Nancy Scheper Hughes

JOURNAL

OF

HUMAN

RIGHTS

,

VOL

. 2,

NO

. 2 (

JUNE

2003), 197–226

Journal of Human Rights

ISSN 1475-4835 print/ISSN 1475-4843 online © 2003 Taylor & Francis Ltdhttp://www.tandf.co.uk/journals

DOI: 10.1080/1475483032000078189

Rotten trade: millennial capitalism, human values and global justice in organs trafficking

NANCY SCHEPER-HUGHES

Amidst the neo-liberal readjustments of societies, North and South, we are experiencingtoday a rapid depletion, an ‘emptying out’ even, of traditional modernist, humanist andpastoral ideologies, values and practices. New relations between capital and labor, bodiesand the state, belonging and extra-territoriality, and between medical and biotechnologicalinclusions and exclusions are taking shape. But rather than a conventional story of thelamentable decline of humanistic social values and social relations, our discussion istethered to a frank recognition that the material grounds on which those modernist valuesand practices were based have shifted today almost beyond recognition.

What the Comaroffs (2001) refer to as millennial or ‘second coming’ capitalism hasfacilitated a rapid dissemination to virtually all corners of the world of advanced medicalprocedures and biotechnologies alongside strange markets and ‘occult economies’.Together, these have incited new tastes and desires for the skin, bone, blood, organs, tissueand reproductive and genetic material of others. Nowhere are these processes more trans-parent than in the field of organ transplant, which now takes place in a transnational spacewith both donors and recipients following new paths of capital and medical technology inthe global economy.

The spread of transplant capabilities created a global scarcity of transplantable organsat the same time that economic globalization released an exodus of displaced persons anda voracious appetite for foreign bodies to do the shadow work of production and to provide‘fresh’ organs for medical consumption. The ideal conditions of an ‘open’ market economyhave thereby put into circulation mortally sick bodies traveling in one direction and‘healthy’ organs (encased in their human packages) in another direction, creating a bizarre‘kula ring’ of international body trade. The emergence of strange markets, excess capital,renegade surgeons,

1

local ‘kidney hunters’ with links to an international Mafia (Lobo andMaierovitch 2002) (and thereby to a parallel traffic in slave workers, babies, drugs and smallarms) has produced a small but spectacularly lucrative practice of transplant tourism, muchof it illegal and clandestine.

This confluence in the flows of immigrant workers and itinerant kidney sellers who fallinto the hands of ruthless brokers and unscrupulous, notorious, but simultaneouslyrewarded, protected and envied outlaw transplant surgeons is a troubling sub-text in thestory of late twentieth and early twenty-first century globalization, one that combines andjuxtaposes elements of pre- and postmodernity. These new transplant transactions are astrange blend of altruism and commerce; consent and coercion; gifts and theft; science andsorcery; care and human sacrifice.

On the one hand, the phenomenal spread of transplant technologies, even in the murkycontext of black markets in medicine, has given the possibility of new, extended or improved

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quality of life to a select population of mobile kidney patients from the deserts of Oman tothe rain forests of the Amazon Basin.

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On the other hand, new developments in ‘transplanttourism’ have exacerbated older divisions between North and South, core and periphery,haves and have-nots, spawning a new form of commodity fetishism in demands by medicalconsumers for a quality product: ‘fresh’ and ‘healthy’ kidneys purchased from living bodies.In these radical exchanges of body parts and somatic information, life-saving measures forthe one demands a bodily sacrifice of self-mutilation by the other. And one man’s bio-sociality (Rabinow 1996) is another woman’s biopiracy, depending on whether one isspeaking from a Silicon Valley biotech laboratory or from a sewage-infested banguay inManila.

Commercialized transplant, a practice that trades comfortably in the domain of post-modern biopolitics with its values of disposability, individuality, free and transparent circu-lation, exemplifies better than any other biomedical technology the reach and the limits ofeconomic liberalism. In transplant gifts of life and death (Parsons

et al

. 1969) promise tosurpass all previous ‘natural’ limits and restrictions. And the uninhibited circulation ofpurchased kidneys exemplifies the neo-liberal episteme, a political discourse based onjuridical concepts of the autonomous individual subject, equality (at least equality ofopportunity), radical freedom, accumulation and universality (the expansion of medicalrights and medical citizenship

3

). The commodified kidney is, to date, the primary currencyin transplant tourism; it represents the gold standard of organ sales worldwide. In the pastyear, however, markets in part-livers and single corneas from living vendors are beginningto emerge in Southeast Asia.

This paper continues my discussion (Scheper-Hughes 2000b, 2001a, 2001b, 2002) ofthe darker side of transplant practice. In all, three crucial points about the organs tradehave emerged. The first is about invented scarcities and artificial needs within a new contextof highly fetishized ‘fresh’ organs. The scarcity of cadaver organs has evolved into an active

Figure 1. Banon Lupa Slum in Manila: site of active kidney selling.Photo by Nancy Scheper-Hughes

07 s-hughes (jk/d).fm Page 198 Friday, June 13, 2003 12:15 PM

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trade in ‘surplus’ organs from living ‘ suppliers’ as well as in new forms of ‘biopiracy’. Thesecond point concerns the transplant rhetoric of altruism masking real demands for humansacrifice. The third point concerns surplus empathy and the relative visibility of two distinctpopulations – excluded and invisible organ givers and included and highly visible organreceivers. We have found almost everywhere a new form of globalized ‘apartheid medicine’that privileges one class of patients, organ recipients, over another class of invisible andunrecognized ‘non-patients’, about whom almost nothing is known – an excellent place fora critical medical anthropologist (Scheper-Hughes 1990) to begin.

Here I will focus on the networks of organized crime (and so called ‘body mafia’) thatare putting into circulation ambulatory organ buyers, itinerant kidney hunters, outlawsurgeons, medical technicians, makeshift transplant units and clandestine laboratories inwhat economist Jagddish Bhagwati (2002) refers to as ‘rotten trade’. By this Bhagwati meansall kinds of trade in ‘bads’ – arms, drugs, stolen goods, hazardous and toxic products as wellas traffic in babies, bodies and slave labor – as opposed to ordinary and normative tradein ‘goods’. In this instance, the rotten traffic in human organs brings together buyers andsellers from distant locations for fleeting, intimate and illicit bodily exchanges occasionedby a dual waiting list, one formed by mortal sickness, the other by human misery.

Like any other business, the kidney trade is driven by a simple market calculus of supplyand demand. For example, in the Middle East, from the Gulf states to Israel, transplantablecadaver organs are extremely scarce owing to religious reservations, both Jewish andIslamic, about the ontological status of the brain-dead donor, and to the elaborate religiousprotocol for the proper treatment and burial of the dead. Both orthodox Judaism and Islampermit organ transplantation, however, and their religious scholars and ethicists generallytreat

living

donation as a meritorious act, even if the donor has been paid (Steinberg 1996).Consequently, one solution to the problem of long waiting lists of frustrated kidney patientsin this region was found in transplant abroad, in some cases (as in Israel) with the supportof government-sponsored medical insurance. For the last twenty years organized programshave carried affluent patients from Israel, Saudi Arabia, Oman and Kuwait initially to Indiafor transplant and later to Turkey, Iran and Iraq and, most recently, to Russia, Romaniaand Moldova where kidney sellers are recruited (sometimes coercively) from army barracks,prisons, unemployment offices, flea markets, shopping malls and bars. So we can even speakof organ-donor vs. organ-recipient nations.

In India, trading a kidney for a dowry has become a common strategy for parents toarrange marriage for an otherwise economically disadvantaged daughter (Cohen 1999).And, ‘one-kidney’ shantytowns have sprung up in the peripheries of Manila and Thailandto service the needs of Saudi and Japanese transplant patients and, in recent years, agrowing number of North Americans ( Jimenez and Bell 2001). Indeed, the commodifiedkidney has become the poor man’s and woman’s ultimate collateral against debt and penuryin many parts of the world. Meanwhile, transplant package tours are arranged in Europe,North America and Japan, to take transplant patients to China where their surgery isarranged, with the complicity of Chinese doctors and surgeons, to coincide with publicexecutions that provide the primary source of highly lucrative transplant organs.Condemned prisoners are reportedly intubated and surgically prepped for ‘harvesting’minutes before execution.

4

‘Transplant tourism’ has become a vital asset to the medical economies of rapidlyprivatizing hospitals and clinics in poorer countries struggling to stay afloat. The ‘globalcities’ (Sassen 1991) in this nether economy are not London, New York and Tokyo butIstanbul, Lima, Lvov, Tel Aviv, Chisenau, Bombay, Johannesburg and Manila. In general,the circulation of kidneys follows the established routes of capital from South to North, from


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poorer to more affluent bodies, from black and brown bodies to white ones, and fromfemales to males, or from poor males to more affluent males. Women are rarely therecipients of purchased or purloined organs anywhere in the world.

Biosociality or bio-sociopathy? The kidney sellers

New forms of ‘social kinship’ and biosociality are invented to link strangers, even political‘enemies’ from distant locations, described by the operating surgeons as ‘a perfect match –like brothers’, while the pair are normally prevented from seeing, let alone speaking, to eachother.

5

If and when these ‘kidney kin’ meet at all, it will be by accident and like ships passingin the night as they are wheeled, heavily sedated, on hospital gurneys into their respectiveoperating rooms where one surgeon

removes

and the other

inserts

the seller’s kidney of despair,his or her kidney of last resort now magically transformed into the buyer’s precious organof opportunity.

Who, for example, would imagine that in the midst of the longstanding religious andethnic hostilities and an almost genocidal war in the Middle East, one of the first ‘sources’of living donors for Israeli kidney transplant patients would be Palestinian guest workers,

6

or that, as recently as March 2002, Israeli patients would be willing to travel to Istanbul tobe transplanted in a private clinic by a Moslem surgeon who decorates his waiting roomwith photos of Ataturk and a plastic glass eye to ward off evil ( Jimenez and Scheper-Hughes2002a)? Or that the transplanted kidneys would be taken from impoverished EasternOrthodox peasants from Moldova and Romania who came to Turkey to sell smuggledcigarettes until they ran into the famous kidney brokers of Istanbul’s Askary flea market( Jimenez and Scheper-Hughes 2002b)?

