ancient perception of
virtue in suffering and dying,
while bioethics creates the semblance
of ethical choice (e.g., the right to buy a kidney) in an intrinsically
unethical context. The transformation of a person into
a “life” that must be prolonged or saved at any cost has made life
into the ultimate commodity fetish. This idea erases any possibility
of a global social ethic.
In the rational choice language of contemporary bioethics the
conflict between non-malfeasance (“do no harm”) and beneficence
(the moral duty to perform good acts) is increasingly resolved in
favor of the libertarian and consumer-oriented principle that those
able to broker or buy a human organ should not be prevented from
doing so. In a market context, paying for a kidney “donation” is viewed
as a potential “win-win” situation that can benefit both parties.2
Individual decision making has become the final arbiter of medical
bioethical values. Social justice hardly figures into these discussions
because bioethical standards have been finely calibrated to
mesh with the needs and desires of consumer-oriented globalization.
The only dissident voices raised against the dominant transplant
narrative come from far afield and are expressed in unpalatable
forms that are all too easily discredited. These alternative bioThe
problem with markets
is that they reduce
everything—including
human beings, their labor,
and their reproductive
capacity—to the status of
commodities.
COMMODITY FETISHISM AND THE GLOBAL TRAFFIC IN ORGANS 63
ethical positions have been expressed, perhaps somewhat “primitively,”
in the context of the discourse of organ theft that represents
the underlying fears of the poor and other socially
marginalized groups. To a great many of those living on the fringes
of the new global disorder, the scramble for “fresh” organs and tissues
increases their profound sense of ontological insecurity in a
world that values their bodies as a reservoir of spare parts.3
The
rumors of blood and body parts theft have provoked strong popular
resistance to new laws of presumed consent recently passed in
such countries as Brazil and Mexico. Opponents of presumed consent
laws contest the state’s right to claim dead bodies for organs
and tissues harvesting. Yet their limited resistance is unable to forestall
the rapid growth of the international organs market as those
on both sides of the transplant equation are beginning to accept
these still largely covert transactions, protected by transplant
medicine’s coyly averted gaze.
Organs Watch: Uncovering the Hidden Dimensions
of Organ Transplant Rhetoric and Practices
Organs Watch, a medical human rights group affiliated with the
University of California, Berkeley, monitors the trade in organs
with a view toward advancing social justice concerns in the organs
market. From this base—and with the assistance of a small group
of anthropology, law, journalism, and medical student interns, volunteers,
and local field assistants—the group conducts basic ethnographic
research on transplantation practices worldwide and is
mapping the mechanics of the organs market. Above all, Organs
Watch attempts to make public and transparent all practices regarding
the harvesting and distribution of human body parts.
Until now, these transactions have been protected from scrutiny
because the population of organ suppliers—both living and brain
dead—is largely poor and socially marginalized.
Organ Watch’s first task has been to raise some basic but
necessary questions: How does the organ market function? Whose
needs are privileged? Whose voices are silenced? What invisible sacrifices
are being demanded? What “noble lies” are concealed in the
transplant rhetoric of gifting, scarcities, and needs? In answering
these questions, three crucial points about the organs trade
emerge. The first is about invented scarcities and artificial needs
despite the widespread fetishization of organs. Supply and demand
for organs has, however, increasingly evolved toward the trade in
64 SAIS Review WINTER–SPRING 2002
“fresh” body parts, which has sustained the rapid growth of “medical
tourism” as well as “biopiracy.” The second concerns altruism
versus invisible sacrifice in the new global markets for bodies and
“fresh” organs. The third point concerns surplus empathy and the
relative visibility of two distinct populations—excluded and invisible
organs givers and included and highly visible organs receivers.
The Body and Commodity Fetishism
Global market capitalism, together with advanced medical and biotechnologies,
has incited new tastes and desires for the skin, bones,
blood, organs, tissues, marrow, and reproductive and genetic material
of others. There now exists an unregulated, international,
multi-million dollar business in tissues and body parts, obtained
in many parts of the world without consent from police mortuaries
or hospital morgues.
In many developing countries, human tissue is exchanged
with first-world countries for medical technology or expertise. In
South Africa, for example, an experimental research science unit
of a large public medical school ships human heart valves, taken
without consent from the cadavers of poor Blacks in police mortuaries,
to medical centers in Germany and Austria. The exorbitant
“handling” fees they charge for supplying such valuable body parts
helps support the unit’s research program in the face of the
downsizing of advanced medical research facilities in the new
South Africa.
