Social Bodies

Helen Lambert, Maryon McDonald, Helen Lambert, Maryon McDonald

• Publisher: Berghahn Books
• Year: 2009
• Print ISBN: 9780857451545
• eBook ISBN: 9781845458973
• Edition: 1
• Topic: Social Sciences
• Subtopic: Anthropology
• Index: Social Sciences

A proliferation of press headlines, social science texts and "ethical" concerns about the social implications of recent developments in human genetics and biomedicine have created a sense that, at least in European and American contexts, both the way we treat the human body and our attitudes towards it have changed.

This volume asks what really happens to social relations in the face of new types of transaction – such as organ donation, forensic identification and other new medical and reproductive technologies - that involve the use of corporeal material. Drawing on comparative insights into how human biological material is treated, it aims to consider how far human bodies and their components are themselves inherently "social."

The case studies – ranging from animal-human transformations in Amazonia to forensic reconstruction in post-conflict Serbia and the treatment of Native American specimens in English museums – all underline that, without social relations, there are no bodies but only "human remains." The volume gives us new and striking ethnographic insights into bodies as sociality, as well as a potentially powerful analytical reconsideration of notions of embodiment. It makes a novel contribution, too, to "science and society" debates.

Chapter 1

AGED BODIES AND KINSHIP MATTERS: THE ETHICAL FIELD OF KIDNEY TRANSPLANT

Sharon R. Kaufman, Ann J. Russ and Janet K. Shim

Renal transplantation has emerged as the treatment of choice for medically suitable patients with end-stage renal disease. More than 60,000 patients await kidney transplantation and are listed on the United Network for Organ Sharing (UNOS) recipient registry. Live donor renal transplantation represents the most promising solution for closing the gap between organ supply and demand.

Journal of the American Medical Association, 2005

How, then, might one begin to mark out the specificity of our contemporary biopolitics?

Nikolas Rose, ‘The Politics of Life Itself’, 2001

Kidneys and the Social Body

What happens to sociality in the face of medical transactions that enable the transfer of organs from one body/person to another? The activities that constitute clinical life extension comprise one site for the governing of life and kinship and the emergence of new forms of social participation in which biological knowledge and identification are foregrounded. Our ethnographic example at this site is kidney transplantation for older adults, and we ask: in what ways are bodies relational – and what is at stake in those relations – when longevity at older ages becomes an object of intervention and apparent choice? We are concerned with how family and other relationships are implicated in a biopolitical field in which certain medical practices (along with their legitimating financial supports), and the desire for and expectation of a longer life, and changing ideas about ‘normal’ old age, and family obligation become intertwined.

The substance of the body, as ground for consideration about affective ties, stands out as a dominant cultural feature in this example, particularly for how kinship is ‘done’. Indeed, the materiality of the body and its relationship to notions of health has become an important frame for ethical judgements generally (Rose 2001). We explore here the kinds of social obligations and, thus, moral order (Mauss 1967) at stake and in play when the age for transplant moves up beyond seventy and, especially, when living donors come from the succeeding generation.

Families have always been implicated in medical care and its social ramifications, but the fact that older lives are routinely extended today by medical technique infuses familial obligation with judgements about the relative worth of clinical interventions, disabling chronic illness, suffering and life itself. While obligation remains an unchanged and essential cultural fact, it is experienced now, in affluent sectors of US society, through the option or even imperative of asking and accepting, offering and giving parts of one’s body (in life or in death) to another. The very routine-ness of transplant procedures extends awareness about obligation, judgement and action to the body itself and to its uses, we found, via the ever-present potentiality of being a donor or recipient. That potentiality, a relatively recent feature of socioclinical life around the world, gives the always already relationality of the body a relatively new form of expression.

The number of kidneys transplanted to people over the age of sixty five, both from live and cadaver donors, has increased steadily in the past two decades in the US.¹ Transplants are routine in the seventh decade of life and sometimes are performed into the early eighties. Cadaver kidneys from donors over the age of fifty are sought and are available so that they can ease the shortage of transplantable kidneys for older recipients. In addition, living kidney donation is on the rise for all age groups, exceeding cadaver donation for the first time in the US in 2001. Of the 15,135 kidneys transplanted in 2003 (among all age groups), 47 per cent were from deceased donors, 53 per cent were from living donors. Among the 1,684 kidneys transplanted to people aged sixty-five and over in 2003, 513 (nearly one-third) came from living donors, 295 of them from adult children.² The phenomenon of live kidney donation for older recipients opens up new dimensions of intergenerational relationships and medical responsibility as yet unexplored.

