And the real scandal of being embodied, one which arguably is a governing feature of all our lives, is that our embodiment comes to an end. We die, and the sociology of death should be the sociology of our lives (Craib 1998: 10).
Abstract Organ transplantation is an innovative 21st century medical therapy that offers the potential to enhance and save life. In order to do so it depends on a supply of organs, usually from cadaveric donors who have suffered brain stem death. Regardless of whether and how the deceased recorded their wishes about donation, health professionals will approach the bereaved relatives, before organs are removed. In this article, the results from 19 semi-structured interviews with Scottish donor families will be presented. These accounts will focus exclusively on the families’ beliefs about death, the dead body and bonds with the deceased, and whether these affected the donation decision or the organs donated. What the families said about brain stem death (BSD); how and when they understood that death had occurred; and whether the families thought that death caused a ‘disembodiment’ (that the self was no longer embodied) will be explored. Finally, attention will turn to the bereaved's previous relationship with the embodied person. I conclude that the phenomenology of embodiment, death and organ transplantation offers new answers to the question of ‘Who am I’? That is, in order to understand what identity is, one might look for what it is that is lost at death; the body, the self and relationships with others.
The dead body as a resource
In the period immediately after the medical pronouncement of death and before bodily destruction the body becomes a valuable resource either as a teaching aid, research model or for cadaveric organ transplantation. Organs for cadaveric transplantation in the UK are not widely available and demand continues to outstrip supply. Data as of 28 December 2003 show 5,860 people awaiting a solid organ transplant (http://www.uktransplant.org.uk/statistics/latest_statistics/latest_statistics.htm). In the UK, organ procurement is based on a voluntary gifting system whereby individuals choose to donate or ‘opt-in’ to organ donation after suffering brain stem death (BSD). Health professionals then negotiate procuring the deceased's organs with the deceased's family. As stated in the 1961 Human Tissue Act, in the UK, health professionals always ascertain a ‘lack of objection’ from the family, regardless of whether the decedent had carried a donor card or had made their wishes known (written or verbally). Latest statistics demonstrate that in nearly 49 per cent of cases the families will refuse to donate; this refusal rate is therefore considered one factor contributing to the current shortage (http://society.guardian.co.uk/health/news). Research with families approached by health professionals with a donation request shows that transplant removal procedures can cause difficulty, ‘dissonance’ and refusal or restriction of particular organs (Belk 1987, Fulton et al. 1987, Sque and Payne 1996, Wilms et al. 1987). Quantitative studies have highlighted that although the dead body is to be ultimately disposed of, some relatives refuse because, ‘they did not want surgery to the body’ (BACCN/UKTCA 1995). In the modern era, the transmission of cultural beliefs about the dead body takes the form of ‘the symbolic meaning of showing respect for the individual who once was’ (Sanner 1994b: 1148). How surgical procedures to the newly dead body are significant in organ donation refusals, when autopsies and dissection have been occurring routinely for the last few centuries, highlights the differing levels of acceptable interference with the corpse, which some have linked to the ‘symbolism of different uses’ (Feinberg 1985: 31).
This article continues to address questions about why surgical transplantation procedures might cause the donor relatives difficulty through examining their perceptions of when death occurs and what a dead body is. Drawing on the findings from 19 donor family interviews, I argue that much is dependent on what an individual believes about death; death either brings about a division between the once-living self and body and the corpus left behind as an empty vehicle from which organs can be harvested. Alternatively, there exists a belief that death does not change the status of embodiment; that is, the person remains embodied at death. In this understanding, the dead body and the organs remain inseparable from the once-living relative. So this discussion is about how such different bodily representations of self-identity after death affect the relatives’ decision whether to acquiesce to organ donation.
The struggle for hearts and minds
Important changes have occurred over the last 100 years in not only what is done to, and with dead bodies, but also in the definition of death itself. One of the most significant changes is from a traditional conception of death as heartbeat cessation, to one where irreversible damage to the brain, a condition known as brain stem death (BSD), has come to be recognised. In 1968, the Harvard Committee ruled BSD as death and this ‘new’ definition went on to supersede cardiac death. BSD was soon implemented in most countries, although for a variety of reasons, Japan and Denmark only recently recognised BSD in the early nineties (Lock 2002, Rix 1990a, Rix 1990b). There are heated ethical, legal, religious and social debates about BSD outside the scope of this article (Gervais 1986). Here, BSD is considered as analogous to decapitation, whereby damage has occurred to the brain stem and no information can be exchanged between the body and the higher brain.
Despite the UK's increasing medical reliance on the diagnosis, studies have regularly shown varying levels of confusion about BSD in both the health professional and lay population (Dejong et al. 1998, Sque and Payne 1996, Tymstra et al. 1992, Younger 1990). Research demonstrates that BSD poses a major obstacle to donation, as it can be difficult for relatives to understand brain-orientated death (Sque and Payne 1996, Tymstra et al. 1992, Fulton et al. 1987). With BSD, apparent breathing and respiration continue, resulting in an ‘ambiguous entity’ termed by some authors as a ‘living cadaver’ (Lock 2002) or described in statements such as, ‘[T]he patient is dead but has not died’ (Hogle 1995). The appearance of brain stem dead individuals is far different from someone who has died from cardio-pulmonary causes. Colour appears normal, the body may still be warm, and the heart continues to beat, albeit with artificial assistance. These patients do not look as if they are dying or are indeed dead.