In some parts of the world, especially in rural Eastern Europe (Romania and Moldovain particular) naïve villagers looking for work and to make their fortunes in seeminglywealthy cities like Istanbul are tricked and coerced into parting with a kidney by knife- andgun-wielding Russian and Turkish small-time Mafia. Afterwards the kidney sellers returnhome to face ridicule and ostracism. While young men in Moldova are targeted by brokersas fair game for the kidney business in Istanbul, village women in the same economic straitsare recruited to work abroad in more conventional forms of body selling. But

both

itinerantkidney sellers and female sex workers of Moldova are held in contempt at home asshameless prostitutes. ‘No’, corrected Viorel, a 27-year-old unemployed kidney seller fromMoldova’s capital city, Chisenau. ‘We [kidney sellers] are

worse

than prostitutes becausewhat we have sold we can never get back. We have given away our health, our strength,and our lives.’ Months and even years later the young men suffer from deep shame andregret. Nicolae, a 26-year-old former welder from the village of Mingir, broke down duringa meeting in his small home in December 2000, calling himself ‘a disgrace to my familyand to my country’.

But in Turkey one actually finds a diverse population of kidney sellers, some of whomgather at weekends on the sidelines of a minibus station and flea market in Aksaray, adilapidated immigrant section of Istanbul. Among them are indigent Turks, small-timecriminals and recently arrived immigrants from Eastern Europe. Negotiations areconducted over a cup of Turkish tea in a café across the street from the ‘suitcase market’and away from the disapproving stares of the more conventional venders of smuggledcigarettes, Russian vodka, Pokamon chocolates and imitation French perfumes. And likethe carpet sellers and gold merchants at the famous Covered Bazaar of Istanbul, they hagglefuriously over the price of their wares but are always willing to agree to less.


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Figure 2. Vladimir, a stigmatized kidney seller from Minger, Moldova, who was recruited by a local broker and trafficked to Turkey where he was paid $2700 for his organ. Today Vladimir is unemployed and ridiculed as a ‘one kidney’ in his home community. He is alienated from his father and ashamed

to be seen in the village. At the age of 19 he is both bitter and self-hating.


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In March 2002 I sat across from Satilmis K, a 40-year-old former baker with dirt-stained fingers, a deeply lined forehead and a defeated air. ‘I never thought it would cometo this’, he said of his desperate decision to enter the kidney market. Originally from a smallvillage on Turkey’s Black Sea coast, Mr K. lost his job and now shares a one-room flat witha friend. He now lives on the $2 a day he earns as a junkman, wheeling his wooden cartpast the cheap hotels and discount leather shops in Aksaray, collecting scrap metal and oldpop cans. It was in the flea market that he first heard about the brokers in suits who arriveat the weekend looking for sellers. He felt lucky to have run into our ‘broker’ [actually aTurkish journalist in disguise] and was anxious to begin the negotiation. Mr K.’s openingprice for one of his kidneys [‘left or right, your choice’] was $50 000. In the space of a fewminutes he reduced his price to $20 000.

Mr K. believes he is a ‘ perfect match’ for a kidney transplant patient with AB bloodtype. When questioned about it, he dismissed the two badly infected sores on his hand assuperficial wounds. ‘I have had a tetanus shot’, he assured us, though he could not affordthe antibiotic he was prescribed. ‘But I am clean’, he insisted, while unraveling the tatteredblood and pus-stained cloth bandage on his right hand. ‘And I am healthy. I’ve only everhad the flu.’ Mr. K. was unafraid of the surgery because his own brother had lost a kidneyas a result of untreated kidney disease and manages to make do without it. Mr K.’s onlyrequirement was that the operation take place in a ‘good hospital’.

Mr K. had his requirements and he realized that the sale of his kidney was a radicaland risky act, one for which he believed he should be well compensated [‘My final offer’,he said definitively, as we rose to leave,

7

‘is $10 000’]. To the ‘guest workers’ from Romaniaand Moldiva, however, the sale of a kidney seemed an unholy and unnatural act, com-parable to rape, and ‘ theft’ was the term most commonly employed by them, even in caseswhere initial consent had been given to the operation. But for those living in parts of theworld that have been subjected to centuries of colonization, forced labor and peonage, asin the Philippines, the idea of selling a spare body part seems as natural and ordinary asany other form of indentured labor. In the extensive shantytown of Banon Lupa, Manila,for example, the majority of young men are willing, even anxious, to sell a kidney, and theyexpress few regrets afterwards, except for the natural limits imposed on other saleable bodyparts. (‘Can I sell a testicle?’, a former kidney seller from the shantytown asked me. ‘Filipinomen’, he boasted, ‘are very potent, very fertile’.)

In the same

banguey

of unemployed stevedores I encountered an unanticipated ‘waitinglist’, which comprised angry and ‘disrespected’ kidney sellers who had been ‘neglected’ and‘overlooked’ by the medical doctors at Manila’s most prestigious private hospital, St Luke’sEpiscopal Medical Center. Perhaps they had been rejected, the men surmised, because oftheir age (too young or too old), their blood (difficult to match) or their general medicalcondition. Whatever the reason, they had been judged as less valuable kidney vendors thansome of their lucky neighbors who now owned new VCRs, karioke machines and expensivetricycles. ‘What’s wrong with me?’, a 42-year-old man asked, thinking I must be a NorthAmerican kidney hunter. ‘I registered on “the list” over six months ago, and no one fromSt Luke’s has ever called me’, Mr S. complained. ‘But I am healthy. I can still lift heavyweights. And my urine is clear.’ Moreover, he was willing, he said, to sell below the goingrate of $1300 for a ‘fresh’ kidney.

Indeed, a great many eager and willing kidney sellers wait outside transplant units;others check themselves into special wards of surgical units that resemble ‘kidney motels’where they lie on mats or in a hospital bed for days, even weeks, watching color television,eating chips and waiting for the ‘lucky number’ that will turn them into the day’s winnerof the kidney transplant lottery. Such macabre scenes can be found in hospitals and clinics


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Figure 3. ‘Willie P.’, an eager kidney seller in Bangon Lupa Slum, Manila. Photo by Nancy Scheper-Hughes


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in India, Iraq, Iran, South Africa, the Philippines and Turkey. Entire neighborhoods, citiesand regions are known in transplant circles as ‘kidney belts’ because so many people therehave found a temporary niche in the kidney trade. One large extended family in aPhilippine slum can and often does supply a steady stream of sold kidneys, borrowingstrength from across the generations as first father, then son, and then daughter-in-law eachstepped forward to contribute to the family income.

The eager kidney sellers of Banon Lupa shantytown are helped by the many new‘donors for dollars’ transplant programs that are sponsored by enterprising hospital admin-istrators. Dr B. Clemente, Medical Director of Capitol Medical Center in Manila, saw noconflict in advertising to foreigners (especially to patients from the USA and Canada) theavailability of modern transplant services at her modest hospital and of fresh kidneysprocured from local donors for whom (she said) ‘a few hundred dollars or even a large sackof rice is payment enough’. When asked why cadaver kidneys were not generally used, DrClemente replied that the Philippines was a very Catholic country in which a great manypeople still had strong feelings about ‘the proper disposal of the dead’. As for the living?They were free to dispose of themselves as they saw fit, the good doctor replied. Donatingan organ for a small compensation – ‘Remember, we are not talking about

sales

’ – wasconsistent, she said, with Catholic beliefs: ‘They would be acting like the Good Samaritan,saving the life of a stranger.’

Bioethics: the handmaiden of free-market medicine

What goes by the wayside in these new medical transactions is longstanding modernist andhumanist conceptions of bodily holism, integrity and human dignity, let alone cultural andreligious beliefs in the ‘sacredness’ of the body. And, it might fair to ask if ‘the life’ that isteased out of the body of the one and transferred into the body of the other bears anyresemblance to the ethical life of the free citizen (

bios

) or whether it more closely resemblesthe bare or naked life of the slave? Here, I am referring to the distinction made by GiorgioAgamben (1998), drawing on Aristotle’s

Politics

, between

bios

, the proper life of the citizen,and

zoe

– the mere, brute life of the species. Thomas Aquinas would later translate theseancient Greek concepts into medieval Christian terms that distinguished the natural lifefrom the good life.

8

But neither Aristotle nor Aquinas is with us. Instead, we are asked to take counsel fromthe new discipline of bioethics, which has been finely calibrated to meet the needs ofadvanced biomedicine/biotechnologies and the desires of postmodern medical con-sumers.

9

Even as conservative a scholar as Francis Fukuyama (2002) refers to the ‘commu-nity of bioethhicists’ as having ‘grown up in tandem with the biotech industry . . . and [attimes] ‘nothing more than sophisticated (and sophistic) justifiers of whatever it is thescientific community wants to do’ (ibid.: 204).

Not surprisingly, bioethics has offered little resistance to the growing markets in humansand body parts. And today the ‘right’ to buy or sell human organs is increasingly defendedin the world’s premier medical journals, including the

Lancet

and

Journal of the AmericanMedical Association

, among others. Recently, a highly respected transplant professionaldefended the patient’s ‘right to buy’ an organ as a ‘mellowing’ and ‘ maturing’ of medicalethics (Friedlaender 2002). This maturation process to which he refers is the attempt tothoroughly rationalize transplant medicine, stripping it of its early religious trappings (seebelow) and of its humanist biases so as to bring it into alignment with neoliberal conceptionsof the human, the body, labor, value, rights and economics.


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In effect, the corrective field of bioethics and the profession of transplant medicine haveboth capitulated to the dominant market ethos.

10

Growing numbers of transplant doctorsnow argue that the real problem lies with outdated laws, increasingly irrelevant nationalregulatory agencies (such as UNOS), and archaic medical professional norms that are outof touch with transplant realities today and with the ‘quiet revolution’ of those who haverefused to face a premature death with equanimity and ‘dignity’ while waiting patiently onan official waiting list for a cadaver organ. Some argue for a free trade in human organs;others argue for a regulated market.