Ironically, even while biological relatedness is no longer a clinical imperative due to improved immunosuppressive techniques,³ the nature of relatedness matters enormously, we found, in terms of one’s sense of duty and responsibility for the health and longevity of a family member (or friend) with end-stage renal disease. Spouses, siblings and adult children are mostly the first to volunteer to donate when they learn of the need for medical intervention to save a life, and they represent the vast majority of living donors in the United States. Other relatives, friends and acquaintances volunteer to donate as well.

In our own observational context,⁴ adult children (in their thirties, forties and fifties) are donating kidneys to their parents (currently, those who are in their sixties and seventies). Nephews and nieces, spouses, other relatives and friends are donating kidneys to older persons as well. While donation to strangers and the global traffic in illegal organ sales have been reported in the media,⁵ heightening consciousness both about the desire and need to give and receive and the relative worth of life and health around the globe, there is little public knowledge or discussion of the transfer of organs from younger to older people. Yet the latter phenomenon is affecting more and more families (Grady 2001; Dowd 2003). In addition, the broadening of the eligibility criteria for legal kidney donation over the past three decades – from healthy, relatively young cadavers and living family members to the inclusion of older cadavers with diseases and non-related living individuals – marks a change in the credit/debt dimension of biomedical subject-making. Along with this expansion in prospective and actual donor type, the recent, highly visible cases of apparently purely altruistic, philanthropic living kidney donation to strangers provide evidence of an expansion of the claims of citizens on one another.

Framing an Ethic of Care

At the site where old age, end-stage disease, clinical medicine and the contemporary, ubiquitous expectation for increased longevity meet (in the US), we are aware of a new kind of ethical knowledge that is emerging through routine clinical treatment. We refer here not to bioethics and the well-known parameters of that still largely philosophically based discipline for clinical decision making in individual situations, but instead to a diffuse ethical field,⁶ located throughout contemporary social life, that contains certain forms of reasoning, expectation and judgement about medical possibility. This ethical field is characterized by the difficulty, sometimes the perceived impossibility, of saying ‘no’ – even in late life – to life-extending interventions, and it is constituted by the following three features. First, the purported choices clinical medicine now provides to patients, prospective patients, their families and their doctors, regarding whether and when to employ life-extending procedures and whether and when to stop them, are not really choices at all. Rather, choice elides into routine treatment. When procedures are shown to be effective at ever-older ages, they become routine and thus expected and desired by clinicians, patients and families (Koenig 1988). When techniques become less invasive and associated with lower mortality risk, consumer demand for them and ethical pressure to make them available both increase. Finally, procedures that are seen to be relatively low risk quickly become standard practice. Treatment rationales and patterns are thus already scripted for patients and doctors, well before any actual ‘decision-making’ begins.

Second, the availability of interventions as therapeutic possibilities elicits hope and expectations for cure, restoration, enhancement, and improved quality of life. In turn, the boundaries between medicine’s focus on cure, prevention and life prolongation are increasingly blurred in the desire to maximize life. These two features support and give form to the third: the nature of caregiving and love has expanded so that expressions of care (both medical and familial), affection and value are explicitly tied to clinical acts that either extend life in advanced age or allow ‘letting go’.

The broadening of medicine’s scope over the management of old age as well as illness per se (Arney and Bergen 1984; Kaufman 1994) reinforces and sustains these three features of the ethical field which are mostly background to the daily activities of health care practitioners and patients in the US. Yet, they are the basis through which we come to understand the value of medical care and the uses of the body, our connections to one another, and the social worth of the oldest lives in our society. Each practitioner, patient and family must work out an ethic of care in the course of unfolding events, active and tacit decision making, and reflection. That ethic is rarely premeditated, autonomous or deliberate. Rather, it emerges during social interaction and the unfolding of medical and interpersonal events. It is shaped by the structural features of medical specialties and the American health care delivery system, the ways in which cultural understandings of kinship and community and epistemologies of clinical medicine influence one another (Franklin and McKinnon 2001: 9), and, in the case of kidney transplantation, by the apparent mechanical ease with which body parts can be transferred from one person to another.

Expectations for ever-longer lives join expectations that routine medical treatment can extend a good life. For many, it is simply unacceptable to die at seventy-one or eighty-one when one can employ the tools of the clinic to restore health and stave off death. While access to life-sustaining treatment, at every age, remains unequally delivered in the US, the treatments themselves exist, and almost everyone knows this. Things can be done, and the family is involved. Love is actualized, often, through the commitment to a longer life and by doing things to prolong life.

