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Gifts money cannot buy

How might one consider debt in a highly emotional situation where its discharge is not possible? In the UK arena of bodily material procured for research or medicine, donations cannot be reciprocated. What are called gifts are not only made to diffuse entities such as society or science, the procurement and treatment process often creates specific, if anonymous, recipients who are burdened with/grateful for a gift they cannot repay. Indeed to pay and thus pay-off the perceived debt is usually against the law. The gift entails, and hence summons, the absence of money. This article offers a comment on gifts in a context where money forever hovers on the margins of the imagination, and where the more it is banned from sight, the more it creeps back in. In endless discussions about remuneration or compensation payments that are meant to fall short of outright purchase, people tend to focus on the characteristics of diverse organs and tissue, including gametes, and assume they know both what money is and what the gift is. The anthropologist is less certain. Totemic debates in anthropology come to the rescue in a rather odd fashion. Key words money, the gift, organ and tissue donation, sacrifice, altruism

More than 20 years ago, Abrahams used the title Plus c a change, plus cest la m eme chose? for an article on organ donation. A comparative anthropology could point to all the ways in which practices people in the UK take as novel have counterparts already elsewhere in the world. Thus kidney donation between close kin is reminiscent of those kinship practices where a man raises a child in the name of a deceased relative, forgoing the opportunity to have a child in his own name (1990: 136). The comparison here is in terms of self-sacrifice: a vital part of oneself given up for the regenerated future of another. He also suggested that when the donation of bodily substance is felt to create a debt, it is like the perpetual debt of birth and nurture that in some kinship regimes one generation may owe another, debts that can never be repaid (1990: 133). For me going back to that piece of the phrase, the more things change the more they remain the same, takes on another colour. Over 201011, I had reason to learn a little about organ and tissue donation (from a UK perspective) 1 and many of the circumstances being talked about today in public and professional discussion are
1 The Nuffield Council on Bioethics, a UK body funded by the Nuffield Foundation, the Medical Research Council and the Wellcome Trust, which produces reflective reports on ethical and social issues in the changing arena of biomedicine, wished to revisit the question of incentives for donors of bodily materials. Over 18 months, I chaired a multi-disciplinary Working Party to inform the Nuffield Council on the matter, whose report (Human bodies: donation for medicine and research) appeared in 2011. It might be assumed that this involvement created a fieldwork platform for me. While it indubitably aroused my interest in the issues discussed here, I must be quite emphatic that I made it nothing of the sort. The present argument comes from materials already in the public domain (including the media reaction noted at the outset) that I was reading at the time. While there was no doubt/hopefully some cross-illumination (both ways), the present article is not an account of that work.

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presaged in that article. Despite changes in technological possibilities, in practices of ethical oversight, in patterns of living and deceased donation, when it comes to how donors and recipients accommodate the transfer of bodily material similar concerns and dilemmas repeat themselves. One realises just how many starting points to analysis there could be. Much of the literature is written accessibly enough; it is the way it engages with a salient category also found in anthropological theory that makes things not at all straightforward. And it is a category I thought I knew how to deal with: the gift. My focus is a transaction construed as a donation for which no return is expected, but where both recipients and donors often feel that something is missing. One indigenous interpretation is to imagine that what is missing is reciprocity; it is from its absence that a sense of debt comes. The interest of this situation is precisely its entanglement with the concept of the gift. Anthropologists obviously share the gift with all manner of people who deploy the term too. What is startling is how recent arguments outside anthropology take one back to a more distant juncture within the discipline.