In the meantime, however, the rupture in medical norms and the disconnect betweenpractice and the law can be summarized as follows: While commerce in human organs isillegal according to the official legal codes of virtually all nations where transplant ispracticed, nowhere in the world are the renegade surgeons (who are well known to theirprofessional colleagues), organs brokers or kidney buyers (or sellers) pursued by the law, letalone prosecuted. It is easy to understand why kidney buyers and sellers would not be thefocus of prosecution under the law. Compassion rather than outrage is the more appropriateresponse to their desperate acts. But the failure on the part of governments, ministries ofhealth and law-enforcement agencies to interrupt the activities of international transplantoutlaws, their holding companies, money-laundering operations and Mafia connections canonly be explained as an

intentional

oversight. Indeed, some of the most notorious outlawtransplant surgeons are the medical directors of major transplant units, and serve onprestigious international medical committees and ethics panels. None has been cast out oreven censored by their own profession, though a few have been investigated, and some aresocially isolated by some of their dissenting colleagues. All practice their illicit trade freely,though the outlaw surgeons move their bases of international operations frequently so asto avoid medical or police surveillance.

One of the world’s leading transplant outlaws, Dr Zaki Shapira of Bellinson Medicalnear Tel Aviv,

served with me on the prestigious international ‘Bellagio Task Force’ ontransplant ethics and traffic in organs (Rothman

et al

. 1997). In one of his subsequent tripsto Italy he was the recipient of a prestigious human service award. Meanwhile, one of DrShapira’s recovering transplant patients in Jerusalem gave me copies of his medical docu-ments that led me to the fraudulent medical society in Bergamo, Italy to whom the patientwas told to forward the $180 000 that his illicit transplant (in Turkey) had cost. But whenI called the ‘medical society’ in Bergamo I was told that it was only a clearinghouse formedical encyclopedias.

The impunity of these transplant outlaws concerns more than governmental lassitudeand medical professional corruption, though these exist. In no small part the surgeons areprotected by their extraordinary privilege over life, death and the bodies of their patientsand by the charisma that accompanies their seemingly miraculous powers. As much as hisyounger colleagues worry about Dr Shapira’s ethics, with few exceptions they continue topraise his surgical technique, his ‘courageous’, if reckless, disregard of medical convention,and the service he is providing to Israeli citizens, even if at the expense of other citizens ofthe world. The same holds true for Dr Yusef Somnez, the notorious ‘Doctor Vulture’ ofIstanbul. The head of the Turkish medical ethics committee lamented that ‘Somnez is oneof our very best transplant surgeons. He is the man who single-handedly put transplant onthe map in Turkey.’

Transplant surgeons do sometimes see themselves as ‘above the law’. In the early yearsof transplant famous surgeons such as Christian Bernard in South Africa and ThomasStarzel in the United States had to battle against the ‘irrationality’ (as they saw it) of thosewho resisted transplant’s necessary redefinition of death as brain death. Barnard, for


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example, refused to respond seriously to his critics, silencing them with his proverbialarrogant reply that the patient was dead ‘when the doctor says he is dead’. That same‘independent’ tradition continues today among the younger generation of transplantdoctors who often still see and describe themselves as societal mavericks breaking down ‘oldtaboos’ standing in the way of advancing technological capabilities. In the face of illicittransplants with paid donors, a great many kidney transplant surgeons simply look the otheraway. Some actively facilitate an informal sale that will save or improve the life of one oftheir patients. Others prepare and counsel kidney patients for transplant trips overseas andadmire the initiative of those who have returned having purchased a kidney from a haplesswomen in a Lima slum or from a Chinese executed prisoner, as the case may be. Patientautonomy, individual freedom, the right to choose and a vague (though unexamined)commitment to a utilitarian ethos of ‘greatest good for the greatest number’ guide a greatmany transplant surgeons’ sense of ‘the ethical’.

In the rational choice language of contemporary medical ethics the conflict betweennon-malfeasance (‘do no harm’) and beneficence (the moral duty to perform good acts) isincreasingly resolved in favor of the libertarian and consumer-oriented principle that thoseable to broker or buy a human organ should not be prevented from doing so. Paying for akidney ‘donation’ is viewed as a potential ‘win–win’ situation that can benefit both parties(see Richards 1998). Individual decision making and patient autonomy have become thefinal arbiters of medical and bioethical values. Social justice and notions of the ‘goodsociety’ hardly figure at all their discussions.

In the late or postmodern, consumer-oriented context, the ancient prescriptions forvirtue in suffering and grace in dying can only appear patently absurd. But the transfor-mation of a person into a ‘life’ that must be prolonged or saved at any cost has made lifeinto the ultimate commodity fetish. And an insistence on the absolute value of a singlehuman life saved, enhanced or prolonged ends all ethical or moral inquiry and erases anypossibility of a global social ethic. Meanwhile, the traffic in kidneys reduces the humancontent of all the lives it touches.

Justice in transplant – scarcity for whom?

The ‘demand’ for human organs, tissues, and body parts – and the desperate search amongwealthy transplant patients to purchase them – is driven, above all, by the medical discourseon scarcity. The specter of long transplant ‘waiting lists’ – sometimes only virtual lists withlittle material basis in reality

11

– has motivated and driven questionable practices of organharvesting with blatant sales alongside ‘compensated gifting’, doctors acting as brokers, andfierce competition between public and private hospitals for patients of means.

But the very idea of organ ‘scarcity’ is what Ivan Illich (1970) would call an artificiallycreated need, invented by transplant technicians and dangled before the eyes of an ever-expanding sick, aging and dying population. The resulting artificially created organsscarcity is ‘misrecognized’ (Bourdieu 1977) as a natural medical phenomenon. In thisenvironment of ‘survivalist’ utilitarian pragmatics, the ethics of transplantation is modeledafter classical ‘lifeboat’ ethics (Koch 2001). With ethical presumptions of scarcity, thereappear to be clear choices to be made, namely who gets into the lifeboat (‘getting on thewaiting list’); who will be shoved off the boat when it gets overcrowded (getting triaged whileon the waiting list); and who will, in the end, be ‘eaten’ so that others may live (race andclass disparities in organs procurement and distribution practices)?

There is little consciousness of the vulnerability of some social classes and ethnic groups


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who can be described as the ‘designated donor’ populations, both living and brain dead. Inthe United States, for example, where cadaver transplant continues to be supported as thenorm for donation (if not so, increasingly, in practice), the brain dead are drawn from apopulation that is disproportionately poor – including whites, Latinos and African-Americans. The poor and minorities are over-represented in the intensive care centers (ICUs)of large urban hospitals, due to their over-exposure to urban violence, higher rates ofhomicide, suicide and vehicular death, as well as the cumulative effects of societal and medicalneglect. The great irony is that those lacking public insurance (44 million citizens) alsocomprise the greatest number of those whose family members are asked to behave altruisti-cally and to donate the organs and tissues of loved ones. That a great many of these poor,African-American and Latino families refuse to donate should come as no surprise. They arebeing asked to support with the bodies of their loved ones a social and medical system thatexcludes them and within which they have a lower probability of receiving an organ, shouldthat need arise. One needs to be relatively affluent and otherwise healthy and well lookedafter to be recommended for organ transplant. The much commented upon refusal ofAfrican-Americans to donate organs should be seen as a political act of considered resistance.

As for living, paid donation, the social inequities are more transparent. Those who sella kidney are normally from social and economic strata where access to basic medical careand necessary aftercare are most often lacking. But to date the only dissident voices raisedagainst the dominant transplant narrative of life-saving come from far afield and aregenerally expressed in unpalatable forms that are all too easily dismissed and discredited.These alternative bioethical positions are often expressed ‘primitively’ and from the socialmargins in the form of rumors and moral panics of body theft and organ stealing, some ofwhich turns out not to be so groundless after all. To a great many of those living on thefringes of the new global disorder, the scramble for ‘fresh’ organs and tissues increases theirprofound sense of ontological insecurity in a world that values their bodies as a reservoir ofspare parts (Scheper-Hughes 1996). While popular resistance in Mexico and Brazil led torevoking new and progressivist laws of presumed consent for the purposes of harvestingorgans, such resistance has been ineffectual or lacking with respect to the growth of theinternational organs market, as those on all sides of the transplant equation have began toaccept as normal and routine these nonetheless still largely covert transactions protectedby transplant medicine’s coyly averted gaze.

Throughout these radical transformations, the voice of anthropology has been mutedwhile the high-stake debates have been waged among transplant professionals, bioethicists,legal scholars and economists. But what other human science and discipline is better suitedthan anthropology to interrogate values and practices from a position of epistemologicalopenness and to offer radical alternatives to the limited pragmatic utilitarianism thatdominates medical bioethical thinking today?

Founding Organs Watch – an anthropology of organs

In the face of this ultimate, late modern dilemma – this ‘end of the body’ as we see it – thetask of anthropology seems relatively straightforward: the recovery of our discipline’s stillunrealized radical epistemological promise, its abiding commitment to basic strangenessand to radical otherness, whilst maintaining a commitment to the critically examinedethical life, while simultaneously risking practical and political involvements in the murky,sometimes criminal and occasionally dangerous field sites under consideration.

To this end my colleague Lawrence Cohen and I co-founded Organs Watch in


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November 1999 as a temporary stop-gap measure in the absence of any other organizationof its kind. We set as our initial task some basic, but necessary, first questions: How doesthe human organs market function? Who are the key players? How are the relationsbetween organized crime and illicit transplant medicine structured? As for the patients,whose needs are privileged? What invisible sacrifices are demanded? What ‘noble lies’ areconcealed in the tired transplant rhetoric of gifting, scarcities and human needs?

