What always throws me about transplant discussions is the degree of importance perfectly reasonable people attach to the bodies of their loved ones. Assuming that we aren't worrying that doctors are murdering dying people for their organs -- that they're being recovered from people who are really irrevocably dead -- I can't imagine an (other than specifically religious) reason for resisting organ donation. It's a body, and if you don't donate the organs they're just going to rot. But lots of people seem to feel that way.

But did you see this in the review: "The book's major shortcoming is its failure to address the fastest growing source of organs: living donors." I seem to recall that Healy promised in comments here that the book would answer whether or not it was fair and just to hunt and trap people for their body parts. I don't see how you can address that issue without addressing living donors. Vile commercialism has corrupted the good professor.

The fear seems to me that the doctor, honestly wishing to save someone else's life, will not do everything in her power to save the organ donor's life. This seems to me to be unreasonable, but I can imagine it being powerful.

That I can see as a comprehensible fear, and I'm thinking that's just a matter of better approaches to/education for the families. But the desecration of the body argument by itself seems to have much more power than I would have guessed.

3: That, and (I think) an unwillingness to treat a human body as something like a machine to be sold off or given away as parts after the prior owner has stopped using it. I'm pretty sympathetic to that sentiment.

God, this problem is fascinating.

We should thank Him for the gift of death and its attendant fascinations!

I suspect our emotional discomfort with some aspects of organ donation are likely to fade over time -- we increasingly do see body as a machine with parts that fail and whose parts can be replaced either with 'spares' from another person or with mechanical replacements.

It's interesting that part of medical education, for doctors, involves a deliberate desensitization. The process of dissection, is part of breaking that taboo about doing that stuff to other people's bodies.

I share LizardBreath's views in 1. But as she says, lots of people do not seem to agree with us.

In my family, the dead are cremated. I wonder if there is a difference in acceptance of organ donation between people who cremate their dead and people who bury them.

Obviously, I haven't read Healy's book, but the core problem just seems to be this. Given our dislike of thinking of ourselves as machine with parts to be sold like so many water pumps and transmissions, we really don't like to be reminded of that when deciding to donate an organ.

Introducing payment introduces all the supply and demand and pricing, and how crass would I be, if my thought upon having to give consent to take my kid's heart because his brain is dead, was 'man, their offer is low', what sort of human being would I have become?

So Healy's idea, according to the article, is to get rid of the 'bargaining' part of it, in the form of tax credits or donations to funeral expenses. Something that feels more like a gift of gratitude rather than a payment for services rendered. Neat idea. I'm wondering how one would go about publicizing it, though, because it seems that the two goals are in tension: provide an incentive but good god don't *talk* about it.

I'm wondering how one would go about publicizing it, though, because it seems that the two goals are in tension: provide an incentive but good god don't *talk* about it.

Maybe, but we do the same with charitable giving of money.

I wonder if there is a difference in acceptance of organ donation between people who cremate their dead and people who bury them.

I was wondering the same thing. Cremation makes me very uncomfortable, as does organ donation. There's a great chaper in the book The Undertaking, in which the auther, an undertaker, keeps repeating that line, "The dead don't care." True, but I can't get over the feeling that even a dead body (maybe especially a dead body) should be treated with reverence. As people have pointed out, this isn't a question that can be answered apart from attitudes more generally about humans and bodies.

I don't think I've ever been to a burial: every friend or family member I've known who's died, has been cremated. So I find the sentiments expressed in 12 quite strange (from a purely personal perspective) since cremation (to me) is perfectly compatible with treating someone with reverence.

11: That doesn't involve the idea of treating the human being as a machine, though.

I don't have any direct experience of with this, but when my grandmother had a stroke, my family had to make the last decisions based on half-medical and half-financial reasons. She *might*, the doc said, relearn how to swallow, but not in the three months of funds you have for a feeding tube. So they had to decide: no feeding tube, lots of morphine, sleep out the week.

Decisions like this are made all the time. All I can say is that having to take into account the financial considerations make you feel like the shittiest excuse for a human being, a cold calculating bastard.

re: 14

Having some sort of universal health care system takes the sting out of that particular problem, I suppose. Although there other equally painful decisions to be made.

