Thinking about organ “donation”

Transplants or organ transplants have imposed itself since the 1970s as the best medical treatment of a certain number of pathologies affecting the heart, the liver, the lungs, the pancreas and especially the kidney. France and the United States have played a pioneering role in this medical adventure strewn with pitfalls, both surgically and medical and humanly and humanly. It was necessary to understand and block the rejection mechanisms, but also to ward off the ethical drifts arising from the transgressive character of this medicine which obliges to violate taboos.

In fact, it blurs the boundaries between life and death by taking living organs in dead to replace dead organs in living ; She mutilates healthy bodies to regenerate sick bodies ; It introduces the other deep within the self ; She calls into question the definition of death, traditionally understood as the cessation of the heart and the breath ; It forces the medical profession to break one of the sacred principles of its professional ethics, the PRIME NOCERE ; It obliges to decide the question of the property of the body and its organs. To whom belong “ my »Reins ? To me or to society ? Do I have the right to dispose of them, including selling them ?

The mere fact that she introduces a third party into the relationship between the doctor and the patient, in the form of a dead or a living, transplantation establishes new forms of relationships between human beings. Hence his interest in the sociologist. Hence the subtitle given to the work by its author: “ A new trade between human beings ». The term trade is understood here in the sense he had in XVIII^e A century: a set of relations between people, the market relationship constituting only one of the possible cases of this trade.

The ultimate border

The object of the work is clear: it is, to understand and characterize the nature of this new trade between human beings, to resolve an enigma posed from the opening. Since the 1960s, the practice of transplant has managed to cross (rape ?) Two borders, the one that separates life and death first, that of the skin then. How to explain that a third border, that of commercial trade, has not yet been crossed in the context of companies where it has managed to impose itself everywhere ? Is it the next step in the history of transplant, or the very nature of this new trade between men will succeed in holding it on the edge of our companies ?

The stakes are high, and Philippe Steiner has deployed to respond to a wide spectrum of approaches. Both sociologist and economist, he successively questions the models of exchanges identified by the great authors of the two disciplines. Max Weber, Marcel Mauss, Vilfredo Pareto, Karl Polanyi, Léon Walras, Joan Robinson, Francis Edgeworth and others are still summoned. The research is partly unsuccessful: this new business is unlike any other, while taking here and there some features from one or the other. The strength of reasoning consists in questioning transplantation from economic and social realities that are a priori foreign. What are the similarities that can be established between an inheritance, death insurance and transplantation ? All three transfer goods or resources post mortem !

American and European land

Theoretically vertebrate, reflection, however, is nothing of an abstract speculation. It is based on an impressive mass of data which fall under the various fields concerned by the transplant. Medicine and surgery first: the author perfectly knows the technical history of this practice, with his tests and his mistakes, his developments in the different countries, organ by organ, over the past fifty years, conflicts between doctors and Surgeons, up to the stages of Thomas Starzl’s university career, virtuoso and pioneer in the field, whose tribulations in large American hospitals say a lot about the evolution of mentalities of the medical profession in the face of transplants.

The vast majority of data on display come from the United States: the American arena is indeed a privileged reflection field, since it was in Boston that Joseph Murray produced one of the first transplants in the world, in Boston as well as ‘Has, under the direction of Henry Beecher, theAd Hoc Committee de Harvard, whose work has given birth to a new definition of death, encephalic death. The large number of transplants carried out in this country for fifty years and the diversity of legislative executives in which they have been carried out have given rise to often lively debates, in particular on the issue of possible remuneration granted to donors – subject still taboo in France.

In addition to the American case, the study is full of comparative data allowing to draw up a panorama of the practice of transplantation in the world: the more a country is rich, the more it grafted, but the share of transplants made from living donors depends more cultural orientations. That said, at the level of GDP Equal, the performance differences observed between countries are less explained by cultural specificities or less impulses of generosity than by organizational issues. If Spain has managed to reduce to less than 15 % The rate of refusals of families to authorize the samples from their deceased relatives, it is following the establishment of a decentralized and more active organization than in France.

The organizational, legislative and regulatory dimensions are also the subject of very excavated analyzes, in particular the parliamentary chronicle of the development of the last two laws of bioethics in France, including the waltz of amendments, proposed, discussed, modified, removed, added , learn a lot about decision -making mechanisms and the weight of doctors, not always the most progressive, in this area.

THE “ Don »

In his desire to identify the exact nature of this starts, Philippe Steiner, an excellent connoisseur of the works of Mauss and Durkheim, rightly twists the neck to the notion of “ organ donation ». He shows that this state expression, which has imposed itself in opinion and the media to designate transplantation, essentially has the function of exorcising the idea of ​​a commercial trade, by sanctifying free gesture.

But, in fact, and on some side that it is considered, a transplant is not a gift. The thing is clear when the person withdrawn has died. She can no longer give anything, and the family, far from being able to give a good that does not belong to her, is limited not to oppose a levy provided by law. In the case of the living donor, interposition, between the latter and the recipient, of the medical profession who considers him as a carrier holder a priori of all sources of contamination, and of the judge who ensures above all that he is not guilty of traffic and subject to pressures, largely dispossessed the “ giver »Of his supposed generosity. It quickly became one element among others of a medical device. As for the receiver, he has neither the obligation to accept nor the possibility of returning: in any of the cases, the Maussian model does not apply.

To characterize this act, Philippe Steiner prefers the notion of sacrifice to that of Don. We can also discuss it, while giving it completely right when it shows that the two Durkheimian forms of solidarity, mechanical and organic, are the concepts which today account for the process at work at the scale of society.

The great merit of this book is to have taken into account the many dimensions of transplantation: medical and surgical, legal and legislative, moral and psychological, social and economic – and that in their history and geography. With transplantation, the human body has become a social resource without becoming a market richness. The economic debate opened by Philippe Steiner clearly refuses the hypothesis of a biomarché. It shows that another path is possible to fight against shortage: more effective economic coordination, better articulating public exhortation and incentive of professionals.