A review of “Living Cadavers” in Bangladesh: Ethics of the Human Organ Bazaar, by Monir Moniruzzaman.
From the moment of organ transplantation’s inception, debates among a range of parties have weighed the viability, economics, and ethics of the commercialization of transplantable human parts, a process known today by a host of names, including “rewarded gifting”, “financial compensation”, “body commodification”, “the organ trade”, and “the organs bazaar”. Positions are often polarized and, further, posited in universalist terms that reference, for instance, the inseparability of the body-self in shaping self worth and human dignity on the one hand, and, on the other, the rights and privileges of individuals to make independent, informed decisions to sell parts of themselves to others in need. Those who embrace a universalist stance rarely draw upon the quotidian experiences and social values of the parties most affected by these body transactions, namely recipient-buyers, donor-sellers, and their associated kin, friends, and communities.
Monir Moniruzzaman’s dissertation offers an invaluable antidote in the form of a richly textured — and frequently gut-wrenching — account of the illegal organ trade in South Asia. This trade involves most notably men drawn from the poorest of the poor in Bangladesh who decide to sell their kidneys to patients whose families can afford to buy their organs and then undergo paired surgeries sometimes in Bangladesh, most often in India, and periodically even farther from home in, say, Pakistan or Singapore.
This is an extraordinary ethnographic study involving 15 months of research among seemingly willing participants (be they sellers or, sometimes, buyers) who undergo a host of extraordinary hardships, dangers, and deceptions in their efforts to survive. Unlike any other study to date of this illicit trade, Moniruzzaman’s project does not focus on a single party (recipient-buyers versus donor-sellers, for example) but circumscribes the lives of the widest range of parties: as he explains early on in the study, efforts to identify sellers proved elusive at first; it is through contacts that eventually led him to middlemen or organ “brokers” that his research networks expanded eventually to include 33 kidney sellers from Bangladesh.
Although sellers’ experiences define the core of this study, Moniruzzaman nevertheless provides an astonishingly complex picture of their lives precisely because he also wins the trust of brokers and, even, in a few instances, patients or their family members themselves who have paid for kidneys. He is careful, too, to provide a highly informative overview of the local context, comprised of a historical overview of Bangladesh’s decline under British rule, an exploitative sociopolitical structure that preys upon the poor (whose lives are expendable), and where corruption is a fact of daily life. Set alongside this is a minimalist health care system where disparities and shortages are so extreme such that services remain out of reach for an astonishing percentage of this nation’s population. Those who buy organs are indeed desperate: close kin refuse to donate kidneys, cadaveric donation is not a possibility, and dialysis and organ transplant surgery services are unable to keep pace with the vast number of those suffering from kidney failure. To save a life one must find others willing to risk endangerment by journeying illegally to India with forged papers (and often under the careful watch of exploitative brokers) to undergo high-risk surgeries with few chances of adequate short- or long-term medical aftercare.
Moniruzzaman structures his study around the theme of a journey, an approach that is richly rewarding because it enables the reader to track sellers’ experiences from their difficult initial decision to sell a kidney and then on through the arduous steps involved in testing for, documenting, and developing expertise in blood and tissue typing; the often numerous dead ends in their search for a buyer; the consequences of relying on exploitative brokers; the hardships of the illegal journey to India with falsified papers; their encounters with other donors (who may in fact be in competition to supply a kidney to the same buyer); the surgery itself and its aftermath; and their return home to unsuspecting kin. As Moniruzzaman convincingly illustrates, this is a world plagued by deceit: brokers cheat sellers of the process in order to increase their own profits at every turn; sellers do not tell even the closest of kin and friends of their involvement in the organ trade, and even strive to hide their large scars from their parents, siblings, wives, and children; and whereas pre-surgical encounters between seller and buyer might be regarded by both parties as ties of presumably new-found kin, even the most compassionate buyers or their family members withhold payments and pay for only minimal post-surgical aftercare.
Perhaps the most important lesson of all, however, is that sellers enter the marketplace when their lives are already plagued by debt, yet selling rarely staves off financial burdens upon their return home (where uninformed kin may well have incurred more debt in their absence). Furthermore, their earning power is often diminished following their surgeries: it is not uncommon for these men to quit their jobs to enter the kidney market, and those who participated in Moniruzzaman’s study are plagued by illness, physical weakness, depression, and diminished self-worth once they have sold a kidney. Most extraordinary, too, is how many of these men nevertheless speak of the worthiness of their personal sacrifices because (at least in those cases where the recipient did not die) they have saved another’s life. This is especially heart-rending because of the many layers of exploitation they themselves have endured alongside the devastating effects of the stigmas associated with having sold part of themselves in a social context where such acts are both illegal and will permanently diminish their social worth.
This dissertation should be required reading for anyone contemplating buying — or, for that matter, selling — a kidney, as well as those who are proponents of the commercialization of organs, regardless of its form (as an illegal, or open, or regulated marketplace). The study is a sobering and deeply convincing portrayal of the myriad sanctioned and unsanctioned consequences of the body bazaar. One can reach only one conclusion: that kidney sales do not alleviate poverty but, potentially, only exacerbate it; that such transactions prey upon the most desperate and thus define an extreme form of social violence; that even seemingly well-informed decisions reap limited benefits that are a far cry from those one had hoped for (what Moniruzzaman labels “misinformed consent,” p. 379); and that arguments that strive to justify this commerce pale when they incorporate the long-term consequences of kidney sales in what Moniruzzaman labels “the post-vending period” (p. ii).
Lesley A. Sharp
Department of Anthropology, Barnard College
Mailman School of Public Health, Columbia University
University of Toronto. 2010. 447 pp. Primary Advisor: Hilary Cunningham.
Image: Kidney Seller from Bangladesh, photograph by Monir Noniruzzaman.