12: True, but I can't get over the feeling that even a dead body (maybe especially a dead body) should be treated with reverence.

I can see where you get this with organ donation (though I don't feel the same way) but I'm curious why you would feel cremation is irreverent. Seems to me to be a pretty time-honored funerary practice in various contexts.

15: Someone's still going to have to make the decision as long as there are finite resources. And obviously, no one's going to want the organs of an 80-year-old stroke victim. But I'm just thinking that in a similar case, adding 'and if we disconnect him now, we save on funeral costs' is just going to add to the anguish of an already shitty decision.

How to market it, how to market it. Maybe as 'allowing society to express its gratitude', rather than payment? I'd feel incredibly icky if someone said '$20,000 for your kid's heart', but much less icky if it were an after-the-fact sincere thank you ('we're so grateful, we've established a scholarship fund in his name.')

It's just the muslim in me talking about cremation, I think. It's not like I have a good reason--it just feels like making the body disappear. I can imagine that burial seems like sticking it in the ground, which isn't inherently reverent or anything. The interesting thing about the passages I quoted in the post is how meaning is created in these practices for which we think out strong "gut" feelings are somehow primordial.

3: If you take a look at studies looking at how docs make decisions you'll find all sorts of unconscious factors operating. It's not for nothing that the "gold standard" for determining what any particular treatment is doing is the double-blind study with a big N. I'm not particularly worried 'cause I'm too old to give a damn but I can see where making the decision with respect to a twenty-something might not be as clear as the docs would have one believe.

18: "Primordial" seems to be bound to cultures, no? The Hindus do cremation, some US Plains Indians do exposure to the sky (and pecking birds) (I'm too lazy to look that one up to make sure tho'). Orthodox Jews do no cremation and in a hurry, and so on. It's all right and good (and primordial?) to the people embedded in those cultures, it seems.

Biohazard has a point: burial practices vary widely across cultures. I'm a little uncomfortable with cremation, but I think that's mainly because Jews don't cremate.

I thought that was ogged's point, too. We create meaning in burial or cremation, and we're so good at creating meaning, that it feels primordial or natural.

That was my point. And not just that they're culture-bound, but that they can be strongly influenced over a short time, such that even manufactured sentiments, like believing that organ donation is a gift, can seem like (or become) gut feelings.

You go, Cala.

So we're all agreed, then. Excellent.

Fuck, I don't think the Unfogged script has a module for what happens when we have comity by comment 25.

Zoroastrians also expose their dead, by the way.

I've read that they're running into difficulty in India because there aren't enough vultures to handle corpse disposal anymore.

That's mentioned in the link in 26.

there aren't enough vultures to handle corpse disposal

Not enough lawyers? We have excess capacity, maybe they could outsource.

More. Not very common practice, it seems, but fairly widespread.

My mother's family is Catholic, but my parents raised us to be fiercely in favor of cremation anyway, because of the sorts of environmental implications of embalming and burial. I can't say I've ever thought of cremation as something that makes me uncomfortable -- it always seemed like the right thing to do.

Jews don't embalm, either. The idea is that you're not supposed to do anything to either speed up or slow down the process of natural decomposition.

Well, it's not the just embalming, it's the taking-up-of-space issue. Also, apparently cemeteries can kill you.

There are several different issues.

First there's the success of what I call the "cultural account" of donation as the gift of life, which overcame a lot of early opposition or discomfort with transplants. In the 70s the practice was a bit like embryonic stem cell research or the issue of cloning today, and transplant advocates successfully moved it away from that kind of controversy.

A second issue is how the gift story is worked into the organizational work of procurement on a day-to-day basis, where the sheer logistics of finding and prepping donors affect how many donors there are. This is the "management" level that Postrel talks about, where consent can be managed in more or less successful ways. There's an awful lot of variation in rates of blood and organ donation, and this should tip us off that there's more to the problem than just people's dispositions to be altruistic or selfish.

