M. Strathern

M A R I LY N S T R AT H E R N

Gifts money cannot buy

How might one consider debt in a highly emotional situation where its discharge is not possible? In the UKarena of bodily material procured for research or medicine, donations cannot be reciprocated. What are called‘gifts’ are not only made to diffuse entities such as society or science, the procurement and treatment processoften creates specific, if anonymous, recipients who are burdened with/grateful for a gift they cannot repay.Indeed to pay – and thus pay-off – the perceived debt is usually against the law. The gift entails, and hencesummons, the absence of money. This article offers a comment on gifts in a context where money foreverhovers on the margins of the imagination, and where the more it is banned from sight, the more it creepsback in. In endless discussions about remuneration or compensation payments that are meant to fall short ofoutright purchase, people tend to focus on the characteristics of diverse organs and tissue, including gametes,and assume they know both what money is and what the gift is. The anthropologist is less certain. Totemicdebates in anthropology come to the rescue in a rather odd fashion.

Key words money, the gift, organ and tissue donation, sacrifice, altruism

More than 20 years ago, Abrahams used the title Plus ca change, plus c’est la memechose? for an article on organ donation. A comparative anthropology could point to allthe ways in which practices people in the UK take as novel have counterparts alreadyelsewhere in the world. Thus kidney donation between close kin is reminiscent of thosekinship practices where a man raises a child in the name of a deceased relative, forgoingthe opportunity to have a child in his own name (1990: 136). The comparison here isin terms of self-sacrifice: a vital part of oneself given up for the regenerated future ofanother. He also suggested that when the donation of bodily substance is felt to createa debt, it is like the perpetual debt of birth and nurture that in some kinship regimesone generation may owe another, debts that can never be repaid (1990: 133).

For me going back to that piece of the phrase, the more things change the morethey remain the same, takes on another colour. Over 2010–11, I had reason to learna little about organ and tissue donation (from a UK perspective)1 and many of thecircumstances being talked about today – in public and professional discussion – are

1 The Nuffield Council on Bioethics, a UK body funded by the Nuffield Foundation, the MedicalResearch Council and the Wellcome Trust, which produces reflective reports on ethical and socialissues in the changing arena of biomedicine, wished to revisit the question of incentives for donorsof bodily materials. Over 18 months, I chaired a multi-disciplinary Working Party to inform theNuffield Council on the matter, whose report (Human bodies: donation for medicine and research)appeared in 2011. It might be assumed that this involvement created a fieldwork platform for me.While it indubitably aroused my interest in the issues discussed here, I must be quite emphatic thatI made it nothing of the sort. The present argument comes from materials already in the publicdomain (including the media reaction noted at the outset) that I was reading at the time. While therewas no doubt/hopefully some cross-illumination (both ways), the present article is not an accountof that work.

Social Anthropology/Anthropologie Sociale (2012) 20, 4 397–410. C© 2012 European Association of Social Anthropologists. 397doi:10.1111/j.1469-8676.2012.00224.x

398 MARILYN STRATHERN

presaged in that article. Despite changes in technological possibilities, in practices ofethical oversight, in patterns of living and deceased donation, when it comes to howdonors and recipients accommodate the transfer of bodily material similar concernsand dilemmas repeat themselves. One realises just how many starting points to analysisthere could be. Much of the literature is written accessibly enough; it is the way itengages with a salient category also found in anthropological theory that makes thingsnot at all straightforward. And it is a category I thought I knew how to deal with: thegift.

My focus is a transaction construed as a donation for which no return is expected,but where both recipients and donors often feel that something is missing. Oneindigenous interpretation is to imagine that what is missing is reciprocity; it is fromits absence that a sense of debt comes. The interest of this situation is precisely itsentanglement with the concept of the gift. Anthropologists obviously share ‘the gift’with all manner of people who deploy the term too. What is startling is how recentarguments outside anthropology take one back to a more distant juncture within thediscipline.

En te r money

42% yes, 57% no: these were figures from an opinion poll conducted by The Guardian(20 April 2010) newspaper, which had been running a series on experiences of organtransplantation. The answers were to the question: ‘Should donors be materiallyrewarded?’ This appeared on the day that the UK Nuffield Council on Bioethicslaunched an on-line consultation to examine ethical issues in connection with a person’sdecision to donate some part of their body for medical treatment or research. TheCouncil had given itself a broad remit – to take into account whole organs (from bothliving and dead donors), gametes, blood and other bodily tissue, and participation infirst-in-human clinical trials. It also gave itself a broad question: How ethical is it to offerincentives in encouraging people to donate? The question of incentivisation arises fromreported, perpetual, shortages of bodily material. Without putting weight on them, TheGuardian’s figures indicated two broad bands of opinion about material reward: 42%‘show me the t-shirt’; 57% ‘it is unethical’.2

