The Notion of the Gift in the Donation of Body Tissues
by Rhonda Shaw
Victoria University of Wellington
Sociological Research Online 13(6)4
<http://www.socresonline.org.uk/13/6/4.html>
doi:10.5153/sro.1832
Received: 2 Jul 2008 Accepted: 27 Oct 2008 Published: 30 Nov 2008
Abstract
Recent social science commentary on the donation of body tissues and organs typically invokes Richard Titmuss's work on altruism and the gift relationship as a way of framing donative processes. Much of this discussion, however, has neglected to consider how altruism and body gifting is structured and promoted by organisations and institutions that make such processes possible. In this article I suggest that the accounts people give of their body gifting practices do not always fit orthodox notions of tissue donation as unconditional. Rather, people's perceptions of body gifting and donation depend very much on the kind of tissue being donated and who the tissue is being donated to. Given these complexities, we need more thoroughgoing discussion of the rituals associated with specific donation practices.
Keywords: Tissue Donation, Body Gifting, Gift, Altruism, Feeling Rules, Ritual Offerings
Introduction: Social Science and the Study of Donation
1.1 Therapeutic treatments and developments in health, medicine, and the life sciences increasingly rely on the availability of donated body tissues to advance their respective fields. While moral deliberation about donation practice has often been dominated by proceduralist bioethics and Principlism, social science studies of the dynamics of donation have begun to contribute to policy and debate in this area. A number of these studies (Busby 2004; Haimes and Whong Barr 2004; Scully et al. 2006; Shaw 2008; Tutton 2002, 2004; Waldby et al. 2004) have focused on the significance of the notion of the gift as a way of conceptualising the donation of body tissues. The strength of these studies has been to address the usefulness of gift-giving language as a model for ethical guidelines and policy discourse in human tissue and organ donation. Additionally, these studies have begun to identify where the moral vocabularies, concepts and models available for people to use as tools to understand and explain their actions are at variance with their perceptions of donation processes. In particular, this work has begun to show how lay understandings of therapeutic tissue donation and donation for research purposes is sometimes out of sync with the dominant ideology of body gifting as a one-way anonymised surrender of body matter over which the donor has no ultimate control or sense of ownership. By identifying discrepancies, social science research can contribute to re-thinking outmoded ethical models and policy frameworks, as well as promote respect for the integrity of tissue donors and donor families by moving closer to the language participants in these processes use to describe what it is they are doing.1.2 The following paper contributes to this ongoing work by discussing the adequacy of gift terminology in the donation of body tissues generally. To this end, examples will be drawn from the literature, from media items on the topic of donation, relevant websites, and from two empirical studies undertaken by the author in New Zealand. Data from the empirical studies consists of thematically coded face-to-face interviews of 50 to 90 minutes duration with 15 male and female organ donor and recipient coordinators and Critical Care Specialists (Intensivists) during 2007 and 2008, and 18 participants in ovarian egg donation and surrogate pregnancy arrangements during 2003 and 2004.[1] In this article I draw on information gleaned from health professionals working in the context of organ donation and directly on interview data provided by the ovum donors and surrogate mothers. The names of all the research participants referred to herein are aliases.