As commercialization has entered almost every sphere of
medicine and biotechnology, those in the North cannot claim any
moral highground. Mortuary practices and tissues harvesting resemble
a kind of human strip farming in some parts of the United
States. Heart valves, cornea, skin grafts, bone fragments, and other
body parts are used for research, teaching, and experimentation as
much as for advanced surgeries. “Excess” cornea are shipped in
bulk from the United States to other countries, including developing
countries, enabling sellers to reap enormous profits from the
handling charges reported as legitimate sales.
The sale of human organs and tissues has resulted in certain
disadvantaged individuals, populations, and even nations being
reduced to the role of “suppliers.” It is a scenario in which bodies
are broken, transported, processed, and sold in the interests of a
more socially advantaged population of organs and tissues receivers.
Desperation on both sides and the willingness of both trans-
COMMODITY FETISHISM AND THE GLOBAL TRAFFIC IN ORGANS 65
plant doctors and their patients to see only one side of the transplant
equation allows the commodified and fetishized kidney to
become an organ of opportunity for the buyer and an organ of last
resort for the seller. The policy among kidney transplant doctors
in the United States might best be described as “don’t ask, don’t
tell.” This also might be called neocannibalism.
In the United States, for instance, organs brokers like “Livers-4-You”
advertise freely on the Internet:
Want a living donor next week, or a morgue organ in five years?
We are a new organization with a New York City phone number
and unique in locating the overseas pathway for those waiting too
long for a transplant.
This group states that it has “joined with medical professionals in
the Philippines (and other as yet undesignated countries) to help
‘fill the gap’ between the supply and demand for organs.” For those
nervous about traveling to a developing country for transplant
surgery, the website notes that medical schools in the Philippines
are “carbon copies” of U.S. schools and that Philippine transplant
surgeons are trained in the United States. Those in doubt about
the quality of medical care in the Philippines are told to contact
the U.S. consulate in Manila, the Manila office of multinational
corporations, or the Catholic Church in Manila. All will provide
positive references on the practice of transplant surgery in the Philippines.
The only glitch is that the cost for a live donor is “higher
than for a cadaver.” Overall though, the cost is still about half the
current cost of transplant in the United States. The payment mechanics—through
bank wire transfers—are handled by the Livers-
4-You online staff. Medical arrangements are handled by the
organization’s head surgeon, who is a U.S.-trained and licensed
doctor who has “done many operations in the United States.”
Transplant procedures are astronomically expensive (in the
United States a heart transplant costs more than $300,000) and
are frequently hindered by unremitting shortages in organs. The
media, prompted by organs procurement organizations, produce
frequent references to the number of people who will die each year
waiting for an organ. In the United States over 70,000 people appear
on organs waiting lists. Every year the demand for organs increases
as transplant organizations, transplant professionals, and
patients’ rights groups demand that new categories of people become
eligible for organ transplants. For example, at their annual
meetings in Leiden, the Netherlands, in September 2000, members
66 SAIS Review WINTER–SPRING 2002
of Eurotransplant supported new experiments that expanded
transplant waiting lists to include the medical margins—those over
70 years, infants, those with hepatitis C and HIV seropositivity, and
those proven to be immunilogically prone to organ rejection. There
was no acknowledgement that these experiments would inflate the
demand for organs and promote the development of desperate
means, including the black market, to obtain them. Instead, these
experiments were defended as a democratic gesture and a service
to those potential transplant consumers demanding the right to
any and all advanced medical procedures now available.
Biopolitics: Race, Class, and
Ethnicity in Organs Procurement
There is little consciousness of the vulnerability of some social
classes and ethnic groups who can be described as the “designated
donor” populations. In the United States, this group is disproportionately
poor—including whites, Latinos, and African Americans.
The poor are over-represented in the intensive care centers (ICUs)
of large urban hospitals, due to their disproportionate exposure
to urban violence, the higher rates of suicide and vehicular death
in their communities, and the cumulative effects of societal and
medical neglect.
The great irony is
that those lacking
public insurance
(44 million citizens)
also comprise
the greatest number
of those whose
family members
are asked to be altruistic and voluntarily donate the organs and
tissues of loved ones. That a great many of these families refuse
to donate should come as no surprise. They are being asked to give
organs to support a social and medical system that excludes them
and within which they would have a lower probability of receiving
an organ, should that need arise. One needs to be relatively affluent
and otherwise healthy and well looked after to be recommended
for organ transplant. Widespread refusal to donate among
poor Latino and African Americans is a political act of considered
resistance.
Meanwhile, across the globe, medical human rights workers
in the West Bank complained of gross violations of Palestinian
Widespread refusal to donate
among poor Latino and African
Americans is a political act of
considered resistance.