The t-shirt was an example of a non-cash incentive that might encourage peopleto go on the organ donor register, and the consultation trailed it alongside tokens ofgratitude and initiatives for living organ donors such as pooled organ donations orbenefit-sharing in the form of priority should they ever be in need themselves. Oneincentive above all dominated the media reaction. The consultation document had alsoaired possibilities such as direct financial remuneration and a regulated market, and itwas the prospect of offering payment that the press seized upon. The Council, it was as-sumed, was really asking ‘whether it would be ethical to pay people for their body parts’.And payment quickly became buying and selling: the newspaper headline to the pollwas ‘Organs for sale’. From incentive to payment to the market, it seems these notionsslide into one another very easily. It is of course the idea of money that allows this.

2 The newspaper’s question was: ‘Medical experts have suggested rewards for organ donors, such asan expenses-paid funeral, or souvenir mugs and t- shirts. Should donors be materially rewarded?’(http://www.guardian.co.uk/commentisfree/poll/2010/apr/20/nhs-organ-donation).

C© 2012 European Association of Social Anthropologists.

GIFTS MONEY CANNOT BUY 399

An image Gell (1975) describes from the Umeda of Papua New Guinea comes tomind: the dance sequence of diverse persons who hold the stage one after another butwho are, he surmises, all one personage in various moments of transformation. Whenit comes to donations of bodily material, and iconically whole organs, one characterwaiting in the wings, dancing onto the stage in numerous characters but always withthe same name, is money. Money mobilises an extraordinary range of sentiments andemotions: flourishing in many places, it is forbidden in others; now gives value to things,now takes value away, and has the capacity to seemingly dissolve everything into itsform. The particular dance of money dwelt on here is a familiar one: its delineationof – the boundaries it draws around – what is deemed acceptable behaviour.

Money would not be the incentive it is understood to be, or attract media attention,if there were already an open market in organs. Black markets flourish, a disgracefultrade in organs from both living and deceased bodies, and locating them in the globalSouth does not distance it from the UK or North America – what happens in affluentcountries feeds that trade through transplant tourism. However, my own focus is onthe highly regulated systems to which these relatively affluent countries themselvessubscribe, both nationally and through international protocols. And one marker ofthe fact of regulation itself is, in the area of organ donation, keeping money atbay.

The UK Human Tissue Act (2004) prohibits commercial dealings in humanmaterial for transplantation, the stance taken by the 1997 Council of Europe’s OviedoConvention, and the 2008 Declaration of Istanbul among others: organs should notbe treated as commodities. It is not that money plays no part at all. Indeed thereare endless discussions about the appropriate forms of reimbursement (of expenses)and compensation (for time and ‘inconvenience’) that donors can be paid. Organprocurement and transplant services are underpinned by commercial enterprise, andonce removed from the donor material apart from whole organs – tissue of allkinds – circulates among third parties as a commodity. So it is not the bodily nature ofthe material that seems at issue. Rather it is the process of procurement or extractionfrom the original body that must be shielded from a particular kind of monetaryexchange. This is most specific in the case of whole organs, whether from the livingor deceased, where a recipient can be imagined. The two parties are joined by theirexclusion from commerce. In brief, the donor cannot sell and the recipient cannotbuy.3

One implication is that money is prevented from doing the work it ordinarily does.Many things are detached from those who possess them and acquired by others throughsale and purchase, the simple effect of monetary transfer. But donors and recipients oforgans cannot deploy money to do the work of transfer. Of course, there are numerouscontexts in which people transact with things and with themselves without resortto commerce. What is arresting in discussions about the ethics of donation is thatwhere money is most emphatically banned it is also most constantly on the horizon.Its banishment to the outer edges creates a meaningful absence. This is the backdropagainst which transfer is effected.

3 Except in donations between those already known to one another, anonymity and clinical practicemean that ordinarily the two are never in direct contact, the transfer being mediated by specialistprocurement nurses, and so forth.