The resulting, collaborative

12

multi-sited field research project has investigated anddocumented dimensions of the organs and transplant trade in nine countries focusing onthe medical and social effects on transplant patients and their providers, who constitute

Figure 4. Ray, a Manila-based kidney seller turned kidney hunter and broker for a local hospital’s ‘donors for dollars’ program. Photo by Nancy

Scheper-Hughes


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some of the most vulnerable citizens of the new world order. Additionally, we have observedthe processes through which human tissues – cornea, bone, skin, heart valves, pituitaryglands – are taken, without consent, from the dead bodies in the morgues of public hospitalsand police mortuaries (from Brazil to Israel to South Africa and the United States) and sentto the tissue banks, eye banks, university research labs and biotech companies where thesehuman parts are processed – often for sale.

In the course of this research we have followed kidney patients from dialysis clinics tomeetings with their intermediaries in suburban shopping malls, and from there to illicitsurgery conducted in rented operating rooms of public and private hospitals, some of theseresembling the old clandestine back alley abortion clinics of the 1940s and 1950s.

We have interviewed dozens of kidney buyers or kidney seekers in their homes, indialysis clinics and in their hospital beds to try to understand the conditions of theirsuffering. We have tracked down petty organ brokers only to discover that many of them,like Ray A. were originally kidney sellers themselves who were subsequently hired by theirtransplant surgeons as kidney hunters in their home communities. My associates and I havemet with local kidney sellers in township

shabeens

in Soweto, in squatter camps in Manila,in shantytowns in Brazil, in jails in Israel, in smoke-filled bars in Chosen, and in wine cellarsof Mangier, both in Moldova.

In short, we have gone to the places where the economically and politically dispossessed– including refugees, undocumented workers, prisoners, AWOL soldiers, aging prostitutes,cigarette smugglers, petty thieves and other marginalized people – are lured into sellingtheir organs. And, we have followed, observed and interviewed international surgeonspracticing or facilitating illicit surgery, their lawyers and representatives of their medicalethics boards, and we have attempted to map the international medical and financial

Figure 5. Kidney transplant in Cape Town, South Africa: ‘Whose Kidney?’ Organs Watch keeps an eye on the traffic in human organs. Organs Watch,

Photo by Vivian Moos


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connections which make their work possible. Though I am not proud to reveal it, I posedduring fieldwork in Turkey in February 2002 as a buyer desperately seeking a kidney for afamily member, in order to meet with hopeful sellers at a ‘Russian suitcase market’ in a run-down, immigrant section of Istanbul.

In its odd juxtapositions of ethnography, documentation, surveillanc, and human rightswork, the Organs Watch project blends genres and transgresses longstanding distinctionsbetween anthropology, political journalism, scientific report, moral philosophy and humanrights advocacy. These new ethnographic engagements require us to enter spaces and intoconversations where nothing can be taken for granted and where a hermeneutics ofsuspicion replaces earlier fieldwork modes of bracketing and suspension of disbelief. Howdoes one investigate covert and criminal behavior as an anthropologist? To whom does oneowe one’s divided loyalties? In traveling incognito, as I did when investigating allegationsof illegal organs and tissues harvesting at the Argentine asylum, Montes de Oca, for theprofoundly mentally retarded, I had only Laud Humprheys (1970) and his highly question-able, later roundly condemned, observational study of impersonal sex in public bathroomsas a shaky reference point. But how else, except in disguise, could one learn of the hiddensuffering of an invisible population? How can the mute and the profoundly mentallyretarded possibly speak for themselves? What alternative methods of investigation areappropriate? This kind of work requires a certain militancy

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as well as a continuous andrelentless form of self-criticism and a constant rethinking of anthropological (as well asmedical) ethics and practice.

From priceless gift to pricey commodity – a question of value

Organ transplant is arguably the most intensely social, one might even say sociable, of allmedical practices. The origins of transplantation depended on forging a new social contractand a social trust based on the willingness of people to share the body parts of a brain-deadrelative, a new and periodically contested diagnosis, with a closely matched mortally sickstranger. Organ transplantation is, as Renee Fox so famously put it, both life-saving anddeath-ridden. Under traditional cadaver donation, the ‘gift’ of life simultaneously demandsa ‘gift of death’ by grieving family members willing to accept, often counter-intuitively, theend of the life of a ‘brain dead’ but heart-beating loved one.

Consequently, from the outset the language of organ sharing and transplantation washighly idealistic, ethical and to a degree (mostly subliminal) very Christian.

While exhortations to altruism and to heroic acts are found in

all

the world’s religions,the emphasis in organ donation on bodily self-sacrifice, anonymous gifting and charitytoward strangers resonates with explicitly Christian values. The benevolent ‘mixing’ andsharing of body parts in transplantation evokes deeply Catholic notions of the MysticalBody and the Communion of Saints as well as images of medieval churchyards and theirossuaries where bones collected and mingled and where death itself was collectivized so asto erase all invidious social and individual markers of earthly difference (see Aries 1974).Indeed, the Last Supper and the Crucifixion offer the living a divine model of self-sacrificeand bodily sharing which to this day motivates some extraordinary acts of organ sharing,as captured in the popular film

Jesus of Montreal

. It is no doubt because of these strong symbolic equivalencies between transplant ethics

and a sacramental approach to life and to the care of the human body as ‘borrowed’ butnot ‘owned’ that Rome readily accepted the technology of organ transplant and ‘blessed’the new definition of brain death that transplantation required. More recently, the tacit


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acceptance of brain death for the purposes of organ harvesting was made explicit by PopeJohn Paul II in his brief address delivered to the 18th International Congress of theTransplantation Society on 29 August 2000. At the same time, the Pope reinforced theoriginal transplant ethic of altruism and empathy for strangers that provides the bedrockfor the gifting of cadaveric organs and he condemned commerce in human organs:

Every organ transplant has its source in a decision of great ethical value: the decisionto offer without reward a part of one’s own body for the health and well-being ofanother person. Here precisely lies the nobility of the gesture, a gesture which is agenuine act of love. It is not just a matter of giving away something that belongs tous but of giving something of ourselves, for by virtue of its substantial union with aspiritual soul, the human body cannot be considered as a mere complex of tissues,organs and functions . . . rather it is a constitutive part of the person who manifestsand expresses himself through it. Accordingly, any procedure which tends to commer-cialize human organs or to consider them as items of exchange or trade must beconsidered morally unacceptable, because to use the body as an ‘object’ is to violatethe dignity of the human person.

Obviously, the pope is at least minimally aware that the ethic of the ‘gift’ is under assaultin many parts of the world where the sale of kidneys has become a lucrative business fordoctors (if not for kidney sellers) and for public and private transplant clinics, some of theseChurch linked, catering to wealthy foreign patients. Consequently, both anonymous cadav-eric donation and living related-kidney donation are rapidly being supplanted by trans-plants with kidneys purchased from strangers.

The present scenario began over two decades ago with the realization by transplantprofessionals in the USA and elsewhere that cadaver organs, for many complex socialreasons (Lock 2002) would never supply the growing demand for a steady supply oftransplantable organs. Meanwhile, advances in immunology and the development ofpowerful new anti-rejection drugs such as cyclosporin made close tissue matching betweendonor and recipient unnecessary. The positive outcomes for kidney transplant patients whohave purchased kidneys from impoverished vendors in various parts of the world wherebasic blood- but not tissue-matching procedures are followed, in clandestine commercial-ized transactions, lead to a growing realization that an excellent HLA tissue match is nolonger required to achieve a successful transplant outcome. Today almost any person willingto be an organ donor, ideally medically suited

or not

, can do so. And living donor organs –one kidney, half a liver and lobe of one lung – are becoming the organs of choice to supplythe growing demands for transplant from ever expanding waiting lists. Meanwhile, livingdonor organs are also preferred by surgeons and their patients to increase the longevity andviability of transplants. In 2001, for the first time, in the United States live donor kidneytransplant accounted for 50% of all transplants, and living donor liver transplants rose to10% (Delmonico 2002).

The consumers: the body and commodity fetishism

Transplant procedures are astronomically expensive (in the United States a heart transplantcosts more than $300 000) and are frequently hindered by so-called shortages in organs.The media, prompted by organs procurement organizations, produce frequent referencesto the numbers of people who will die each year waiting for an organ. (There is no system


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to track or record the health, medical problems, or deaths of those who have donatedorgans.) In the United States over 70 000 people appear on organs waiting lists. Every yearthe demand for organs increases as transplant organizations, transplant professionals andpatients’ rights groups demand that new (and marginal) categories of people becomeeligible for organ transplants.

For example, at their annual meetings in Leiden, The Netherlands, in September 2000,members of Eurotransplant actively and enthusiastically supported new experiments thatexpanded transplant waiting lists to include the medical margins – those over 70 years,infants, those with hepatitis C and HIV seropositivity, and those proven to be immuno-logically prone to organ rejection. There was no consciousness or recognition that theseexperiments would inflate the demand for organs and promote desperate means, includingthe black market, to obtain them. Instead, these programs were defended as democratic intheir inclusiveness and as a service to medical consumers demanding the right to any andall advanced medical procedures now

available

.Similarly, kidney and transplant patient advocacy groups in many parts of the world –

from Brazil to Israel to Iran to the United States – have articulated a new medicalconsumers bill of rights, one that includes a patient’s right to transplant and even tounobstructed access to the life-saving and healthy spare organs of ‘the other’, for whichpatients are willing to travel great distances and to pay a negotiable, market-based price.In continuing to articulate the current dilemma of transplant, under these new socialconditions, in terms of scarcity, supply and demand – when the precious ‘commodities’ inquestion are increasingly attached to living bodies – serious ethical dilemmas are createdfor the patients and for their doctors who find themselves in the position of passively andinadvertently or actively creating a medically protected space for the kidney commerce.