Authors have used this to suggest that fears about bodily mutilation are related to respect for the deceased; relatives are confused and, ‘. . . generally not able to imagine a difference between the living and the dead. The dead body was ascribed qualities that only a living individual possesses’ (Sanner 1994b: 1147). Indeed, early work with donor relatives found that respondents who were unsure about whether death had transpired tended to conflate the self/body at, and after, death (Fulton et al. 1987). Remarkably, this aided donation as some relatives donated because they believed the organs carried remnants of the deceased within them. Subsequently a form of ‘bodily immortality’i.e. a continuation of the decedent's identity, was gained through organ donation (admittedly only one that lasted until the recipient's death). The need to know that the deceased achieved a certain amount of bodily immortality was found to be frustrated by a lack of information about the recipient (Bartucci and Seller 1986, Pelletier 1993, Sque and Payne 1996).
Historical ambiguity about death
Death, it is generally supposed, separates the state of being alive from being dead; but the ambiguity that surrounds death is not unique to contemporary society. Throughout history, distrust of the medical profession and ambivalence about the diagnosis of death is frequently noted, and accounts as far back as 1740 have suggested that, ‘putrefaction was [death's] only sure sign’ (quoted in Lamb 1985: 51). During the 18th to 20th centuries, because of new medical technologies such as artificial resuscitation, which demonstrated that individuals previously thought dead could now be revived, there was increasing uncertainty about the diagnosis of death. This has led Pernick to suggest that ‘Lay mistrust of doctor's definitions has been the historical rule rather than the exception, though such mistrust only periodically caused great alarm’ (Pernick 1988: 61). The paradox, as Pernick goes on to argue, is that accompanying the advancement of scientific and technological precision of defining death come doubts about its diagnosis (Pernick 1988). Giacomini (1997: 1478) argues that death (i.e. BSD) is not solely a clinical definition, but a socially constructed one:
Brain-dead bodies had to be created, recognised, and defined in the development of brain stem death criteria: brain stem death was socially as well as clinically constructed. The 1968 definition did not produce a more ‘accurate’ description of death so much as mark new delineations between the living and the dead.
With shifting and mutable definitions of death it is to be expected that relatives neither immediately nor decisively accept such ‘new delineations’. Then, continuing with such a line of reasoning, BSD might cause relatives to be concerned about post-mortem bodily mutilation, as they do not understand death has occurred, and therefore they continue to conflate the living person with the dead body.
Social death and the separation of self
Like Giacomini, two classic ethnographies conducted in the late 1960s demonstrated that death and dying were not purely biological classifications (Glaser 1966, Sudnow 1967). Rather, death and dying are ‘socially infused activities’, a definition that implies the differential between death as social and biological is neither clear cut nor distinct (1967: 9). Both authors develop Goffman's idea of a non-person into the concept of ‘social death’, describing how an unconscious patient can be treated by health professionals and relatives as incapable of a presence in the existential sense: that is, of being an autonomous, aware individual. Sudnow, for example, defines social death as ‘. . . that point at which socially relevant attributes of the patient begin permanently to cease to be operative as conditions for treating him, [sic] and when he is, essentially, regarded as already dead’ (1967: 74). A hospital patient can become implicitly a permanent non-person whilst still alive, as other people foresee the patient's death and change their conduct with this in mind (Mulkay and Ernst 1991: 174). In other words, they are socially dead to those around them and to all intents and purposes become a non-person. The patient's body is no longer co-existent with the person and the family comes to recognise ‘the absence of a future’ (Mulkay and Ernst 1991). I will go on to show that the current study replicates the finding of Glaser and Sudnow, demonstrating the applicability of their work 40 years later, within a modern intensive care unit setting, with a ‘newer’ category of death as brain stem death. In this study, donor families said they understood BSD, they demonstrated this understanding, and they articulated a version of death before the medical confirmation of it. Hence at this point the families understood that death of the body had occurred. I argue, then, that relatives in this sample were not confused about BSD. The respondents in the present study showed that they could tell the difference between a living and a dead body and they went on to articulate differing views on what the dead body subsequently represented.