Defining Terms
2.1 Before discussing how the gift is used to talk about the donation of body tissues it is important to clarify the meaning of the term body tissues itself. In this article, I use the term in much the same way as Waldby and Mitchell (2006: 6); that is, in a 'generic sense to include blood, organs, and any other kind of living matter taken from the body'. The use of the word tissue in this way is also consistent with its deployment in the context of New Zealand legislation (see The Human Tissue Act 2008: 13-14), and includes what health professionals refer to as solid organs such as the heart, kidneys, and lungs. Ordinarily, health professionals distinguish between solid organs and body tissues. In science textbooks too the terms are used more precisely: tissue refers to 'a collection of cells coordinated to perform a specific body task' and an organ is 'a collection of specialised cells and tissues that carry out a defined function within the body, such as the heart' (Kiessling and Anderson 2007: 264, 261). For New Zealand health professionals working in the context of brain-dead and cadaveric organ donation and transplantation the distinction between solid organs and body tissues is important in terms of when families are approached to consider the option of organ donation. Currently, cadaveric organ donation is first discussed with potential donor families in an Intensive Care Unit (ICU) by an Intensivist, whereas the donation of body tissues such as heart valves, whole eyes, cornea, sclera, and skin may be discussed for the first time within 24 hours after the death of a loved one by a Donor Tissue Coordinator.[2]2.2 It is also useful to clarify the notion of 'bodily gifting' or 'body gifting', a phrase I have used previously in empirical work on giving and receiving breast milk, ovarian eggs, surrogate pregnancy relationships, and current work on perceptions of organ donation and transplantation (e.g. see Shaw 2004). I first used the terminology of body gifting because it seemed a philosophically neutral way of discussing various analogous, sometimes deliberate, bodily exchange practices. In contrast, Diprose's (2002: 5) notion of 'corporeal generosity', which describes a pre-reflective, interpersonal affective openness to others, draws explicitly on the works of Derrida, Merleau Ponty, and Levinas to frame a discussion of inter-corporeal and interpersonal exchange. While my rendering of body gifting is meant to be more descriptive than theoretical or normative the concept is politically loaded. This is especially true for people involved in body tissue exchange who do not strictly see their donations or the donations of others as 'gifts'. If people do use the language of gift to describe their donations in this way, then their perception of what a gift is does not always coincide with dominant or institutionalised understandings. For some, altruism and gift are not coterminous. Although some people do view tissue donation as unconditional, others envisage gifts as nodes in relations of social exchange. While these gifts may extend exchange relations beyond quid pro quo reciprocity, they are nonetheless connected to the larger intersubjective field of social life.
2.3 Despite my stated reservations regarding body gifting as a concept, the term connects the literature on embodiment and the body in sociology with the burgeoning literature in the social sciences on ethics and moral relationships. I bring these two literatures together because I am interested in the imbrications of embodiment with moral and ethical matters as well as the different ways in which people explicitly use their bodies to constitute themselves as moral and ethical subjects.
Conceptualising Tissue Donation
3.1 While body gifting enables novel ways of doing ethics, advances in medicine, science and technology also subject individuals to new forms of responsibilisation. As Rabinow and Rose (2003: 22) have said, innovations in the field of medicine and health not only create moral selves but also new social subjects and new social groupings. The creation of new social subjects and groups occurs when people identify with bio-medical, genetic categories and start to generate self-imposed obligations specific to their embodiment in light of the new knowledge available to them about their condition. At the same time, under neo-liberal economic conditions, these individuals and social subjects have changed expectations about what they should get back as participants of medical and genetic research. Hayden (2007) points out that this amounts to more than simply 'helping others', although this is often how the altruistic donation of body tissues is read in the public domain. While Hayden is correct and we are beginning to see shifts in public demand regarding reciprocity and pay-back for tissue donation in medical research and in the therapeutic context, the prevailing ideology governing the movement and exchange of body tissues remains largely shaped by debates around informed consent, altruism, and the gift (e.g. Williams et al. 2008). More often than not, ideas about altruism underscore discourses about donation and bodily gifting.3.2 As stated elsewhere, there are multiple ways to conceptualise gifts and gift-exchange in social life (Berking 1999; Komter 1996; Osteen 2002; Schrift 1997; Vaughan 2004; Wyschogrod et al. 2002), as well as numerous ways to think about the interplay of embodiment and ethics. Nevertheless, most discussions in the social sciences and bioethics about altruism and the gift begin with Richard Titmuss's influential book The Gift Relationship: From Human Blood to Social Policy, first published in 1970 (for early examples, see Murray 1987; Novaes 1989; Raymond 1990; Simmons 1991). As is well known, the book is a comparative analysis of the commercial system of blood transfusion that operated in the United States (USA) and the voluntary system that operated in the United Kingdom in the late 1960s and early 1970s. For Titmuss (1997: 282), the merits of the voluntary system outweighed those of the commercial system, as he basically believed that if strangers donate blood to one another then they will eventually benefit as members of that society. This was his rendering of gift-reciprocity (or giving-receiving-and-reciprocating) which he ostensibly drew from Marcel Mauss's (1990) work.
3.3 As Richard Tutton (2002, 2004) has noted, many analysts who draw on Titmuss's work have focused on his writing regarding altruism and donation and the view that altruistic behaviours would hold the wider community together. Titmuss's model, says Tutton, which is based on the gift relationship, has recently been used as a template to encourage the public provision of tissues samples to genetic research. According to Hayden (2007: 740) however, what these newer accounts often fail to elucidate is that Titmuss's model of the gift relationship is underpinned by a particular version of the social enshrined in ideas about the welfare state as a benevolent 'undifferentiated sphere of public good'.