The possibility of giving away a part of the body becomes implicated both in the demonstration of care and love and in the ability and responsibility to prolong another life. The possibility of receiving the body part of another – the always already quality of this social fact – becomes part of the calculus by which the potential risk to another life and the sacrifice of another’s bodily integrity are weighed in relation to the value of extending one’s own life and improving one’s own well-being. The expansion of love and care, and of expectations about medical intervention to include the possibility of the transfer of bodily substance, are cultural facts now regardless of whether the acts of giving and receiving actually occur. To be confronted with end-stage kidney disease (of self or other) in a context in which transplantation and live donation are normalized is to existentially engage the sociality of the body.

In this way, living donor transplantation joins the new reproductive technologies (Franklin 1997; Rapp 1999; Thompson 2001) in broadening the field of ethical action to include proactive deliberation about the uses of one’s own body and the uses of the bodies of others to achieve health and promote new or extended life. In the case of organ sharing, biology is not mobilized to configure kinship (Thompson 2001: 175, following Schneider 1980), but rather, biology, as corporeal substance in the form of ‘one’s own body’ (in the US at least) becomes the central object in articulating what is ‘natural’ about the demands of interpersonal relationships – and thus what one can ethically claim from others – and in deciding what to do.

Intersubjectivity and the Ethical Field

Intersubjectivity is the quality, the pre-condition, that makes possible this ethical field. By ‘intersubjectivity’ we refer to the inextricable joining of self-knowledge, interpersonal relations and social/ethical participation that constitutes, in large part today, the making of subjects. We might say that, together, embodiment and social emplacement shape experiences of self and other, the parameters of identity and subjectivity and the nature of our relationships.⁷ Contemporary biomedicalization (Clarke et al. 2003) inflects bodily experience, self-making and sociality with particular kinds of knowledge: about how the body is implicated in the ethical; for what becomes naturalized about the human, the family and the life span; and for objectivizing the subject (Foucault 1983: 208). In the case of the life-extending medical practice we describe here – kidney transplantation in later life – the body, understood as transferable parts, becomes a central feature of intersubjective knowledge and relations. Organs can be variously ‘owned’ and symbolically characterized, and they can be understood as things, persons, self and other, depending on one’s point of view (Sharp 1995, 2001). There is slippage among these categories and the breakdown of body and identity boundaries creates some angst in the transplant world that has been described in detail (for example, Fox and Swazey 1992; Lock 1996, 2002; Sharp 1995, 2001). Yet the ‘good’ of transferability (as illustrated in the opening epigraph) is widely accepted and is evident in the growing demand for organs. That demand emerges from the broad expectation that end-stage kidney disease need not be fatal and the fact that kidney transplantation is a standard medical treatment for end-stage disease. There is thus growing opportunity for family (and other) relationships to be ethically circumscribed via biological exchange.

Life-extending medical practices in general and kidney transplantation in particular present useful case studies for intersubjectivity for two reasons. First, intersubjectivity includes somatic experience. Being-in-the-world is conditioned by the body-self and thus commitments, intimacies and a naturalized, embodied (and thus non-reflexive) ethic flow from that experience (Merleau-Ponty 1962; Csordas 1990, 1994; Kleinman 1997). Second, participation in standard-of-care life-extending medical treatments involves – indeed, cannot be separated from – the formation of self-responsibility and rights on the one hand and social connection and obligation on the other. These two aspects of subject-making are always co-constitutive. They are informed, more and more often, by clinical developments and imperatives.

On the self-responsibility side of the equation, older persons (and their families) in the US come to understand their bodies, lives, possibilities and futures – including what constitutes the ‘normal’ life span – in terms of their options about medical interventions that may or do extend life by postponing, altering or ameliorating an ‘end-stage’ condition. Nikolas Rose notes that by the late twentieth century, knowledge of the living body ‘became instrinsicially linked to interventions that transformed those living bodies’ (Rose 2001: 14). Life, health, illness and death became objects to be acted on via the instrumental tech...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Introduction
• 1 Aged Bodies and Kinship Matters: The Ethical Field of Kidney Transplant
• 2 Anatomizing Conflict – Accommodating Human Remains
• 3 On the Treatment of Dead Enemies: Indigenous Human Remains in Britain in the Early Twenty-first Century
• 4 Towards a Critical Ötziography: Inventing Prehistoric Bodies
• 5 Bodies in Perspective: A Critique of the Embodiment Paradigm from the Point of View of Amazonian Ethnography
• 6 Using Bodies to Communicate
• Notes on Contributors
• Index