Strange Harvest. Lesley A. Sharp
2002; Shrader 1986). As she illustrates, this model of the double death, so to speak, is pervasive in transplant contexts: first declared brain dead, the organ donor later experiences biological death when his or her organs are removed during procurement surgery. As Lock demonstrates, historicized cross-cultural comparison proves especially helpful for underscoring that this is a Euro-American biomedical construction (or struggle). In contrast, in Japan, proponents of brain death criteria (and, thus, transplantation) have encountered especially hostile resistance from the lay public precisely because of the widespread understanding that the body houses an individual's spirit or essence, and to remove body parts (particularly the heart) threatens a spirit by trapping it in a dangerously liminal state between life and death (Lock 1995: 7). Unlike in the United States, where key legislation supporting organ transfer spans the 1960s to the 1980s, Japan's Organ Transplantation Law took effect only in 1997. In an effort to recognize a plurality of voices, this law (inspired by the “conscience clause” of New Jersey's Declaration of Death Act) allows self-designated donors to “choose between brain death and traditional death by writing their preference on their donor cards” (Morioka 2001). In essence, Japanese citizens can designate what form of death they consider legitimate. The Japanese public nevertheless remains skeptical of brain death and critical of transplantation in general (Lock 2002), which frustrates Japanese transplant surgeons, a few of whom may have received some training in American medical or research institutions.
In contrast, within North America (and, more particularly, the United States), brain death criteria overcame legal hurdles much earlier because of a more widespread acceptance of mind-body dualism, which stresses that the self resides in the mind. As Lock and Christina Honde (1990) illustrate, the arenas that circumscribe ethical debates over medical practices expose important cross-cultural differences. Whereas in the United States ethical discussions that shape transplant policy have involved overwhelmingly those working within the clinical realm, national health decisions in Japan are regularly subjected to heated debate in the larger public sphere.
In the United States, official medicolegal rhetoric precludes the possibility that one can die twice. As a result, challenges are quickly silenced, a phenomenon that is especially pronounced in the realm of organ transfer. Nevertheless, anthropologists have long known that normative assumptions are regularly accompanied by unconventional thoughts and actions. Anthropologists know, too, that cross-culturally there are many ways to die. As data from a range of societies attest, death is not understood universally as the moment when a person permanently loses consciousness, or has no pulse, or when a body turns cold and gray. Instead, death encompasses a range of other possibilities far less biologically deterministic in their outlook. Separating definitions of death per se from what are often extraordinarily complicated ritualized forms of mourning may be difficult (Bloch and Parry 1982; Metcalf and Huntington 1991).The cross-cultural perspective reveals the limitations of the clinical assertion that the threshold between life and death is clearly marked by the measurable cessation of brain or bodily functions. Rather, anthropologically speaking, death should be viewed more broadly as a social process that allows for the possibility that a person may gradually slip away.
This is, however, a dangerous assertion within the realm of organ transfer because it ultimately destabilizes a key component of transplant ideology. In official contexts—ranging from clinical to forensic—great care is taken to identify the exact moment when death occurs. More specifically in reference to organ donors, a shift to considering death as a gradual process would inevitably generate questions about how a donor died and, potentially, who might be responsible. Such questions would expose hospital, procurement, and transplant staff to relentless lawsuits driven by accusations that these professionals orchestrate the deaths of vulnerable patients under the guise of ICU care in anticipation of the subsequent surgical removal of vital organs.
Such accusations in fact shaped the first legislative initiatives generated as protective measures in response to early instances in which transplant surgeons faced criminal charges for murdering donors for their organs (Starzl 1992: 148). I regard as absurdly simplistic the assertion that organ procurement is a medically sanctioned form of murder. As an anthropologist, I am nevertheless intrigued by the paradoxes that arise in response to this particular form of hospital death. Among the most striking developments is the manner in which transplant ideology most certainly shapes sanctioned, public sentiments and actions. Thus, I have learned to listen carefully to what people express privately as their personal perceptions, and how these may at times coincide with, and at others challenge, medicolegal rhetoric specifically about brain death. What if, instead of insisting that death can (or must) be linked to a specific, timed event, we allow it to occur incrementally, its progress marked by discrete episodes detectible sometimes by clinical tests, and at others through heartfelt sentiments of love and loss? As I will show, if we indeed pay close attention to this seepage of covert sentiments, beliefs, and turns of phrase, we discover a wondrous counterreality to the official rhetoric and public face of organ transfer in America.
A MOST PECULIAR DEATH
A Brief History of Donation
Brain death is a truly peculiar category of human experience because its mere definition dictates that professional and lay parties alike must embrace medical criteria that contradict commonsense understandings of the evidence of life. Brain death was first supported by medical specialists who, by the 1960s, were increasingly confronted with the conundrum of dying patients who were nevertheless sustained artificially on respirators. Such specialists' recommendations later shaped federal policy and state-by-state legislative initiatives that render the practice of acquiring organs from patients diagnosed as “brain dead” both legally and socially acceptable. A relatively unchallenged opinion voiced within medical circles today is that brain death criteria were most certainly developed to produce a supply of transplantable organs (see, for instance, Cowan et al. 1987; Fox and Swazey 1978, 1992; Lock 2002; Starzl 1992; P. Young and Matta 2000).
The sanctioning of brain death criteria, alongside the surgical harvesting of organs, initiated a significant ideological shift in twentieth-century medicine. This shift is reflected quite clearly in the language offered by liver surgeon Thomas Starzl, who twenty years ago explained it thus in his memoir The Puzzle People: “With the wide acceptance of brain death in the Western world, all injured patients who come to the hospital in a helpless condition could have a fair trial at resuscitation. Then, in an orderly way, it can be determined whether these people already were dead but with functioning hearts and lungs, or if they had a chance of restoration of brain function. The quality of care and the discriminate application of such care to terribly damaged people was one of the great fringe benefits of transplantation” (1992: 148). Although Starzl's language may strike the reader as calculating or macabre, it nevertheless exposes a seasoned surgeon's willingness to speak frankly about the early years of transplantation. Among the most revealing developments is the manner in which ventilator use marks a clear watershed. Not only could this new technology sustain brain-damaged patients, but, when paired with cardiopulmonary resuscitation, the ventilator permitted health professionals to revive the dead, assess their subsequent status, and then, through an unusual form of triage, ultimately determine whether subsequent care should focus on healing or in preparation for organ procurement as yet another form of death. Although organ procurement is never described in these terms by involved professionals, such conditions have in fact become the mainstay of contemporary practices in the realm of organ transfer.
Thus, some patients might well be described as the “thrice dead” because they die, first, from a head injury, accompanied by cardiac and/or pulmonary crisis, only to be resuscitated by emergency medical technicians (EMTs) through CPR and then placed on a ventilator. These patients' second deaths, so to speak, occur when they are pronounced brain dead while still sustained by machines. The third (and final cardiac) death, or death of the body, occurs during procurement surgery. The importance of CPR was underscored by a statement made during an interview in 2003 with Octavia Zamora, who works for an organ procurement organization based in a western state. In Octavia's area, the speed limit had been raised from fifty-five to seventy-five miles per hour only a few years before we met; local EMTs linked subsequent drops in donation levels to the fact that victims of high-speed car accidents typically are so badly injured as to render CPR impossible. Under earlier limits of fifty-five miles per hour, there