Enter money
42% yes, 57% no: these were figures from an opinion poll conducted by The Guardian (20 April 2010) newspaper, which had been running a series on experiences of organ transplantation. The answers were to the question: Should donors be materially rewarded? This appeared on the day that the UK Nuffield Council on Bioethics launched an on-line consultation to examine ethical issues in connection with a persons decision to donate some part of their body for medical treatment or research. The Council had given itself a broad remit to take into account whole organs (from both living and dead donors), gametes, blood and other bodily tissue, and participation in first-in-human clinical trials. It also gave itself a broad question: How ethical is it to offer incentives in encouraging people to donate? The question of incentivisation arises from reported, perpetual, shortages of bodily material. Without putting weight on them, The Guardians figures indicated two broad bands of opinion about material reward: 42% show me the t-shirt; 57% it is unethical. 2 The t-shirt was an example of a non-cash incentive that might encourage people to go on the organ donor register, and the consultation trailed it alongside tokens of gratitude and initiatives for living organ donors such as pooled organ donations or benefit-sharing in the form of priority should they ever be in need themselves. One incentive above all dominated the media reaction. The consultation document had also aired possibilities such as direct financial remuneration and a regulated market, and it was the prospect of offering payment that the press seized upon. The Council, it was assumed, was really asking whether it would be ethical to pay people for their body parts. And payment quickly became buying and selling: the newspaper headline to the poll was Organs for sale. From incentive to payment to the market, it seems these notions slide into one another very easily. It is of course the idea of money that allows this.
2 The newspapers question was: Medical experts have suggested rewards for organ donors, such as an expenses-paid funeral, or souvenir mugs and t- shirts. Should donors be materially rewarded? (http://www.guardian.co.uk/commentisfree/poll/2010/apr/20/nhs-organ-donation).
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An image Gell (1975) describes from the Umeda of Papua New Guinea comes to mind: the dance sequence of diverse persons who hold the stage one after another but who are, he surmises, all one personage in various moments of transformation. When it comes to donations of bodily material, and iconically whole organs, one character waiting in the wings, dancing onto the stage in numerous characters but always with the same name, is money. Money mobilises an extraordinary range of sentiments and emotions: flourishing in many places, it is forbidden in others; now gives value to things, now takes value away, and has the capacity to seemingly dissolve everything into its form. The particular dance of money dwelt on here is a familiar one: its delineation of the boundaries it draws around what is deemed acceptable behaviour. Money would not be the incentive it is understood to be, or attract media attention, if there were already an open market in organs. Black markets flourish, a disgraceful trade in organs from both living and deceased bodies, and locating them in the global South does not distance it from the UK or North America what happens in affluent countries feeds that trade through transplant tourism. However, my own focus is on the highly regulated systems to which these relatively affluent countries themselves subscribe, both nationally and through international protocols. And one marker of the fact of regulation itself is, in the area of organ donation, keeping money at bay. The UK Human Tissue Act (2004) prohibits commercial dealings in human material for transplantation, the stance taken by the 1997 Council of Europes Oviedo Convention, and the 2008 Declaration of Istanbul among others: organs should not be treated as commodities. It is not that money plays no part at all. Indeed there are endless discussions about the appropriate forms of reimbursement (of expenses) and compensation (for time and inconvenience) that donors can be paid. Organ procurement and transplant services are underpinned by commercial enterprise, and once removed from the donor material apart from whole organs tissue of all kinds circulates among third parties as a commodity. So it is not the bodily nature of the material that seems at issue. Rather it is the process of procurement or extraction from the original body that must be shielded from a particular kind of monetary exchange. This is most specific in the case of whole organs, whether from the living or deceased, where a recipient can be imagined. The two parties are joined by their exclusion from commerce. In brief, the donor cannot sell and the recipient cannot buy. 3 One implication is that money is prevented from doing the work it ordinarily does. Many things are detached from those who possess them and acquired by others through sale and purchase, the simple effect of monetary transfer. But donors and recipients of organs cannot deploy money to do the work of transfer. Of course, there are numerous contexts in which people transact with things and with themselves without resort to commerce. What is arresting in discussions about the ethics of donation is that where money is most emphatically banned it is also most constantly on the horizon. Its banishment to the outer edges creates a meaningful absence. This is the backdrop against which transfer is effected.

