Repaying and Cherishing the Gift of Life: Gift Exchange and Living-related Kidney Transplantation in the Philippines Yosuke Shimazono ABSTRACT: This paper considers living-related kidney transplantation, especially that between family members in the Philippines. Drawing on the anthropological theory of gift, it explores two aspects of the gift relationship—the relationship between the do- nor and the recipient and the relationship between the recipient and the object—and describes two categories of acts—‘acknowledging the debt/repaying the gift of life’ and ‘taking care of a kidney/cherishing the gift’. This paper seeks to show that there is an internal tension in live kidney transplantation between two rival principles of gift operative in the world of Filipino family and kinship: one akin to the Maussian or ‘ar- chaic’ gift and the other that places cherishing of the gift over repaying of the debt. KEYWORDS: ‘archaic’ gift exchange, family, gift, kidney transplantation, Marcel Mauss, Philippines In his seminal essay, The Gift, Mauss attempted is to make a present of some part of oneself’ to unravel the common principles running (1990: 16). The objects given are typically the through gift exchange practices in societies important substance and being of the indi- which he termed ‘archaic’—Melanesia, Poly- vidual and/or group. Even after being given nesia and the Pacific Northwest (Mauss 1990). away, they still bear the ‘stamp of those who According to Mauss and his successors, gift possessed it previously’ (Carrier 1994: 25). exchange as practised in these societies was According to Weiner and Godelier, they are characterised by two major elements that are ‘inalienable possessions’, which cannot com- intertwined: the obligatory transfer of the ob- pletely be alienated; the original owner retains ject and the inalienability of the object. inalienable ownership (Godelier 1999; Weiner Firstly, the giver and the receiver of ‘archaic’ 1992). Mauss’s exposition of the ‘archaic’ gift gifts are bound by a moral obligation to give, provides us with an important platform for an receive and repay, although these acts may be anthropological investigation on organ trans- spontaneously fulfilled or performed with the plantation. This is because, as an internal part attitude of generosity. It is well known that of the body, human visceral organs resist the Mauss singled out the obligation to repay as dichotomy of the ‘person’ and the ‘thing’ and the most important obligation, as it acts as a appear to be ‘part of the person’ as well as part hinge for propagating the circuit of gift-giving. of the body. Secondly, the object transferred through this The aim of this paper is to consider living- kind of gift exchange is inalienable. In Mauss’s related donor kidney transplantation in the term, ‘to make a gift of something to someone Philippines in the light of the anthropological Anthropology in Action, 15, 3 (2008): 34–46 © Berghahn Books and the Association for Anthropology in Action doi:10.3167/aia.2008.150304 Repaying and Cherishing the Gift of Life | AiA theory of the gift. Focusing on cases of live of stewardship over the object given overshad- kidney transplants between family members, ows the norm of reciprocity. I explore the gift relationship between the recipient and the donor. More specifically, I address the following issues. What kind of gift Organ transplantation and the is the donation of kidney from a living family anthropology of the gift member to another? What kind of relationship does this unique form of gift object create? Does organ transplantation have something in What kind of obligation does this gift engen- common with ‘archaic’ gift exchange depicted der? How is this object treated after it has been by Mauss? From one viewpoint, deceased transplanted? donor organ transplantation seems to be even My fieldwork was carried out for 18 diametrically opposed to the Maussian gift months between June 2004 and December exchange. Deceased organ donation may be 2005. It consisted of participant observation characterised as the ‘modern’ gift, not only of the activities of the Kidney Transplant for the obvious reason that this form of gift is Association of the Philippines (KITAP) and made possible by modern medical technology, interviews with its members. KITAP is an as- but also because of the moral and legal rules sociation of ‘kidney transplantees’ or people pertaining to it.1 who have undergone kidney transplantation. Just like blood donated to the British Na- Established in 1984, the KITAP has over 1,500 tional Health Service (NHS), deceased organ members, and organises activities, such as donation is supposed to be nonreciprocal and Patients’ Forum, Kidney Transplant Anni- ‘free’; the donor, who is expected to act out versary Celebration and Philippine National of ‘altruism’, will not receive any countergift Transplant Games. In total, I interviewed and the recipient has no reciprocal obligation 53 transplantees, of whom 22 had received to the donor. This gift-giving