Theoretically, the practice of, and apparent resistance to, donating organs in this country, has interesting implications for the sociology of the body. The discussion that follows reflects a move within the sociology academy, from locating the body within social-structuration theories to what some have argued is a ‘corporeal’ sociology whereby the lived experience of embodiment is stressed (Howson and Inglis 2001, Turner and Wainwright 2003). The phenomenology of embodiment, interpreted here to mean the experience of self and body, is de rigueur though controversial in the current sociological climate (see, for example, Howson and Inglis 2001, Turner and Wainwright 2003). Although some authors use the term ‘embodiment’ differently, I liken it to a person's experience of the body and whether individuals feel they have a body, or the alternative of whether a person feels they are a body. For example, Turner suggests that people both ‘have’ and ‘are’ bodies at the same time (Turner 1996). I go on to demonstrate that it is precisely this that caused the difficulties for the donor families. For, as the important question in this article poses, ‘What happens to an embodied identity at or after corporeal death’? The practice of removing an organ from a previous living self, in order to place it into another, raises unavoidable issues around where ‘I’ am located in my body and what kind of relationship I have with my body. Authors have found it difficult to locate precisely where we might be in the corpus:
We can only give confusing answers to the curious question of where in this whole corpus we think we truly live. Science tells us the brain, and no one would naturally give such an answer. Much of the time, I think, we feel ourselves concentrated just behind the eyes; when someone says ‘look at me’ we look at his face – usually the eyes, expecting there to encounter the person or at least his clearest self-manifestation (Kass 1985: 23).
The common intuitive answer to ‘where am I’ gives contradictory answers. Am I in my brain? Or am I somewhere behind my eyes? Do I ‘have’ my body in the same way I ‘have’ a car? Or is the relationship with my corporeality more entwined? Providing answers to sociological questions about how we experience ourselves as embodied is neither a new nor an easy endeavour. Part of the problem, as I suggest, resides in a dichotomy between: having a body, a dualist image that organ transplantation depends on, or an alternative being a body; a holistic image that stresses the inter-connected nature of self and body.
Cartesian embodiment: having a body?
Philosophers have long reflected on the relationship between body and self. Descartes’ methodological contemplation of whether he ‘was’ or ‘had’ a body eventually led to the Cartesianism that dominates Western medicine today, and is a legacy that advocates the separation of the non-tangible aspects of self from the body. This ‘dualistic’ way of viewing the self/body became historically and culturally associated with the medical profession, and was fundamental to the development of anatomical dissection and ‘clinical detachment’ (Richardson 1988). Cartesian thinking is not only associated with the medical realm but is also the building block for most rational, Western models of thinking about embodiment. Taking for example, Gidden's work, he has been subject to recent criticisms of ‘dualistic mind/body thinking’ in that he privileges the mind over that of the body (Witz 2000). Giddens argued that the current ontological and existential insecurities regarding our status of ‘who we are’ relates to an era in society where individuals are increasingly ‘reflexive’ about their self identity (Giddens 1991). Authors counter-argued that Giddens’ over-emphasis on reflexivity produces a body that is strangely disembodied from the self (Shilling and Mellor 1996).
Holistic embodiment: being a body?
Contra the Cartesian ideology, and in parallel to it, a holistic view also exists that stresses the relationship between self and body as closely inter-linked; the emphasis therefore is that we are our bodies (Turner 1996). We are not platonic entities but material bodies that are intimately connected to selfhood. In a criticism of the ‘choice’ in Giddens’ suggestion that the body/self is always under construction, one researcher suggests, ‘[N]either the self nor the body can be chosen because they are very often lived as though they are already there. The body is already the self. The self is already the body’ (Budgeon 2003). In interviews with teenage girls, it was apparent that modifications to the body through cosmetic surgery not only produced changes in the exterior body surface, but in the interior self, for example, the person had become more confident. Hence an alternative perspective to the Cartesian one exists that highlights an inalienable ‘self-in-body’ (Joramelon and Cox 2003) or ‘body-as-self’ (Belk 1990) linkage whereby the living body is the tangible concrete expression, or manifestation, of individual identity. These terms share a common phenomenological approach to the individual's lived experience of embodiment, and henceforth will be referred to as a ‘holistic’ relationship between self-corporeal identity. A phenomenology of the body highlights the experience of a body/self inter-link; leading Howson and Inglis to suggest that ‘the body is the subject and the subject is the body’ (2001: 304).