Imba l ance

From accounts of organ transfer, it seems that both donors (in the case of cadaver donors,their families, who are invariably asked to consent to the donation) and recipients (theymay have families too) often feel that something is missing, maybe something notproperly articulated. A difference between donations among those already related andthose who are not is that, in the latter case, desiring to know who has been the donoror who the recipient becomes one of the elements that people think would help theiraccommodation of the transfer. ‘One donor mother . . . speaks . . . of locating an organrecipient [the organ coming from her deceased offspring] as akin to finding a long-lostchild’ (Sharp 2006: 196).4

The missing element seems linked to the pressure people often feel under. Abrahamsreported how ‘the request for a kidney [for a kinsperson] creates tensions and mixedfeelings of reluctance and guilt in potential donors’ (1990: 136). The coercion of therequest has long been recognised by the transplant profession, but the complexity offamily entanglements is usually taken as an externality beyond their competence. Thenthere is the other pressure, one felt by potential recipients not wishing to accept an organfrom a close relative pressing it upon them. A study of living donors in the US offersseveral examples of elderly people being persuaded to accept a kidney from a relative,the would-be recipient’s initial distress at the idea turning into acquiesence. ‘I said, I’mnot taking my daughter’s kidney! But other family members persuaded me . . . It didn’tfeel like it was the right thing to do. Help should go the other way, from parent to child’(Kaufman et al. 2009: 33).

Speaking of cadaver donations (also in the US), Sharp (2006: 108) observes thatthe knowledge that recipients’ ‘well-being springs from the lost lives of others’ is aburden some find ‘overwhelming’. One recipient of a kidney from a deceased donortalked of ‘donor guilt’. As a result, many recipients feel ‘they are not entitled to speakof ongoing forms of suffering because their surgeries have saved . . . their lives’ (2006:108). One solution in the US is public conventions at which thankful recipients givetestimonials to the miracle that has extended their lives. As the survivor of a hearttransplant declared: ‘I am alive today only because of a young twenty-year-old man whodied very suddenly . . . Every day I think of him . . . I can hear his heart beating insidemy chest’ (2006: 111, original emphasis). Sharp points to one way of articulating thesense of something missing when (after Fox and Swazey 1992) she observes that manyrecipients of cadaver organs struggle to make sense of an ‘imbalance’. The imbalanceis between what they received and – and what? Well, nothing: no recompense to thedonor can be effected by the recipient. Nonetheless, their families are there: whenorgan donor families do manage to track down a recipient, the possibility of creatinga relationship can offer succour on both sides, and there are stories of the sense ofobligation created between those connected by the surgery. Recipients in turn may beencouraged by procurement professionals to write thank you letters to their unknown

4 This is the first of several studies undertaken in the USA on which I draw; the US literature is readwidely in the UK. From time to time I note points of divergence from UK practice, but do not hereembark on a deliberate comparison between the countries. The desirability of this was mentionedby a reviewer of the present article, and it is a shame it cannot be pursued here; however, thespecific regret gives me an opportunity to thank the reviewer more generally for his/her penetratingcomments.



donors, and some feel they owe it to donors to take special care of their organs. Thesegestures towards making up what is missing are gestures towards what Sharp identifiesas ‘reciprocity’: a burden weighs upon people precisely because of the perceived inabilityto reciprocate.

Now the invitation to examine what reciprocity means probably conjures up forthe anthropologist a bit of social or relational glue, but that is not necessarily impliedin general discussion. In the vernacular reciprocity can also be understood as a kind ofself-interested tit-for-tat, by contrast say with (dis-interested) ‘altruism’. Nonetheless,one way in which people deal with what is missing is through imagining things might bemore balanced – a sense of exchange between those thought of as donor and recipientwould help all parties. It is as though a shadowy contract had been created by thetransfer, maintained as a debt the one owes or has discharged to the other. Among theliving, ‘Many prospective and actual donors view donation as simply “giving back” forall a parent or other relative has done for them’ (Kaufman et al. 2009: 24).

It seems to be in the absence of money that a need to show reciprocity is articulated.After all, a monetary exchange would otherwise take care of reciprocity. Or wouldit? Or to put the question another way, even when there is a felt imbalance, is therestoration of reciprocity only and inevitably at the root of the sense of somethingmissing?

Dramas o f g i v i ng

Perhaps what keeps money at bay, and thus ever present in its absence, is also whatcreates that shadowy sense of contract: the concept of the gift. I return to the gift inorder to follow through an analytical point, that in this arena some of the contours ofgift-giving have the contours of a monetary transaction. The isomorphism between giftand payment extends, we shall see, to an ambiguity in each.

It can be controversial to use the term ‘donor’, rather than provider or somethingmore neutral, for the source of organs, though it is prevalent across the spectrum ofprocurement agencies, clinics and regulators in the UK. For laid over the process ofdetachment and attachment, in lieu of money is the language of giving, and specificallyof gift-giving. Reference to gift-giving is not confined to organs; originally applied inthe context of blood donation, the procurement of bodily material of all kinds maybe described as a ‘gift of life’. The phrase is part of an international language. It mightmerely seem a colourful figuration of the idea of donation, with its stress – leavingaside the tyranny of the gift (Fox and Swazey 1992) – on something voluntarily yielded.However, for any critical commentator there is a question about the work the conceptdoes. It appears in two dramatic forms, now at cross-purposes, now in concert witheach other. I first narrate the drama of Gift and Commodity, then that of Gift andAltruism.