is also seen as kidneys from a sibling, parent or child; this a charitable act, directed to an anonymous particular group of interviewees forms the stranger. The giver is an individual citizen focus of this article. who performs this act for the public good I will first present a brief discussion of the (Titmuss 1970; Lock 2002: 317–8). Some ob- relevance of the theory of the gift to anthro- servers also argue that the anonymous gift pological studies of organ transplantation, relationship presupposes the anonymity of the together with an overview of kidney trans- object transferred. As Strathern puts it, ‘Organ plantation in the Philippines. Secondly, I will donors can give anonymously because human describe a public event, then relate the story organs are regarded as anonymous: kidneys of a transplantee that will enable us to gain differ in physical condition rather than social a glimpse of the intricacies of this gift rela- identity […]. Such organs or materials as can tionship. Thirdly, I explore two categories of be excised or secreted from the body become recipients’ acts, both of which are important free-standing entities’ (Sharp 1992: 129). components of the gift relationship between Ethnographers have observed, however, the recipient and their donor: ‘acknowledging that the deceased organ donation is not always and repaying the debt’ and ‘taking care of the a ‘free’ gift and the object given is not totally kidney/cherishing the gift’. In doing so, I aim anonymous (Fox and Swazey 1978; 1992; Lock to show that behind these two categories of 2002; Sharp 1995; 2001; 2006). Firstly, in spite acts are two rival conceptions of the gift: one in of the policy of anonymity, some recipients which the gift compels the receiver to give in wish to meet or write letters to the donor return and the other in which the significance family to express their gratitude, while some | 35 AiA | Yosuke Shimazono donor families hope to form ‘fictive kinship’ ‘As Marcel Mauss could have foretold, what with recipients (Sharp 2006). Secondly, some recipients believe they owe to donors and the recipients regard transplant organs as still be- sense of obligation they feel about repaying ing attached to the donor; incorporation of the “their” donor for what has been given, weigh inalienable object may lead to ‘transformative heavily on them’ (Fox and Swazey 1992: 40). A experience’ (Sharp 1995; 2006). Some donor transfer of an inalienable possession can also families also hold the view that the life of the lead to a situation in which the donor and the deceased donor somehow persists in the re- recipient are ‘locked in a creditor-debtor vise cipient’s body. that binds them one to another in a mutually It appears then that the predominant logic fettering way’ (1992: 40). of the gift—the nonreciprocal gift of an anony- Although such a picture of live organ trans- mous and alienable object—is haunted by plantation seems to fit well with the Maussian another logic of the gift, which is reminiscent picture of the archaic gift exchange, it leaves of the one which Mauss thought operative in some questions unanswered. Does living do- ‘archaic’ societies. Deceased organ donation nor organ transplantation necessarily lead to may create an enduring bond between the the ‘mutually fettering’ creditor–debtor rela- transacting parties. Unlike transfusion blood, tionship? If not, how this can be explained? the impersonality of which is fostered by the Is this because kidney donation is somehow technological process of separating its com- understood as the ‘free’ gift? Is reciprocity the ponents and storing them (Copeman 2005), only moral principle that governs the gift rela- transplant organs still bear the social identity tionship between the recipient and the donor? of their giver and remain attached to the spe- cific person—at least for some donor families and recipients.2 Kidney transplantation in the What then about living donor organ trans- Philippines plantation? Live donor organs also are ex- pected to be given ‘freely’. The moral concepts Kidney transplantation is a medical procedure of ‘altruism’, which also appear in the Western that is performed on patients who are suf- bioethical discourse on live organ donation, fering from end stage renal disease (ESRD) however, conceal obvious differences between or whose kidneys have irreversibly lost most the economy of live and deceased organs. A of their functions. Kidney transplantation is live donor organ is predominantly expected considered more cost effective than kidney to be transferred within an interpersonal rela- dialysis and is associated with a better ‘quality tionship of family and friendship, where the of life’. A kidney can be donated either by a anonymity between the donor and recipient is deceased or by a living person. The very first precluded.3 successful kidney transplantation, performed Although the amount and scope of anthro- in 1954, used a kidney donated by the patient’s pological literature on living donor kidney monozygotic twin.