‘Who am I to second guess, let alone to judge, my patients?’, asked Michael Fried-laender,

14

kidney transplant specialist at Hadassah Hospital, with reference to the growingnumbers of patients in his hospital-based practice who have returned from overseas havingpurchased a kidney. Later, he was to write (2002: 971–972): ‘Here began my conversionfrom fierce objection to kidney marketing to passive acquiescence in this trade. We couldnot prevent our patients travelling to Iraq [later to Turkey, Romania, and the USA]. Wegave patients who asked our advice all the information I have presented here, and warnedthem that we could not help them outside our national boundaries, but assured them thatwe would immediately assist them on their return.’ Part of the information that is given tohis dialysis patients is the differential survival rates for

living donor

kidneys vs. cadaverickidneys, based on research by Wolfe and his colleagues (1999) – a median (50%) graftsurvival of 21.6 years (living donor kidney) compared with 13.8 years for a cadaver kidney.‘If my own kidneys failed I would opt for a transplant from a living donor’, Dr Friedlaenderhas said on more than one public occasion. The data on differential survival rates arecirculated widely among kidney transplant surgeons around the world, and are frequentlycited by their patients and directly contribute to the decision to abandon conventionalcadaver organ waiting lists in pursuit of ‘fresh’ kidneys from living people.

Antother consumer-based stimulus behind the occult economy in living donor kidneys(and part livers) is the growing rejection of hemo-dialysis by increasingly sophisticatedkidney patients. Dialysis treatment for any period of time, even as a bridge while waitingfor transplant, is increasingly viewed by kidney activists as unacceptable suffering, as timeon the cross. In September 2000 a young man I will call Amatai, a 23-year-old universitystudent from Jerusalem, flew to New York City for a kidney transplant with an organpurchased from a local ‘donor’ arranged through a broker in Brooklyn. Most of the cost ofthe surgery ($200 000) was paid for by his Israeli ‘sick funds’ (medical insurance that is


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guaranteed to all Israeli citizens). Particularly noteworthy in his narrative was the almostseamless naturalization of living donation and the rejection of the artificiality of the dialysismachine:

Kidney transplant from a living person is the most natural solution because you arefree of the [dialysis] machine. With transplant you don’t have to go to the hospitalthree times a week to waste your time for three or four hours. And after each dialysisyou don’t feel very well, and you sleep a lot, and on weekends you feel too tired to goout with your friends. There are still a lot of poisons left in the body and when youcan’t remove them, you feel tired. Look, dialysis isn’t a normal life. And also you arelimited to certain foods. You are not allowed to eat a lot of meat, salt, fruits, vegetables.Every month you do tests to see that the calcium level is OK, and even if so your skinbecomes yellow. Aesthetically, dialysis isn’t very nice. A kidney transplant from a livingdonor is the very best, and the most natural solution.

At the same time many kidney patients resist the idea of conventional ‘waiting lists’ forcadaver organs as archaic vestiges or residues of wartime triage and rationing or worse asreminiscent of socialist bread lines and petrol ‘queues’. In the present climate of biotechno-logical optimism and biomedical triumphalism, the very idea of a shortage, even an organsshortage, suggests a basic management, market or policy failure. The ideology of the globaleconomy is one of unlimited and freely circulating goods. And those new commodities areevaluated, like any other, in terms of their quality, durability and market value.

The cadaver kidney has been consigned to the dustbins of surgical history by those withthe ability to get a living donor, like 71-year-old Avirham, a retired lawyer with end-stagekidney disease for whom time was running out and for whom neither a spectral waiting listnor a dead man’s kidney seemed like reasonable options. So, in 1999 Avraham took thedecisive step to fly with Dr Zaki Shapira and several other Israeli and Italian kidney patientsto an undisclosed location in Eastern Europe where they were all transplanted with kidneyspurchased from displaced rural workers. The entire venture was, Avriham admits, anenormous risk. ‘You have no idea how poor where we went to was!’ he said. ‘The hospitalwas like something you would expect maybe in a third world country.’ But it was a risk hewas willing to take to avoid the queue at home for a cadaveric kidney transplant:

Why should I have to wait months and years for a kidney from someone who was ina traffic accident, pinned under the car for many hours, then in miserable conditionin the ICU [intensive care unit] for weeks and only after all that trauma, have thatsame organ put inside me? It’s really a disgusting idea to think about putting thatdead man’s organ inside you. That organ is not going to be any good! His kidney ispractically dead. After it was kept on ice for several hours, how can you expect it togo right back to work for me? Or worse, I could get the kidney of an elderly person,or an alcoholic, or a person who died of a stroke. That kidney is all used up. No, itis far better to get a kidney from a healthy man or woman who can also benefit fromthe money I can afford to pay. Where I went for my transplant the people were sopoor they did not even have bread to eat. Do you have any idea what one thousand,let alone five thousand dollars means to a peasant? The money I paid was a gift equalto the gift that I received.

Obviously, free-market medicine requires a divisible body with detachable and demystifiedorgans seen as ordinary and ‘plain things’, simple material for medical consumption. But


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these same ‘plain’ objects have a way of reappearing and returning like the repressed, whenleast expected, almost like medieval messengers and gargoyles from the past in the form ofhighly spiritualized and fetishized objects of desire. As Veena Das once wryly observed: ‘Anorgan is

never

just an organ’.And the fetishized or ‘designer’ kidney purchased from a living donor conjures up

primitive beliefs in human immortality, transcendence and magical energy. As Averhamexplained his frantic and dangerous search for a living kidney donor: ‘I chose the betterway. I was able to see my donor [in a small town in Eastern Europe]. My doctor pointedhim out to me. He was young, strong, healthy – everything that I was hoping for!’ Here,the symbolic equations between kidney market, slave market and brothel come to thesurface.

Meanwhile, international Internet brokers prey on consumer prejudices and on theanxieties of transplant candidates. For example, ‘Livers-4-You’, until a few weeks ago whenit was forced off cyberspace, advertised the following via [email protected]:

‘Wanta healthy living donor next week, or a morgue organ in five years? We are a neworganization with a New York City phone number and unique experience in locating theoverseas pathway for those

waiting too long

for a transplant.’

Brokers, kidney hunters and outlaw surgeons

Obviously, finding an available supply of organ vendors was only a partial solution to thenew scarcities produced by transplant technologies. Even Jesus knew that ‘the poor wewould always have with us’. In fact, the real scarcity in organ transplant is of patients, likeAvriham, of sufficient economic means to pay for these astronomically expensive operations(between $100 000 and $200 000 depending on location) as well as sufficiently ‘courageous‘ or foolhardy to travel to the locations where people are desperate enough to self-mutilatein the interests of short-term survival. Here was a classic problem in microeconomics – oneof supply- and demand-side sources separated by vast geographies, different cultures, andeven by fierce religious and political hostilities. ‘I think my donor was an Iraqi soldier’, anIsraeli transplant patient told me, admiring the organizational skills and the chutzpah ofthe doctors and brokers who had pulled such a feat off.

Indeed, the new transplant transactions are exceedingly complex, requiring extensiveand expert teamwork among medical professionals, from lab technicians to nursing staff,to nephrologists and blood and tissue laboratories, to the surgical teams who operate intandem. Surgical units must be rented, passports, visas and air travel arranged, andimmigration officials must be dealt with. The entire process is facilitated by a new inter-national network of body Mafia ranging from the sleazy (and sometimes armed anddangerous) underworld ‘kidney hunters’ of Istanbul and Cesenau, Moldova to the sophis-ticated but clandestine ‘medical tourism’ bureaux of Tel Aviv and Manila to the medicalintermediaries posing as religious or charitable trusts and ‘patient’s advocacy organizations’found in downtown Philadelphia, Brooklyn, and Chinatown, New York City.

The ‘Livers-4-You’ brokers (cited above) had ‘joined with medical professionals in thePhilippines and “nearby countries” (including Thailand) to help “fill the gap” between thesupply and demand for organs’. For Americans who might be nervous about traveling to adeveloping country for transplant surgery, the website reassured them that medical schoolsin the Philippines are ‘carbon copies’ of US schools and that Philippine transplant surgeonsare all trained in the United States. Those in doubt about the quality of advanced medicalcare in the Philippines were told to contact the US consulate in Manila, the Manila office


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of multinational corporations, or the Philippine Catholic Church. All are willing, thewebsite assured the wary Internet transplant shopper, to provide positive references on thepractice of transplant surgery in the Philippines. While the cost for a live liver donor isconsiderably ‘higher than for a cadaver organ’ it was still ‘less than half the current cost ofa liver transplant in the United States’. The payment mechanics – through bank wiretransfers – would be discreetly handled by the Livers-4-You online staff. Medical arrange-ments would be supervised by the organization’s head surgeon, a US-trained and licenseddoctor who has performed ‘many operations’ in the United States.

In addition to the faceless Internet brokers who try to match desperate North Americanpatients15 to kidney sellers in the Third World, locally based brokers have appeared inethnic enclaves of Los Angeles, Baltimore, New York City and Philadelphia where theyrecruit new immigrants and undocumented workers as kidney sellers and assist wealthyforeign transplant patients to find the doctors, hospitals and even the hotel accommodationthat they need. In the last two years transplant tourism packages arranged mostly in theMiddle East have brought scores of kidney patients to US transplant centers, both publicand private, for surgery conducted with both cadaveric and living donor purchased kidneys.

One such active group, United Lifeline, began in Israel as a charitable organization tohelp Israeli children get expensive cancer treatments in the United States. Over time,United Lifeline developed into a larger organization with many representatives in east andwest coast cities of the USA who have helped to facilitate transplant surgery for Israelicitizens who tire of waiting for a cadaver organ at home. But this service contributes to theparadox of US transplant centers accepting and even actively recruiting wealthy foreignpatients to receive organs that are otherwise described as painfully scarce.16 The Universityof Maryland Medical Center, for example, advertised (until recently, and under criticismfrom Organs Watch) its kidney transplant program in Arabic, Chinese, Hebrew andJapanese on its website.17 The United States is extremely democratic in at least one sense:anyone, regardless where they come from, with enough cash can become a ‘medical citizen’of the USA and receive a bona fide ‘Made in the USA’ organ. Local representatives of‘United Lifeline’ (though linked to the international transplant tourism business of theMiddle East) are often unpaid and religiously motivated volunteers who would resiststrongly any hint of ‘brokering’ for patients or for transplant organs. Like many of thesurgeons they deal with, these patient advocates either deny the origins of the purchasedorgans or suggest that existing laws restricting sales are out of touch with reality.