First, the commodity, which in being normally opposed to the gift can also be hiddenby it. Bluntly put, the language of gift conceals commodification of the body (Sharp2001; 2006: 12; see also Frow 1997: 171). Pushing into the background the commercialuse subsequently made of body parts, and the manner in which bodily material mustbe depersonalised for the sake of medical practitioners, appeal to would-be donors is interms of the generosity of their gift. In fact it is not just donors who are persuaded bythis language, the argument goes; it is appropriate for recipients too, and not least for



third-party professionals who also need to invest their acts with significance. The giftis where the commodity is not.

Yet it is already a gift shaped in a particular way. It has some of the contours ofthe commodity in a monetary transaction: it effects an alienation.5 For the gift peoplehave in mind is the gift that, without expectation of return, brings about transactionalclosure. The donor’s consent or wish does the work of alienation, recognised in law.As stated in a protocol for giving blood for research: ‘Your sample will be used foracademic (non commercial) research purposes only. In a legal sense it will be treated asa “gift” and you will have no claim over the same should the results of this research leadto commercial development’. The voluntarily-given gift, once severed, is freed up forfuture transactions. In other words, if the language of the gift conceals commodification,the gift already conceals the commodity.

When bodily matter is received by third parties, such as tissue banks for researchpurposes, the transactional form of the gift purifies the substance, in so far as donorscan have no further interest in its future. In keeping with this there is no materialreturn, either at the outset or later. When the gift has a specific recipient, however, as inwhole organ donation, there is no question of any future exchange value – the organ ispressed into use at once. Indeed, sustained through immunosuppressant drugs, it muststay alive, in the case of the heart keep beating, along with the recipient’s own organs.In making attachment less certain perhaps this work the organ has to do also makesdetachment (from the donor) less certain too. Alienation appears less clear cut. Thisis true in another sense. Appealing to people to give means that the donor is beingtreated as an active agent, as someone who might have acted otherwise, and there is thequestion of recognising that choice. The tyranny of the gift may have less to do withcoercion, and more with the expectation that acknowledgement would be appropriate,a recognition that the consenting donor – or their family – took a particular decision.Appreciation of the action taken would be a return. ‘Oh, recipients where are you,you who live because our beloved donor has died? Can you not acknowledge yourappreciation to your anonymous donor’s beloved family? After all, the organ didn’tcome from a donor, it came from my beloved brother’ (Healy 2006: 29 from an on-linememorial; see Sharp 2001: 126–7 for the original rendition).

For the second drama, altruism shapes the gift all over again. In everyday parlance,altruism is not opposed to the gift; on the contrary it is supposed to enhance it.Discussions that uphold the virtues of the gift of life invariably figure the donoras a disinterested, altruistic person. It might seem, then, as though altruism simplysupplements the absent commodity, underlining the significance of giving withoutmaterial return. However, it reminds one of another facet of the commodity too, thatthe ‘single’ transaction creates ‘two’ parties; altruism conjures a similar dyad. Nowone may talk of altruistic effects without implying altruistic motives, but in much ofthe literature the epithet is assumed to signify inner disposition. Gift-giving implies acertain state of mind. While one could say this of any action, it comes with a pointerto sentiment created in its extension towards other persons. The idea of altruism turnsthe alienating character of the gift-without-return into an alienation for the sake ofsomeone else. This is where the disinterest comes in. And the other party – knownrelative, complete stranger, future compatriot – is there for the imagining. So too isthe absent reciprocity between them: altruism contours the gift in a second denial of

5 This kind of gift has the contours of the commodity, not vice versa. The terms are not reversible.



reciprocity. Why otherwise should the crediting of altruism to the donor, as a moralevaluation of the donor’s acts, bear in on the recipient’s sense of obligation?

We could stop now, with the view that disinterested altruism doubles up the notionof no return. Yet this would overlook its frequent identification in situations wherereciprocity also flourishes. I refer to the flourishing of sentiment in interpersonalcontexts (Cheal 1988), including familial ones, such as the reciprocity in kinshipanticipated by Abrahams (1990: 132, 139). Here both altruism and gifting are construedto contrary effect: they are supposed to go with a mind-set appropriate to keepingrelationships going for their own sake.

