Last Best Gifts

More than any other altruistic gesture, blood and organ donation exemplifies the true spirit of self-sacrifice. Donors literally give of themselves for no reward so that the life of an individualoften anonymousmay be spared. But as the demand for blood and organs has grown, the value of a system that depends solely on gifts has been called into question, and the possibility has surfaced that donors might be supplemented or replaced by paid suppliers. Last Best Gifts offers a fresh perspective on this ethical dilemma by examining the social organization of blood and organ donation in Europe and the United States. Gifts of blood and organs are not given everywhere in the same way or to the same extentcontrasts that allow Kieran Healy to uncover the pivotal role that institutions play in fashioning the contexts for donations. Procurement organizations, he shows, sustain altruism by providing opportunities to give and by producing public accounts of what giving means. In the end, Healy suggests, successful systems rest on the fairness of the exchange, rather than the purity of a donor's altruism or the size of a financial incentive.

Kieran Healy is assistant professor of sociology at the University of Arizona.

List of Illustrations

ix

Acknowledgments

xi

1 Exchange in Human Goods

1

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Procurement rates for blood and organs vary strikingly.

This variation has its roots not in individual dispositions to give but in institutional differences between procurement systems.

Organizations responsible for procuring blood and organs create and sustain altruism by providing opportunities to give and by producing and popularizing accounts of what giving means.

2 Making a Gift

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Advocates of organ transplantation have, over the past thirty years, articulated and refined a cultural account that has changed public understanding of organ procurement and exchange.

This account has described and motivated donation, in part by addressing two problems: harvesting organs both introduces a utilitarian calculation at the time of death and threatens to place a cash value on human life.

As structural pressure on the transplant system has increased, so has the possibility of commodification.

Recent changes in discourse should be understood in the context of organizational efforts to produce viable accounts of caring and altruism and to manage the expressive dimensions of money.

3 The Logistics of Altruism

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There is no donation without a procurement organization, but some organizations are more successful than others at finding donors.

Structural and organizational characteristics of organ procurement organizations explain much of the variation in procurement rates within the United States.

Small changes in organizational strategy can have large effects on procurement.

These findings are in sharp contrast to the emphasis on individual motives for giving found in both public accounts of donation and much of the research on donation.

4 Collection Regimes and Donor Populations

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Procurement systems also vary cross-nationally.

Data on blood collection in Europe shows that variations in national collection regimes affect both donation rates and the composition of the donor pool.

Some systems attract many once-off donors, others have smaller populations of regular donors.

Blood collection regimes produce their donor populations by providing differing opportunities to give to different sorts of people.

For example, Red Cross systems take greater advantage of personal ties to transfusion recipients than do state-run systems or those based on blood banks.

5 Organizations and Obligations

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Procurement organizations do not stand outside the exchange system or manage donors in a purely strategic way.

Like individual donors, decision makers within these organizations may be affected by the moral economy of exchange.

When HIV appeared in the U.S. blood supply, there was a crucial period of uncertainty about the nature of the disease and its presence in the blood supply.

The structure of institutionalized exchange relations shaped how organizations that collect blood from unpaid donors and those that buy plasma from sellers perceived their environments and helps to explain why they reacted differently.

6 Managing Gifts, Making Markets

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A complex technical infrastructure determines a great deal about how systems of exchange in human goods work, irrespective of whether the core exchange is for-profit or voluntary.

In many ways, whether exchange is commodified matters less than whether it is industrialized—that is, administered by rationalized organizations that try to collect goods like blood and organs as efficiently as possible.

The proliferation of secondary markets inhuman goods exposes a tension between the short-run logistical demands faced by procurement organizations and the long-run development of ideas about the "gift of life" that legitimate the exchange system.

Treating human goods either as ordinary commodities or presents given without obligation results in similar problems.

Appendix: Data and Methods

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Notes

143

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Bibliography

169

(16)

Index

185

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