Except in donations between those already known to one another, anonymity and clinical practice mean that ordinarily the two are never in direct contact, the transfer being mediated by specialist procurement nurses, and so forth.
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Imbalance
From accounts of organ transfer, it seems that both donors (in the case of cadaver donors, their families, who are invariably asked to consent to the donation) and recipients (they may have families too) often feel that something is missing, maybe something not properly articulated. A difference between donations among those already related and those who are not is that, in the latter case, desiring to know who has been the donor or who the recipient becomes one of the elements that people think would help their accommodation of the transfer. One donor mother . . . speaks . . . of locating an organ recipient [the organ coming from her deceased offspring] as akin to finding a long-lost child (Sharp 2006: 196). 4 The missing element seems linked to the pressure people often feel under. Abrahams reported how the request for a kidney [for a kinsperson] creates tensions and mixed feelings of reluctance and guilt in potential donors (1990: 136). The coercion of the request has long been recognised by the transplant profession, but the complexity of family entanglements is usually taken as an externality beyond their competence. Then there is the other pressure, one felt by potential recipients not wishing to accept an organ from a close relative pressing it upon them. A study of living donors in the US offers several examples of elderly people being persuaded to accept a kidney from a relative, the would-be recipients initial distress at the idea turning into acquiesence. I said, Im not taking my daughters kidney! But other family members persuaded me . . . It didnt feel like it was the right thing to do. Help should go the other way, from parent to child (Kaufman et al. 2009: 33). Speaking of cadaver donations (also in the US), Sharp (2006: 108) observes that the knowledge that recipients well-being springs from the lost lives of others is a burden some find overwhelming. One recipient of a kidney from a deceased donor talked of donor guilt. As a result, many recipients feel they are not entitled to speak of ongoing forms of suffering because their surgeries have saved . . . their lives (2006: 108). One solution in the US is public conventions at which thankful recipients give testimonials to the miracle that has extended their lives. As the survivor of a heart transplant declared: I am alive today only because of a young twenty-year-old man who died very suddenly . . . Every day I think of him . . . I can hear his heart beating inside my chest (2006: 111, original emphasis). Sharp points to one way of articulating the sense of something missing when (after Fox and Swazey 1992) she observes that many recipients of cadaver organs struggle to make sense of an imbalance. The imbalance is between what they received and and what? Well, nothing: no recompense to the donor can be effected by the recipient. Nonetheless, their families are there: when organ donor families do manage to track down a recipient, the possibility of creating a relationship can offer succour on both sides, and there are stories of the sense of obligation created between those connected by the surgery. Recipients in turn may be encouraged by procurement professionals to write thank you letters to their unknown
4 This is the first of several studies undertaken in the USA on which I draw; the US literature is read widely in the UK. From time to time I note points of divergence from UK practice, but do not here embark on a deliberate comparison between the countries. The desirability of this was mentioned by a reviewer of the present article, and it is a shame it cannot be pursued here; however, the specific regret gives me an opportunity to thank the reviewer more generally for his/her penetrating comments.
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donors, and some feel they owe it to donors to take special care of their organs. These gestures towards making up what is missing are gestures towards what Sharp identifies as reciprocity: a burden weighs upon people precisely because of the perceived inability to reciprocate. Now the invitation to examine what reciprocity means probably conjures up for the anthropologist a bit of social or relational glue, but that is not necessarily implied in general discussion. In the vernacular reciprocity can also be understood as a kind of self-interested tit-for-tat, by contrast say with (dis-interested) altruism. Nonetheless, one way in which people deal with what is missing is through imagining things might be more balanced a sense of exchange between those thought of as donor and recipient would help all parties. It is as though a shadowy contract had been created by the transfer, maintained as a debt the one owes or has discharged to the other. Among the living, Many prospective and actual donors view donation as simply giving back for all a parent or other relative has done for them (Kaufman et al. 2009: 24). It seems to be in the absence of money that a need to show reciprocity is articulated. After all, a monetary exchange would otherwise take care of reciprocity. Or would it? Or to put the question another way, even when there is a felt imbalance, is the restoration of reciprocity only and inevitably at the root of the sense of something missing?