Third is the question of how the gift account meshes with the the transplant and health care system overall -- the fact that most transplants cost a lot of money, that many people don't have health insurance, and that consent to donation usually involves the donation of tissues which end up as inputs to profit-making firms making products for cosmetic surgery, etc.

And finally there's the matter of the social meaning of money and the ways people use forms of payment to express different kinds of relationships (cash payments are different from indirect reimbursements, etc), in addition to its power as an incentive.

None of these issues is well addressed in the standard framework in which debate in this area gets carried on -- namely, whether we should appeal to people's self interest or their better natures, and whether and markets are in the abstract better at motivating people than appeals to charity, and so on.

I think traditionally Jews didn't use caskets, also.

Traditional practice is a plain pine box.

The space issue is a big one, of course, and a disadvantage to any sort of inhumation, especially in densely-populated urban areas.

(Densely-populated urban areas being where most Jews live, of course, so we're not really off the hook.)

http://shamash.org/lists/scj-faq/HTML/faq/11-06-05.html

Sometimes there didn't used to be a casket used. I think still not sometimes in Israel.

As Rabbi JB Soloveitchik put it, the deceased can't appreciate the fine furniture. Better you spend that money getting your synagogue a new pew!

Sometimes I love my religion.

Funny, PK and I were having an extended discussion about corpses and organ donation in the Atlanta airport a couple days ago, prompted by his spotting a copy of "Stiff" on a display table. I was a little self-conscious about people overhearing it, but the one guy who did was v. complimentary.

What I was thinking about in the convo was how it seems to me that folks who are more secular--more likely to think that when you die, that's it--are more likely (I think) to be unsentimental about the body, which is a little odd when you think about it. If the body is the essence of the individual (rather than the soul), then it makes sense to want to hang onto it for as long as possible; I can certainly understand on an emotional level why in case of a sudden death, people would be very reluctant to agree to organ donation, just as it would be hard to get rid of the dead person's personal effects.

Anyway, I'll have to read the book and discuss it with PK.

whether we should appeal to people's self interest or their better natures

Why does it have to be a binary choice? Pure altruism doesn't have very good track record and neither does pure greed. Better to come up with a scheme that appeals to both and makes them fungible too.

As for cost, an up-close and personal experience with a transplant was the most gruesome 1.5 years I've ever spent and I wasn't even the patient. I think the total bill came to well over one million USD, not to mention wear and tear on all concerned.

After that, I'll be a donor but not a recipient and would probably vote for restricting them to the under sixties. IMX, the intensive care bit at the far end is for the benefit of soft-headed relatives, not the patient.

Why does it have to be a binary choice? Pure altruism doesn't have very good track record and neither does pure greed. Better to come up with a scheme that appeals to both and makes them fungible too.

This is basically what the book says, right?

After that, I'll be a donor but not a recipient

My sister is a liver transplant surgeon, and has expressed similar doubts as to whether the whole experience nets out as worth it to the patient. But I think that's very variable depending on the organ.

This was a liver. Kidneys seem to be routine and the patients can mostly be kept in reasonable shape via dialysis. The other major organ transplants are a whole different thing entirely I think, tho' my knowledge is becoming dated.

In any event, the patient is doing rather nicely after ten years but definitely doesn't want anything involving more than trivial patching done to fix anything else.

Why does it have to be a binary choice?

It doesn't. The book is partly about why this standard way of debating the issue is too limiting and also empirically wrong.

My grandfather had a Jewish funeral, buried in an unfinished (bot not exactly plain) wood casket. Which I thought was in keeping with tradition. But then they put the casket inside a concrete box. Which I thought rather obviated the point of the unfinished casket. Or am I missing some obscure point of midrash, here.

Where did they put the concrete box?

The concrete box went into the grave, the casket went into the concrete box, then they lowered the concrete lid (for which they had to use an arrangement of pulleys, it was clearly very heavy) onto the box, and the earth went on top of that.

When I first got my driver's license (aged 17, I think), my dad tried to persuade me against signing the organ donor consent portion of the card. "They'll take your heart out while you're still alive," he warned. To which I objected, "No they won't." Etc, etc. (But I think he may have been partly right about this? that you might be pronounced brain-dead but with a still-beating heart?...or maybe not). Anyway, he was really quite adamant, and did not want me to sign the consent. As a compromise, I did sign, but only with the hand-written proviso "anything BUT my heart."