COMMODITY FETISHISM AND THE GLOBAL TRAFFIC IN ORGANS 67
bodies by Israeli pathologists at the National Legal Medical Institute
in Tel Aviv. An official investigation committee appointed by
the Minister of Health confirmed the suspicions of Palestinian
health workers. The harvested organs and tissues were sold by the
Institute to hospitals and medical centers for surgical procedures,
research, and medical teaching. A special “squad” of surgeons on
military reserve duty performs the harvesting. This practice was
established by the head of the national skin bank, who was formerly
also Chief Medical Officer of the Israeli Defense Forces. Relying
on “presumed consent” the staff of the Forensic Institute and
the surgeons who illegally harvested skin and organs said that they
believed they were helping to save lives, and that this was more
important than trying to procure the consent of ill-informed and
grieving family members. As elsewhere, tissues and organs were
regarded as mere detachable objects that could be transformed into
something valuable. Some bodies were, however, exempt from this
practice, namely the bodies of Israeli soldiers, which are returned
intact to their families for burial.
Invented Scarcities—The Slide to Living Organ
Donation and Medical Tourism
Sadly, however, the discourse on scarcity conceals the actual existence
of excess and wasted organs that end up in hospital
dumpsters on a daily basis throughout those parts of the world
where the necessary infrastructure to use them is lacking. Indeed,
the ill will and competitiveness of some hospital workers and medical
professionals also contributes to the production of organ “wastage.”
For example, transplant coordinators in public hospitals in
many developing countries are often told to dispose of usable organs
rather than allow the competition to “get their hands on
them.”
The very idea of organ “scarcity” is what Ivan Illich would call
an artificially created need, invented by transplant technicians and
dangled before the eyes of an ever-expanding sick, aging, and dying
population. The resulting artificially created organs scarcity is
“misrecognized” as a natural medical phenomenon.4
In this environment
of “survivalist” utilitarian pragmatics, the ethics of transplantation
is modeled after classical “lifeboat” ethics.5
With ethical
presumptions of scarcity, there appears to be clear choices to
be made, namely who gets into the lifeboat (“getting on the waiting
list”); who will be shoved off the boat when it gets overcrowded
(getting triaged while on the waiting list); and who will, in the end,
68 SAIS Review WINTER–SPRING 2002
be “eaten” so that others may live (race and class disparities in organs
procurement and distribution practices).
A new kind of organ trade has emerged out of the global
economy: transplant tourism. Along with it, a group of self-defined
transplant outlaws—doctors, patients, brokers, and kidney sellers—
has emerged. They short-circuit national waiting lists and make a
mockery of national and international codes of ethics prohibiting
the sale of organs, from either living or dead donors. The key actors
are a new class of entrepreneurial organs brokers, who take
advantage of questionable organs scarcity panics and the desperation
of both the organs buyers and the organs sellers. The sellers
are recruited from populations that are suffering from economic
transitions. These include displaced rural populations, guest workers,
refugees, and young soldiers.
Supplying the Market Through Biopiracy: Tissues
Procurement Practices
Drawing on widely sited ethnographic field research, Organs
Watch has investigated international organs buying, selling, and
transplantation in an effort to document the impact of the organs
market on the bodies of some of the most vulnerable citizens of
the new world order. Organs Watch researchers have followed
transplant patients from dialysis clinics to meetings with brokers
in suburban shopping malls, and into illicit surgeries. They have
also visited the township shabeens, squatter camps, and city jails
where people are most likely to sell their organs, sometimes in “organs
motels” inside private hospitals. They have seen dead bodies
flow from hospital morgues and police mortuaries to the issue
banks and biotech companies where their parts are harvested and
processed—often for sale. All of this field research confirms the
existence of a new form of “apartheid medicine” that privileges one
class of patients, organ recipients, over another class of unrecognized
“patients,” organ donors, about whom almost nothing is known.
In its odd juxtapositions of ethnography, documentation,
surveillance, and human rights work, the Organs Watch project
blends genres and transgresses old distinctions between anthropology,
political journalism, scientific report, moral philosophy, and
human rights advocacy. More than any other discipline, however,
anthropology is best suited to investigate values and practices from
a position of epistemological openness and to offer alternatives to
the limited pragmatic utilitarianism that dominates medical bioethical
thinking today.
COMMODITY FETISHISM AND THE GLOBAL TRAFFIC IN ORGANS 69
Brazil: Organ Theft
The spread of biopiracy has affected many in the developing world,
whose plight is often the result of the medical establishment’s
complicity in the illegal organ trafficking. For example, during the
summer of 1998 Laudiceia Cristina da Silva, a young mother and
office receptionist in Sao Paolo, filed a formal denuncia—a complaint—requesting
a criminal
investigation of the
large teaching hospital
where, a year earlier, during
a routine operation to
remove an ovarian cyst she
had “lost” a kidney as well.
The “missing kidney” was discovered soon after the operation by
the woman’s family doctor during a follow-up examination.