Dramas of giving
Perhaps what keeps money at bay, and thus ever present in its absence, is also what creates that shadowy sense of contract: the concept of the gift. I return to the gift in order to follow through an analytical point, that in this arena some of the contours of gift-giving have the contours of a monetary transaction. The isomorphism between gift and payment extends, we shall see, to an ambiguity in each. It can be controversial to use the term donor, rather than provider or something more neutral, for the source of organs, though it is prevalent across the spectrum of procurement agencies, clinics and regulators in the UK. For laid over the process of detachment and attachment, in lieu of money is the language of giving, and specifically of gift-giving. Reference to gift-giving is not confined to organs; originally applied in the context of blood donation, the procurement of bodily material of all kinds may be described as a gift of life. The phrase is part of an international language. It might merely seem a colourful figuration of the idea of donation, with its stress leaving aside the tyranny of the gift (Fox and Swazey 1992) on something voluntarily yielded. However, for any critical commentator there is a question about the work the concept does. It appears in two dramatic forms, now at cross-purposes, now in concert with each other. I first narrate the drama of Gift and Commodity, then that of Gift and Altruism. First, the commodity, which in being normally opposed to the gift can also be hidden by it. Bluntly put, the language of gift conceals commodification of the body (Sharp 2001; 2006: 12; see also Frow 1997: 171). Pushing into the background the commercial use subsequently made of body parts, and the manner in which bodily material must be depersonalised for the sake of medical practitioners, appeal to would-be donors is in terms of the generosity of their gift. In fact it is not just donors who are persuaded by this language, the argument goes; it is appropriate for recipients too, and not least for
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third-party professionals who also need to invest their acts with significance. The gift is where the commodity is not. Yet it is already a gift shaped in a particular way. It has some of the contours of the commodity in a monetary transaction: it effects an alienation. 5 For the gift people have in mind is the gift that, without expectation of return, brings about transactional closure. The donors consent or wish does the work of alienation, recognised in law. As stated in a protocol for giving blood for research: Your sample will be used for academic (non commercial) research purposes only. In a legal sense it will be treated as a gift and you will have no claim over the same should the results of this research lead to commercial development. The voluntarily-given gift, once severed, is freed up for future transactions. In other words, if the language of the gift conceals commodification, the gift already conceals the commodity. When bodily matter is received by third parties, such as tissue banks for research purposes, the transactional form of the gift purifies the substance, in so far as donors can have no further interest in its future. In keeping with this there is no material return, either at the outset or later. When the gift has a specific recipient, however, as in whole organ donation, there is no question of any future exchange value the organ is pressed into use at once. Indeed, sustained through immunosuppressant drugs, it must stay alive, in the case of the heart keep beating, along with the recipients own organs. In making attachment less certain perhaps this work the organ has to do also makes detachment (from the donor) less certain too. Alienation appears less clear cut. This is true in another sense. Appealing to people to give means that the donor is being treated as an active agent, as someone who might have acted otherwise, and there is the question of recognising that choice. The tyranny of the gift may have less to do with coercion, and more with the expectation that acknowledgement would be appropriate, a recognition that the consenting donor or their family took a particular decision. Appreciation of the action taken would be a return. Oh, recipients where are you, you who live because our beloved donor has died? Can you not acknowledge your appreciation to your anonymous donors beloved family? After all, the organ didnt come from a donor, it came from my beloved brother (Healy 2006: 29 from an on-line memorial; see Sharp 2001: 1267 for the original rendition). For the second drama, altruism shapes the gift all over again. In everyday parlance, altruism is not opposed to the gift; on the contrary it is supposed to enhance it. Discussions that uphold the virtues of the gift of life invariably figure the donor as a disinterested, altruistic person. It might seem, then, as though altruism simply supplements the absent commodity, underlining the significance of giving without material return. However, it reminds one of another facet of the commodity too, that the single transaction creates two parties; altruism conjures a similar dyad. Now one may talk of altruistic effects without implying altruistic motives, but in much of the literature the epithet is assumed to signify inner disposition. Gift-giving implies a certain state of mind. While one could say this of any action, it comes with a pointer to sentiment created in its extension towards other persons. The idea of altruism turns the alienating character of the gift-without-return into an alienation for the sake of someone else. This is where the disinterest comes in. And the other party known relative, complete stranger, future compatriot is there for the imagining. So too is the absent reciprocity between them: altruism contours the gift in a second denial of
5 This kind of gift has the contours of the commodity, not vice versa. The terms are not reversible.
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reciprocity. Why otherwise should the crediting of altruism to the donor, as a moral evaluation of the donors acts, bear in on the recipients sense of obligation? We could stop now, with the view that disinterested altruism doubles up the notion of no return. Yet this would overlook its frequent identification in situations where reciprocity also flourishes. I refer to the flourishing of sentiment in interpersonal contexts (Cheal 1988), including familial ones, such as the reciprocity in kinship anticipated by Abrahams (1990: 132, 139). Here both altruism and gifting are construed to contrary effect: they are supposed to go with a mind-set appropriate to keeping relationships going for their own sake. Where the debt created by the altruistic gift is regarded as a burden, it is highly suggestive that accounts of live organ transfers between kin veer between stress laid on the obligations involved in relationships, to which I have made reference, and to the contrary need to suppress talk of obligation. Some may assume that the younger generation has a natural obligation to donate to older kin. One woman, from the US study of live donation already mentioned, donated a kidney to a boss and friend who was like family: Were like family it wasnt a question. It was an easy decision . . . I discussed it with my daughter [who had only one kidney herself, for whom the mother might have been a future donor] . . . [and she] was totally for it and she and I talked about it and I didnt even have to say anything. She was the one who said, Well, I have two sons, you know, if I need a kidney . . .. And that made me even more comfortable. (Kaufman et al. 2009: 389). Children assist in their parents project of self-responsibility for keeping healthy. Not only must older persons continue to live, but also younger persons must give . . . [O]ld and young are deeply committed to one another, sometimes beyond deliberative choice. Its just something you do, no question about it, we were repeatedly told by donors (2009: 24). If the not-thinking-about-it shields actors from articulating any kind of calculative self-interest, for some there is nonetheless an expectation of an indirect counter gift that the altruism of one will encourage future altruism in others. What kind of altruism is this? In this particular narrative of the gift, the graphic notion of giving for no return also belongs to an area of interactions where among kin, friends, intimates returns are routine, reciprocities abound. The recipient may be compelled to receive the gift of a longer life regardless of health or suffering because of a debt another feels. So any single altruistic act is likely to be part of a longer sequence; one has others in mind all the time. Now when others are in mind all the time, it is not at all clear where self-interest and other-interest begin and end. People ask themselves how altruism can remain disinterested. 6 Indeed, the professional literature seems often perplexed by how to label the mixture of interests found in family life or close interpersonal relations. If the altruistic gift can simultaneously deny and point to reciprocity, we encounter the ambiguity evident in commodity transactions. Both effect alienation at a single stroke and entail a transfer between parties. My question is whether those seeking acknowledgement or relationship or familial connection imagine that reciprocity will fill in what is missing. A specific answer is embodied in the example of the cascading relations of obligation that cannot be named: the woman with one kidney who supported her mothers donation to another in the expectation that one of her own
6 In the history of blood transfusion (Whitefield nd), wartime propaganda to create a visible recipient was first thought to violate pure altruism, and then to encourage it.
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children might come forward should she have need herself. A general answer is that summoning the idea of reciprocity is beginning to look like a place-holder or stop-gap that reiterates the lack (something is missing) rather than specifies what would remedy it. Nonetheless, the concept has been taken up as a response 7 to continuing ethical questions concerning appropriate treatment of parties involved in organ transplants, and other transfers of bodily material, and to them I turn briefly.

