Last Best Gifts: Altruism and the Market for Human Blood and Organs

Donations of blood, tissue, and organs save lives and restore health. Yet, even in rich countries, the promise of these medical miracles remains unfulfilled because of perennial shortages of donors. Because most organs and tissue come from cadavers, the life-saving gift of an organ typically follows a death. How then can supply be increased—and increased without reducing quality or cutting corners on full, informed consent of donors? Would it be wise to introduce more monetary incentives or should blood, tissue, and organs be treated as gifts? These questions have been explored by philosophers, ethicists, legal scholars, and economists. Last Best Gifts will delight sociologists, though, because it confirms our discipline’s most cherished article of faith: the action really is at the social level. Where others have focused on incentives and altruism, Healy looks instead at “the cultural contexts and organizational mechanisms that provide people with reasons and opportunities to give” (p. 2). After a first chapter reviewing arguments about commodification of the body and the relationship between incentives and action, Healy considers a series of empirical puzzles about the cultural acceptability of organ donation, U.S. regional variations in organ donation rates, European national variations in blood donation rates, and the purity of American blood products coming from voluntary and commercial procurement. Emulating Viviana Zelizer’s work on life insurance, Healy shows how an otherwise unpalatable action—asking bereaved family for their relative’s body parts—was made socially acceptable. Organ procurement organizations (OPOs), donor families, and transplant professionals use carefully selected stories to create an account of donation as a moral act that helps families cope with bereavement and allows a loved one to live on after death. Although donation is now culturally acceptable, some OPOs get more donations than others. Regional variations in the success of American OPOs arise from differences in the features of OPO catchment areas (population density, education levels, poverty rates, and race) and characteristics of the OPOs themselves. Ties to referring hospitals and administrative spending on procurement predict success, but, oddly, an OPO’s stance on procurement policy seems less important. A tantalizing fragment of data suggests both that procurement rates can be improved by carefully dividing the work of bereavement counseling from “the ask” and that more evidence about the policies and practices of the individual OPOs would have been illuminating. Turning from organ to blood donation (and therefore to living donors who might give repeatedly) and from the United States to Europe, Healy asks whether organizational arrangements also help account for the substantial variations in donation rates across countries. It can’t be simply a matter of individual altruism when Danes are much more likely to have given blood than their culturally similar Norwegian neighbors. Healy asks who is in charge of collecting blood (the state, the Red Cross, or independent blood banks) and whether countries have volunteer donor groups and for-profit plasma collection. By and large these organizational factors are important, but it’s complicated (this is another place where a close comparison of a handful of cases would have been helpful). As Healy puts it, the type of collection system “shapes the kind of activity that blood donation is” (p. 85)—state collection systems get one-time donors in mass drives, Red Cross systems recruit donors through network ties (including to recipients) and can call on them repeatedly.