3.4 In much of the debate about donating body tissues and organs the focus is on whether human beings can be altruistic or whether we are innately self-interested. Those who take the latter position argue that other-oriented behaviours or acts have ulterior self-serving motives. Hence, the socio-biologists ask what purpose altruism as a behavioural trait serves in terms of survival and reproduction (Healy 2004: 3). In other words, the question is asked why anyone would want to be altruistic if it 'decreases' one's own reproductive fitness but enhances the fitness of other human beings.
3.5 Contrastingly, says Healy (2006), the social-psychologists ask about the basis of altruistic behaviours and practices, whether or not people's motives are pure, and if altruism does exist whether it is a disposition or aspect of one's identity. Healy does not explain, but I take him to mean that psychologists conceptualise altruism as either a human trait that can be cultivated and practiced to connote moral excellence, or an aspect of oneself that is acquired in the early stages of moral development so as to become a determining influence on a person's conduct. The latter perspective intersects with anthropological debates about the gift in that what may appear to be a subjectively altruistic act is in fact part of an obligatory system of giving, receiving, and reciprocating. Henceforth, a person's motives to give may be subjectively "pure", but objectively speaking the effect of their gift is to secure social solidarity. Arguments in medical ethics and philosophy provide another angle in the debates about tissue donation. These tend to focus primarily on normative questions regarding conditional allocation of organs (Wilkinson T.M. 2007), financial inducements, the sale of human organs, and the matter of coercion (Wilkinson S. 2003), as well as definitions of brain death (Caplan and Coelho 1998).
3.6 Social scientists certainly keep these various arguments in mind, but what a social science perspective offers, as Healy (2004, 2006) astutely observes with respect to Titmuss's work, is an account of the social-organisational management of altruism and the donation of body tissues. According to Healy (2004, 2006), there are two significant features of this account, and these features are not typically recognised in ethics debates about altruistic acts. The first point Healy (2004: 5-6) makes is that altruistic behaviours and their incidence (rate or frequency of occurrence) vary depending on the act. Although Healy identifies Oliner's work as focused on motivated altruism, like Oliner (2002) who envisages a continuum of altruistic forms, Healy outlines a typology of different kinds of altruistic acts. These vary from one-off spontaneous acts of heroism, for example, to regular, institutionalised forms of what we might call 'obligated altruism' such as mothering or domestic labour within the household. The upshot of Healy's classificatory schema is that we need to be specific when talking about altruism and not talk about altruism as if it were a general phenomenon. Likewise, we need to acknowledge that some body tissues are given and received anonymously (blood or donated breast milk, for example) whereas others may involve more intimate social relations between donors and recipients (giving human gametes and living organ donation, for example).
3.7 The second point Healy makes is that altruism 'is structured, promoted, and made logistically possible by organisations and institutions with a strong interest in producing it' (2004: 1). As Titmuss's (Titmuss 1997: cht. 16) statistics of blood donation indicated, the highest category of altruistic or donative actions in institutionalised settings tend to occur in response to direct requests. The figures Titmuss cited showed that 31.2 percent of all people who donated blood in the United Kingdom under the welfare system of the 1970s donated under the 'response to appeal categories'; either personal appeal (13.2 percent) or general appeal (18 percent), and of the 14 categories of 3,800 donors interviewed, this was the highest recorded category of donations.
3.8 While donated body tissues can be treated analogously, differences should be noted. Both blood donation and cadaveric organ donation, for instance, can be altruistic. However, giving blood rests on a personal decision made by a healthy person donating a replenishable body fluid; whereas cadaveric organs are usually donated by a grieving family who has been asked to sacrifice the sanctity of a loved one's body for the benefit of a stranger or several strangers.
3.9 Although the perception exists that cadaveric organ donation occurs voluntarily, this is far from the case. In New Zealand in 2007, Intensivists or Registrars sought authority for organ donation in 92 percent of cases, and only five percent of cases were volunteered. Australian figures for 2007 show 60 percent of cases were broached by Intensivists or Registrars (Anzod 2008: 1). Whilst New Zealand and Australian Intensivists offer the option of organ donation to families whose loved one has been diagnosed brain-dead, requesting organ donation in Spain is a somewhat more vigorous appeal process. Recent figures for organ donation rates in Spain indicate that direct and repeated efforts by transplant coordination teams to 'request' or 'obtain consent' from families to donate the organs of loved ones precipitate higher donation rates. As Streat (2004) notes, the use of language such as 'obtaining consent' and 'requesting donation' in this context is not morally neutral and reflects a utilitarian view of organ donation focused on organ procurement as an end goal rather than on the needs of donor families. While the initial consent rate in Spain is 59 percent upon first request, which is consistent with the willingness to donate elsewhere in western societies, rates of up to 81 percent have been reported by making up to five additional requests (Marmisa and Escalante 2002; McCall 2006).
