Last Best Gifts: Altruism and the Market for Human Blood and Organs by Kieran Healy

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More than any other altruistic gesture, blood and organ donation exemplifies the true spirit of self-sacrifice. Donors literally give of themselves for no reward so that the life of an individual—often anonymous—may be spared. But as the demand for blood and organs has grown, the value of a system that depends solely on gifts has been called into question, and the possibility has surfaced that donors might be supplemented or replaced by paid suppliers.
 
Last Best Gifts offers a fresh perspective on this ethical dilemma by examining the social organization of blood and organ donation in Europe and the United States. Gifts of blood and organs are not given everywhere in the same way or to the same extent—contrasts that allow Kieran Healy to uncover the pivotal role that institutions play in fashioning the contexts for donations. Procurement organizations, he shows, sustain altruism by providing opportunities to give and by producing public accounts of what giving means. In the end, Healy suggests, successful systems rest on the fairness of the exchange, rather than the purity of a donor’s altruism or the size of a financial incentive.

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Altruism and the Market for Human Blood and Organs

Copyright © 2006 The University of Chicago
All right reserved.
ISBN: 978-0-226-32237-7

Exchange in Human Goods

For I can raise no money by vile means: By heaven, I had rather coin my heart, And drop my blood for drachmas ... JULIUS CAESAR 4.3.80-82

There is no production market for human blood and organs. In most parts of the world, it is illegal to sell your blood and you cannot offer one of your kidneys (or those of a dead relative) for sale. With the major exception of plasma in the United States, these goods-all of which are in great demand-are supplied for free by voluntary donors.

The gift exchange of these goods is unusual enough to have provoked a long-running though sporadic debate about its importance. Thanks in part to new possibilities for commercial trade in human goods opened up by medical science, and to the growth in for-profit traffic in human organs and tissue around the world, these arguments have recently been taken up with renewed vigor in a number of disciplines. At their core are questions about how and why the introduction of money affects formerly noncommercial goods and the social relations that surround them. Is there something special about the things we reserve for nonmonetary exchange? Does gift exchange have beneficial effectsthat market exchange does not?

Although gift giving is the mechanism through which most blood and organs are collected, it does not happen everywhere in the same way or to the same extent. The number of organs and the volume of blood given each year, both cross-nationally and within particular countries, vary widely. This fact has not received enough attention in debates about the morality of gift and market exchange in human goods. Yet its implications are striking. If donation simply involves individuals coming forward to give, in much the same way everywhere, why is it so much more common in some countries and regions than in others? Why, for instance, have more than 40 percent of French people given blood but only 16 percent of Norwegians? Why is it that, in the United States, the Midwest yields twice as many organ donors, proportionate to its population, as the South? Does this variation have something to do with the ways the procurement of blood and organs is organized in different places? This is the question I ask in this book.

Put in its broadest terms, my argument is this: to understand this world of goods we must get away from the character and motives of individual donors and look instead to the cultural contexts and organizational mechanisms that provide people with reasons and opportunities to give. Further, we will not understand the social organization of procurement-whether gift based or for profit-if we think there is a simple division between giving and selling. In this introductory chapter, I sketch the theoretical questions at stake and give some background on the specific cases of blood and organs. I then go through some current arguments about commodification and altruism in more detail, with an eye to their relevance to the main question. Finally, I lay out the argument of the book.

Commodifying the Body

Exchange in human goods has grown rapidly over the past thirty years. By human goods I mean body parts or products, from corneas to cadavers; by exchange, any transfer of them, from altruistic donation to for-profit sales. A sense of the size and variety of the "body bazaar" can be found in a recent survey that documents the growth in markets for products as diverse as human hair, leukemia cells, eggs, entire bodies, genetic material, placentas, and brains. As the range and volume of this kind of exchange has grown, so has debate about the form it should take, the risk of exploitation to those involved, and, above all, the proper role of the market. As a rule, the debate is cast as one in which existing relations of selfless, altruistic exchange are threatened with replacement by market-based, for-profit alternatives.

Blood and organ donors give of themselves both figuratively and literally. This mingling of metaphor and reality means that exchange in human goods always has the potential to be more than a simple transfer of products. The U.S. blood supply grew out of the war effort in the 1940s, when the idea of the "nation's blood" was not merely an abstract idea. Blood donations always jump suddenly after disasters as people express their sorrow in a direct and practical way, even though their gift may not always be needed. The long queues outside hospitals and blood centers around the country following the September 11 attacks are the most striking recent example of the moral economy of donation.