Objective and method of study
The research objective was to explore whether the donor families were aware and understood that death had occurred. If they were aware that death had occurred did the relatives view the moment of death as the rite of passage that separated the once living self from the newly-dead body; a ‘dis-selve’ perhaps? Or did they continue to conflate the person/body? Finally, did this affect the donation decision? During 1999–2001, interviews with 19 donor relatives from three different regions in Scotland were carried out. These families were selected only on the basis that, at some point between eight months and three years earlier, health professionals had approached them with a request to donate the organs of their deceased next of kin. Approval was gained from the local research ethics committees before the recruitment of families. Health professionals (both the respondents’ GP, transplant surgeons and co-ordinators) were closely involved at different times of the study, from the design of the interview aide memoir, to the selection and contact of the families from intensive care unit records, to discussing emergent findings. A letter of introduction from health professionals, alongside a patient information sheet and consent form, was sent to the families on my behalf by health professionals. No follow-up or reminders were sent. The families returned the consent form to myself indicating whether or not they were willing to participate. In total, 46 donor families were contacted with 29 letters returned and 15 families agreeing to take part. The respondents were advised that a family member could also be present for support; then 19 relatives who were involved with the donation decision were interviewed at a time and place convenient to them. The families were given assurances of confidentiality and anonymity (pseudonyms are used in the following accounts to protect the identities of both participants and deceased). The interview schedule was based on five general sections derived from a reading of previous studies. I started with general questions about the respondent. I then moved on to specifics about the donation and the circumstances leading up to it, followed by their views on death and the deceased's body, and finally to a discussion on their reasons for donation. We finished with how they viewed these events and their life subsequently. The questions were fairly open and not followed in a regimented manner; the way in which the questions were asked, and their sequence, depended on the flow of conversation with the respondent and their emotional well-being. The respondent's wellbeing was the paramount concern and they were advised that they could stop the interview (without offering a reason). The interviews generally lasted between one and three hours, including a period at the end of the interview, where a context amenable to closure was created. None of the respondents demonstrated significant levels of distress, although most became emotional and tired. Some said they found relating their experiences ‘enjoyable’ (Mrs Kildare) and ‘almost like counselling’ (Mr Forbes). Interviews were transcribed verbatim and then imported into NUD*IST QSR v.4, a computer aided qualitative data analysis software package, which aided the identification and comparison of themes. Table 1 outlines the social demographic characteristics of the deceased and the next-of-kin.
|Donor Card Ownership**||8*||10|
As mentioned, the families were approached on the basis that they had, at some point in the past, agreed to donate the organs of their deceased relative. It was during fieldwork that four of the families made it known that they had initially refused donation. Further, seven of the donor respondents shared a common trait of having some form of ‘medical background’ in the family – the selection process was not conducted in order to produce this sample and their contribution might have biased the research towards a medicalised view of organ donation. Nonetheless, despite a wide variation in what amounted to a medical background (e.g. one respondent's father was a hospital porter, another respondent worked in biomedical research) it allowed an interesting comparison with the ‘non-medical’ donor respondents. The analytical value of beginning in this fashion demonstrates the way in which the dualistic representation of embodiment is associated with the medical sphere and generates the cultivation of a more ‘detached’ stance towards the body of the deceased.
The deaths of the donors were caused by an internal trauma to the brain such as a blood clot or through an external trauma caused by a fall or a car crash. The patient had been rushed to an intensive care unit where they were usually attached to a mechanical ventilator to aid breathing. If the brain injury proved untreatable, as was the case in the present study, it caused them to suffer brain stem death. Unlike death from cessation of heartbeat when we can generally tell that the person is dead or dying – these patients do not look as if they will die, or indeed are dead. Yet the majority of families in this study said that health professionals explained BSD to them, that they had understood it and also demonstrated this understanding of BSD (whilst not denying that intense grief and emotion also clouded comprehension at times). Mr. Andrews, for example, when asked what he understood by the term brain stem death, made a cutting action at the back of the neck demonstrating severance of the spinal cord and thus, ‘there was nothing else I needed to know’. Eight participants recalled hearing the term brain stem death through televised medical dramas such as ER, Holby City and Casualty and these programmes were often mentioned, unprompted, by respondents. Unanticipated data also arose regarding the propensity of the donor families to ‘make sense’ of the intensive care unit technology, in order to gain some indication of a likely prognosis:
He [husband] didn't have anything in his mouth or anything; they were just keeping his heart going. So he wasn't all wired up, but when you were sitting you could see the numbers going down, whether it said heart beats or whatever, you could see him going down. You could see him slowly dying (Mrs. O’Neill, Donor wife).
You know in Intensive Care? You know they have this machine that measured the pressure? In the brain? And it should be whatever figure and it was much higher you know than it should be. And you become fixated that you’re just looking at this machine all the time and it's going up and up and up . . . (Mrs. Kildare, Donor mother).
Relatives searched for, assessed, interpreted and examined available information from a variety of sources, enabling them to make their own judgement regarding the potential outcome. These relatives were not passive recipients of health professional information but were active, intelligent and aware agents (Haddow 2004). Nevertheless, this is not to overstate understanding and acceptance of BSD as there were instances where respondents, mostly parents, articulated levels of difficulty:
You know if she [daughter] was totally dead, you have less concern. But the fact that she was there with the life support thing, but we know that she was not really alive, but there was a slight concern about that. You know that she was almost still alive, but she was alive but brain dead. So you think how long would the body survive? So just that, not a concern, a slight worry (Mr Roberts, Donor father).
Mr Roberts's quote demonstrates a lack of clear distinction between being ‘alive’ and being ‘dead’. He thought his daughter was ‘almost still alive’ and although he goes to great lengths to stress that he is not ‘concerned’ about BSD, he simultaneously acknowledges that it causes him a ‘slight worry’. The problem, as Hogle describes it, ‘stems in part from the fact that humans have both biological and cultural bodies. The biological death event thus requires an attendant social death’ (1995: 210). In the absence of such a ‘moment of death’ relatives identified a point when they thought death had occurred and this was before medical confirmation:
Basically, I think, my wife died, that was the Thursday the 6th February, but I'm convinced myself that she died on the Wednesday. I think she died on the Wednesday and it was only the machines that kept her going (Mr. Verble, Donor husband).