3.10 Healy's perspective, coloured as it is by the North American health care system where there exist separate organ procurement organisation s (OPOs) for the identification, collection and retrieval of transplantable organs, is that giving body parts, body fluids, love, or care, and even money for that matter, is 'systematically elicited from people by these organisations' (2004: 1). While this appears to be the case in Spain, this situation does not apply in the New Zealand or Australian organ donation and transplantation environment. In New Zealand OPOs are absent and the option of organ donation is first raised with families of brain-dead patients in the ICU by Intensivists. Healy is nonetheless right in saying that various organisation s are the immediate recipients and direct beneficiaries of people's generosity and goodwill, and, in the case of OPOs, they are sometimes 'the necessary brokers for it' (2004: 1). While the commericalisation of organ donation is prohibited in the USA, this is not the case for all body tissues. In California recently, a privately owned company called Prolacta Bioscience set itself up to sell human breast milk, at 10 times the price available from not-for-profit North American milk banks (Ensor 2006). The sale of human gametes provides another example of the commodification of body tissue in the USA.
Promoting Altruism
4.1 Although the system in the USA is renowned elsewhere in the Anglophone world for its commercialisation of gamete donation, benefits accruing to organisations from tissue donation also occur in the non-commercialised context, even when donation is said to be altruistic. This is true of private and public fertility clinics in New Zealand, where the commercialisation of gamete donation is prohibited by law (see Human Assisted Reproduction Technology Act 2004), and where, as of 2006, New Zealanders have been eligible for two publicly funded cycles of fertility treatment if they meet the Clinical Priority Assessment Criteria.[3]4.2 Direct and indirect requests for donation occur in the fertility clinic context for couples who need people to donate gametes, especially if family or friends are unavailable to do so. One of the ways this happens in New Zealand is when clinic professionals such as counselors help people construct advertisements for gamete donors, and these are subsequently placed in national magazines and newsletters (e.g., see NZ Listener or Little Treasures Magazine). While fertility clinic counselors do not 'design' advertisements for couples,[4] they can provide people with folders or dossiers of previously published advertisements and may offer advice and suggestions as to how best construct advertisements if people require this. This is an important part of the fertility clinic service because without the altruistic donation of gametes, New Zealand fertility clinics would not be able to initiate some treatment services that involve in vitro fertilisation or donor insemination.
4.3 As elsewhere, the New Zealand media also indirectly help promote and facilitate the process of altruistic donation of gametes and surrogate pregnancy arrangements in the domain of assisted conception. Since the primary aim of newspapers and magazines is arguably to enlist readers not donors, the process is far from conspiratorial, but benefits do accrue from the media promotion and advertisement of health related research and campaigns to encourage tissue donation. First, as Ragone (1994: 53), Farquhar (1996: 148), and Michelle (2006: 111) independently observe with respect to assisted human reproduction, media impart knowledge and information about the processes and capacities involved with new technologies, including assisted reproductive technologies, thereby allaying people's fears and anxieties about their complexities. Second, media also encourage, if not recruit 'readers' and viewers' identifications with those who provide, use, or are impeded in using the technologies themselves' (Michelle 2006: 111).
