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Revue française de sociologie

2003/5 (Vol. 44)



Article précédent Pages 147 - 162 Article suivant
1

The recent reedition of Richard M. Titmuss’ work on blood donation, The Gift Relationship : From Human Blood to Social Policy, is the perfect occasion to return to this major early 1970s work. [1]  Richard Titmuss was a professor at the London School... [1] Titmuss was a politically committed sociologist whose purpose was to defend the British system of voluntary blood donation against those who considered the market the nec plus ultra of any type of human organization. [2]  Titmuss was responding to a work by M. H. Cooper and... [2] His critique of the effects of commercializing blood collection was a challenge to economists on a crucial point : how far could economic reasoning be extended to what Karl Polanyi (1944) had called “fictitious commodities”, ie, goods that are not really products of the same type as what is termed commodities in economic theory ? Titmuss’ analysis remains acutely relevant today given that in contemporary societies, the human body is an increasingly valued “fictitious commodity”.

2

I shall begin by recalling Titmuss’ thesis and the reactions of two renowned economists to his gift/market opposition. Then, on the basis of surveys conducted since the appearance of the AIDS virus, I will examine the industrial aspect of medical donation, too often neglected when the problem is considered exclusively in terms of the gift/market opposition. I shall then look at organ donation in light of Titmuss’ ideas, showing that the problems he raised are still with us, and underlining the institutional aspect of giving; ie, the social construction without which the modern practice of donation would hardly be able to flourish.

Giving vs the market ?

Titmuss’main points and the reactions of two economists

3

For Titmuss, blood is an example of a total social fact, bringing into play symbolic, economic, axiological, and political aspects of contemporary societies as well as technical ones pertaining to both personal and public health. Titmuss is interested in the economic, axiological, and political dimensions. First, in order to be distributed and consumed, blood is collected; in this it is different from the produced goods usually discussed by economists. In the economy of collection, the donor is essential. Given rapidly increasing demand for blood for medical purposes, the fragility of the product (it can only be kept a short time) and the limited amount of blood any one donor can supply, the number of donors must be increased, not only to meet regular increase in demand but also to satisfy exceptional peak demand. This quantitative aspect is complicated by a serious qualitative problem : the risk of transmitting viruses through blood transfusion (for Titmuss, hepatitus). This means the quality of the donated product is of crucial importance. According to Titmuss, the major contrast is between blood collected from unpaid versus paid volunteers. With the fragmentary statistics at his disposal, he showed that the American system, where a third of blood donors were paid, was less efficient both quantitatively (supply problems, high level of waste) and qualitatively (high number of post-transfusion accidents) than the British system, which relied on unpaid volunteers. In short, Titmuss took up the challenge launched by evangelists of the market [3]  K. Dixon used this expression as the title for his... [3] who were recommending the commercialization of blood in Great Britain. Using comparative statistics, he affirmed that the self-interested behavior on which market relations are based was less efficient in allocating a scarce resource than unpaid donation by volunteers coupled with para-state institutions.

4

Another original feature of Titmuss’ work is that he called this kind of giving altruistic, destined for an unknown person and with no expectation of anything in return, no financial or moral reward. The very form of the gift in question is characteristic of what Émile Durkheim called societies based on organic solidarity. Giving is no longer built into a set of social rules of the type operative in archaic societies such as those studied by Marcel Mauss; it is not even related to what modern society has preserved in the way of community life (the family, for example). Instead it is implicated in a world of radically distant relations, relations among strangers. [4]  These philosophic al c onnections become obvious when... [4]