While the free gift of blood is seen as an expression of social solidarity, profit-making blood centers have been held up as examples of the depths to which the market can drag a society. In the early 1970s, when the for-profit sale of blood was at its peak in the United States, news features about the squalid world of "ooze for booze" blood centers were common. The international market in blood has proved a powerful symbol of global inequality, too. Douglas Starr describes the fate of the Compañía Centroamericana de Plasmaféresis, a large plasma center in Managua during the Somoza dictatorship that bought its product from poor locals and sold it to companies in the United States. The Somoza family appeared to be involved in the business. After a journalist investigating the plant was killed in suspicious circumstances, the building-known locally as casa de vampiros-was attacked by protesters and burned to the ground. Commercial trade in both blood and organs has been seen as the leading edge of a market invasion. Organ procurement has uncomfortable echoes of nineteenth-century body snatching and grave robbing. Policy critics like Jeremy Rifkin and Andrew Kimbrell have argued that technological change in science and medicine, combined with the profit motive, has led companies to turn the human body into a "human body shop." Anthropologists have documented the recent growth of black and gray markets in human organs, in which poor Brazilians, Moldovans, or Filipinos sell their kidneys to wealthy citizens of more developed countries in transactions facilitated by organ brokers. For all these reasons, the sale of human body parts is a standard trope in broader debates about commodification.

The blood supply is generally sufficient for medical needs but is prone to shortages. The demand for organs, by contrast, far outruns the supply. For some commentators, the natural solution to shortages is to introduce a financial incentive-a market price for organs -thus turning donors into paid suppliers. Long considered beyond the pale, the for-profit exchange of blood and organs is now a serious alternative to current policy. For many, however, the prospect of commercial traffic in organs remains disturbing, even obscene, and an altruistic system seems the only morally viable solution. Their intuition is that if the market is going to do damage anywhere, it will be in the exchange of human body products or parts. This area, they believe, is naturally governed by norms of gift giving, altruism, affection, or love, all of which are prime candidates for dissolution or debasement by market institutions.

Commodities are goods produced in order to be traded on markets for profit, and to commodify something is simply to create a market for its exchange where none existed before. But ever since Marx's critique of commodification, the term has connoted much more than this. Marx sees two main things wrong with commodity exchange under capitalism. First, it is exploitative. Marx argues that capitalism cannot exist without a pool of workers who have nothing but their labor power to sell and that the cycle of competition between capitalists will tend to keep wages low. Workers are therefore systematically vulnerable to capitalists in the labor market. Second, this exploitation is obscured because capitalist markets lead people to believe that commodities possess value in their own right, rather than because of the social labor that goes into producing them. This is commodity fetishism. Capitalism is not the only exploitative economic system, but in most others the ultimate source of value-the labor of peasants in a manorial economy, for instance-is at least clear to everyone. Under capitalism, these social relations of production are obscured because people are linked only through the exchange of goods in the market. As a result, the goods appear to have value through some mysterious power of their own.

In one sense, Marx's arguments imply that markets in human goods are no different from other markets. Here, as elsewhere under capitalism, we can expect the vulnerable to be preyed upon. It is not such a big step from exploiting the labor power embodied in workers to exploiting those bodies themselves. Marx's rhetoric, however, shows us that there might be more at stake. His critique of capitalistic commodification is filled with metaphors of bodily violation. The commodity form is "always ready to exchange not only soul, but body, with each and every other commodity." The factory night shift "only slightly quenches the vampire thirst for the living blood of labour," while apologists for industry insist that "British industry, ... vampire like, could but live by sucking blood, and children's blood, too." Whereas labor power has "no other repository than human flesh and blood," the magic of credit means "man himself has been changed into money or money has become incarnate in him. Human individuality, human morality has itself become both an article of commerce and the material in which money exists. Credit no longer analyses money value into money but into human flesh and the human heart." Conversely, the "capitalized blood of children" or other workers moves easily from one country to the next. In all, "capital comes dripping from head to toe, from every pore, with blood and dirt." In considering trade in human blood and organs, then, we find ourselves facing a literal market in the very things Marx used as metaphors of capitalistic excess. Horror at the prospect of wholly commodified bodies is built into the foundational critique of capitalist society. We should not be surprised, then, when people see these markets as a confirmation of Marx's intuitions about the insatiability of capitalism.