My memory of the above exchange is all mixed up with the memory of another exchange (or perhaps it was the same conversation), where my dad told me about someone who had almost been buried alive, except that even as they were burying him, they heard the guy banging on his coffin and realized their mistake. Oh, and he also told me that eating bread crusts would make my hair curl, so yeah, okay.

I do sort of understand his ooginess, though. What others have said above about the body as a machine, with transferable parts and etc., which challenges deeply-held notions of uniqueness and sacredness and so on.

48: Like a sarcophagus? Weird.

Yeah. But it was a proper Jewish cemetery, so I suppose they know what they're doing. If I weren't a coward about all religious ritual, I would have asked.

someone who had almost been buried alive, except that even as they were burying him, they heard the guy banging on his coffin and realized their mistake.

The sociology of death is a whole subfield to itself these days, so I'm sure this is something people have noticed before, but there seems to have been this shift in sensibility on this point. The 19th century had a lot of people who were afraid of being buried alive, and many eccentric types who constructed various ingenious coffins (complete with air supplies, alarm bells, and so on) in case they found themselves in that awful position. Today, though, people are much more likely to worry that they will be killed too soon as a result of overzealous doctors wanting their organs. Of all the people I've talked to about organ donation, only one -- a Brazilian woman at a party a few years ago -- joined these two ideas together when she told me that she very much wanted to be an organ donor because she had a fear of being buried alive.

51: It doesn't totally defeat the purpose; part of it is about discouraging ostentatious displays of wealth (the link in 38 focuses on this reasoning). It still seems weird, but narrowly following a tradition often trumps addressing the concerns for which that tradition was instituted.

So, Kieran, could you say more about Postrel's concern regarding living donors?

After reading Postrel's account of her own experience, I actually started thinking seriously about becoming a donor, but put the idea on hold when I realized just how much of a bother would it be, for no compensation at all. My time may be near worthless, but still.

Plus, from reading various websites, it seemed like I'd be subject to a lot of disapproving frowns, and even outright rejections, if I truthfully answered "because I'm desperately seeking meaning in my life, and recognize that my weakness of will is an insuperable barrier towards more modest but sustained displays of altruism" to questions about why I wanted to donate. Hrmph. Darn paternalism.

That's basically why I give blood -- it's about the least troublesome thing you can do that lets you preen yourself about possibly having saved someone's life. I have this vague sense that thinking that way makes me shallow and awful, but I figure the blood is still useful.

They'll take your heart out while you're still alive," he warned. To which I objected, "No they won't." Etc, etc. (But I think he may have been partly right about this? that you might be pronounced brain-dead but with a still-beating heart?...or maybe not).

How dead is brain-dead? Few of us think about the flesh and blood on the ventilator, the chest going up and down in regular breaths, the heart pumping the blood around and keeping many of the organs working and thus reusable. What seems to have disturbed Sharp most was the fact that brain-dead donors are anaesthetised before the organs are extracted. Brain-dead, and hence incapable of feeling pain: why do they need anaesthesia? There appears to be a serious amount of denial here. When Sharp first started asking that question, three organ procurement staff, two neurologists and two internists told her that she was misinformed; another physician told her to ask an anaesthetist, since he did not want to talk about it.

When she did get answers, they were various. Anaesthetists can monitor and control blood pressure by the use of various drugs; these can relax muscles so that operating is easier, and also help to prevent the abdomen collapsing at a critical moment. So the anaesthetist's drugs make the cadaver more tractable. But, Sharp reveals, there is a lot more going on. A brain-dead body will move in a lifelike way when nerves are pinched or cut. The body, warm and looking healthy enough where it has not been injured, may seem to shrug or kick or even signal. This is very disturbing to some of the staff attending the operation. These effects are reduced almost to nothing when the cadaver is anaesthetised. And some of the people involved reflect, perhaps, that if, despite all the tests, the person is not quite dead, then at least he will be spared pain in the moments before the heart stops. All this despite the official conviction that brain-death implies no possibility of feeling pain - 'pain is a cortical phenomenon.'