Relatives suggested that they had had a personal realisation of when death had occurred due to health professional communication, attending to the intensive care unit technology and through previous awareness of brain stem death from television medical-dramas. Based on the current findings, it would seem reasonable to suggest that ‘brain stem death’ is not solely existing in the medical realm, but gaining awareness and understanding in the public arena. The relatives made a judgement as to when death had occurred; a social death based on the specific environment and the previous wider lay context.
Cartesian dualism/holism and the dead body
An important point is therefore established; that is, despite the ambiguity of the dead body's appearance, there was no uncertainty about BSD evidenced in this study. We can now claim that a subsequent view of the self/body representation was not related to confusion around whether or not death had occurred. So what then of the newly dead body? As mentioned, in this sample, it emerged, somewhat unexpectedly, that seven donor families had some form of medical background. Obviously, one cannot treat the medical respondents as a homogenous group, but some appeared to offer a representation of the dead body as an empty car and, as the ‘driver had got out’, the parts could be legitimately salvaged. Mr Roberts was the strongest example of this:
[F]or me I just look at it like, somebody that is brain dead, whatever, is just like a broken car. A broken car itself is not going to be of use, but you can cannibalise the parts for something else (Mr Roberts, Donor father).
Opposed to the Cartesian representation, however, another image was also apparent; one that tended to emerge in the non-medical sample and emphasised the newly-dead body's integrity and previous living identity:
In fact not even so long ago it flashed in front of me that his [son] body, which I'd lain with, touched and stroked, wouldn't have looked the same. That he would have scars. That he would be cut (Mrs Evans, Donor mother).
Mr Forbes, again a non-medical respondent, explained his initial refusal to the donation request of his wife's organs and why he would not donate his own in the future. He likened the organ transplantation removal procedures to a ‘butcher's shop’:
I know it's not but it's too much like a butcher's shop to me . . .
Let's have half pound of heart, three quarters of a pound of liver. Eh, I'm afraid that's in me. I'm just trying to be as honest as I can and that's the way I feel about it . . . (Donor husband).
In his view, organ transplantation is tantamount to treating his wife's remains like those of any other animals (despite no obvious vegetarian sympathies) and thereby negates the social identity of his deceased wife. Mr Davidson also suggested that he required reassurances about the conduct and outcome of the procedure:
Are you just going to be, this is going to be one of these ‘take them out and throw them in the bucket’ sort of things. And they said ‘oh no, that's not it’ and my sister-in-law assured me it's just like a normal operation and somebody going in and opening her up, and instead of putting something in, they’re taking it out, you know. Everything is done with sort of respect, it's not just mutilation you know (Donor husband).
Most donor family respondents reported some level of concern about whether organ removal procedures would compromise the body's integrity: four initially refused because of this anxiety.
Restricting the eyes
Such emotional and symbolic capital invested in the dead body and its parts by relatives implies that it is not altogether easily separable from the once-living self. For most of the non-medical donor respondents a continuing link between corpus and self caused concern not only about the transplantation removal procedures, but also affected what organs were to be donated. There was no evidence of anyone refusing donation of the heart as found by earlier studies (Fulton et al. 1987). But nearly a third of all respondents refused to donate the deceased's eyes when health professionals asked them (and was unrelated to the deceased's wishes). Being able to see a person's eyes when living, and presumably newly dead, was mentioned as important and hence concerns regarding the cosmetic effects of the actual removal were articulated. Another reason commonly offered was that a person's eyes were the ‘windows of the soul’. In everyday interactions, the eyes play a significant role in communication, and are a visible expression of the less tangible aspects of personhood, as affected by metaphors such as, ‘being able to see it in her eyes’, ‘he couldn't look me in the eye’, etc. Hence, the eyes provide sight, but also in-sight. Respondents who did not restrict any organs suggested the following:
Well, what's the use to her [laugh]. That's basically the idea behind it, as they say, ‘they can't take it with you’ so might as well use them. I mean it's a body. It's not really a person that you grew up with or anything like that (Mr Johns, Donor son, emphasis added).
Mr Johns’ denial of any personal element attributed to the newly-dead body (‘it's not really a person’) allows him to stress the utility of the corpse and its parts. In this way he cultivates a degree of detachment and reserve. In addition, he states that ‘you can't take it with you’ and therefore the organs can serve a purpose only in this life, clearly demonstrating that the body and the self are no longer one and the same.
Organ donation and post-mortems – with/out consent:
Why did organ transplant removal procedures cause some families angst when autopsies and dissections have been occurring routinely for centuries? Given the conundrum around differing levels of acceptable interference post mortem, I thought it important to discover whether, and how, concerns about organ removal compared with other surgical procedures conducted on the dead body. A minority of participants, who expressed concern about the conduct of an autopsy, also expressed fear vis-à-vis the organ transplantation procedures. Those who voiced fears about the transplantation procedures but not post-mortems emphasised the perceived mandatory aspect of post-mortems; they felt it was something that was required and had to be undertaken.