In other parts of the world, the necessary intermediaries and organ brokers are small-time criminals in the employ of highly sophisticated Mafia involved in all kinds of traffickingin human bodies. The brokers who approached the naïve young men of Mingir andChisenau in Moldova were themselves former prostitutes and kidney sellers who hadsubsequently developed lucrative ties to larger networks of human traffickers spread amongcities in Russia, Turkey, Israel and Italy. The infamous Nina Ungureanu of Mingir villagein Moldova made no pretenses about the financial motives that got her deeply involved inthe Middle Eastern kidney trade. Despite ‘police harassment’ Ms Ungureanu remainsuncontrite. When asked by an undercover reporter18 why she had engaged in the entrap-ment of young village men in Mingir, Nina Ungureanu replied:

We needed the business. . . . We had a hard life. We could not quite stand on our ownfeet [financially]. But now we’ve built this house, we’ve sorted ourselves out. . . . Andthe police are not going to do anything to us and they are certainly not going to doanything to the [big shots] in this trade [i.e. Nina Sobiola and her co-workers]. Butthey should at least make them pay us the money they owe us. But where are they


216 NANCY SCHEPER-HUGHES

Figure 6. Viorel, a 27-year-old kidney seller from Chisenau, Moldiva, is still angry at Nina, the broker who trafficked him to Turkey, and at Dr. Sonmez,

the surgeon who took his right kidney. ‘How can that man call himself a doctor? That son of a bitch left me an invalid’, he told me. Photo by Nancy

Scheper-Hughes


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going to find them? I imagine they all live somewhere in America. . . . The police arenever going to find them. Especially the main guys [behind this business]. . . . I thinkI could settle for what I’ve made so far, but they (the police) come here to the village,take me off to Chisinau. . . . They abuse you – if you don’t want to talk, they slap you.Yes, they slapped me once! Me, a woman! . . . But at least I’ve made some money inthis business. Thanks be to God! I need it badly enough! We were in dire straits. Butnow we have had to stop. The police are going to make us sweat a little and than theyare going to let it all go.

Meanwhile, the outlaw surgeons, like Dr Zaki Shapira of Tel Aviv, and his partner YusefSonmez of Istanbul, practice their illicit operations in rented, makeshift clinics or, whenpolitical conditions allow, in the operating rooms of some of the best public or privatemedical centers in Israel, Turkey, Romania, Iraq and, Sonmez for one has boasted,19 ‘evenin Europe’. They perform their illicit operations under the frank gaze of local and nationalgovernments, ministries of health, international regulatory agencies, professional medicalassociations. They are quite clearly protected. In short, the illegal practice of transplanttourism, relying on an extensive network of competitive markets in patients, bodies andorgans, is a public secret and one that involves some of the world’s leading transplantsurgeons and some of the most prestigious academic hospitals and medical centers aroundthe world. And transplant crimes – even when they explode into gunfire and leave a trailof blood as they do from time to time – go officially undetected and unpunished.20 In largepart, this is because of fear and intimidation on all sides. And even the most aggressivetransplant surgeons can find themselves trapped and more deeply involved in ‘the business’than they had anticipated.

Medicine, mafia and the military: the biopolitical terrorism of free trade transplant

In addition to the involvement of organized crime in the international organs business,military interests and military governments, particularly during periods of intense internalconflict and war, have played a role in protecting and even in organizing illegal organharvesting from those considered enemies or from those considered social garbage.

The emergence of death camps, torture camps, and tissue- and organ-harvesting campscame together at certain junctures in the late twentieth century. Our research has uncoveredwhat can only be called ‘fascist’ military and ‘dirty war’ tactics used on the bodies and theorgans of the enemy. A footnote and subtext to the story of military terrorism during (andfollowing) the ‘dirty war’ in Argentina, the apartheid state in South Africa and the dicta-torship years in Brazil is the role that doctors played in providing not only children (as inthe Argentine case) but also the blood, bones, heart valves and organs needed for transplant,taken from the bodies of the politically and the socially ‘disappeared’. During the ArgentineDirty War (of the 1970s) and during the military state years of Brazil (1964–84), forensicand state pathologists and transplant doctors were at times under orders to produce quotasof usable organs and tissues needed for shoring up the defenses of the social body and themilitary state.21

In addition to stripping organs and tissues from the bodies of the politically disap-peared, state doctors in Argentina helped themselves to the bodies of captive and sociallydespised populations, such as the mentally retarded, warehoused – as they are to this day– in massive state institutions, such as Montes de Oca and Open Door in Lujan, BsAs

07 s-hughes (jk/d).fm 7 Friday, June 13, 2003 12:15 PM


province, Argentina. There inmates were routinely used, dead and alive, as a convenientsource of blood, cornea and other valuable tissues and organs throughout the decades ofthe 1970s and 1980s. Even today blood is routinely taken from the hapless inmates withouttheir consent and given to public blood banks while cornea are harvested at death frompatients who are mentally incapable of giving (or denying) their consent.22 There areindications, as yet unverified, that the organ-trafficking business in Eastern Europe beganamidst the chaos and utter dehumanization of the death camps during the genocidal warin the former Yugoslavia.

A highly militarized Israel is today a major player in the global market for organs, amarket that began in the West Bank and then moved to nearby Arab countries. Accordingto well-placed Israeli medical sources,23 Israel’s citizens purchase, proportionally, the largestnumber of organs per capita in the world. Caught between a highly educated and medicallyconscious public and a very low rate of organ donation owing to religious pressuresoperating in a secular society, the Israeli Ministry of Health permitted the expansion oftransplant tourism by allowing Israeli patients to use their national insurance programs topay for transplants conducted elsewhere, even if illegally. Several large ‘business corpora-tions’ (including the firm of Coby Dyan) developed necessary links with transplant surgeonsand medical centers in Turkey, Russia, Moldova, Estonia, Georgia, Romania and (mostrecently) the United States.

In Israel, the cost of the transplant ‘package’ increased from $120 000 in 1998 to$200 000 in 2001. The package, as patients call it, includes the air travel, bribes to airportand customs officials, the ‘double operation’ (kidney extraction and kidney transplant),rental of private operating and recovery rooms, and hotel accommodation for accompa-nying family members. The donor’s fee of between $3000 and $15 000 (depending on thedonor source) is included. With pressure from transplant candidates to develop links in moredeveloped countries, the cost is still rising. The specific sites of the illicit surgery are normallykept secret from transplant patients until the day of travel, and the locations are continuallyrotated to maintain a low profile. The surgery is performed in secret between midnight andthe early morning hours. In the most common scenario, Israeli patients and doctors (atransplant surgeon and a nephrologist) fly to Istanbul or to a small town in Turkey wherethe kidney donors are AWOL Iraqi soldiers or Eastern European guest workers. In anotherscenario, the Israeli and Turkish doctors travel in tandem to a third site in Eastern Europe,where the organ sellers are unemployed locals or guest workers from elsewhere.

The refusal of the Israeli Ministry of Health to crack down on this multi-million dollarbusiness, which is making Israel something of a pariah in the international transplant world,is troubling. But in the absence of a strong culture of organ donation and under pressurefrom well-organized and demanding transplant candidates, every person transplantedabroad is one less angry client with which to contend at home. More disturbing still,however, is the support and involvement of the Ministry of Defense in the illicit transplanttourism. Several Israeli patients who traveled on a transplant junket to Turkey and EasternEurope noted the presence of military personnel accompanying the flights or participatingin the transplants.

Meanwhile, medical human rights workers in the West Bank complained of medicalviolations of Palestinian bodies by Israeli pathologists at the National Legal MedicalInstitute in Tel Aviv.24 An official investigation committee appointed by the Minister ofHealth in 2001 confirmed the suspicions of Palestinian health workers. Harvested organsand tissues were distributed by the Institute to hospitals and medical centers for surgicalprocedures, research and medical teaching. A special squad of surgeons on military reserveduty perform the harvesting. This practice was first established by the head of the national



skin bank, who was formerly Chief Medical Officer of the Israeli Defense Forces. Relyingon ‘presumed consent’ the staff of the Forensic Institute and the surgeons who illegallyharvested skin and organs defended themselves by saying that they were saving lives, andthat this imperative was more important than procuring the consent of ill-informed andgrieving (Palestinian) family members. In this instance the tissues and organs of the deadwere regarded as detachable objects that could be medically transformed into somethingvaluable. Some bodies, however, were exempt from this practice, specifically the bodies ofIsraeli soldiers, which are always returned intact to their families for burial.

Beyond bioethics

If a living donor can do without an organ, why shouldn’t the donor profit and medicalscience benefit?’ ( Janet Ratcliffe-Richards)

For most bioethicists the ‘slippery slope’ in transplant medicine begins with the emergenceof an unregulated market in organs and tissue sales. But for the anthropologist the ethicalslippery slope occurred the first time one ailing human looked at another living human andrealized that inside that other living body was something that could prolong his or her life.

Dialysis and transplant patients are highly visible and their stories are frequentlyreported by the media. Their pain and suffering are palpable. But while there is empathy– even a kind of surplus empathy – for transplant patients, there is an absence of empathyfor the donors, living and brain dead. Their suffering is hidden from the general public.Few organ recipients know anything about the impact of a transplant procedure on thedonor’s body. If the medical and psychological risks, pressures and constraints on organdonors and their families were more generally known, transplant patients might want toconsider opting out of procedures that demand so much of the other.

From an exclusively market-oriented perspective the problem of unsavory anddangerous black markets in human organs can be resolved by regulation rather than byprohibition. The human and ethical dilemmas are thereby reduced to a simple problem inmanagement. The problems with this rational solution are many. The argument for‘regulation’ is out of touch with the social and medical realities operating in many parts ofthe world but especially in Second and Third World nations. The medical institutionscreated to ‘monitor’ organ harvesting and distribution are often dysfunctional, corrupt orcompromised by the power of organ markets and the impunity of the organ brokers andof outlaw surgeons willing to violate the first premise of classical medical bioethics: Aboveall, do no harm.