4.4 Audience identifications are actively pursued via a host of different strategies. An oft-used narrative strategy, especially in women's magazines but also in other media such as television 'talk shows' is 'anecdotal personalisation'. As Michelle (2006: 112) says, this strategy relies on '"real life" human interest stories featuring the struggles, triumphs and personal testimonies of women and couples' who have used assisted reproduction technologies. Readers and viewers identify with the characters (some of whom are fictional, but many are not), and share in what they are going through. These real life stories elicit strong feelings of empathy, especially from women who, for whatever reason, are unable to have children. The point is that while we may think that decisions to act altruistically are fundamentally principled, empathic motivation is extremely important in the ethics of gamete donation. This is also true of organ donation and transplantation stories; donors and recipients are often motivated to draw attention to their plight, to raise awareness of the issues, and to help others by telling their stories. Oliner (2002) makes this point in his discussion of altruism in that it 'involves concern with the fate of another in distress', creating 'overpowering feelings that lead people to react spontaneously' (2002: 126, 127). Justifiably, organisations like private fertility clinics would not discourage producing or entreating such feelings, and may even be in the business of cultivating such sentiments since specific forms of (corporeal) generosity, re-branded as altruism, contribute to the future of an organisation or enterprise.[5]
4.5 Like Ragone's (1994: 53) research with surrogate mothers in the USA, three separate accounts from surrogate mothers I interviewed included anecdotes from the life stories of other surrogate mothers published in women's magazines. In my interviewees' narratives the life stories of other surrogate mothers played a part in their decision to become either traditional or gestational surrogate mothers. The story of Amanda McLeod, a traditional surrogate mother, who was recently dubbed Mrs. Normal New Zealand, is an example of the kind of account Ragone, Farquhar, and Michelle are referring to.[6] On a less elaborate scale, but also before learning about what was actually involved in reproductive gift-giving, seven ovarian egg donors I interviewed said they responded to advertisements requesting ovarian egg donors in several New Zealand magazines (Little Treasures and Next magazine were frequently cited). Describing how the donation process proceeded for her, one of my interviewees, Rhea, remarked that the advertisement she read:
'Was actually a personal request, like: "Couple has been married eight years, been trying, would love to complete our family by a child, and the only chance for that to happen is through egg donation"… You know, "if you think this is you" sort of thing, contact the clinic. So, it was like a personal plea if you like.'
4.6 Women's motivations to donate ova are invariably complex and sometimes incorporate several classes of motivation at once (see Kirkman 2003; Orobitg and Salazar 2005; Shaw 2008). However, by their own admission, the women I spoke with said that notices requesting egg donors acted as triggers prompting them to consider ovarian egg donation or surrogate pregnancy as a requisite form of bodily generosity. As Penia, one of my interviewees stated; 'it just sort of put the seed in my mind to make me think about it, and then I started doing some reading and doing a bit of research…'
Emotion Work and Tissue Donation
5.1 As well as encouraging altruistic acts, organisations are also in the business of ensuring donors and recipients display and enact 'appropriate' emotional responses toward one another throughout the process of donation and once the donative process is held to be complete. Hochschild's (1983) thesis on the orchestration of feeling in the context of capitalist society is useful in understanding this phenomenon. Both Cheal (1988), who has written about gift giving in contemporary consumer society, and Healy (2006), who writes about organ transplantation, independently draw attention to the robustness of her argument in conjunction with a social-organisational account of gift giving. While Hochschild's empiric work is about the commercial context, specifically flight attendants of Delta Airlines, her points are salient for all kinds of social encounters that involve defining which emotions are appropriate and acceptable for particular social settings and situations. Hochschild's view is that when people do 'emotion work' or manage their emotions they follow scripts or adopt a moral line to direct their actions (Hochschild 1983: 56). These scripts are defined and determined culturally by formal rules of etiquette as well as by gatekeeping professionals and institutions who must manage the proximity of social interchanges between participants in gift-exchange encounters. Scripts or feeling rules, as Hochschild calls them (1983: cht 4), guide emotion work 'by establishing' for people what they are entitled to, or what they are obliged to do for others, in terms of emotional exchange (Hochschild 1983: 56, 18). Additionally, while requisite emotion work in displays of altruism, as an exceptional form of generosity, must be recognised as consistent with the social situations in which it occurs, it is often supplemented and managed by the exchange of expressive tokens of acknowledgement, gratitude, offerings, and gifts.5.2 Feeling rules and emotion work play a significant role in the reception of bodily gifts in contemporary societies, and this is often materialised through various 'interpersonal rituals' (Goffman 1971: 63). This is definitely the case with respect to the kinds of rules governing the receipt of ovarian eggs, for example. In New Zealand, when recipients are gifted ovarian eggs, fertility clinic personnel encourage the show of gratitude by suggesting recipients do several things – they are encouraged to give donors a bunch of flowers when they have donated ova, possibly a card or letter expressing thanks and a box of chocolates, and if the fertilisation of gametes and implantation is successful and a baby arrives, then perhaps a photograph of baby.
5.3 These are all good things to encourage recipients to do, and, as ovarian egg donors have indicated to me in interview situations about their experiences, when they get flowers, small gifts, and so on they are usually really pleased. Although these ritual offerings are indicative of 'supportive interchanges' (Goffman 1971: 62) in most situations, it is sometimes the case that minor tokens of exchange are untimely or miss the mark. This is certainly true for recipients of ovarian eggs who say that they can never thank people enough for what they have done for them, and that the etiquette involved in gift-giving does not compensate for what Thetis, an interviewee in the ova donation study, described as 'the kindness of strangers'.