Laudiceia was continuing to experience excruciating pain and
changes in her urination. Her doctor was suspicious of the large
surgical scar and ordered a sonogram.
When confronted with the information, the hospital representative
told a highly improbable story—that Laudiceia’s missing
kidney was embedded in the large “mass” that had accumulated
around her ovarian cyst, and was removed with it. But the hospital
refused to produce their medical records or the evidence. The
diseased ovary and the kidney had been “discarded,” she was told,
and her medical records had been temporarily misplaced. Laudiceia
and her family doctor are convinced that her kidney was taken to
serve the needs of another, wealthier patient in the same hospital.
To make matters worse, the young woman’s only brother had been
killed in a random act of urban violence several weeks earlier, and
the family arrived at the hospital too late to stop organ retrieval.
Brazil’s new “presumed consent” law, which has since been revoked,
allowed doctors to remove organs unless the individual had
gone to a civil registry office and had a declaration stating “I am
Not A Tissues or Organs Donor” stamped on his official identification
papers. “Poor people like ourselves are losing our organs to
the state, one by one,” Laudiceia complained angrily.6
Laudiceia’s
legal case is now “in process” and will most likely be resolved, as
many of these cases are, out of court. If so, the young woman will
not be allowed to discuss her case any further.
Neither is there a lack of desperate people willing to sell a
kidney for a pittance—as little as $1,000. Many of them wait outDuring
a routine operation to
remove an ovarian cyst she
had “lost” a kidney as well.
70 SAIS Review WINTER–SPRING 2002
side transplant units or in special wards of surgical units reserved for
them, in places like India, Iraq, Moldova, the Philippines, and Turkey,
begging to be considered and hoping for a good match with a
prospective buyer. In general, the circulation of organs flows from
South to North, from poorer to more affluent bodies, from black and
brown bodies to white ones, and from females to males. Entire regions
are known in the transplant world as “kidney belts” because
so many who live there are willing to sell their “extra” kidney.
India: The Right to Sell?
Across the globe during the summer of 1999, Lawrence Cohen sat
in a one-room flat in a municipal housing project in a Chennai
slum in South India talking with several local women, each of
whom had sold a kidney for about $1,000. Each had undergone
her kidney removal at the clinic of Dr. K. C. Reddy, India’s most
outspoken advocate of the individual’s “right to sell” a kidney. The
women Cohen interviewed
were primarily
low-paid domestic
workers with husbands
in debt. The
kidney sale was usually
preceded by a financial
crisis: the
family had run out of
credit and the bill collectors were at the door. The women said that
the money from selling their kidneys had offered temporary relief
but that it was soon swallowed up by the usurious interest charged
by local moneylenders. The families were all in debt again. They
also stated emphatically that they would do it again. If only they
had three kidneys, with two to spare, then things might be better.7
A decade ago, when townspeople first heard through newspaper
reports of kidney sales occurring in the cities of Bombay and
Madras, they responded with predictable alarm. Now, Cohen says,
some of these same people speak as matter of fact about when it
might be necessary to sell a “spare” organ. Globalization has encouraged
the development of new forms of “debt peonage” in
which the commodified and fetishized kidney occupies a critical
role as collateral. Today the spare kidney represents everyman’s last
economic resort, one’s ultimate collateral.
If only they had three kidneys,
with two to spare, then things
might be better.
7
COMMODITY FETISHISM AND THE GLOBAL TRAFFIC IN ORGANS 71
Argentina: Targeting the mentally ill
One place where Organs Watch found social justice lacking in the
organs harvesting process was Argentina. In January 2000, the
group conducted an undercover visit to the Montes de Oca state
mental asylum to investigate reports of blood, tissue, and organ
stealing from the bodies of mentally retarded, but otherwise physically
healthy, inmates. Reports of illicit organs trafficking surfaced
during the early 1990s in respected medical journals, as well as in
the popular press. A court-ordered investigation of the grounds of
the asylum by members of Argentina’s celebrated anthropological
forensic team recovered the bodies of several “unidentified” patients
from a swamp and a water tower on the grounds of the asylum.
The causes of death were never determined and the bodies
were too decomposed to verify whether they had been tampered
with. “The fact is,” said Alejandro Inchaurregui, a member of the
forensic team, during a visit to his Missing Persons Bureau in the
Police Station of La Plata, “nobody really cares about the bodies
of those who are abandoned [at the mental asylum] and left to the
care of the state.”8
Montes de Oca remains a frightening place. The asylum is
grossly understaffed, and the inmates, many naked and almost all
emaciated, wander the asylum grounds unsupervised. A night
nurse and ward supervisor interviewed later at her home explained
that hospital staff members commonly take blood from living inmates
and remove cornea from the deceased, almost always without
consent. She described these practices as a “payback” for the
inmates’ care at the state’s expense. “Isn’t that the way it is done
everywhere?”9
These horrific stories, which are far from unique, highlight
the need to bring social justice concerns to bear on global practices
of organ harvesting and distribution. Transplant surgery is
the most social practice of medicine and as such is particularly
dependent on trust within the medical community.
