Twice Dead: Organ Transplants and the Reinvention of Death

How comfortable are we with declaring the death of someone who has color in their cheeks and is still warm? 

• what is a person?
• what is the relationship between a person and their body?
• does a person cease to exist when their physical body dies?
• what exactly is death---?
• physical
• social
• personal

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What contributions can anthropology make to the study of ethics and technology?

• Lock is the lone anthropologist on the International Forum for Transplant Ethics and is involved with social, cultural and legal issues to do with "Genome Canada". 
• These discussions are often left to bio-ethicists, lawyers and philosophers -- what role can social scientists play?

• Anthropologists, through ethnographic research, collect responses from those whose lives have been directly confronted with these issues. 
• "We're dealing with everyday life. We're dealing with the impact of these technologies on families and individuals. We are the only discipline that really does that systematically." (Lock)
• Sociologists, and bioethicists do survey research, and that provides another kind of information about what people believe, what their attitudes are, what their values are, but the anthropologist is doing more of the qualitative approach.
• "Very often what that shows is that being on the front line of many of these technologies is very different from what the people in power are telling us what the experience is like." (Lock)
• Social scientists can "look at the way in which scientific knowledge is actually produced and put into practice." (Lock) Scientists obviously understand what they are doing, but they are part of the system. 
• "What we need above all is to recognize that new technologies often can bring major advances and be very helpful in many many ways. But that there is always the other side of the story as well." (Lock)

• What is death? Is it a process or a moment? 

• When are you dead? 
• Death has different meaning depending on culture and religion and it has had different ways of being defined throughout history, which has changed based on the needs and advancements of medicine.

• In the US and Canada the concept of brain death has not created a controversy...WHY NOT?
• In Japan, the concept of brain death runs contrary to the beliefs in Japanese culture...WHY?

• What is Brain Death?
• Brain death occurs when there is no longer any brain activity and someone cannot breath unassisted.
• Only possible because of the invention of the ventilator and other life support technologies 
• (these technologies have forced a reconsideration of the boundaries between life and death in general)
• A new death had to be invented before commodification of the brain dead could come about
• put the body to good use, don't waste resources on life support or waste potential body parts
• no possibility of cognitive function (claim)
• For some people this is not death...other definitions?
• heart stops beating
• person stops breathing
• person can not live without life support
• person has a terminal illness
• person no longer speaks (social death to us maybe)
• what is  the accuracy of determining brain death?
• Do people who are brain experience pain and suffering?

• Brain death is a legal death that was created so that doctors could be covered (legally speaking) from homicide on the moment they were procuring organs. 
• why do we "trust" doctors and technology?
• Has the "need"for securing organs shifted the care that "brain dead" individuals get?
• has it transformed them from "patients" to "living cadavers"? 
• Are patients kept alive just to maintain the health of their organs?
• why is the organ "the brain" the only one that determines death when it ceases to work?
• Physicians and ethicists often blame this struggle on culture and "tradition" often interpreted as an aversion to technology in modernity. 
• Lock convincingly counters such essentialized depictions of Japanese attitudes by exposing the complexity of the "rhetorics of difference". 
• The individualism, utilitarianism, and rationalism that undergird organ donation are distinctly Western values.
• The concept of an autonomous individual whose "self" resides in the brain is a distinctively western concept.
• In Japanese society, a "person" is constituted in the public domain of relationships and exchange
• Practices and meanings around the body at death—both biological and social—differ
• In Japanese society, ---has a history of deaths that make statements about social conflicts or conditions, as in ritual suicide Sepukku. 
• Elements of a changing moral order in Japan: 
• a growing mistrust of physicians 
• conflicting discourses that influence notions of "self" 
• ability to manipulate the natural world as never before.
• A resort to tradition and cultural uniqueness can be mobilized by groups for specific purposes---in this case---such as dealing with threats to the social order imposed by globalizing forces of technological medicine and the existence of ambiguous entities ushered in by organ transplantation.
• No¯shi mondai (the brain death "problem") involves more than legal or medical constructions of an organ donor's biological status or personhood
• objects, discourses, reasoning, clinical practices, and grieving practices are bound up in managing the ambiguous category of "brain dead".
• Lock challenges the presumed dichotomy between "nature" and "culture" by demonstrating that societies have different understandings of and relations with different technologies. 
• The Japanese are simply less concerned than North Americans about "transcending" death yet...
• They "animate" machines in all walks of life in complex ways, and accept genetic and reproductive techniques with little difficulty (they aren't technophobes!)
• The "technological imperative" operating in industrialized societies not applied evenly or without a "cultural imperative"

• Why American's are ok with "brain death"
• An ad hoc committee of physicians from Harvard Medical School defined brain death, and this "was accompanied by quite a vigorous campaign in which the worth of organ donation was highlighted." (Lock)
• message: Get something positive out of a tragic event
• message: Let the deceased "live on" through someone else
• message: The promotion of this "gift of life" glossed over the sad fact that for an organ to be donated, someone had to die, and the recipient would have a life-long dependence on immuno-suppressant drugs with harsh side effects. 
• also can leave those who decide not to donate organs with feelings of guilt
• The American Bar Association immediately supported the position of the doctors. 
• there was a tacit understanding from the outset that the law would be not opposed to this change (in the definition of death)

• the Pope had made it clear as well-- that diagnosing death-- "recognizing death" was a medical matter and not a religious matter"
• in Canada and America everything around you is working towards you deciding in favor [of donating]. And everything in Japan is working towards making you not do it if there's any hesitation.

• Why The Japanese are not ok with "brain death"
• There was very little religious opposition to organ donation. 
• "On many occasions Buddhists have said that the saving of lives, and giving and being generous are very positive things." (Lock) 
• The first heart transplant in Japan was a big problem,--- 1968, and after the brief accolades and talk of medical triumph, it was discovered that the doctor had needlessly endangered the life of the recipient (who later died) and lied about details of the procedure. 
• This confirmed an already strong distrust towards the medical establishment. 
• It wasn't until 1999, after the Organ Transplant Law of 1997, that another heart transplant took place.
• The Japanese bar association was opposed to the concept of brain death from the outset, "partly to do with rivalry with the medical profession, but partly to do with rather conservative beliefs, concerns about tampering with the body." (Lock)
• Culturally, Japan is very concerned with reciprocity and was never comfortable with notions of charity and the rhetoric of "the gift of life."
• "If you're giving something that is as symbolically valuable as a human organ, then surely there must be some anticipation of some sort of reciprocity. So to just give anonymously is breaking through a strong cultural tradition." 
• Donating to strangers would also cause feelings of disquiet. (can't engage in exchange)
• In Japan, death is a socially determined event, a process, not a moment. 
• In the intensive care unit families are left with complete control about deciding when the ventilator will be turned off.

• Difficulty of research
• These decisions are made under enormous pressure, and often a a family member has died under horrific circumstances. Family members are asked to permit this body to be cut up and retrieved from   
• particularly difficult with a child

• Moral Economies of Science 
• value culture over nature
• culture is an improvement over nature
• science is exemplary of progress
• science is "valueless" and "rational"
• death is separated from religion ---defined by science
• lay people do not have the expertise or objectivity to judge