Such questioning took on a new light however, with events that unfolded during 1999–2001, when fieldwork was taking place. Reports in the media at that time highlighted the practice in a variety of UK hospitals of retaining children's organs after post-mortems, without full consent of the parents. This ‘public scandal’ subsequently led to a number of reviews and consultation documents in Britain (Department of Health 2002, Donaldson Report 2000, Independent Review Group on Retention of Organs at Post-Mortem (Scotland) 2001). An open question about these events was included during some of the interviews. None of the donor respondents equated their experiences of consented organ donation with the post-mortem retention of organs without consent. In the donor families’ views, the issue of ‘consent’ was key and they created a distinction between ‘donation’ and ‘retention’– between giving with permission and taking without. The donor families in the present study mostly expressed sympathy for the relatives involved. A minority of respondents did question the emotional attachment that some of the parents placed on burying parts of the children's body. Again, Mr Johns, a medical respondent, explained: ‘[W]e have to bury the heart, then we have to bury the bits as well. It's like, I hate to say it, but it's like burying bits of meat I'm afraid . . . It's dead organs. It's not the person’[emphasis added].
Comparing this quote with the earlier ‘dead meat’ comment of Mr Forbes, who initially refused to donate his wife's organs, and his own in future, highlights the emergent conceptual differences between some of the medical and non-medical donor relatives about what a dead body represents. For some of the non-medical respondents stress was placed on the holistic representation of the once living person and dead body. Implicit within the contrasting dualistic embodiment was an emphasis on detachment; death detached the person from the body; a ‘dis-selve’. Arguably, medical respondents could therefore ‘detach’ themselves from the body of deceased.
The dissolution of the embodiment dichotomy
Differences in the sample between the medical and non-medical relatives’ discourse of the body are arguably symptomatic of wider ontological questions about the nature of embodiment, personhood and corporeal identity. For some donor families it is not merely a question of removing organs or ‘body parts’, as they are otherwise referred to in the medical literature. Yet socio-cultural beliefs about bodies, organs and their relationship to personal identity are not always amenable to medical re-conceptualisations, even by those who might have cultivated ‘clinical detachment’. One should not over-emphasise the division between holistic and dualistic embodiment, as such metaphors and representations are ‘entwined’ (Birke 1999). There were exceptions to such a medical/dualistic and non-medical/holistic portrayal. For example, a medical respondent substantiated the ‘body immortality’ argument, whereby post-donation parts of the deceased may ‘live on’. As Mrs Stewart, a retired nurse, suggested:
GH: How do you feel now about the decision to donate her organs?
Mrs Stewart: Well I feel that there is a little bit of her out there somewhere.
GH: In what way?
Mrs Stewart: Well somebody is being able to use it. You know? She's not gone. Not completely gone [Donor aunt].
Through donating, Mrs Stewart's niece continued to be present to her and she was still about ‘somewhere’. In this sense, she seems to imply that her niece is not completely gone. She also articulated a fear about a potential confusion of personal identity for the recipient, and a suggestion that personal characteristics were transferred from donor to recipient although it was unclear how this transference occurred:
Mrs Stewart: But eh, I think that some people would want to know too much about the donor and then say, well if the donor, was a drunkard, well maybe ‘I’ll end up the drunkard’.
GH: But I mean, what you’re saying …
Mrs Stewart: I mean taking on the personality. I don't think that's a good thing. I think the less we know is better than knowing too much (Donor aunt).
Other non-medical respondents were interested in the whereabouts of the organs and the age of the recipient. Miss Allison, for example, asked the transplant co-ordinator whether her son's organs could stay in the area (whilst simultaneously recognising that allocation was based on matching organs with the recipient waiting lists throughout the UK). What she wanted was to:
… Try here [Scotland] first. Because I don't want ever to go to Bristol thinking somebody is walking about here with David's heart. I hate Bristol. I'm not going back there. You know? I don't want that feeling. Cos it would be as though, ‘well where is he? [Her son]’[emphasis added].
For Miss Allison, it would appear that her son is co-existent with the location of his organs. Donating his body parts implies that the body/self as a whole persists. Indeed, other facets of the self, for example, national identity, appeared noteworthy. Two respondents mentioned a desire for the organs to stay in Scotland:
It was her liver or something but it did go to like an 18-year-old in Ayrshire I can remember that and thinking that ‘I'm glad it stayed in Scotland’ and her heart went to somebody down South. One of her other kidneys, I think that went somewhere, but not too far down South. Mid kind of way [Emphasis added, Mrs Moon, Donor sister].
In these accounts the self continues to be inextricably linked with the parts that were neither cremated nor buried. In contrast, other respondents generally denied the organs could carry personal vestiges of the deceased and, ‘it was not the person only their organs’ continuing to exist:
Mr Evans: No it occurred to me a week later that was where his body went. But parts of him that were very much alive are still alive. I think eh, I felt that that was em, a strong consoling moment for me.
