Attempts to transfer human tissue date back to antiquity, but until recently attempts to transfer ontologically necessary tissue like recipients’ own bodies consistently defeated solid organs. The immune system identifies and destroys any tissue coded with macromolecules that identify it as alien, and the recipient dies due to organ failure and necrosis.
Hitherto, the best strategy for success hinged on making the tissue as identical a genetic match as possible, so the pool of potential donors for transplant was typically limited to close relatives. This changed with the development of immunosuppressant drugs like cyclosporine in the early 1980s.
Immunosuppressants suppress the body’s immune response, delaying tissue rejection. Cyclosporine transformed the global biopolitics of organ transfer, radically increasing the pool of potential donors for successful transplant.
Lawrence Cohen notes, “Cyclosporine globalises, creating myriad biopolitical fields where donor populations are differentially and flexibly materialized.” In practical terms, this has meant that economic imperatives have increasingly been able to play a part in defining the donor pool, particularly on the black and grey markets: “With cyclosporine, the operability of the poor increases many times over”. While most of these donations are technically consensual, financial pressures often drive living donation for sale, to the extent that the United Nations’ Bellagio Task Force has warned that “inequities in political power and social well-being remain so profound that the voluntary character of the sale of an organ remains in doubt.”
In other ways too, transnational tissue transfer is by no means immune to the pressures of twenty-first-century capital. Most countries have made it illegal to sell most human tissue; there are exceptions, such as and Iran where paid donation is legal, and the market in blood in the USA. Yet even in countries where ontologically-necessary tissue cannot be legally sold, tissue transfer remains a multi-billion dollar global industry.
Lesley Sharp, an anthropologist, specialising in analysing the communities involved in organ transfer, explains: “Without question, much money is exchanged, but payments made by insurance companies, individual patients, transplant hospitals, and procurement agencies are typically described as covering technical, transportation, and other support services, rather than being directly linked to the cost of the organ itself.”
Similarly, Scott Carney observes that US hospitals “increasingly turn profits on organ transplants; some even return revenues to shareholders”. The complexity of tissue transfer is exacerbated in the way that it is often not a simple movement of tissue from x to y: as Catherine Waldby and Robert Mitchell note that transfer involves “a complex network of donor-recipient relations heavily mediated by biotechnical processes and an institutional complex of tissue banks, pharmaceutical and research companies, and clinics”. There is a complex and diffuse market in procurement and transplantation.
In addition, government funding structures can have a dramatic influence on tissue procurement practice. In the USA, for example, the government funding structure for Organ Procurement Organisations (OPOs) mandates reaching targets for transplant or cannot retain funding. This funding structure can become an ethical problem when, as occurs in the USA, the end of life care of potential donors is routinely put into the hands of OP professionals without family necessarily being made aware that the new nurses and doctors with whom they are working are actually employed by an OPO rather than the hospital, and that their success in their role is linked to meeting procurement targets.
In addition, invasive and potentially harmful procedures may be done to the potential donor to help their tissues survive the transplant, without the donor kin necessarily being made aware that these can be painful and/or hasten death. All these things may impair end of life care. In multiple subtle ways, then, economic pressures can be imbricated in tissue transfer economies.
The dystopian novels in this article can be best understood within these contexts of rapidly expanding transnational operability and capital pressures on organ procurement. Transplantation is an extraordinary life-extending procedure, and tissue donation can be an act of profound generosity. Yet science fictions of organ procurement rarely present it in voluntary or benevolent contexts; instead, these dystopias imagine certain groups preyed upon for tissue.
While in no way “realist” fiction, their fantasies of predation are not entirely unfounded: there is evidence that certain groups are more likely to be organ sources. Human rights organisations have found evidence that prisoners in certain regimes have become vulnerable to non-consensual harvest, and given the realities of economic incentives, living donation correlates with particularly striking economic and gender divisions.
It is commonly thought that solid organs only rarely become explicit “commodities”, such as on the black market and in the few states with legal organ sales, or in controversies like the UK’s Alder Hey scandal where organs removed from children were sold without parent knowledge or consent. Yet even in less explicit markets, the process of marking tissue off as transferrable, as acceptable for transplant in legal and cultural terms, echoes many of the detachment processes that necessarily accompany commodification in late capitalism.
As Margaret Lock and Vinh-Kim Nguyen observe, “In order for body parts to be made alienable, they must first be visualised as thing-like, and detachable from the body, dead or alive”. Economists call the process by which an object becomes alienable “disentanglement”, and it is a fraught and fragile symbolic process. Michel Callon explains, “to transform something into a commodity […] it is necessary to cut the ties between the thing and the other objects or human beings one by one. It must be decontextualised, dissociated and detached”.
The process of alienating human tissue is as complex and culturally specific as any other act of commodification and has taken a wide variety of forms throughout history. If there has been a defining feature of the way the alienation process has changed in recent decades, it is that it is now possible for the distance between procurement and transplantation — between production and consumption, in economic terms — to be substantially greater than in the past.
Thanks to pharmaceutical advances that have partially loosened the need for a tight “match” between donor and recipient, procurement and transplant may be distant in terms of their geography, genetics, ethnicity, and the full range of their sociocultural circumstances.