Marx presented a comprehensive critique of capitalism as a whole, and this is not the place to assess its merits or detail its difficulties. But the problems he identified-systematic exploitation and the atomizing, socially destructive nature of market exchange-are, though often in more refined or narrowly targeted forms, still central to contemporary debates. Critics worry that, by allowing market logic to dictate the terms of an exchange, we risk losing something important. Markets reduce different ways of valuing things to one dimension, measured in money. They encourage us to treat people as means rather than ends. They erode our desire to carry out principled actions unmotivated by profit. They undermine altruistic action-whether heroic or mundane-by rendering it unintelligible. (Why do something for free when you could be paid for it?) They break up social relations, networks, or forms of organization and replace them with ersatz equivalents devoid of depth and meaning. It is also often argued that commodification can have negative effects both on the goods being traded and the people who exchange them. Goods can be debased by money, as, for instance, when someone tries to buy an award or an academic degree. In the same way, people can be corrupted by money, as they come to act only out of self-interest or for profit, and treat others as means to their own ends.

Recent commentators are much less likely than Marx to believe that all goods and actions are equally susceptible to the market's dangers. It is hard to see how commodifying the exchange of, say, paper clips would do anything to debase the paper clips themselves. And it is easy to think of cases where self-interest is an uncontroversially appropriate motive, as when one fends off an attacker. Indeed, as Jon Elster points out, while we can imagine a (nasty) world where everyone is always and only self-interested, a world populated only by pure altruists is harder to conceive. It might be possible for some people to always and only care for the welfare of others, but this could not be true of everyone. Accepting assistance means putting yourself first at least some of the time, and in this sense altruism is parasitic on self-interest. 22 As for the moral dangers posed by commodification (as opposed to mere self-interest), few if any argue that trying to make an honest living in business is an inherently debasing activity that entails being corrupted by money. There is a distinction between profit making and profiteering.

This raises the question of where to draw the line. Goods will not conveniently classify themselves for us: There is little point in "searching fruitlessly for the magic distinction between commodities and other sorts of things." (To think this distinction is built into goods is just another kind of commodity fetishism.) We can roughly distinguish three orientations to commodification. Some things are uncontroversially commodities and we do not worry about their marketability at all. In other cases, commodification is acknowledged as a problem-something that in principle ought not to happen-but corrective responses are possible; a certain amount of it may even be seen as inevitable and tolerable. In the final case, the problem is much more severe: commodification is thought to undermine basic distinctions or sacred values or to threaten social institutions that have powerful defenders.

What kinds of things provoke this last response? It turns out that many intuitively compelling examples of commodification involve, not tangible goods or products in the usual sense, but a social relationship. Depending on the particular relationship, this sort of commodification may be thought to be especially pernicious. Friendship, for instance, is a social tie that is not supposed to be instrumental. Trying to purchase a friend, the argument goes, shows that the buyer (or seller) just doesn't understand what friendship is. Whatever you are getting for your money, ipso facto it cannot be friendship. Goods like friendship, love, and respect by definition cannot be brought to market. When we see items or services for sale bearing those labels, we are really looking at some ersatz or debased alternative, not the good itself.

Michael Walzer's influential catalog of "blocked exchanges" is a list of goods he claims are in this sense naturally and properly outside the sphere of monetary exchange. It does not include many items that you could put in a shop window, apart from human beings. Instead, it is made up mainly of social relations and institutions: he procscribes the sale of political influence, freedom of speech, marriage, criminal justice, and so on. The commodification of political influence, merit, justice, and the like prompts charges of corruption. Indeed, sales of these goods have well-established names: graft, nepotism, simony, bribery. In many of these cases (the pursuit of political office, for instance) we wearily expect money to be present, even if we might prefer to keep it out.

Other goods seem to have a different character. The threat of commodification provokes especially strong reactions where aspects of persons (and their social relationships) that are supposed to be intimate or sacred are made to yield marketable goods or services. Within the household, for instance, money mixes with domestic relations in complicated ways. People frequently end up in court as a result. Social scientists and legal scholars have recently begun to pay serious attention to how money works in these intimate relations. Women's domestic and reproductive labor is typically embedded in the institution of the family, but it also has the potential to be a marketable service. The most common good that is both intimate (usually embedded in affect-laden social relations) and marketable (capable of being separated from a particular individual and sold commercially) is domestic labor. In the 1960s and '70s, proposals to commodify housework often provoked strong reactions, as today do arguments about the growth of markets in child care.

Blood and organs can be thought of as tangible counterparts to these intimate yet marketable social relationships. They are literally part of oneself but can now be turned into discrete, marketable items. The same anxiety-provoking questions-about the place of money in theory and in practice, its role in exchange, and its potential to corrupt people or debase social relationships-are raised in both cases. But unlike a social relationship, you really could put a kidney in a shop window, which makes the prospect of debased exchange seem that much more real.

(Continues...)

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Excerpted from Last Best Gifts by KIERAN HEALY Copyright © 2006 by The University of Chicago. Excerpted by permission.
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