GH: That he was still kind of alive?
Mrs Evans: No, his organs [Donor mother and father].
Likewise, other respondents stated that irrespective of embodiment views, part of the reason why they donated was ‘once you’re dead, you’re dead. Eh, it's [organ donation] not going to hurt you’ (Mr Davidson, Donor husband) and that the deceased ‘couldn't use them [organs] any more, so why burn them?’ (Mrs O’Neill, Donor wife). More generally, the colloquial expression of ‘when you’re dead, you’re dead’ indicated no lingering embodiment and stressed the benefit of further utility of the deceased's body.
Continuing social bonds
Hence, a minority of respondents’ views on the representation of the dead body could not be easily categorised or explained. One way the dissolution of the holistic/dualistic dichotomy arose was via a change in the medical respondents’ articulation of embodied dualistic representations. Then, the dualistic rhetoric and representation often weakened at certain points in the donation process, primarily in relation to previous ties with the deceased. In the present study, the ‘ability to let go’, especially for parents, regardless of any medical associations, appeared almost insurmountable. In this study, Mrs. Cohen, a nurse, initially refused to donate because of fears relating to the violation of her daughter's body:
My initial reaction was no. I don't want to. I mean I don't have a problem with it [organ transplantation] for myself. If that were to happen to me I would give, I would donate. But when it's your child, I don't know.
I just think the whole idea . . . Your child has died; you’re in a situation, which, never in your wildest dreams you would have expected to happen to you. You don't expect your child to die before you. You kind of, you think, you know just the fact that they were going to cut her [daughter] open and take her heart out.
Indeed, in modern Western society, characterised by falling child mortality rates, ‘you don't expect your child to die before you’. It appeared that parents in this sample had not yet relinquished a pre-existing protective bond with their child, causing a contradiction between accepting their child was dead and having to leave them ‘unprotected’. Mrs Cohen found it difficult to leave the hospital, wanting to ‘turn round and run back in again’ to be with her daughter. Mrs Evans, a non-medical respondent, recalled not having any concerns regarding the procurement procedures at the time, but that she felt ‘very sad, I wasn't there when they did the operation. That struck me. That he'd [son] gone through this surgery’. Recent research has also found that mothers who lost a child were more likely to suffer from psychosocial problems (Cleiren and Van Zoelen 2002).
Above then, we have two mothers articulating similar concerns about the organ transplantation procedures at different points of the donation process. What they shared was a continuation of the maternal role that they had had with the deceased and the emphasis therefore is on the previous relationship with the person and not the representation of their body. Mrs Moon, who offered to donate her sister's organs, would not have done the same after her mother's death, 13 years previously. She related that, ‘I probably had, like, a very close relationship with my mother. Like she was my friend as well. You know what I mean? I wouldn't have liked her to have been cut or anything like that’[Donor sister]. There was a history of past tension and conflict with her sister, and Mrs Moon did not consider them to have a close relationship. Hence, fears about mutilation are not only about what the dead body is thought to represent, but appears also related to the relationship with the deceased.
Conclusion: representation and relationship
The best way that the interaction between death, embodiment, and organ donation can be formulated is via the following table (Table 2). This emerged from the current study and from a review of previous qualitative research with donor families (Fulton et al. 1987, Sque and Payne 1996). It can be used as a conceptual tool in order to demonstrate the different ways that beliefs around death and the dead body inter-relate (as discussed above). Purely for the purposes of presentation, the various scenarios can be tabulated as follows:
|i||Non-awareness of death||Non-separation of body/self||Body Immortality||Organ donation (Fulton et al. 1987)|
|ii||Awareness of death||Non-separation of body/self||Body Immortality||Organ Donation (Present study)|
|iii||Awareness of death||Non-separation of body/self||Fear of mutilation||Organ donation (Sque and Payne 1996 and Present study)|
|iv||Awareness of death||separation of body/self||No concern||Organ donation (Present study)|
In the current model, views of embodiment were not caused by uncertainty about whether death had occurred, or confusion produced by the ‘life-like’ appearance of a BSD individual (Table 2: ii, iii, iv). Certainly the current study challenges arguments that one is related to the other. On the contrary, the donor families in this sample said they had been previously familiar with the term ‘brain stem death’; they demonstrated what it meant, and understood that death had taken place. The majority had even had a ‘personal realisation’ of death prior to medical confirmation (Sque and Payne 1996). Essentially, the patient was socially dead to them (Glaser 1966, Sudnow 1967).
Representations of the dead body
Cadaveric organ transplantation depends on a view of the dead body as a Cartesian material entity separate from a self no longer associated with the corpse. Indeed, in this research the removal of body parts for some donor families was the equivalent of stripping parts of a car, and caused no concern (Table 2: iv). The articulation of such views appeared related to a medical background or familial association with the medical profession and the families with such characteristics generally suffered less conflict, or anxiety about the decision to donate, or what organs were to be donated.