The end of the gift?

For years, in both the US and UK, there have been advocates for a market in organs regulated or otherwise that would render the language of gift and altruism redundant. Recently, however, other arguments have begun appearing that directly address the place of the gift in donations of bodily material. Some prophesy the end of the gift. Four brief versions of these arguments follow. First, commentators point to the increasingly commercial environment in which bodily material circulates. If conventions about the donation of body parts as altruistic gifts of life once held the moral high ground, it is now argued that the model of a gift free of proper compensation may have run its course. Too many counter-examples have built up where the gift form simply cannot function as a rejoinder or clear alternative to the incursion of market values into human tissue economies (Waldby and Mitchell 2006: 182). Most body tissue circulates in fractionated rather than whole units, which complicates thinking in terms of donors and recipients; there is uncertainty about donating for unknown research use, not to speak of financial profit derived from procurement schemes, and so on. All in this view demand re-thinking the act of donation. First, then, the gift is an anachronism. Second, frequently discussed among practitioners, ethicists and regulators is the degree of compensation or remuneration that should find its way back to donors and their families. The act of giving needs facilitating, many say, and along with reimbursement of expenses some financial recognition of the role of the donor and their families might make giving easier. Proper compensation for the families of deceased organ donors could increase overall supply and in unregulated areas check the abuses of the black market. Here the gift can be encouraged or supplemented by financial supports. Third, a more complex debate gives the gift a new location altogether. It would be too much to throw out the benefits of altruism (it is said), and indeed is not necessary, for an organ market can efficiently coexist with the present altruistic procurement system (Goodwin 2006: 151). A lawyer, writing of African America, Goodwin advocates a model involving funeral expenses whereby potential organ donors (who have made their wishes known) do not receive anything while alive but know that payment will come to their relatives at death; this would conserve the notion of altruism while providing remuneration for the deceaseds family. Such a hybrid system for organ procurement explicitly supports altruistic procurement, for it would allow