To date only kidneys, bone marrow and liver lobes can be taken from living donorsand transplanted into ailing patients. Living donation remains a risky procedure andobviously cannot supply the ‘demand’ for hearts, lungs and other irreducible or irre-placeable body parts. There is minimal attention in the medical literature on the risksand complications living donors often suffer in the First World let alone in countrieswhere living donors are operated on and sent packing within a few days by bus, car ortrain to their home communities, their futures uncertain and their medical destiniesunrecorded. In the USA two kidney donors have died during the past 18 months andanother is in a persistent vegetative state as a result of donation.25 The fact that manyliving donors have either died immediately following the surgical procedure, or are them-selves in dire need of a kidney transplant at a later date, sounds a cautionary note aboutliving donation and serves as a reminder that nephrectomy is not a risk-free procedure.26



The unnecessary and brutal death of Mike Hurewitz, 57, following the removal of part ofhis liver transplanted to his brother at Mt Sinai Medical Center in New York City thispast January underscores the dangers of treating live organ donation in a cavalier andreckless fashion.

The problems multiply when the buyers and sellers are unrelated because the sellersare likely to be extremely poor and trapped in life-threatening environments where theeveryday risks to their survival are legion, including exposure to urban violence, transpor-tation and work-related accidents, and infectious disease that can compromise their kidneyof last resort. And when that spare part fails, kidney sellers often have no access to dialysis– let alone to organ transplant. While poor people in particular cannot ‘do without’ their‘extra’ organs, even affluent people need that ‘extra’ organ as they age and when onehealthier kidney can compensate for a failing or weaker kidney.

Transplant surgeons have disseminated an untested hypothesis of ‘risk-free’ livedonation in the absence of any published, longitudinal studies of the effects of nephrectomy(kidney removal) among the urban poor living anywhere in the world. The few availablestudies of the effects of neprectomy on kidney sellers in India (Goyal et al. 2002) and Iran(Zargooshi 2001) are unambiguous. Even under attempts (as in Iran) to regulate and controlsystems of ‘compensated gifting’ by the Ministry of Health, the outcomes are devastating.Kidney sellers suffer from chronic pain, unemployment, social isolation and stigma, andsevere psychological problems. The evidence of strongly negative sentiments – disappoint-ment, anger, resentment and even seething hatred for the doctors and the recipients of theirorgans – reported by 100 paid kidney donors in Iran strongly suggests that kidney sellingthere represents a serious social pathology.

My qualitative research among dozens of kidney sellers in Moldova and the Philippines,which included diagnostic follow-up medical exams and sonograms, found that kidneysellers frequently face medical problems, including hypertension and even subsequentkidney insufficiency, without access to medical care or necessary medication. On returningto their rural villages or urban shantytowns kidney sellers often find themselves both sickand unemployed, unable to sustain the demands of heavy agricultural or construction work,the only labor available to men of their skills and backgrounds. Kidney sellers are oftenalienated from their families and co-workers, excommunicated from their churches, and ifsingle they are even excluded from marriage. The children of kidney sellers are ridiculedas ‘one-kidneys’.

In Moldova I was able to document the ill health, social disability and subsequentunemployment faced by young male kidney sellers. Not one among the kidney sellers hadseen a doctor or been treated at a medical clinic following their illicit operations in Istanbul.Moreover, I had to coax the young men to agree to a basic clinical exam and sonogram atthe expense of Organs Watch. Some said they were ashamed to appear in a public clinicas they had tried to keep the sale a secret; others said they were fearful of learning negativeresults from the tests. All said that if serious medical problems were discovered they wereunable to pay for follow-up treatment or necessary medication. Above all, they said, theyfeared being labeled as ‘weak’ or ‘disabled’ by employers and co-workers, as well as (forsingle men) by potential girlfriends and brides. ‘No young woman in the village will marrya man with the tell-tale scar of a kidney seller’, the father of a village kidney seller said sadly.‘They believe that he will be unable to support a family.’ Sergei, a married man fromChisenau, revealed that his mother was the only person who knew the reason for the large,saber-like scar on his abdomen. Sergei’s young wife believed that he had been injured in aconstruction accident while he was away in Turkey.

In any case, how can a national government set a price on a healthy human being’s



body part without compromising essential democratic and ethical principles that guaranteethe equal value of all human lives? Any national regulatory system would have to competewith global black markets which establish the value of human organs based on consumer-oriented prejudices, such that in today’s kidney market an Indian kidney fetches as little as$1000, a Filipino kidney $1300, a Moldovan or Romanian kidney yields $2700, while aTurkish seller can command up to $10 000 and an urban Peruvian can receive as much as$30 000. The circulation of kidneys transcends national borders and international marketswill coexist and compete aggressively with any national, regulated systems. Putting a marketprice on body parts – even a fair one – exploits the desperation of the poor, turning theirsuffering into an opportunity. And the surgical removal of non-renewable organs is an actin which medical practitioners, given their ethical standards, should not be asked toparticipate. Surgeons whose primary responsibility is to provide care should not be advo-cates of paid self-mutilation even in the interest of saving lives.

Bio-ethical arguments about the right to sell an organ or other body part are based onEuro-American notions of contract and individual ‘choice’. These create the semblance ofethical choice (e.g. the right to buy a kidney) in an intrinsically unethical context. The socialand economic contexts make the ‘choice’ to sell a kidney in an urban slum of Calcutta orin a Brazilian favela or Philippine shantytown anything but a ‘free’ and ‘autonomous’ one.The idea of consent is problematic with ‘the executioner’ – whether on death row or at thedoor of the slum resident – looking over one’s shoulder and when a seller has no otheroption left but to sell an organ. Putting a market price on body parts – even a fair one –exploits the desperation of the poor, turning their suffering into an opportunity. Asking thelaw to negotiate a fair price for a live human kidney goes against everything that contracttheory stands for. When concepts like individual agency and autonomy are invoked indefending the ‘right’ to sell an organ, anthropologists might suggest that certain ‘living’things are not alienable or proper candidates for commodification. And the surgicalremoval of non-renewable organs is an act in which medical practitioners, given theirethical standards, should not be asked to participate.

The demand side of the organ scarcity problem also needs to be confronted. Part ofthe current scarcity derives from expansions of organ waiting lists to include very smallinfants and patients over 70 years, a practice that needs to be questioned. Liver and kidneyfailure often originate in public health problems that could be treated more aggressivelypreventively. Ethical solutions to the chronic scarcity of human organs are not alwayspalatable to the public but also need to be considered. Foremost among these are systemsof educated, informed ‘presumed consent’ in which all citizens are assumed to be organdonors at brain death unless they have officially stipulated their refusal beforehand. Thispractice, widespread in Europe, preserves the value of organ transplant as a social good inwhich no one is included or excluded based on the ability to pay.

Conclusion: a return to the gift

The material needs of my neighbor are my spiritual needs. (Imannuel Levinas, NineTalmudic Readings (quoted in Donoghue 1996: 39)

This essay ends with a return to the radical ethical challenge implied in organ sharing inwhich the body is understood as a gift, meaning also a gift to the self. The body and itsparts remain inalienable from the self because in the most simple Kantian or Wittgen-steinian formulation, the body provides the grounds of certainly for saying that one has a



self and an existence at all. Humans both are and have a body. For those who view the bodyin more collectivist terms (whether following Judeo-Christian, Buddhist or animistic beliefsand values) as a gift, the body cannot be sold, while it can be re-gifted and recirculated inhumanitarian acts of caritas.

From its origins transplant surgery presented itself as a complicated problem in giftrelations and gift theory, a domain to which sociologists and anthropologists from MarcelMauss to Claude Lévi-Strauss to Pierre Bourdieu have contributed mightily. The spread ofnew medical technologies and the artificial needs, scarcities and the new commodities thatthey demand have produced new forms of social exchange that breach the conventionaldichotomy between gifts and commodities and between kin and strangers. While manyindividuals have benefited enormously from the ability to get the organs they need, theviolence associated with many of these new transactions gives reason to pause (see Lock2001). Are we witnessing the development of biosociality or the growth of a widespreadbio-sociopathy?

In his 1970 classic, The Gift Relationship, Richard Titmuss anticipates many of thedilemmas now raised by the global human organs market. His assessment of the negativesocial effects of commercialized blood markets in the USA could also be applied to theglobal markets in human organs and tissues.

The commercialism of blood and donor relationships represses the expression ofaltruism, erodes the sense of community, lowers scientific standards, limits bothpersonal and professional freedoms, sanctions the making of profits in hospitals andclinical laboratories, legalizes hostility between doctor and patient, subjects criticalareas of medicine to the laws of the marketplace, places immense social costs on thoseleast able to bear them – the poor, the sick, and the inept – increases the danger ofunethical behavior in various sectors of medical science and practice, and results insituations in which proportionately more and more blood is supplied by the poor, theunskilled and the unemployed, Blacks and other low income groups. (Titmuss 1970:314)

The goal of our project is to bring broader social and social justice concerns to bear on globalpractices of organs procurement and transplant. This essay has been an attempt to delineatesome of the contradictions inherent in a market-driven solution to the problem of ‘scarcity’of human organs as well as a frank attempt to recapture the original biosociality inherentin the daring proposal to circulate organs as a radical act of fraternity and, finally, to bringa critical medical anthropological sensibility into the current debates on the commodifica-tion of the body.