On the other hand, the non-medical respondents in the sample were inclined to articulate a holistic embodiment viewpoint and this appeared to cause difficulties when considering the donation decision leading some initially to refuse (Table 2: iii). They articulated powerful fears about whether the donation procedures would mutilate the body or cause it some form of ‘disrespect’. This is not to insinuate that corporeal identity is understood in a purely materialistic sense. Rather, the personal body is coterminous with the interior of self and as such, is perceived by others to be an externalisation of that self. This, I argue, explains why a few of the donor family respondents initially refused to donate; most stated concerns about whether the transplantation procedures would harm or mutilate the deceased, and the majority restricted organs. The newly-dead body remains a powerful representation of the self – a person's features and characteristics are imprinted on their corporeal identity – both the interior and exterior. The findings showed that certain organs, such as the eyes, are closely associated with a person's identity. The eyes, as the organs of perception, were significant and in a society that places so much emphasis on appearance in general, they are the definitive outward expression of personal identity. From this we gain further understanding of who we are and from where our identity is given its clearest expression. In answer to Kass's question posed earlier, ‘Where am I in this corpus?’ it would appear that for the respondents in this sample the answer is ‘I am behind the in/sightful eyes’. The paradox of holistic embodiment is that in some cases, it led to organ restriction, in others to donation. But this is not just about representations of Cartesian or Holistic embodiment, although both appeared to play a part early on in the donation process by affecting the initial reaction to donation and the organs to be donated. On closer scrutiny, what we discover is that this is a rather simplified analytical model of dualistic and holistic representations and there were exceptions to the rule. The utility of the body was not restricted to those with a medical association because for others, ‘when you’re dead, you’re dead’. Likewise, although the numbers were small, the phenomenon of bodily immortality was found regardless of background (Table 2: ii).
The continuing relationship
Organ transplantation is dependent on death of the body, but death does not mean the termination of the relationship with the previous embodied self. For instance, it is widely recognised that pronouncing death does not cause the immediate separation of self from body, and therefore ties to the deceased ‘self’ persist (Klass et al. 1996, Mulkay and Ernst 1991, Seale 1998, Walter 1996). As Joramelon and Cox argue, death does not cause an instantaneous cutting of ties:
. . . it is a basic human recognition that our ‘self’, our identity exists in the space of social relations, and that the ongoing flow of social life necessitates a gradual disaggregation of the deceased from the ties to the living that constituted the social self (2003: 30).
Although numbers are small, and more research is required, in the current study this caused particular difficulties for parents who wanted to continue the relationship with their child. This research indicates the importance and existence of ties to the dis-embodied self that are strongly related to previous corporeal existence. In agreement, other authors have suggested that it is generally assumed that when we are socially alive, we are biologically alive; when we are biologically dead we are also socially dead (Hallam et al. 1999). There is no clear-cut biological/social and death/existence division, however, and my own research provides a clear illustration of this. The majority of families demonstrated awareness that death had occurred, to the extent that they often articulated a moment of social death prior to medical confirmation of BSD. However, they also appeared to continue in the relationship they once had. The analytical value of this research suggests, quite simply, that regardless of how clinically detached one is, or purports to be, the strength of previous social/kinship relationships can prove overwhelming, especially for parents in the present study.
The interconnection between stable relationships and fluid representations
I stress, therefore, the fluidity of changing bodily representations invoked by the dying or dead body and the stability of a continuing previous relationship. These bonds, I show, appeared to be more durable than the fluid and permeable nature of differing views of embodiment. The ties that parents had formed with their children often challenged the Cartesian representation of embodiment when faced with a donation request or when thinking over events. Richardson (1988) once wrote that historically, the cultivation of clinical detachment represented a huge adjustment to the human psyche, and there is certainly evidence of that in this study.
Thus, what I have attempted to show is that a previous medical association was generally associative with experiencing less conflict about donation and vice versa. Nevertheless, this was not always the case, and examining the reasons for the exceptions to the rule is as important as showing what the cause of it was in the first instance. Through this method, what the study adds is value and insight into discussions of ‘who we are’, demonstrating that it is equally important to investigate ‘who we were’ to those around us. It leads to a more complex but nuanced analytical representation of the different meanings around what happens to our self-identity at death and the bonds that we form as embodied beings, and how these issues impact on the lives of the bereaved. Undoubtedly, there is scope for further research on this. What has become obvious is that respecting the deceased's body is not just about dying and death, but the experience of the living, the identity of the deceased and the strength of social relationships. The meanings about identity and bodies, both in life and in death, are often complex and contradictory. Today in contemporary society, with the pace of medical and information technological change, there is ahead of us an exciting but uncertain future. But it is only through careful unpacking and scrutiny that some recognition can be given to the way that the past and present shape of personal, social and corporeal identity structures the impact modern medical progress has on our lives.
I am grateful to the Economic and Social Research Council for funding this research. Thanks to Ross Bond, Alex Howson, Irene Rafanell, and Steve Platt and to the two anonymous referees for their constructive feedback.