Where the debt created by the altruistic gift is regarded as a burden, it is highlysuggestive that accounts of live organ transfers between kin veer between stress laidon the obligations involved in relationships, to which I have made reference, and tothe contrary need to suppress talk of obligation. Some may assume that the youngergeneration has a ‘natural’ obligation to donate to older kin. One woman, from the USstudy of live donation already mentioned, donated a kidney to a boss and friend whowas ‘like’ family: ‘We’re like family – it wasn’t a question. It was an easy decision . . . Idiscussed it with my daughter [who had only one kidney herself, for whom the mothermight have been a future donor] . . . [and she] was totally for it and she and I talkedabout it and I didn’t even have to say anything. She was the one who said, “Well,I have two sons, you know, if I need a kidney . . ..” And that made me even morecomfortable.’ (Kaufman et al. 2009: 38–9). Children assist in their parents’ project ofself-responsibility for keeping healthy. ‘Not only must older persons continue to live,but also younger persons must give . . . [O]ld and young are deeply committed to oneanother, sometimes beyond deliberative choice. “It’s just something you do, no questionabout it”, we were repeatedly told by donors’ (2009: 24). If the not-thinking-about-itshields actors from articulating any kind of calculative self-interest, for some there isnonetheless an expectation of an indirect counter gift – that the altruism of one willencourage future altruism in others.

What kind of altruism is this? In this particular narrative of the gift, the graphicnotion of giving for no return also belongs to an area of interactions where – amongkin, friends, intimates – returns are routine, reciprocities abound. The recipient may becompelled to receive the gift of a longer life regardless of health or suffering becauseof a debt another feels. So any single altruistic act is likely to be part of a longersequence; one has others in mind all the time. Now when others are in mind all thetime, it is not at all clear where self-interest and other-interest begin and end. People askthemselves how altruism can remain disinterested.6 Indeed, the professional literatureseems often perplexed by how to label the mixture of interests found in family life orclose interpersonal relations.

If the altruistic gift can simultaneously deny and point to reciprocity, we encounterthe ambiguity evident in commodity transactions. Both effect alienation at a singlestroke and entail a transfer between parties. My question is whether those seekingacknowledgement or relationship or familial connection imagine that reciprocity willfill in what is missing. A specific answer is embodied in the example of the cascadingrelations of obligation that cannot be named: the woman with one kidney whosupported her mother’s donation to another in the expectation that one of her own

6 In the history of blood transfusion (Whitefield nd), wartime propaganda to create a visible ‘recipient’was first thought to violate pure altruism, and then to encourage it.



children might come forward should she have need herself. A general answer is thatsummoning the idea of reciprocity is beginning to look like a place-holder or stop-gapthat reiterates the lack (something is missing) rather than specifies what would remedyit. Nonetheless, the concept has been taken up as a response7 to continuing ethicalquestions concerning appropriate treatment of parties involved in organ transplants,and other transfers of bodily material, and to them I turn briefly.

The end o f t he g i f t ?

For years, in both the US and UK, there have been advocates for a market in organs –regulated or otherwise – that would render the language of gift and altruism redundant.Recently, however, other arguments have begun appearing that directly address theplace of the gift in donations of bodily material. Some prophesy the end of the gift.Four brief versions of these arguments follow.

First, commentators point to the increasingly commercial environment in whichbodily material circulates. If conventions about the donation of body parts asaltruistic gifts of life once held the moral high ground, it is now argued thatthe model of a gift free of proper compensation may have run its course. Toomany counter-examples have built up where ‘the gift form’ simply ‘cannot functionas a rejoinder or clear alternative to the incursion of market values into humantissue economies’ (Waldby and Mitchell 2006: 182). Most body tissue circulatesin fractionated rather than whole units, which complicates thinking in terms ofdonors and recipients; there is uncertainty about donating for unknown researchuse, not to speak of financial profit derived from procurement schemes, and so on.All in this view demand re-thinking the act of donation. First, then, the gift is ananachronism.

Second, frequently discussed among practitioners, ethicists and regulators is thedegree of compensation or remuneration that should find its way back to donorsand their families. The act of giving needs facilitating, many say, and along withreimbursement of expenses some financial recognition of the role of the donor andtheir families might make giving easier. Proper compensation for the families of deceasedorgan donors could increase overall supply and in unregulated areas check the abusesof the black market. Here the gift can be encouraged or supplemented by financialsupports.

