Review of The Political Economy of Organ Transplantation: Where Do Organs Come From? By Hagai Boas, New York: Routledge. 2022. pp. 214.

Angela Leocata

Stanford University

Hagai Boas’s The Political Economy of Organ Transplantation intertwines the bioethical and autobiographical to invite a reconsideration of how anthropology might approach organ transplantation. Offering a theoretical framework for this political economy, Boas suggests a refocus on organs themselves: in their movement, structures, and the moral milieus through which they travel. The myriad routes of organs, Boas argues, might attune the analysis to in-between spaces, “shunning away from normative or critical premises about the link between transplantations and morality, not because the conflicting moral economies of transplant medicine are incorrect but because it is exactly this link that should be under investigation” (56, emphasis added). Boas considers how the increasing shortage of organs generates an economy wherein organ securement becomes “a do-it-yourself project” in a broader landscape of privatization, triangulated across the state, market, and family (xvi).

The book is organized into six chapters interwoven with autobiographical sections on the author’s search for organs from 1986 to 2020. Each is enveloped within its own history of medicine and means of transplantation. Together, the chapters engage the contours of the political economy of Boas’s proposal.

Situating organ shortage as the driving force of the political economy of transplantation, the opening chapter engages the dynamics of this shortage and an unsettled history that evokes ethical questions and debate. Promises of medical horizons are met with the structural shadows of shortage, as Boas considers layers of waiting: patients on waiting lists, the waiting of eventual organ rejection, and transplantation medicine itself as “an instrument waiting to be used” (7). The second chapter highlights the dichotomy that discussions of transplantations can slip into: the “see-saw of images” (52) of “organs as mere objects,” on the one hand, and “organs as the potential bearers of ‘the gift of life’” (34), on the other. The author suggests political economy as a possible direction outward, tracing modes of donation and commodification and highlighting the in-between spaces that organ transplantees must navigate. Treading in the spaces between and among the dichotomous allows the analysis to dwell in “the crowded paradoxes and hybrids that populate this world” (56). Focusing on the social institutions through which organs move, chapter 3 delves further into living and deceased organ economies and their social and ethical significations. These contours are granularized in chapter 4. Exploring a globalized organ economy, the analysis engages the specificities of and spaces between living/deceased, privatized/public, and familial/market/state economies.

Drawing on interviews with organ donors, chapter 5 considers kin dynamics, forms and formations of relatedness, and their ethical textures in what the author frames as a growing living organ economy. Questioning the assumption of kin donations as necessarily an act of altruism, Boas grapples with anthropological notions of “the gift,” the symbolism of exchange and debt, and the family as a social institution. Chapter 6 offers a case study of institutionalized familial consent to brain death, providing insight into the boundary blurring and paradoxes at the center of the text’s proposal. Finally, the epilogue considers ethical questions of a potentially changing political economy, threaded by an unresolved reflection of whether recent medical advancements can, in fact, open “a new horizon” (180).

For the author, the question of where organs come from is an academic and personal inquiry that remains open-ended across the text. Raised across “a twisted labyrinth” of connected ethical and moral fabrics, the autobiographical brings the reader into how medical innovations, and medical uncertainties, are lived with (4). Beginning with a bicarbonate solution in hot milk that was Boas’s childhood morning drink (“instead of chocolate milk or tea”) in a time when “the transplant horizon looked very far away” to a replacement of cyclosporine with orange juice and four eventual kidney transplantations (2–3), Boas engages living-with as on-edge, embedded with a sense of unknowing and uncertainty that evokes the ethnographic genre itself (see Biehl and Locke 2017). Perhaps this is felt most with the often inevitable yet unknown rejection of the organ: what, Boas argues, compounded with organ shortage, drives the political economy of the text’s concern.

Across the work, Boas returns to the question of what it might mean to “live with”: to “live on the frontiers of scientific innovation” (xiv), to “live with the knowledge that the day will come when my body rejects the organs transplanted in me” (xiv). A thread of the text, these questions are of deep relevance to anthropology: How might attention to transplantee experience generate attunement to these forms of living-with? In what ways, as Boas suggests, has the pandemic sharpened global sensibility toward these forms? What might this open for anthropological attention, or the ways we notice in anthropology?

In my reading, the text appears generative for courses in and beyond medical anthropology. Boas tells a history of transplantation that remains morally open-ended. Puncturing and interweaving history with the ethically unsettled, the book raises questions that classrooms can grapple with. The opening chapter’s review of brain death, consent, and altruism raises crucial concerns, such as “Does consent, informed or presumed, take into account the scientific-clinical complexity of determining brain death?” (19). Or, “What is the meaning of consenting to an act after death? How is the wish of the deceased determined?” (22). The text invites a nonromanticized engagement with the family as a primary social institution. To this end, chapter 3 would be especially helpful in courses centered around questions of kinship and gender. Relating transplantee experiences to the pandemic, Boas connects the bioethics of transplantation medicine to a continued ethos of our times:

The “new normal” of life on the verge of danger . . . and the understanding that our lives are not only a story that we write but rather the outcome of our dependence on the environment and the other. . . . (xvi)

The text, then, emblematizes the social landscape, and lived social inequalities, of health—what remain at the core of our field—and would act as a critical tool for courses in medical anthropology.

An intimate engagement with the topic of concern, the book offers a crucial reconsideration of normative configurations between organ transplantation and morality, escaping the dichotomies through which discourse of this world can slip into. Political economy allows the author to dynamize what can otherwise fall into the horizontal, all while maintaining the structural shortage that makes access to health, and the search for an organ, unequal and uneven.

Reference

João Biehl, and Peter Locke, eds. 2017. Unfinished: The Anthropology of Becoming. Durham, NC: Duke University Press.