By diverse professionals; also by academic observers and commentators as in the following examples (all with primary disciplines outside anthropology).
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for altruism and commoditization to mutually thrive (2006: 21). 8 This third set of arguments does not jettison the altruism seen in gift giving, but ties such giving to the kinds of transactions the gift was once thought to deny. Among other things, in this view, payment would signal a compulsion to reflect something of the transactional complexity that defines the body parts career. An exclusive focus on gifts conceals the often-remarked fact that human donations enter [the organ procurement and distribution system] altruistically and exit commercially (2006: 18). Remunerating (compensating) the relatives of deceased organ donors could create a more equitable system than exists at present, embracing a transparent but limited market approach (2006: 21). Goodwin points to a precedent for market systems coexisting with altruism in gamete donation. 9 In the US, but not the UK, egg donation for fertility treatment, which is often very close to a market transaction, contrasts with donation for research, where payment is at present legally forbidden. Thompson (2007) has proposed that donors who provide material for research should be treated as research subjects, and receive proper payment. Direct commercialisation is to be avoided, but monetary compensation computed on the basis of a wage would lead to both a better procurement system and justice for the donor. If it is the fear of driving out the ethical impulse of altruism that prevents recompense, egg donation for fertility treatment, she argues, shows that the two kinds of motivation, far from being incompatible, seem to bolster one another . . . It is wrong then to worry that being paid substitutes a financial for an altruistic motivation (2007: 208). The willing research subject can still be regarded as making a donation to science or to society; ethical ends (it is claimed) can still be met. Although in the UK direct remuneration for either kind of egg donation is forbidden, there is discussion at present about more substantial compensation for those who donate to research; an experimental egg-sharing scheme for such donors found different motives sitting side by side (Haimes et al. 2012). Altruism, by itself a proxy for the disinterested gift, can coexist with payment. Fourth among arguments newly aired is the idea that acknowledgement of a gift need not be a terminus to a relationship but in the case of tissue given for research encourage the development of one. It envisages on-going relations between donor and recipient. Questioning whether we may be witnessing the end of the traditional gift relationship (the gift given for no return), between participant and researcher, the authors of a UK study (Haddow et al. 2006: 2) of DNA databases and their commercial potential suggest that people are interested in the future of what they have given not in terms of a return to themselves but in terms of the common good and future society. Individuals, it is reported, would be content if the community were a recognised stakeholder in any commercial returns. The authors propose a benefitsharing (including profit-sharing) model in which donors are imagined as having a role as research participants. Benefit-sharing could either displace or extend the idea of the gift; they go for displacement. Given their view that the altruistic tenor of the traditional gift implies no enduring obligation on the part of researchers and profiteers, they say it is important to leave it behind. The gift must be remodelled to encompass the continuing obligation now advocated.
8 Compare Sharp: paying burial fees unabashedly commodifies human organs (2001: 116); Goodwin advocates dialogue about the benefits as well as drawbacks of commodification. There is no suggestion of direct compensation to living donors. A point anticipated by Radin (1996).
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Where I have moved away from organ donation, it is to suggest that current arguments over adding money while saving altruism are part of a larger field of debate across different types of bodily material. The proposition that the gift could be supplemented by money or generate relationships once more points to reciprocity as a remedy for what is missing in present arrangements. Even where the gift is etherealised into the sentiments accompanying donation, when what is left are feelings of altruism or obligation, it is suggested that material and immaterial transactions can coexist. In short, insofar as it is thought to bring closure to peoples concerns and difficulties, reciprocating the gift is imagined as doing the work of transfer that monetary transactions do, not in their absence but actually, now, in their very presence.

