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BOOK REVIEW

In with the New

Nancy Scheper-Hughes

Raising the Dead: Organ Transplants, Ethics, and Society. Ronald Munson. x + 288 pp. Oxford University Press, 2002. $30.

Organ transplantation is intensely social, depending for its very existence on a unique trust between society and physicians, and on the willingness of ordinary people to share their organs and tissues. The language of transplantation is thus highly idealistic and ethical; it is steeped in religious and cultural values of altruism, sacrifice and generosity, and in political notions of community, reciprocity, shared risk and social solidarity.

Underlying the beautiful rhetoric, however, are deep contradictions: Organ transplantation, as bioethicist Renée Fox has famously observed, is both lifesaving and death-ridden. The so-called gift of life most often demands a counter gift, a "gift of death" from the donor or his or her next of kin. The selfless generosity of the donor is matched by a necessary "selfishness" of the recipients, who speak unabashedly of their spirits and hopes rising when stormy weather bodes more traffic accidents. And behind the death-defying scenes of transplantation is a life-and-death struggle for scarce organs.

In recent years the gap between ideology and practice has widened: Tissues and organs can be bought and sold in various parts of the world; in the United States, amendments to the National Organ Transplant Act have been proposed to allow financial compensation for donors or their families; and inequities in access to transplantation medicine and in the regional distribution of organs have been revealed. The once seemingly settled issue of brain death is being debated anew. Recent experiments with artificial hearts have raised and then dashed hopes. Meanwhile, living donors have come to the fore as the best "last chance" for some patients, but excessive zeal in procuring kidneys and half livers from living sources has resulted in the unnecessary deaths of several donors, initiating a call for a national living donor registry to monitor health consequences and enforce mandatory reporting of complications.

Surgeons who perform transplantations often see themselves as embattled by overly cautious social norms that stand in the way of saving lives. Most would rather not have to consider where the organs they need come from or exactly how they were procured. "Doctors are not police," they are likely to say—or, when faced with ethical quandaries, "Let's let the philosophers figure that one out." But Aristotle and Aquinas are no longer with us. Instead, the new hybrid profession of bioethics has come to fill the role of moral guide and social conscience, with uneven and sometimes less-than-satisfying results.

Both the strengths and the weaknesses of bioethical reasoning are very much on display in Ronald Munson's Raising the Dead. On the one hand, Munson, a professor of the philosophy of science and medicine, is a realist about transplantation's benefits and limitations: It's "a second-rate technology," he says, which solves some problems while generating others. Life-threatening diseases are replaced by a new chronic illness requiring a rigorous, lifelong regimen of antirejection drugs, which have adverse effects. On the other hand, he is a somewhat starry-eyed believer in the unfulfilled promises of xenotransplantation (in which humans receive organs from other species) and stem-cell engineering.

Munson provides an accessible, if somewhat breezy, account of high and low points in the history of transplantation ethics and practice. His intended audience—"bakers and bricklayers" as well as "ethicists and attorneys"—is broad, and he does an excellent job of explaining in lay terms such technicalities as tissue matching and the difference between harvesting organs from a donor who is "brain dead" and taking them from one whose heart has stopped beating.

He addresses many moral quandaries: Is it right to give an alcoholic a new liver, or to experiment by transplanting a baboon heart into a human baby? Should a kidney be taken from a child or adult who is mentally unable to give informed consent to save the life of a "normal" sibling? Is it just for those without adequate medical insurance to be denied transplantation because they are unable to pay for expensive antirejection drugs, while rich, famous people jump to the head of the queue for organs? Should patients with money be permitted to buy the kidney they need from a poor person? Should waiting lists be governed by the principle of "first come, first served," or should organs be given to those most likely to survive or able to get the most mileage out of a transplant? Are xenotransplantation and embryonic stem cell research ethical? To bring these issues to life and make their policy implications clear, Munson refers both to real cases and to hypothetical scenarios (some bordering on science fiction).

The narratives are compelling; Munson certainly knows how to tell a good story. He conveys the drama of each case and summarizes succinctly the conflicting interests of the parties involved. Disappointingly, however, his discussions and analyses of ethics are often truncated and carried only in a final quip or "sound bite." For example, Munson provides a harrowing account of the controversial use of anencephalic neonates as organ donors, which involves removing them from life-support ventilators until their final vital signs fade so that they can be declared dead and then putting them back on ventilators to protect the organs until they can be harvested; he then notes that this procedure "saved the life of Paul Holc, who's now a teenager." And that, he concludes "should be recommendation enough for anybody."

