During the summer of 1998, I was sitting at a sidewalk café in downtown São Paulo with Laudiceia Cristina da Silva, a young mother and office receptionist, who had just legally requested an investigation of the large public hospital where in June 1997, during a routine operation to remove an ovarian cyst, she had “lost” a kidney. That she was missing a kidney was discovered soon after the operation by the young woman’s family doctor during a routine follow-up examination. When confronted with the information, the hospital representative told a highly improbable story: Laudiceia’s missing kidney was embedded in the large “mass” that had accumulated around her ovarian cyst. But the hospital refused to produce either their medical records or the evidence—the diseased ovary and the kidney had been “discarded,” she was told, along with some of her medical records. The regional Medical Ethics Board refused to review the case. Laudiceia believes that her valuable kidney was taken to serve the needs of another, wealthier, patient in the same hospital. To make matters worse, Laudiceia’s 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 assumes that people have agreed to donate their organs unless the proper paperwork has been filled out. “Poor people like ourselves are losing our organs to the state, one by one,” Laudiceia said angrily.
In July of 2000, Avraham, a retired lawyer in Jerusalem, explained why he went through considerable expense and danger to travel to Eastern Europe to purchase a kidney from a displaced rural worker, rather than wait in line for a cadaver organ in Israel:
Why should I have to wait years for a kidney from someone who was in a car accident, pinned under the car for many hours, then in miserable condition in the I.C.U. [intensive care unit] for days and only then, after all that trauma, have that same organ put inside me? That organ is not going to be any good! Or, even worse, I could get the organ of an elderly person, or an alcoholic, or a person who died of a stroke. That kidney is all used up! It’s far better to get a kidney from a healthy man who can also benefit from the money I can afford to pay. Where I went the people were so poor they did not even have bread to eat. Do you have any idea of what one thousand, let alone five thousand dollars, means to a peasant? The money I paid was a gift equal to the gift that I received.
Amidst the neo-liberal readjustments of the new global economy, there has been a rapid depletion of traditional, modernist, and humanist values. New relations between capital and work, bodies and the state, citizenship and social and medical inclusion (and exclusion) are emerging. The rapid growth of “medical tourism” for transplant surgery and for other advanced bio-medical and surgical procedures has exacerbated older divisions between North and South, core and periphery, haves and have-nots, spawning a grotesque niche market for sold organs, tissues, and other body parts. There are race, class, and gender inequalities in the procurement and distribution of tissues and organs. In general, the flow of organs, tissues, and body parts follows the modern routes of capital: from South to North, from third to first world, from poor to rich, from black and brown to white, and from female to male. In the very worst instance, this market has resulted in theft and coercion ranging from kidney theft, as in the case of Laudiceia, and a selfserving belief in property rights over the spare parts of the poor, as in the case of Avraham.
A triumphant global and “democratic” capitalism has released a voracious appetite for foreign bodies to do the shadow work/dirty work of production and for “fresh” bodies for domestic and international medical consumption. A confluence in the flows of immigrant workers and itinerant kidney sellers who fall into the hands of unscrupulous and highly sophisticated transnational organs brokers is a sub-text in the story of late twentieth century and early twenty-first century globalization, one which combines elements of preand post-modernity. As practiced today in many global contexts, these new organs procurement transactions are a blend of altruism and commerce; of science, magic, and sorcery; of gifting, barter, and theft; of voluntarism and coercion. Transplant surgery has re-conceptualized social relations between self and other, individual and society, and among the “three bodies”: the existential lived body-self; the social, representational body; and the body politic.11xSee Nancy Scheper-Hughes and Margaret Lock, “The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology,” Medical Anthropology Quarterly 1.1 (1987): 6–41. Finally, it has redefined the meanings of real/unreal, seen/unseen, life/death, body/corpse/cadaver, person/nonperson, rumors/fiction/fact. Throughout these radical transformations, the voice of anthropology (and of medical anthropology) has been relatively muted, and the real and high-stake debates have been waged among surgeons, bio-ethicists, international lawyers, and economists.
There now exists an unregulated, international, multi-million dollar business in tissues and body parts, obtained from naive donors who believe their gifts are being used in heroic rescues to save lives and comfort burn victims. Instead, as in many parts of the U.S., the bones and skin are sold and processed by private bio-tech firms into expensive products for dentistry and plastic surgery. One of these new products is DermalogenTM, recently released by Collagenesis. The company describes this processed human skin product as an injectable human tissue implant for the treatment of facial contour defects. It is designed “to meet the needs of patients who are seeking a safe, long-lasting and natural alternative to animal and synthetic implants for soft tissue augmentation.” In fact, DermalogenTM is a skin-based gel sold to plastic surgeons, who use it in operations to enlarge the lips and smooth wrinkles. The targeted market is the aging “baby boomer generation.”
In many third-world countries today, human tissue is exchanged with first-world countries for medical technology or expertise. In South Africa the director of an experimental research science unit of a large public medical school showed me official documents approving the transfer of human heart valves taken (without consent) from the bodies of poor blacks in the police mortuary and shipped for “handling costs” to medical centers in Germany and Austria. These fees, which were intentionally inflated to the maximum, helped support the unit’s research program in the face of austerities and the downsizing of advanced medical research facilities in the new South Africa.
Global market capitalism together with advanced medical and biotechnologies have incited new tastes and desires for the skin, bones, blood, organs, tissues, marrow, and reproductive and genetic material of the other. In these new transactions the body as we knew 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, alienated, 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, fetishized objects of desire and of consumption, a form of neo-cannibalism.
For most bio-ethicists the “slippery slope” in transplant medicine begins with the emergence of a black market in organs and tissue sales; for the anthropologist the slippery slope is other and earlier: it is the first time one ailing human looked at another living human and realized that inside that other body was something that could prolong his or her life. Desperation on both sides and a willingness of the transplant doctors 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. Ads like the following one, which appeared in the Diario de Pernambuco, of Recife, Brazil, pop up almost every day in newspapers around the world:
I, Manuel da Silva, 38, unemployed sugar cane worker, father of three hungry children and a sick wife, announce my willingness to sell any organ of which I have two, and the immediate removal of which will not cause my immediate demise.
The sale of human organs and tissues requires that certain disadvantaged individuals, populations, and even nations have been reduced to the role of “suppliers.” It is a scenario in which only certain bodies are broken, dismembered, fragmented, transported, processed, and sold in the interests of a more socially advantaged population of organs and tissues receivers. I use the word “fetish” advisedly to conjure up the displaced magical energy that is invested in the purchased living, and thereby strangely animate, kidney.
The ultimate fetish—as recognized many years ago by Ivan Illich—is the idea of “life” itself as an object of manipulation, a relatively new idea in the history of modernity. The fetishization of life—a life preserved, prolonged, enhanced at almost any cost—erases any possibility of a social ethic.