Sharp turns to the UK, which is apparently the only place where the anaesthetising of cadavers has been debated in public by experts. A letter from an anaesthetist to the Journal of the Royal Society of Medicine in 1999 pulls no punches. 'The greatest misconception is that the donor will be dead in any ordinary sense of the word. Most people equate death with [the heart having stopped], not the warm, pink, pulsating, breathing (albeit by machine), reactive state that we call brainstem death.' The debate continued through the following year in Anaesthesia, where there were heated remarks about 'the transplant lobby'.

There is evidently a lot of disquiet, even if everyone - and certainly Sharp herself - agrees that organ transplantation is an invaluable way to grant life. And it is life of quality, for many who would otherwise die having lived lives of no quality in the time remaining to them. For the patients who can carry on, bound to a dialysis machine, say, a kidney transplant is immensely cost effective (at present almost 2 per cent of the NHS budget goes on dialysis for about 0.05 per cent of the British population).

I had always thought of brain-death as being unequivocal, for I am one of those who locates the soul in the loving (or hating) conscious being. I had accepted the metaphor of a person first passing into a vegetative state - although on the ventilator the human is nearer to being a machine than a vegetable. I had never thought of what it might be like to see the tranquil body of someone close to me 'breathing', yet declared dead.

(source)

[giving blood is] about the least troublesome thing you can do that lets you preen yourself about possibly having saved someone's life.

That's not true. You could tell others that you gave blood without having done so, and tell yourself that your lie convinced others to give blood and thereby was worth some preening.

You know what would be a sweet project? Opening a blood clinic staffed with hot busty nurses in skimpy outfits. I bet you'd see better turnout and more return business.

It's a wash, the lie cancels the donation, unless the person giving blood reports back that the unit given saved someone good. Of course, it's possible it saved a gangbanger who then fires off one of those kiddie-seeking bullets they seem to be able to find.

I feel like gang-bangers would be better shots if they stopped holding the guns all sideways like that. maybe some after-school inner-city firing ranges are in order.

on the topic of organ donation, I think that it can really help parents who lose a child, if they feel that they have saved one or more other children. the idea that something good could come out of life's most horrible tragedy. I remember an american child got killed in Italy (mafia gunfire or something?) and the parents donated the organs. it made a big impression; I guess organ donation is rarer there.

it made a big impression; I guess organ donation is rarer there.

Used to be - according to a paper that Kieran presented here last year, it's now skyrocketing/

Recently, I came to the conclusion that the driver's license donor setup should be opt-out, rather than opt-in. If you don't want to donate (i.e., if you belong to one of the bizarre Xtian cults that says your body is taken up to heaven, but has so little faith in God's talents that separating the bits would confuse Him), sign the card. Otherwise, your parts are up for grabs.

As for 52, the doctors declaring a patient dead rarely have anything to do with the patients needing parts. Often, organs are transported across the country when a match has been determined, but that occurs after the potential donor has kicked it and the harvest has occured (with the doctors in their overall scrubs and straw masks driving the combines over the bodies, and the organ silos filling up . . .)

I can tell you that the word "harvesting" isn't doing donations any favors.

I can tell you that the word "harvesting" isn't doing donations any favors.

Stories like yours aren't helping on the living donor front. Think I'll hold on to my kidneys for a while.

Racist!

Plus, from reading various websites, it seemed like I'd be subject to a lot of disapproving frowns, and even outright rejections, if I truthfully answered "because I'm desperately seeking meaning in my life, and recognize that my weakness of will is an insuperable barrier towards more modest but sustained displays of altruism" to questions about why I wanted to donate.