5.4 Timing is also significant in terms of giving and receiving tokens of exchange. In the organ donation and transplantation context in New Zealand, recipient coordinators forward letters to donor coordinators from organ recipients to pass on to donor families if the family wishes to receive the letter. According to one donor coordinator I spoke with, most but not all families want to receive letters, but 'not all of them want to immediately.' In one case, as this coordinator told me, a mother of a young child who died tragically in an accident phoned her eight years after the donation to say she was ready to receive a letter from the recipient of her child's organs.
5.5 The failure of ceremonial gestures such as giving flowers or thank you notes to signify gratitude appropriately can also be experienced by donors of body tissues who find the etiquette involved in these ritual exchanges somehow insufficient. While donors are supposed to feel good about receiving token gift offerings, this is not always enough. Although such cases are uncommon, they do draw attention to the fact that existing rites do not necessarily 'fit' each and every donative situation.
Gift Terminology
6.1 I would suggest that donor dissatisfaction or disgruntlement with the box of chocolates or bouquet of flowers is partly related to the different ways that donors and recipients conceptualise the notion of the gift. As social scientists have noted, the meaning of 'gift' is not homogeneous. Rather, the notion is used to refer to a variety of acts, services, and things. For instance, when Scully et al. (2006) interviewed people about their views on pre-implantation genetic diagnosis for social sex selection one group identified the birth of a child as a 'surprise' gift, not to be pre-determined by the engineering of sex selection criteria. Likewise, Cheal (1988: 13) has noted interpretations of the gift in consumer societies as multifarious. For many people gifts tend to be superfluous, of no advantage or benefit to the recipient, could have been provided by the recipient themselves, and are frequently excessive.6.2 The multiple meanings of the term gift can lead to problems when people have different ideas about what a gift is and how to give it. In my research on ovarian egg donation and surrogate pregnancy it is clear people have different understandings of the term and that there is no hard and fast rule regarding gifts as one-way transactions. While most of the women I spoke with had no preconceived expectation of reciprocity, several women viewed their reproductive gifts as unconditional. That said, many were open to the possibility of establishing some kind of relationship with the recipients of their gametes should such a situation arise (Shaw 2007, 2008). My interpretation was that for some women the word gift did not describe a transfer of material or a service over which control or interest was unilaterally relinquished or surrendered. Rather, as anthropologists impress about gift-exchange in archaic societies, gifts exist as ritual offerings in a chain of giving-receiving-and-reciprocating.
6.3 The polysemic nature of the gift is frequently subsumed by the language used in health care information manuals, as well as by ethics committees. Tutton (2002, 2004) points out that the gift is typically conceptualised by ethics committees, medical councils, and research institutes interested in fostering the donation of body tissues as a one-way transaction. Yet the language that is used in these contexts to talk about donation is couched in terms of the 'gift relationship'. This move conflates altruism and the pure gift as unconditional with the gift relationship and gift-exchange, which is construed and understood as a part of a chain in a social system of prestation and counter-prestation.