Growing Demand for Live Organ Donation and the Rise of
Medical Tourism
The real scarcity in organs transplant is of patients of sufficient
economic means to pay for these expensive operations. Hence the
paradox of U.S. transplant centers actively recruiting wealthy foreign
patients, so-called “medical tourists,” to receive organs that
72 SAIS Review WINTER–SPRING 2002
are otherwise described as painfully scarce.10
The University of
Maryland Medical Center, for example, advertises its kidney transplant
program in Arabic, Chinese, Hebrew, and Japanese on its
website.11
The United States is extremely democratic in at least one
sense—anyone, regardless where they come from, with enough cash
can become a “medical citizen” of the United States and receive a
bonafide “Made in the USA” organ.
The idea of the organ as fetish conjures up the magical energy
that is invested in the “fresh” organ purchased from a living
donor. Averham, a 71 year old kidney buyer who flew from Jerusalem
to Georgia in Eastern Europe where he purchased a kidney
from a young peasant, explained to me why he would never tolerate
a cadaveric kidney: “That kidney is practically dead. It was probably
pinned down under the wheels of a car for several hours and
then it was put on ice for another several hours. Then you expect
it to go right back to work for me? It’s really disgusting to think
about putting that dead man’s organ inside you. So I chose a better
way. I was able to see my donor [in a small town in Eastern Europe].
He was young, strong, healthy. Just what I was hoping for.”
As Averham’s preferences show, cadaver organs are no longer
the primary organs of desire. In the last decade, there has been a
dramatic shift worldwide toward the procurement and use of organs
from living donors who can give one kidney, half a liver, or
the lobe of one lung. The move to living organ donation is seen as
the only solution to the chronic scarcity of organs for transplant
and a means to increase the viability and longevity of transplanted
organs. In the United Sates live donor kidney transplants account
for 50 percent of all transplants, and live donor liver transplants
for 10 percent.12
Similarly, in Israel, an experimental program of
live, unrelated kidney donation was established to screen and select
purely “altruistic” donors. But the head of the screening committee
stated that: “Of the 40-some applications we reviewed and
approved, it is possible that two were truly altruistic. All the others
were paid.”
Israel, for example, is a major player in the global market for
organs; its citizens purchase, proportionally, the largest number
of organs in the global market. Caught between a highly educated
and medically conscious public and a very low rate of organ donation,
only 7 percent of the population was registered in 1996 as
“card-carrying” donors in contrast with 20 to 30 percent in the
United States and most of Western Europe. As a result, the Israeli
Ministry of Health has permitted the expansion of transplant tour-
COMMODITY FETISHISM AND THE GLOBAL TRAFFIC IN ORGANS 73
ism. But the Israeli market operates in one direction only and no
organs are sold from Israel to the global market.
The business of transplant tourism in Israel is fairly transparent
and organized through a local business corporation in conjunction
with a leading transplant surgeon, Dr. Zaki Shapira from
Bellinson Medical Center near Tel Aviv. The “company” has developed
links with transplant surgeons in Turkey, Russia, Moldavia,
Estonia, Georgia, Romania, and (most recently) the United States.
The cost of the transplant “package” increased from $120,000 in
1998 to $200,000 in 2001. With pressure from transplant candidates
to develop links in more developed countries, the cost is still
rising. The covert operation (in both senses of the term) is accomplished
in five days. On the first day, the patients rest and undergo
a dialysis. The operations take place on the second and third days.
Depending on the size of the group, doctors will perform two to
three operations per night. On days four and five, the patients recover
on site and then fly home. The transplant “package” covers
the rental of a private plane, which accommodates six patients,
each of whom can be accompanied by a family member, the Israeli
doctors, and the business coordinator. The cost also includes the
“double operation” (kidney extraction and kidney transplant), the
“fees” paid to bribe airport and customs officials, the rental of private
operating and recovery rooms, and hotel accommodations for
accompanying family members. The donor fee is also included but
the donor is paid no more than $5,000, and most of the donors
from rural Eastern Europe are paid less than $3,000.
The specific sites of the illicit surgeries are normally kept secret
from transplant patients until the day of travel. Meanwhile,
the locations are continually rotated to maintain a low profile. The
surgeries are performed between midnight and the early morning
hours. In a common scenario, Israeli patients and doctors (a surgeon
and a nephrologist) fly to a small town in Turkey on the Iraqi
border, where the kidney sellers are often young Iraqi soldiers or
guest workers. In another scenario, the Israeli and Turkish doctors
travel to a third site in Eastern Europe, where the organ sellers are
unemployed locals or guest workers from elsewhere.