Third, a more complex debate gives the gift a new location altogether. It would betoo much to throw out the benefits of altruism (it is said), and indeed is not necessary, for‘an organ market can efficiently coexist with the present altruistic procurement system’(Goodwin 2006: 151). A lawyer, writing of African America, Goodwin advocates amodel involving funeral expenses whereby potential organ donors (who have madetheir wishes known) do not receive anything while alive but know that paymentwill come to their relatives at death; this would conserve the notion of altruismwhile providing remuneration for the deceased’s family. Such a ‘hybrid’ system fororgan procurement explicitly ‘supports altruistic procurement’, for it ‘would allow

7 By diverse professionals; also by academic observers and commentators as in the following examples(all with primary disciplines outside anthropology).



for altruism and commoditization to mutually thrive’ (2006: 21).8 This third set ofarguments does not jettison the altruism seen in gift giving, but ties such giving to thekinds of transactions the gift was once thought to deny.

Among other things, in this view, payment would signal a compulsion to reflectsomething of the transactional complexity that defines the body part’s career. Anexclusive focus on gifts conceals the often-remarked fact that ‘human donations enter[the organ procurement and distribution system] altruistically and exit commercially’(2006: 18). Remunerating (‘compensating’) the relatives of deceased organ donors couldcreate a more equitable system than exists at present, embracing ‘a transparent butlimited market approach’ (2006: 21). Goodwin points to a precedent for market systemscoexisting with altruism in gamete donation.9 In the US, but not the UK, egg donationfor fertility treatment, which is often very close to a market transaction, contrasts withdonation for research, where payment is at present legally forbidden. Thompson (2007)has proposed that donors who provide material for research should be treated as researchsubjects, and receive proper payment. Direct commercialisation is to be avoided, butmonetary compensation computed on the basis of a wage would lead to both a betterprocurement system and justice for the donor. If it is the fear of driving out the ethicalimpulse of altruism that prevents recompense, egg donation for fertility treatment,she argues, shows that the two kinds of motivation, ‘far from being incompatible,seem to bolster one another . . . It is wrong then to worry that being paid substitutes afinancial for an altruistic motivation’ (2007: 208). The willing research subject can stillbe regarded as making a donation to science or to society; ethical ends (it is claimed) canstill be met. Although in the UK direct remuneration for either kind of egg donation isforbidden, there is discussion at present about more substantial compensation for thosewho donate to research; an experimental ‘egg-sharing’ scheme for such donors founddifferent motives sitting side by side (Haimes et al. 2012). Altruism, by itself a proxyfor the disinterested gift, can coexist with payment.

Fourth among arguments newly aired is the idea that acknowledgement of a giftneed not be a terminus to a relationship but in the case of tissue given for researchencourage the development of one. It envisages on-going relations between donorand recipient. Questioning whether we may be ‘witnessing the end of the traditionalgift relationship’ (the gift given for no return), between participant and researcher,the authors of a UK study (Haddow et al. 2006: 2) of DNA databases and theircommercial potential suggest that people are interested in the future of what theyhave given not in terms of a return to themselves but in terms of the common goodand future society. Individuals, it is reported, would be content if the community werea recognised stakeholder in any commercial returns. The authors propose a benefit-sharing (including profit-sharing) model in which donors are imagined as having arole as research participants. Benefit-sharing could either displace or extend the ideaof the gift; they go for displacement. Given their view that the altruistic tenor of the‘traditional’ gift implies no enduring obligation on the part of researchers and profiteers,they say it is important to leave it behind. The gift must be remodelled to encompassthe continuing obligation now advocated.

8 Compare Sharp: paying burial fees ‘unabashedly commodifies human organs’ (2001: 116); Goodwinadvocates dialogue about the benefits as well as drawbacks of commodification. There is nosuggestion of direct compensation to living donors.

9 A point anticipated by Radin (1996).



Where I have moved away from organ donation, it is to suggest that currentarguments over adding money while saving altruism are part of a larger field ofdebate across different types of bodily material. The proposition that the gift could besupplemented by money – or generate relationships – once more points to reciprocityas a remedy for what is missing in present arrangements. Even where the gift isetherealised into the sentiments accompanying donation, when what is left are feelingsof altruism or obligation, it is suggested that material and immaterial transactionscan coexist. In short, insofar as it is thought to bring closure to people’s concernsand difficulties, reciprocating the gift is imagined as doing the work of transferthat monetary transactions do, not in their absence but actually, now, in their verypresence.

And?

But will this notion of reciprocity do? Is closure what people are seeking? Are debts tobe paid off? Or will reciprocity conceal again what is missing? I quote Sharp’s researchon cadaver donations for the last time: closure is impossible, she says (2006: 164).