6.4 The example Tutton gives that is typical of this kind of thinking comes from a statement made by the Medical Research Council in the UK, 2001. For the Medical Research Council, treating such donations as gifts is 'preferable from a moral and ethical point of view, as it promotes the 'gift relationship' between participants and researchers, and underlines the altruistic motivation for participation in research' (in Tutton 2002: 523). Similar language is used by Jones (2002) in an article discussing the retention of body parts in the context of New Zealand bioethics. In this article the author acknowledges the value of following the principle of the 'gift relationship' in relation to the 'donation' of body parts, but states that this guideline 'fail[s] to address the interests of both medical professionals and researchers' who need to access tissue for research purposes' (2002: 10).[7]
6.5 Although the terminology of donation (as opposed to gift) goes some way to redress the emphasis on procuring or retaining body tissue, concepualisation of the gift as one-way and altruistic, and the feeling rules that are supposed to accompany that gift, do not always coincide with everyone's felt perceptions and experience of what they are doing. This is evident in the following examples recounted to me as part of conversations about body gifting. The first example is taken from an interview with a research participant who described what she called a 'bad experience' regarding interactions with the recipients of her ovarian eggs.[8] In short, although this research participant (Philia) said that her recipients were 'totally anonymous', she also stated that she 'wanted to know who they were', 'I wanted a face.' In actuality donors often meet recipients in the NZ fertility clinic context and the meetings are usually mediated by counselors, so what this particular donor means by wanting a face amounts to more than the simple co-presence of her recipients in a one-to-one interchange. What Philia says is borne out by Goffman's (1967: 55) well known distinction between substantive rules governing moral and ethical matters and ceremonial rules and expressions governing etiquette. In Goffman's view it is etiquette; the rules of politeness and decorum, that orders the norms of social interaction and how we communicate and manage impressions in everyday practice and face-to-face encounters, not aspirations to a common good. Wanting to go beyond the show of appearances, Philia's perception is that her recipients may have conveyed an impression of the right emotions in the brief meetings she had with them, but genuine moral concern and connection was in fact absent. What Philia really wanted was a relationship with the recipients of her gametes, but this was not forthcoming. Further in her narrative account Philia stated:
Everything was just so geared up for the couples. Everything is geared up for them, but you just felt so unsupported. You were just this piece of meat. I mean, 'because you weren't paying the money you just felt used and abused big time. And I just felt I had given someone … I didn't expect a big huge parade or anything like that, but, um ... to give someone a child. … You know what I mean, you've given a lot, I mean that's my DNA and that's my make-up and that's my body, you know, that's who I am.
6.6 While feeling rules are scripted to prompt people to act in certain ways for the benefit of specific organisations and institutions, the rules which are supposed to guide or prescribe how people should behave do not always express their feelings (Hochschild 1983; Healy 2006: 23-24). Indeed earlier on in Philia's interview she stated her view of parenting as essentially social, so her ova did not give her entitlement to lay claim to the offspring of her donation. However, as her narrative progressed and she began to talk about her emotional distress regarding the donation process Philia began to contradict herself. As quoted above, Philia intimated that her cells were inalienable ('that's my DNA', she said), because the spirit in which they were received was violated. Such interpretation is consistent with the notion of gift as a relationship, and as Godelier (2002) has recently suggested, it is in line with a reading of Mauss that explains the alienability of gifts in terms of use but inalienability in terms of possession.
6.7 Many of the interviewees I spoke with in the ova donation and surrogate pregnancy study indicated an openness to establish social bonds with the recipients of their eggs (and the offspring they gestated) beyond the anonymous and one-way 'gift' transaction. However, Philia's take on the lack of reciprocity by the recipients of her ova refutes the notion, sometimes promulgated by medical professionals as well as laypersons, that the symbolic weight of whole organs like the heart, kidneys, and the brain means that they are not fungible in the same way as other body matter such as blood, tissue, and ova, which might be construed as waste. For instance, Jones (2002: 10) argues that some tissue samples, notably brains, kidneys and limbs 'have far greater symbolic significance than do others' such as blood or bone. This may be true for some cultural groups. The Ministry of Health (2004: 46) for example, states that Maori are traditionally said to place more importance on the whole body than on body cells, although the significance of genetic material which 'contains' one's ancestral heritage remains nonetheless important (Glover and Rousseau 2007). In contrast, several women I interviewed for the ovarian egg donation study described their gametes going to waste if they were not used up (Shaw 2008).
6.8 Although an instrumental class of motivations exists for some women who donate ova, in that they perceive their gametes having a limited lifespan, this is not the case for everyone. Some women do not see such bodily gifts as either fungible or alienable, and in the context of rapid advancements in tissue transfer it becomes increasingly difficult for these donors to call their acts anonymous, especially when it is possible to map DNA in blood and human gametes.
6.9 It is also worth noting the difficulties many people have donating whole eyes or parts of eyes (Haddow 2006: 325); as one donor coordinator stated, many people view the eyes of others as a 'window to the soul' since they are the most expressive part of a person's identity. This donor coordinator also recounted a story that debunks the idea of a gift as one-way. In this example, which was understandably complicated by grief and personal circumstances, a woman who donated the eyes of a loved one was anxious when she had not heard back from the recipient a week after the donation as she wanted to receive direct recognition from the recipient of gratitude. Apparently, the woman had an expectation of giving and receiving many letters, not just the standard thank you letter sent on behalf of the recipient via the donor coordinator.