Amidst the tension between organ givers and organ recipients, between doctors,patients and non-patients, between North and South, between the illegal and the ‘merely’unethical, clarity is needed about whose values and whose notions of the body andembodiment are being represented. Are the frank concerns, expressed here, for bodilyintegrity and human dignity merely a residue of the Western enlightenment? In fact, thesemodernist values, so embattled and under multiple assaults in the postmodern, postindus-trial world, are nonetheless intensely defended in many pockets of the Third and Fourthworlds. Deeply held beliefs in bodily integrity and in human dignity lie behind the demands‘of First Peoples’ for the repatriation and reburial of human remains now warehoused inmuseum archives (see Scheper-Hughes 2000a). They lie behind the demands of thewretchedly poor for dignified death and burial (Scheper-Hughes 1992). And they certainlylie behind the fears of organ theft, and the deep anger expressed in Eastern European



villages today toward the medical ‘vultures’ and ‘mafia dogs’ who have turned them into‘communities of half-men and -women’. Indeed, the division of the world into organ buyersand organ sellers is a medical, social and moral tragedy of immense and not yet fullyrecognized proportions. We hope that this project will help to establish a new ethicalblueprint for anthropology and for medicine in the twenty-first century.

Acknowledgments

This article is a revised version of the paper presented at a plenary session of the conferenceorganized by Anthony Elliott, Director, Centre for Critical Theory, University of the Westof England and Bryan S. Turner, University of Cambridge, on Human Frailty: Rights,Ethics and the Search for Global Justice, 6–7 September 2001, Bristol, UK. It was alsopresented in another version at the SSCR-sponsored Workshop, Oikos & Anthropos, 26–27 April 2002 Prague, Czech Republic, organized by Aihwa Ong and Steven Collier. Theauthor is grateful to the organizers, discussants and participants of both events for theirmany critical comments. Ian O’Reilly of the BBC, who attended the Bristol Frailty Confer-ence, provided the impetus to the author to extend her research to Moldova. CatherineBerthillier, Calin Goina and Alina Radu were indispensable field research partners inChisinau and Mingir, Moldova. The original field research in Israel, Moldova, Argentinaand the Philippines reported on here was supported by a generous grant from the OpenSociety Institute, New York City, with matching funds from the University of California,Berkeley.

Notes

1. See Jimenez and Scheper-Hughes (2002), part 1 of a three part series in the National Post (Toronto), Saturday30 March, B1, and B4, B5.

2. Ferreira and Scheper-Hughes (n.d.). Dr Ferreira and I interviewed Domba recovering at the famous Hospitaldas Clinicas in Sao Paulo following a kidney transplant that the middle-aged, traditional shaman faced withenormous equanimity in comparison witho the anxious Sao Paulo businessman in the hospital bed next to himwho approached his own kidney transplant surgery with mortal dread. The relative ease with which Brazil’sindigenous people face elective surgery is captured in the recently reported story of Sapaim, shaman andspiritual leader of the Camaiura tribe in the southern Amazon, who underwent plastic surgery after a spiritdirected him in a dream to ‘change his face’. Sapaim reported afterwards that the operation made his face feel‘like new’, as if he were a young boy again. See ‘Shaman gets facelift after dream’, Monday 29 April 2002,Brasilia, Brazil (Reuters).

3. By medical citizenship I mean the growing awareness and claims made by patients and by organized patientadvocacy groups of their rights as citizens and as medical consumers to free access to medical information,including the latest cutting-edge research, to participation (or not) in experimental drug-testing procedures, tocontrol over the conditions of one’s treatment regime, and ultimately over the management of one’s sicknessand death.

4. See ‘Organs for Sale: China’s Growing Trade and Ultimate Violation of Prisoner’s Rights’. Hearing beforethe Subcommittee on International Operations and Human Rights of the Committee on Internationalrelations House of Representatives, One hundred Seventh Congress, First Session, June 27th, 2001.

5. One exception to this rule is Iraq where Arab kidney patients from various countries, including the West Bank,are introduced to their paid kidney donors – poor Arabs from Iraq and Jordan (for the most part) – before thedual surgery and the pair are encouraged to bond with each other so as to prevent subsequent ‘rejection’,understood there to have a psychological as well as a physiological component.

6. Source: Interviews with Prof. Shamoye Cotev, anesthesiologist at Assota Hospital, Tel Aviv and chairman ofthe ethics committee established by the Israli Ministry of Health to investigate charges of criminal behavior byDr Zaki Shapira of Bellinson Medical Center, regarding his involvement in kidney commerce in Israel in themid-1990s. Dr Shapira was cleared on the grounds that even if he did transplant organs purchased from poorPalestinians, the law was vague and at most the committee could only ‘slap Shapira’s hand’ for medicalmischief.



7. Before ending the conversation we revealed to Mr K. that we were not kidney hunters but two journalistsand an anthropologist looking to understand the situation that brought people to this decision. We made adonation toward his most immediate necessities and explained the risks and dangers of neprectomy. Mr K.was not too disappointed and neither was he particularly dissuaded by my cautionary arguments. ‘Tell meanother way’, he said, ‘I could earn so much money so quickly. How many used soda pop cans do you thinkI would have to resell?’

8. Both Agamben (1998: 2–3), and Hannah Arendt (1958: 12–49) treat the translation from ancient Greek toChurch Latin in slightly different ways.

9. As bioethicists become more of a force in public policy, they are coming under scrutiny with respect to thebargains they strike with medical scientists and with biotech companies and their independence is beingquestioned. See, for example, ‘Bioethicists find themselves the ones being scrutinized’, New York Times, 1August 2001, 1, A-14.

10. ‘Offering money for organ donation ethical, HHS Committee says’, AP/Nando Times, 3 December 2001.11. In Sao Paulo Brazil the head of a kidney patients advocacy network has tirelessly tracked the regional waiting

list there to discover that hundreds of transplant candidates were dropped from the list without theirknowledge and that powerful transplant doctors always find ways to transfer ‘public’ cadaver organs to their‘private’ patients. While Neide B. does not recommend that patients stranded on dialysis try to find a paidliving donor, she understands the frustration of those who have been deceived by falsified and readilycorruptible waiting lists. ‘Those with only basic [national] insurance’, she said, ‘are just “decorating” thewaiting list’. Nonetheless, thanks to SUS, Brazil’s national insurance program, dialysis treatments are availableto most citizens there who need it.

12. Lawrence Cohen is the co-founder of this project. Associate field researchers and summer interns haveincluded Aslihan Senal (Turkey), Limor Saminian (Isreal), Juan Obarrio (Argentina); Maria Epele (Argentina);Mariana Ferreira (Brazil), Monga Mehlwani (South Africa), among others.

13. See Nancy Scheper-Hughes, ‘The primacy of the ethical: towards a militant anthropology, Current Anthropology,1995. In one of his last major public lectures, delivered in Athens in the summer of 2000, Pierre Bourdieuembraced the life of the ‘engaged and militant intellectual’ which for him implied a direct and politicalengagement in new social movements (including the anti-globalization forces organizing against genericallyaltered foods) and with more traditional labor movements in a united struggle against globalization recognizedas a particular theory of the world and not as a description of that same world.

14. Interview with author, March 2001, Jerusalem.15. Canadian patients are also actively recruited by transplant brokers . See ‘Transplant patients wait years – or

they can pay this man’, an investigative report by Lisa Priest and Estanislao Oziewicz, Globe and Mail (Metro),1 June 2001. The article reports on the practice of a Vancouver-area businessman, Walter Klak, who hasventured into the shadowy world of transplant tourism, putting desperate patients on a faster track for freshChinese kidneys for a $5000 (US) down-payment. Klak said that as of June 2001 more than 100 patients wereinscribed on his waiting list for a transplant operation in a Shanghai hospital. He revealed that he and hisShanghai partner were using China for transplants because ‘we found that to be the largest supply of organsthat are available’.

16. The United Network for Organ Sharing (UNOS) allows 5% of organ transplants in US transplant centers tobe allotted to foreign patients. However, only those centers reporting more than 15% foreign transplantsurgery patients are audited.

17. See, for example, the Arabic (as well as Hebrew and Japanese) version of the university’s advertisement [http://www.umm.edu/transplant/arabic.html].

18. Transcription of an interview in Mingir, Moldova in July 2001, courtesy of Ian O’Reilly, BBC.19. Interview in June 2000 with a representative of Berkeley Organs Watch.20. The local mafia that controls the traffic in organs in the Philippines is, for example, held responsible for the

murder of the daughter of a former director of the National Kidney and Transplant Institute in Manila. The22-year-old daughter was shot down in June 1999 in front of her home by unknown assailants. The murderers,believed to have been engaged in an act of vengeance against the victim’s father, were never discovered orbrought to justice, although an investigation was launched by the Ministry of Health and the Philippinegovernment responded by ordering a moratorium on organs donated by non-relatives. But both the investi-gation and the moratorium are over and the present director of the National Kidney Institute has no interestin reopening the case or even discussing the tragic event.

21. This theme is elaborated on in my article, ‘Theft of Life’ (Scheper-Hughes 1996).22. Author’s interview with nursing staff of Montes de Oca asylum in January 2000.23. This statistic is cited by many transplant doctors including those charged with the unsuccessful official Israeli

transplant harvesting program. It also appears in the writings of Prof. Meira Weiss, medical anthropologist,Hebrew University, Jerusalem, author of the forthcoming The Chosen Body (Stanford University Press).

24. See ‘Israel kills Palestinian boys, steals their organs for transplants’, Jerusalem Post, 9 January 2002 (IAP News).The article reports that Israeli government officials tacitly admitted that doctors at the Israeli forensic instituteat Abu Kabir in Tel Aviv had extracted the vital organs of three Palestinian teenage children killed by theIsraeli army in late December 2001. The Israeli Minister of Health, Nessim Dahhan, said in response to aquestion by Arab Knesset Member Ahmed Teibi that he could not deny that organs of Palestinian youthsand children, killed by the Israeli forces, were taken out for transplants or scientific research. Teibi said he



had received evidence proving that Israeli doctors at the forensic institute extracted such vital organs as theheart, kidneys and liver from the bodies of Palestinian youths and children killed by the Israeli army in Gazaand the West Bank. In June 2000 I was given the photo of a murdered Palestinian youth returned to his familyfollowing dissection at the Forensic Institute.

25. ‘Man keeps vigil for comatose wife who gave him kidney, life’, Holland Sentinel, 15 February 2001.26. The live donor consensus conference’, Journal of the American Medical Association, No. 284 (2000), 2919–2926.

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