The refusal of the Ministry of Health to crack down on this
multi-million dollar business, which is making Israel something
of a pariah in the international transplant world, requires some
explanation. In the absence of a strong culture of organ donation
and under the pressure of angry transplant candidates, each person
transplanted abroad is one less demanding and angry client
74 SAIS Review WINTER–SPRING 2002
with which to contend. More troubling is the support and involvement
of the Ministry of Defense in the illicit transplant tourism.
Patients who traveled on the outlaw Israeli transplant junkets to
Turkey and Eastern Europe noted the presence of members of the
military among the organized groups of patients.
Transplant surgery has reconceptualized social relations between
self and other, individual and society, and among the “three
bodies”—the existential live body-self; the social, representational
body; and the body politic.13
Throughout these radical transformations,
the voice of anthropology has been muted while the highstake
debates have been waged among surgeons, bioethicists, international
lawyers, and economists.
The spread of new medical technologies and the artificial
needs, scarcities, and the new commodities (i.e., fresh organs and
tissues) that they demand raises urgent public issues concerning
the emergence of new forms of barter and social exchange that
breach the conventional dichotomy between gifts and commodities
and between kin and strangers.
The Lie Behind the Demand for Donor Altruism
The language of organ donation, which stresses altruism and benevolence,
both obscures and contributes to the social inequalities
of the larger medical system. Organ transplantation is, as Renee
Fox so famously put it, both life-saving and death-ridden. Under
traditional cadaver donation, the “gift” of life simultaneously demands
a “gift of death.” It demands that grieving family members
readily accept “brain death” as the end of the life of a loved one. To
this day, brain death is not recognized by a great many people, including
many intensive care workers who express profound misgivings
about the “real” ontological status of their brain dead patients.14
The director of a private eye bank in Pretoria, South Africa,
complained that the American company that sold his private institution
corneas charged exorbitant prices—up to $1,000 per cornea.
“Where do all these ‘excess cornea’ come from in the United
States?” The answer is that they are procured from naive donors who
believe their “gifts” are being used to heal and comfort burn victims.
One unethical aspect of the organs market is that organs solicitors
commonly deceive people in times of grief, asking them to
perform acts of mercy and altruism by donating the organs of a
deceased loved one. This is what happened to Linda JohnsonSchuringa,
a middle class woman from Orange, California. She put
COMMODITY FETISHISM AND THE GLOBAL TRAFFIC IN ORGANS 75
her late husband’s body into the care of the Orange County Eye
and Tissue Bank, believing that his tissues and bone would alleviate
the suffering of another person. Several months later she
learned through an investigative reporter that the “gift” of her
husband’s bones had been shipped to Germany where they were
“processed” into a dental product and sold internationally. Ms.
Johnson-Schurninga still believes in organs and tissues donation
but she wants the consent forms to explain that some or all parts
of the donated body parts may be sold to biotech firms and processed
into commercial products.15
Organs and tissue donors—both living and dead—are treated
not as people, but as suppliers of the organic medical material
needed for research, experimentation, and advanced medical technologies.
Prof. Johan Brink, of Goorte-Schuur hospital at the University
of Cape Town, South
Africa, and currently head of
the South African Transplantation
Society, explained that
during the apartheid years,
transplant professionals simply
took the organs they
needed from the bodies of
black, brain dead patients in
the Intensive Care Unit without seeking the consent of their family
members. These organs were destined for transplant into the
bodies of privileged white patients: “The surgeons were from conservative
backgrounds and they followed a rural Christian family
ethic. The idea of ‘wasting’ a good organ was sinful to them, like
wasting a good piece of bread.”16
Surplus empathy
Dialysis and transplant patients are highly visible and their stories
are frequently reported by the media. We can see and hear their
pain and suffering. But while there is empathy—even a kind of surplus
empathy for transplant patients, there is an absence of empathy
for both living and dead organ and tissue donors. Their suffering,
for the most part, is hidden from the general public.
Few organ recipients know anything about the impact of
transplant procedures on the donor’s body. They recognize, of
course, that their good fortune comes out of the tragedy of another,
and they pass along the transplant folklore of the permissible guilt
The idea of ‘wasting’ a
good organ was sinful to
them, like wasting a good
piece of bread.”
16
76 SAIS Review WINTER–SPRING 2002
and glee they experience on rainy nights when traffic accidents
arise. Donor anonymity prevents contact between donors and recipients,
though transplant patients often do try to learn something
about their donors, whether they were living or dead. They
are never privy, however, to the secret negotiations involving occasional
psychological manipulation of the donor’s family members
while they are grieving deeply.