When I began in this area, I had been reading Juillerat, whom Gell encouraged towork in Yafar, Papua New Guinea. If advocates for greater compensation for bodilymaterial are in effect attaching reciprocity to the once disinterested gift, Juillerat’smessage was the reverse. His reference was the ‘traditional’ Maussian/Levi-Straussiangift as anthropologists would see it: specifically the obligation in the formulation ofreciprocity was the very problem. ‘Melanesian ethnography shows that (the intention of)giving does not necessarily entail the obligation of receiving or reciprocating’ (Juillerat2002: 11). In its place he puts desire and its psychic consequences. Yafar gifts can bedivided into those that are reciprocated and those that are not. To allow theoreticalroom for the latter, he concludes, ‘we should pursue the unshackling of gift-giving fromexchange, to which Levi-Strauss’ theory bound it’ (2002: 183).

Juillerat drew me to think again about the ‘traditional’ Euro-American formulationof the disinterested donor of bodily material. The Yafar donor to whom no returncan ever be made is a primordial spirit Mother who showers her bounty on initiatesand would-be hunters, her gift ritually enacted under the maternal totem, a floweringcoconut. For the men who stand under the palm, the event is an omen of futureflourishing: eyes averted, they are in a state of anxiety as to whether or not flowerswill fall into their upturned hands. Many, Juillerat tells us, will fail to receive theMother’s gift. No-one can repay it. And I had a sudden image of organ and tissueprocurement programmes, research bodies and fertility clinics: always chronically shortof raw material, they have their hands outstretched too. What they so avidly desirecannot, they believe, be taken.

How to express the dependency of recipients? How much reciprocity would beneeded so to speak to alleviate it, and should it be alleviated? Should things be madeeasier? Think of the organ transplantees who, as the object of someone else’s altruism,feel they cannot talk about their own continuing medical misery. Why? Because theother’s sacrifice was too great. Research in the UK (Sque et al. 2008) to answer thequestion of why some families of deceased persons approached by organ procurementprofessionals refuse to allow their relative’s body to be used, explicitly pushes thegift aside for this reason. The authors take organ donation as fulfilling the criterion of



personal sacrifice, good deeds or gifts to others undertaken at great individual expense.10

Concomitantly, people’s aversion to relinquishing guardianship of the dead body hadless to do with objections to donation, about which many were positive, than withthe widely reported (e.g. Rid and Dinhofer 2009) concern about the integrity of thebody. They baulked at allowing the body to go under the surgeon’s knife in suchcircumstances. Refusal made them feel guilty and selfish, but they were being asked togive up too much.

Cohen (2001: 22–3) famously describes how, in one (illegal) organ market, people’sefforts to save their kin from sacrificing themselves through organ donation includepurchase from a vendor. It is the vendor whose sacrifice is disregarded. Maybe he pointsto something else too: the universal language of the gift, and specifically the altruisticgift, under the highly regulated regimes considered here, can put the voluntariness ofthe act in front of acknowledgement of harm suffered for another.11 For supplementingthe gift with more material reciprocity is not going to address the question of sacrifice.In this frame, it is not as so many have fearfully argued that payment would take awayaltruism, substituting self-interest for other-interest, but that reciprocity would takeaway sacrifice.12 Nothing is adequate to loss. What the idea of ‘sacrifice’ conserves, inthis thinking, is the suggestion that what is missing is indeed precisely what is missing:a vital part of embodiment, whether one’s own or another’s. Two sisters who had eachin turn donated a kidney to their father said: ‘This journey is not about choice. It’s justsomething that you do. We weren’t forced to . . . We were willing to sacrifice our livesto maintain the integrity of the family unit’ (Kaufman et al. 2009: 35). This brings us towhere we began: Abrahams’ East African comparison was in terms of self-sacrifice – avital part of oneself given up for the regenerated future of another.

Othe r s t a r t i n g po i n t s

It also comes back to the reflection on multiple starting points. Returning to theobservation about self-sacrifice reveals that what could have been a starting point wasnot taken as one – it has only re-emerged at the end. There are other starting points Idid not take.

Rio has an almost throw-away remark that, had I followed it at the outset, wouldhave saved me much labour. Of course, he says, ‘In western society gifts are typicallymodelled after commodity exchange, after economy, and even though gifts pretend tobe a denial of reciprocity . . . they always stand to complement reciprocity – as a shadowplay of economy’ (2007: 451). Then there is the Maussian position that ‘reciprocal [or, asthe author prefers, friend-making] gift exchange is not opposed to, but is an embryonicform of, commodity exchange, and its principles are still to be found . . . in modern

10 After Mongoven (2003).11 Or rather, in what otherwise might be seen as medically safe procedures, the notion of sacrifice

draws attention to harm (for example, the breach of bodily integrity).12 Either as it appears in the accounts cited here (e.g. see Sharp 2006: 164–5), where sacrifice for

another may still trail intimations of reciprocity in its very denial, or taken in further directionsaltogether. I am grateful to Wenzel Geissler (pers. comm., Oslo University) for his reminder ofsacrifice as a transcending act in itself, where an object such as another party or the communitypales into insignificance by comparison with what it brings about in terms of self- (or world-)transformation.



commerce. It is located on the logical and phenomenological trajectory between puregift and commodity, which are therefore shown to be genetically related and mutuallyconstitutive’ (Laidlaw 2000: 628).