And?
But will this notion of reciprocity do? Is closure what people are seeking? Are debts to be paid off? Or will reciprocity conceal again what is missing? I quote Sharps research on cadaver donations for the last time: closure is impossible, she says (2006: 164). When I began in this area, I had been reading Juillerat, whom Gell encouraged to work in Yafar, Papua New Guinea. If advocates for greater compensation for bodily material are in effect attaching reciprocity to the once disinterested gift, Juillerats message was the reverse. His reference was the traditional Maussian/L evi-Straussian gift as anthropologists would see it: specifically the obligation in the formulation of reciprocity was the very problem. Melanesian ethnography shows that (the intention of) giving does not necessarily entail the obligation of receiving or reciprocating (Juillerat 2002: 11). In its place he puts desire and its psychic consequences. Yafar gifts can be divided into those that are reciprocated and those that are not. To allow theoretical room for the latter, he concludes, we should pursue the unshackling of gift-giving from exchange, to which L evi-Strauss theory bound it (2002: 183). Juillerat drew me to think again about the traditional Euro-American formulation of the disinterested donor of bodily material. The Yafar donor to whom no return can ever be made is a primordial spirit Mother who showers her bounty on initiates and would-be hunters, her gift ritually enacted under the maternal totem, a flowering coconut. For the men who stand under the palm, the event is an omen of future flourishing: eyes averted, they are in a state of anxiety as to whether or not flowers will fall into their upturned hands. Many, Juillerat tells us, will fail to receive the Mothers gift. No-one can repay it. And I had a sudden image of organ and tissue procurement programmes, research bodies and fertility clinics: always chronically short of raw material, they have their hands outstretched too. What they so avidly desire cannot, they believe, be taken. How to express the dependency of recipients? How much reciprocity would be needed so to speak to alleviate it, and should it be alleviated? Should things be made easier? Think of the organ transplantees who, as the object of someone elses altruism, feel they cannot talk about their own continuing medical misery. Why? Because the others sacrifice was too great. Research in the UK (Sque et al. 2008) to answer the question of why some families of deceased persons approached by organ procurement professionals refuse to allow their relatives body to be used, explicitly pushes the gift aside for this reason. The authors take organ donation as fulfilling the criterion of
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personal sacrifice, good deeds or gifts to others undertaken at great individual expense. 10 Concomitantly, peoples aversion to relinquishing guardianship of the dead body had less to do with objections to donation, about which many were positive, than with the widely reported (e.g. Rid and Dinhofer 2009) concern about the integrity of the body. They baulked at allowing the body to go under the surgeons knife in such circumstances. Refusal made them feel guilty and selfish, but they were being asked to give up too much. Cohen (2001: 223) famously describes how, in one (illegal) organ market, peoples efforts to save their kin from sacrificing themselves through organ donation include purchase from a vendor. It is the vendor whose sacrifice is disregarded. Maybe he points to something else too: the universal language of the gift, and specifically the altruistic gift, under the highly regulated regimes considered here, can put the voluntariness of the act in front of acknowledgement of harm suffered for another. 11 For supplementing the gift with more material reciprocity is not going to address the question of sacrifice. In this frame, it is not as so many have fearfully argued that payment would take away altruism, substituting self-interest for other-interest, but that reciprocity would take away sacrifice. 12 Nothing is adequate to loss. What the idea of sacrifice conserves, in this thinking, is the suggestion that what is missing is indeed precisely what is missing: a vital part of embodiment, whether ones own or anothers. Two sisters who had each in turn donated a kidney to their father said: This journey is not about choice. Its just something that you do. We werent forced to . . . We were willing to sacrifice our lives to maintain the integrity of the family unit (Kaufman et al. 2009: 35). This brings us to where we began: Abrahams East African comparison was in terms of self-sacrifice a vital part of oneself given up for the regenerated future of another.

Other star ting points

It also comes back to the reflection on multiple starting points. Returning to the observation about self-sacrifice reveals that what could have been a starting point was not taken as one it has only re-emerged at the end. There are other starting points I did not take. Rio has an almost throw-away remark that, had I followed it at the outset, would have saved me much labour. Of course, he says, In western society gifts are typically modelled after commodity exchange, after economy, and even though gifts pretend to be a denial of reciprocity . . . they always stand to complement reciprocity as a shadow play of economy (2007: 451). Then there is the Maussian position that reciprocal [or, as the author prefers, friend-making] gift exchange is not opposed to, but is an embryonic form of, commodity exchange, and its principles are still to be found . . . in modern
10 11 12 After Mongoven (2003). Or rather, in what otherwise might be seen as medically safe procedures, the notion of sacrifice draws attention to harm (for example, the breach of bodily integrity). Either as it appears in the accounts cited here (e.g. see Sharp 2006: 1645), where sacrifice for another may still trail intimations of reciprocity in its very denial, or taken in further directions altogether. I am grateful to Wenzel Geissler (pers. comm., Oslo University) for his reminder of sacrifice as a transcending act in itself, where an object such as another party or the community pales into insignificance by comparison with what it brings about in terms of self- (or world-) transformation.