Yet there is hardly any mention of the medical, social, and
psychological complications donors often suffer from. For instance,
at least two kidney donors have died during the past 18
months and another is in a persistent vegetative state as a result
of donation.17
The fact that many living donors have either died
immediately following the surgical procedure, or are themselves in
dire need of a kidney transplant at a later date sounds a cautionary
note about living donation and serves as a reminder that nephrectomy
is not a risk free procedure.18
Most recently, Organs Watch research in Moldova in December
2001 was able to document the ill health, social disability, and
subsequent unemployment faced by young male kidney sellers who
return to their natal villages to find that they can no longer sustain
the demands of heavy agricultural or construction work, the
only paid labor that s available to men of their backgrounds. Not
one of the kidney sellers had seen a doctor or been treated at a
medical clinic following their illicit operations in Istanbul. More
telling Organs Watch had to coax the young men to agree to a basic
clinical exam and sonogram at the expense of the organization.
Some said they were ashamed to appear in a public clinic as they
had tried to keep the sale a secret; others said they were too fearful
of learning negative results from the tests. All said that if serious
medical problems were discovered they were unable to pay for
follow-up treatments or necessary medications. Above all, they said
they feared being labeled as “weak” or “disabled” by employers and
co-workers, as well as (for single men) by potential girlfriends and
brides. “No young woman in the village will marry a man with the
tell-tale scar of a kidney seller,” the father of a village kidney seller
said sadly. “They believe that he will be unable to support a family.
Meanwhile, organs brokers, like any other brokers, try to keep
organs buyers and sellers apart. But even when live donation is
transacted within families, recipients can be protected from knowing
the human cost of donation. If the medical and psychological
risks, pressures, and constraints on organ donors and their families
were more generally known, potential transplant recipients
COMMODITY FETISHISM AND THE GLOBAL TRAFFIC IN ORGANS 77
might want to consider opting out of procedures that demand so
much of the donor.
Can the language of gifting, of life saving, of altruism, or of
scarcity and need be maintained in the face of the new economic
climate? Not so long ago any mention of payment for organs and
tissues was rejected. Today bioethicists and transplant specialists
in many parts of the world, including the United States, are actively
exploring ways to promote a blended system in which altruism and
commercialism, science and sentiment, love and profit, gift and
commodity can coexist. The American Medical Association’s proposals
for a “futures market” in cadaveric organs are just one example.
Serious proposals to expand paid-for organs donation are
on the table. At present, Congress is reviewing several new proposals
to reform organ donation, including one that would allow
transplant coordinators to offer a “gratuity” to relatives at the bedside
of a dying or brain dead patient. Another proposal seeks tax
credits for organs donation. A great many bioethicists, religious
leaders, social scientists, and transplant specialists are now leaning
toward the individual’s “right to sell.”
So, What’s Wrong with Selling an Organ?
If a living donor can do without an organ, why shouldn’t the donor profit
and medical science benefit?19
In the developing world, poor people cannot really “do without”
their “extra” organs. Transplant surgeons have disseminated an
untested hypothesis of “risk-free” live donation in the absence of
any published, longitudinal studies of the effects of organ removal
on the poor. Organs
Watch has found that
living kidney donors
from shantytowns, inner
cities, or prisons
face extraordinary threats
to their health and personal
security through violence, accidents, and infectious disease
that can all too readily compromise their remaining kidney. As the
use of live kidney donors has moved from the industrialized West,
where it takes place among kin and under highly privileged circumstances,
to areas of high risk in the developing world, transplant
surgeons have become complicit in the needless suffering of a hidden
population.
In the developing world, poor
people cannot really “do without”
their “extra” organs.
78 SAIS Review WINTER–SPRING 2002
In all these transactions, the body, as we know it, is radically
transformed. The integration of the body and its parts as naturally
given is exchanged for a divisible body in which individual organs
and tissues can be detached, isolated, and sold. This juncture
points to the demise of classical humanism and holism and to the
rise of what Lawrence Cohen refers to as “an ethics of parts”—part
histories, part truths, and now, it seems, divisible bodies in which
detached organs emerge as market commodities, as fetishized objects
of desire and consumption.
Bioethical arguments about the right to sell an organ or other
body part are based on Western notions of contract and individual
“choice.” But the social and economic contexts that make the
“choice” to sell a kidney in an urban slum of Calcutta, a Brazilian
favela, or a Filippine shantytown is anything but a “free” and “autonomous”
one. The idea of consent is problematic when one has
no other option but to sell an organ.