Laidlaw is pursuing a longstanding debate in anthropology, for which there are twoother starting points. The distal one is Mauss’s 1925 essay, the proximal one Parry’s1986 rendition of Mauss’s thesis as an archaeology of contractual obligations. Archaicgifts are ‘the forerunners of today’s market transactions, they are the way “the market”operated before its more characteristic instruments (such as money, formal contracts,and “self interest”) had developed’ (Laidlaw 2000: 626–7). Parry joins Godelier (1999[1996]) as a starting point too for Graeber (2001: 158), in reminding us of Mauss’s overallscheme. ‘Mauss emphasizes that in most of the societies he was examining, there’s nopoint in trying to distinguish between generosity and self-interest. It is we who assumethe two should normally be in conflict’ (2001: 162). Graeber’s account contains other‘reminders’ that would have set my own remarks on a different trajectory. The modernideal of the free gift as a mirror of market behaviour (2001: 161) could have lit up a quitedifferent route to detecting the contours of the commodity in the gift. Clearly I couldgo on.13

And clearly I could have saved us all some trouble had I begun with suchconclusions, past and present, about commerce and gift. They might have illuminatedthe account of organ donation from the start. Yet here I pause. If they had, I am not sureI could have simultaneously conveyed what current arguments outside anthropologyare like for an anthropologist to live with, that is, enter into debate with. I haveindeed been trying to argue with (‘with’ in the dual sense of against and alongside),through means including irony and surprise, some of the ideas and formulations incirculation at the moment. And it is they that make these other potential startingpoints, from anthropological debate, fascinating. If the ‘ideology of the disinterestedgift emerges in parallel with an ideology of a purely interested exchange’, then Maussis wistfully looking back, Parry says, ‘on a primitive past where interest and disinterestare combined’ (1986: 458). Indeed, it was a ‘moral conclusion’ on his part that ‘thecombination of interest and disinterest in exchange is preferable to their separation’(Parry 1986: 469; my emphasis). In the contemporary field created by developmentsin medicine where vital parts of persons circulate, it seems to have taken some time toshift general feeling towards accepting (if such is the case) what is conceptualised as thecoexistence of altruism and commerce, of thinking of others and dealing with moneyat the same time. What is new is being categorically explicit about such propositionswhen these terms are so polarised in protocol, regulation and professional practice. Ofcourse the imp money can always dance on to the stage and say, ‘I told you so: you canadd a dash of money to anything!’ Yet among the many things going on here is a hugecultural effort to re-align the separations that have been so precious so long.

Classically, in anthropologists’ own ‘traditional’ rendering, the debt created bya gift is not, insofar as the relationship endures, cancelled by a countergift: ‘to give inreturn does not mean to give back, to repay, it means to give in turn’ (Healy 2006: 146–7,

13 ‘[G]ift and commodity economies [are] . . . always intertwined in various hybrid configurations’(Frow 1997: 124); Gregory (1982: 115) famously pointed to the co-flourishing of gift exchangewith wage labour and commodity transactions; Healy (2006: 114–15) reminds us that Bourdieudid ‘not want to reduce the act of gift-giving to a simple exercise in accounting for one-to-oneexchanges: that would make gifts too much like markets’, and so forth.



after Godelier 1999 [1996]: 42). I would recognise something like that in prestations ofaltruism between close kin. It makes one sit up and think about the assumptions – ormisrecognitions – of those who see imbalance, dependency and admitting the element ofsacrifice as a problem, and its solution in terms of reciprocity. Some say compensation forbodily material can never make up the loss, some that acknowledgement brings closure,while some seek justice in pay-off or pay-back, views wide apart but all negating debt’sother potentials.

Acknow l edgemen t s

This was delivered as the first Annual CUSAS (Cambridge University SocialAnthropology Society) Lecture in 2011, also part of the proceedings of the Debtconference [this volume], and keeps something of its lecture format. Giving it in severalvenues, I hope I made my thanks evident to colleagues at the time. I am particularlygrateful to the Nuffield Council on Bioethics, whose invitation to serve on the WorkingParty sparked my interest. Views expressed here represent neither those of the NuffieldCouncil nor of the Working Party – nor of myself in the capacity of chair.

Marilyn StrathernGirton CollegeCambridge CB3 [email protected]

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