I talk about this issue a little in the book: it shows the limits of the "gift of life" account and the strength of self-interested accounts of our motives. In the 1990s, people started to come forward saying, "I've heard of this terrible donor shortage, I'd like to donate a kidney to someone -- not a relative or anyone, I don't care who." Now, you might think that this would have been hailed as a crowning success by those who for years had been tirelessly advocating for the gift-of-life account. Instead, doctors tended to assume such people must be mentally ill or otherwise weirdly motivated. So, news stories about their efforts to donate typically contained references to the extensive psychological testing and so on that they had been put through by doctors to confirm their sanity. By contrast, the norm of self-interest means people are happy to agree that saying "I want to sell my kidney to a stranger for three thousand dollars" is not only not mad but perfectly rational. It could easily be the other way around -- and indeed it is, or has been, for cadaveric organs.

John Bates Clark.
Maybe John Clark Bates.
Probably the first.
Yeah, it turned out well for him making the proposition that ethical and moral decisions in economic exchange might take precedence over profit motive. So they named a prize after him and no one remembers at all, well, exept for me.
Healy, now there's a wishful thinker, perhaps even delusional, "The idea that markets inevitably corrupt is not tenable...". Jesus the self-deception. Damn and the series of non-sequiturs strains the imagination, "Commerce isn't antithetical to culture: it is part of it."

Rich, why're you addressing Kieran in the 3rd person? You do realize he's here?

I had never thought of what it might be like to see the tranquil body of someone close to me 'breathing', yet declared dead.

Last year a relative was like this after a massive stroke. Even after being briefed on the extensive damage and the results of the tests to determine brain death it was very very disturbing to see him "sleeping" and making odd movements. It was difficult, but the family did decide to donate his organs.

The transplant team took a few days before deciding that the organs coudn't be used. This was extremenly hard. People had said goodbye, yet we felt obliged to visit as long as the body was alive. So it was like he died multiple times to us. The uncertainty and the false certainty of the transplant team about when they would finish things was a big part of the problem.

Despite all that, I believe it was the right thing to do. Then again, I'm disposed that way. In another branch of my family, my grandmother (a devout Catholic) was a "waste not want not" type and donated her body to a local medical school.

My strong personal sentiment is against opt-outs. I'd much prefer a donation market, for both the living and the dead.

Racist!

Christ. Re-reading that, it really could be taken that way.

You really can't have a donor opt-out. Some of the people most strongly opposed to donation (e.g. Hmong, especially the older ones; probably Gypsies; various others) are also least likely to understand what's at stake when they get their drivers' licenses. So you could end up with a whole extended family in the hospital fighting the doctors.

pdf23ds,
Sorry.

Rich

so little faith in God's talents that separating the bits would confuse Him

Sincerely awesome.

I grew up hearing that organ donation was a great good but no one in my family would actually do it. My oldest sister was the first person in my family whose organs were donated (some, anyway, but that's a long story). Now we're all rabid donor types. I understand being a little squicky about the body being parted out like an old VW - I suspect my relatives had latent old-timey religious motivations for their hesitation even as they would say aloud what a wonderful thing organ donation was - but with my sister, who died unexpectedly and young (late 30's) and who was an actively and generously charitable person in life, there was a real shift in attitudes on the part of my relatives.

Throw in a family friend who died of cancer and wished to be cremated (another thing no one in my family would say bothered them, but clearly there were some "but how will I fly up to Sky Jesus on Judgement Day" kinds of hesitations) and in whose ceremony to spread the ashes both my parents participated, and all of a sudden - in the last five or ten years - even the oldest living generation of my relatives have all become organ donors and all changed their plans to be cremated rather than buried after anything useful has been given away.

So, I understand why people such as ogged say what they say about wishing to be reverent towards the body of someone we love, but I know first-hand that the experience of being the survivors who execute the generosity requested by the deceased can massively and very quickly shift one's attitudes on these things. To some degree I also believe that having to confront the contradiction of "your spirit goes to Heaven and you leave the earthly world forever at death, but you still need your body because, um... give me just a minute on this one..." in an active way really caused that sort of fear to collapse on itself.

(On reflection, that could be read to mean that I think anyone who's uncomfortable with donation in one aspect or another simply hasn't been there, done that with death and grieving, and that's not what I mean. I mean that was the view-altering experience for some members of my family, not that it should or would be view-altering for everyone or that different opinions indicate anything other than different opinions.)