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commerce. It is located on the logical and phenomenological trajectory between pure gift and commodity, which are therefore shown to be genetically related and mutually constitutive (Laidlaw 2000: 628). Laidlaw is pursuing a longstanding debate in anthropology, for which there are two other starting points. The distal one is Mausss 1925 essay, the proximal one Parrys 1986 rendition of Mausss thesis as an archaeology of contractual obligations. Archaic gifts are the forerunners of todays market transactions, they are the way the market operated before its more characteristic instruments (such as money, formal contracts, and self interest) had developed (Laidlaw 2000: 6267). Parry joins Godelier (1999 [1996]) as a starting point too for Graeber (2001: 158), in reminding us of Mausss overall scheme. Mauss emphasizes that in most of the societies he was examining, theres no point in trying to distinguish between generosity and self-interest. It is we who assume the two should normally be in conflict (2001: 162). Graebers account contains other reminders that would have set my own remarks on a different trajectory. The modern ideal of the free gift as a mirror of market behaviour (2001: 161) could have lit up a quite different route to detecting the contours of the commodity in the gift. Clearly I could go on. 13 And clearly I could have saved us all some trouble had I begun with such conclusions, past and present, about commerce and gift. They might have illuminated the account of organ donation from the start. Yet here I pause. If they had, I am not sure I could have simultaneously conveyed what current arguments outside anthropology are like for an anthropologist to live with, that is, enter into debate with. I have indeed been trying to argue with (with in the dual sense of against and alongside), through means including irony and surprise, some of the ideas and formulations in circulation at the moment. And it is they that make these other potential starting points, from anthropological debate, fascinating. If the ideology of the disinterested gift emerges in parallel with an ideology of a purely interested exchange, then Mauss is wistfully looking back, Parry says, on a primitive past where interest and disinterest are combined (1986: 458). Indeed, it was a moral conclusion on his part that the combination of interest and disinterest in exchange is preferable to their separation (Parry 1986: 469; my emphasis). In the contemporary field created by developments in medicine where vital parts of persons circulate, it seems to have taken some time to shift general feeling towards accepting (if such is the case) what is conceptualised as the coexistence of altruism and commerce, of thinking of others and dealing with money at the same time. What is new is being categorically explicit about such propositions when these terms are so polarised in protocol, regulation and professional practice. Of course the imp money can always dance on to the stage and say, I told you so: you can add a dash of money to anything! Yet among the many things going on here is a huge cultural effort to re-align the separations that have been so precious so long. Classically, in anthropologists own traditional rendering, the debt created by a gift is not, insofar as the relationship endures, cancelled by a countergift: to give in return does not mean to give back, to repay, it means to give in turn (Healy 2006: 1467,
13 [G]ift and commodity economies [are] . . . always intertwined in various hybrid configurations (Frow 1997: 124); Gregory (1982: 115) famously pointed to the co-flourishing of gift exchange with wage labour and commodity transactions; Healy (2006: 11415) reminds us that Bourdieu did not want to reduce the act of gift-giving to a simple exercise in accounting for one-to-one exchanges: that would make gifts too much like markets, and so forth.
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after Godelier 1999 [1996]: 42). I would recognise something like that in prestations of altruism between close kin. It makes one sit up and think about the assumptions or misrecognitions of those who see imbalance, dependency and admitting the element of sacrifice as a problem, and its solution in terms of reciprocity. Some say compensation for bodily material can never make up the loss, some that acknowledgement brings closure, while some seek justice in pay-off or pay-back, views wide apart but all negating debts other potentials.

Acknowledgements
This was delivered as the first Annual CUSAS (Cambridge University Social Anthropology Society) Lecture in 2011, also part of the proceedings of the Debt conference [this volume], and keeps something of its lecture format. Giving it in several venues, I hope I made my thanks evident to colleagues at the time. I am particularly grateful to the Nuffield Council on Bioethics, whose invitation to serve on the Working Party sparked my interest. Views expressed here represent neither those of the Nuffield Council nor of the Working Party nor of myself in the capacity of chair.
Marilyn Strathern Girton College Cambridge CB3 0JG UK ms10026@cam.ac.uk

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