Putting a market price on body parts—even a fair one—exploits
the desperation of the poor, turning their suffering into an
opportunity. Asking the law to negotiate a fair price for a live human
kidney goes against everything that contract theory stands for.
When concepts like individual agency and autonomy are invoked
in defending the “right” to sell an organ, anthropologists might
suggest that certain “living” things are not alienable or proper candidates
for commodification. And the surgical removal of non-renewable
organs is an act in which medical practitioners, given their
ethical standards, should not be asked to participate. The argument
for regulation is out of touch with the social and medical
realities operating in many parts of the world but especially in developing
nations. The medical institutions created to “monitor”
organs harvesting and distribution are often dysfunctional, corrupt,
or compromised by the power of organs markets and the
impunity of the organs brokers and of outlaw surgeons willing to
violate the first premise of classical medical bioethics: above all,
do no harm.
Amidst the tension between organ-givers and organ-recipients,
between doctors and patients, between North and South, between
individuals and the state, between the illegal and the
“merely” unethical, clarity is needed about whose values and whose
notions of the body and embodiment are being represented. In
fact, the values of bodily integrity and dignity are more widespread
in the poorer parts of the world than they are in the more affluent
and more secular parts. The values of bodily integrity and dig-
COMMODITY FETISHISM AND THE GLOBAL TRAFFIC IN ORGANS 79
nity lie behind “First Peoples” demands for the repatriation and
reburial of human remains warehoused in museum archives. They
lie behind the demands of the wretchedly poor for dignified death
and burial.20
And they certainly lie behind rumors of organ theft
and popular resistance to presumed consent laws.
Organs Watch wants to make sure that that trust is not broken
by aggressive doctors who are acting as organs brokers, and
by a ruthless pursuit of purchased organs that exploits the poverty
and the desperation of newly displaced populations searching
for a niche in the global economy via the grotesque market in fresh
organs. Transplant surgeons must pay more attention to where
organs come from and the manner in which they are procured.
There must be firm assurances that organ donation everywhere is
voluntary and uncoerced. Finally, the risks and benefits of organ
transplantation need to be more equally distributed among and
within nations, ethnic groups, genders, and social classes. The division
of the world into organ buyers and organ sellers is a medical,
social, and moral tragedy of immense and not yet fully recognized
proportions.
Notes
1
“Offering Money for Organ Donation Ethical, HHS Committee Says,” AP/
Nando Times, 3 December 2001.
2
Radcliffe-Richards J., Daar A., Guttmann R., et al., “The case for allowing
kidney sales,” Lancet 351 no. 9120 (1998):1950–2.
3
Nancy Scheper-Hughes, “Theft of Life: Globalization of Organ Stealing
Rumors,” Anthropology Today 12, no. 3 (1996): 3–11.
4
Pierre Bourdieu, Outline of a Theory of Practice (Cambridge University Press,
1977).
5
Tom Koch, Scarce Goods: Justice, Fairness and Organ Transplantation (Westport,
CT: Praeger, 2001, in press).
6
Interview by author.
7
Arthur Max, “Stolen Kidneys Supplying India’s Transplant Industry,” San
Fransisco Chronicle, April 1995; “Researchers to Monitor Trade in Human
Organs,” New York Times, 5 November 1999, A23.
8
Interview by author.
9
Interview by author.
10
The United Network for Organ Sharing (UNOS) allows 5 percent of organ
transplants in U.S. transplant centers to be allotted to foreign patients. However,
only those centers reporting more than 15 percent foreign transplant surgery
patients are audited.
11
See, for example, the arabic (as well as Hebrew and Japanese) version of the
university’s advertisement, <http://www.umm.edu/transplant/arabic.html>
80 SAIS Review WINTER–SPRING 2002
12
Frank Demonico, Robert Arnof, Nancy Scheper-Hughes, et al., “Organ
Donation by Ethical Incentives—Not by Sales,” New England Journal of Medicine
(2001) in press.
13
See Nancy Scheper-Hughes and Margaret Lock, “The Mindful Body: A
Prolegomenon to Future Work in Medical Anthropology,” Medical Anthropology
Quarterly 1, no. 1 (1984): 6–41.
14
see Margaret Lock, Twice Dead: Organ transplant and the Reinvention of Death
(Berkeley, California: University of California Press, 2001).
15
Interview by author.
16
Interview by author.
17
“Man keeps vigil for comatose wife who gave him kidney, life,” The Holland
Sentinel, 15 February 2001.
18
“The live donor consensus conference,” JAMA no. 284 (2000): 2919–2926.
19
Janet Radcliffe-Richards, et al., footnote no. 2.
20
Nancy Scheper-Hughes, Death Without Weeping: The Violence of Everyday Life in
Brazil (Berkeley: University of California Press, 1992), 249–264.