This kind of reductionism is not really enough for either bricklayers or attorneys. The goal of saving an individual life has to be balanced against concern for the social good and the wish to preserve such basic values as justice, fairness, human dignity and bodily integrity.

The crux of the matter lies in Munson's humanistic personalism, his emphasis on the individual and his claim that "the thread that strings the chapters together is a concern for people." When moral dilemmas are individualized, one loses sight of the larger social frame and the extent to which some individuals (and social classes) are perhaps being valued at the expense of others. In Munson's analysis the donor is largely invisible; he focuses instead on organ recipients. Their medical needs are allowed to trump other people's squeamishness or ethical reservations—such as, for example, legitimate concerns about the alacrity required to procure organs from "nonheartbeating" donors at the moment the heart stops and respiration ceases, while the organs are still "fresh enough" to be used. Munson wrongly concludes that public misgivings about the use of such donors are based on a popular consensus that brain death is the only form of death appropriate for organ-harvesting. In fact, reservations concern whether adequate attempts are being made to restart the hearts of patients who are potential donors. Moreover, a great many people (including nurses, intensive care workers and grieving family members) are still not entirely comfortable with the idea of brain death.

Although Munson is quite concerned about the need to protect certain vulnerable people—especially those who are institutionalized because they're mentally impaired—from becoming "living organ donors of last resort," he is not nearly so bothered by those who might be forced to sell a kidney or a part of their liver to survive. Indeed, the chapter on kidney selling is particularly weak. Rather than relying on a real medical case (of which thousands now exist worldwide, some in North America), Munson creates a highly improbable scenario in which donor and recipient are very much alike. But the people who sell kidneys are very much unlike the people who buy them. Sellers, many of whom are socially marginal and politically vulnerable, include beggars, debtors, shantytown dwellers, undocumented foreign workers, soldiers who are absent without leave, former prisoners, the homeless and the hungry. Those not driven by desperation are often tricked and sometimes coerced into selling their kidneys and livers. Most lack access to medical treatment and follow-up care, and the majority suffer after the surgery from untreated physical, social and psychological complications, including pain, weakness, depression and an inability to work. The "win-win" scenario suggested by those who, like Munson, favor the right to buy or sell an organ is inaccurate; the hard truth is that, as David Rothman observed in the October 2, 2002, issue of the Journal of the American Medical Association, "For everyone except recipients, commerce in organs is a dead-end proposition."

Munson seems similarly unconcerned about the class inequities that lead to wealthy patients easily getting the organs they need while others languish on waiting lists. In reviewing, for example, all the possible reasons why Mickey Mantle got a liver (which, sadly, did not save his life) less than 48 hours after his name was posted on the United Network for Organ Sharing waiting list, Munson gives "the system" the benefit of the doubt. The rules were followed, and he concludes that "Equating Mantle's short wait with favoritism because of his celebrity status has no discernible basis in fact. While Mantle was famous and rich, it was need and luck that got him a new liver so quickly." That and, I would add, the built-in social inequities of a regionalized system of waiting lists. Munson acknowledges those inequities but treats them as inevitable rather than as resulting from a social policy that can be changed. Transplantation professionals generally agree that in the very human process of evaluating candidates for transplantation, social capital counts—and that includes celebrity status.

Apart from futuristic possibilities such as xenotransplantation and growing one's own organs from stem cells, Munson considers no alternatives to the present system. What, for example, would be required to implement a policy of educated presumed consent, whereby every person is automatically considered a potential donor unless he or she has registered an objection and "opted out"? (Such a system has operated successfully in parts of Europe without sacrificing the right of the individual to refuse.) What was lost when the proposal for a single national waiting list (which would have reduced the discrepancies between rural and urban areas with respect to access) was rejected in 1998 in favor of maintaining an inherently inequitable system?

Nor does Munson question the extent to which the expansion of waiting lists to include patients on the medical margins (those over 70 years of age, very sick infants, the immunologically sensitive, and those with hepatitis C, cancer or HIV infection) exacerbates the scarcity of transplantable organs. And he gives not even a nod to the need for more aggressive public health measures to decrease the incidence of kidney, heart and liver failure.

It would be unfair to expect transplantation medicine to solve all of our nation's social and medical inequities. But one would hope to get from Munson and our other moral philosophers and bioethicists a more critical assessment of where we are today and what needs to be done to make this tremendous medical technology less ethically problematic.—Nancy Scheper-Hughes, Anthropology, University of California, Berkeley


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