6.10 These kinds of exchanges can occur but they are infrequent in the context of tissue and cadaveric organ donation in New Zealand (see Sharp (2006) for an alternate view). This is due to the careful mediation of such relationships by health professionals, psychologists, and counselors. One possibility for connection between donors and recipients occurs twice yearly, in two major city cathedrals in New Zealand where Thanksgiving Services are held for donor families and organ recipients. At these services, transplant recipients are invited to light a candle as a symbol of gratitude to those who have given them renewed life and members of families of those who have donated organs and tissues are invited to receive a variety of Camellia plant called 'Donation' in recognition of their 'gift'. The service is followed by Lunch at which it is possible for donor families and recipients to serendipitously meet, thereby collapsing the social distance required of anonymous donation to a stranger. Despite media anecdotes suggesting otherwise,[9] professionals working in the donation area maintain that matching donors with recipients at these services is not common practice. However, it is difficult to say categorically that people do not try to meet up at Thanksgiving Services and that the purpose of the ceremony, for people to recognise and share a view of the ceremonial significance of the ritual as a social good is paramount, as the ends of individuals attending these such services may be very different. Some people could be keen to objectify the symbolic act of donation via more tangible social relationships and may go to lengths to do this. Aside from the Thanksgiving services, it would be difficult to orchestrate such meetings in the New Zealand context. This is because, in the interests of protecting donor families and recipients in the case of organ donation and protecting recipients in the case of ovarian egg donation, unmediated interchange between these parties is not institutionally encouraged. Letters pass through the hands of counselors and psychologists in fertility clinics and through the hands of donor and recipient coordinators in organ donation situations to protect the personal preserves of those involved. In this way, the management of interpersonal rituals in the case of body gifting by incumbents in professional contexts plays a pivotal role in the social organisation of emotion work in the domain of tissue donation as well as managing the legitimate expression of emotion, affect, and connection in that domain.
Conclusion
7.1 What we can take from the above examples is that while gift terminology is often viewed as morally neutral in the public arena, especially for transplant recipients whom health professionals say are much more likely to use the notion of gift than donor families, closer attention needs to be paid to how we use language in the context of tissue donation. As Healy says, it is currently the coordinating organisation s themselves that not only 'work to elicit donations from donors, to elaborate the meaning of donation, and to specify the nature of the gift and the obligations that flow from it. […] Organizations provide opportunities to give and produce and popularise 'accounts of what giving means' (2006: 17).7.2 In personalised stories posted on websites and reproduced in other media, and in institutional leaflets and policy documents, organisations produce ideal conceptions of donor behaviours and corresponding emotional displays and affects. These discourses and accompanying practices provide a ready-made frame of reference for lay people to understand and make sense of the practices and procedures they are engaged in, but they are not always in line with the accounts people give themselves and each other of those practices. Often this depends on the kind of tissue being donated and who the tissue is being donated to. Bringing the language of donation and reception closer to donors and recipients' gift-exchange practices will require deeper discussion of the rituals associated with donation related activities. This means appropriate recognition and acknowledgement of body tissue donors as well sensitivity to those who wish their donations to remain anonymous.
Notes
1 Many thanks to all those who contributed to the research projects discussed in this article, especially the interviewees for the reproductive gifts study and the Intensivists and organ donor and recipient coordinators. Thank you also to Victoria University of Wellington Human Ethics Committee (Ref. 2-2007-SACS).2 Waldby and Mitchell's (2006) definition includes reproductive tissue such as human gametes and human embryos. Under New Zealand law, reproductive tissues are not considered "tissue" for the purposes of the Human Tissue Act 2008 but are covered under the Human Assisted Reproduction Technology Act 2004.
3 The CPAC criteria for women include meeting body mass index rates, being a non-smoker, age criteria, number of previous children, and prognosis of conception without treatment, FSH levels, previous sterilisation, and duration of infertility.
4 This assurance was given to me by personal communication with a Fertility Associates (NZ) counselor on 3 July, 2007.
5 For example, see 'Stories' and 'Newsroom' on the Organ Donation New Zealand website < http://www.donor.co.nz/donor/>, and Weekend Herald, 3 May, 2008: 8-11 ( http://www.nzherald.co.nz/public-healthcare/news/article.cfm?c_id=294&objectid=10508797), which ran a magazine story about cadaveric organ donor Robbie Stewart.
6 See Sunday Star, 5 March, 2006.
7 See also Gillett (2007) for a more extended discussion of this issue.
8 I have used this example elsewhere in published work (Shaw 2007, 2008).
9 For example, see Weekend Herald, 3 May, 2008: 8-11.
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