5

Unpaid volunteer action versus self-interest, the state versus the market – the terms of the debate seems highly conventional. But Titmuss gave it new life, both through fine empirical study and careful explanation of the issue’s significance. At the microsocial level, bought blood was collected from individuals for whom the payment all too often represented badly needed income that could be gotten no other way. At the macrosocial level, buying blood had the effect of reversing redistribution in that the well-off benefited from the blood of the poor. [5]  This is a literal example of what some American economists,... [5] Worse yet, commercial blood banks were opened in povertystricken districts, meaning that the blood collected by market means was of sharply lower quality than that supplied by unpaid volunteers. The reason for this was simple : whereas unpaid volunteers had no reason to lie about their health or medical histories, this was not the case for those who made money giving blood. Unpaid voluntary action was more conducive to trust than self-interest was. In this way Titmuss brought his political concerns to the fore. Against the classic free-market economic approach, whose proponents were calling for dismantling the unpaid volunteer system and replacing it with a blood market, Titmuss called for a policy decision in favor of altruism. On this point his approach can be considered extreme : it was not enough to allow room for altruistic giving or favor it over market-guided collection; he was against any and all contact of blood collection with the market. The market would devastate and ruin the whole system of values in which altruistic giving was rooted; in sum, the market in this area had to be proscribed if the “right to give” was to survive. [6]  Titmuss’ two arguments in support of this radical... [6]

6

Kenneth Arrow acknowledged that the market was only one means among many to distribute goods. He also agreed with Titmuss that in this specific case it was inferior to unpaid volunteer action (Arrow, 1972, pp. 351-352; see also Solow, 1971, pp. 1699-1702). Moreover, if we study “trust” in terms of the “invisible institutions” that make the market work (Arrow, 1976, p. 28), it is not hard to understand why people are so reluctant to trust donors in a state of moral and economic decline who provide blood to banks in povertystricken areas in exchange for money. It is simply not in such persons’ interest to tell the truth about their health. [7]  Many examples of this are given in a study conducted... [7] The opposite is probably true for most unpaid volunteers, who are acting in the interest of solidarity with others. In the same vein, Robert M. Solow (1971, pp. 1706-1709) accused Titmuss’ opponents of narrow-minded economicism when they declared that only self-in-terest-based economic action could account for social behavior (of donors, doctors, and administrators) and failed to take into account the basic conditions for applying Pareto’s optimality criterion. [8]  According to Pareto’s criterion, a social state B... [8]

7

But despite these points of agreement, Arrow refused to accept the idea that a mix between the market and giving would hurt giving. Why should the creation of a blood market reduce the altruism that fuels giving ? he asked (Arrow, 1972, pp. 350-351; 1997, p. 762). The market only increased choice; it didn’t restrict already existing possibilities. In Arrow’s view, Titmuss had no answer to this objection. For his part, Solow criticized Titmuss for comparing two extreme cases and suggested that analysis of intermediate setups where blood was both given and sold would prove a more useful approach to the question, as it would specify the impact of the institutional environment on blood supply (Solow, 1971, pp. 1704-1705), adding that a study conducted on the Harvard campus during blood collection in no way suggested that the behavior of students who had not given blood was to be explained by the possibility open to them of selling their blood (ibid.). [9]  Solow perspicaciously suggested that the British position... [9] But while the two economists had reservations about Titmuss’ anti-market attitude–Arrow (1972, p. 360) claimed it was the mirror image of Hayek’s– they considered the problem he raised to be fundamental : “Despite–and in part because of– its flaws, Titmuss’ book is a resonant evocation of central problems of social value. […] This is not a systematic abstract work on the foundations of ethics. It is not a meticulous descriptive or causal analysis of the functioning of social systems. But by suggestively combining a passionately informed commitment to an ideal social order and an illustration of problems within the context of a concrete situation, it has greatly enriched the quality of socialphilosophical debate.” (ibid., p. 362).

Donation, the market, and industry

8

We need to reexamine unpaid voluntary action compared to the market in light of studies showing how dismally flawed the French blood transfusion system proved in the years 1983-85. The well-documented “tainted blood” affair in France shows the problem involved in collecting blood from unpaid volunteers. [10]  The origin and development of the ta inted blood a... [10] While Titmuss emphasized the necessity of carefully selecting donors because of the problem of hepatitus transmission (1970, pp. 70-73), he could not have imagined the tragic course of events ten years later with the appearance of the AIDS virus. The difficulty has to do with the fact that selecting donors has become a much more delicate operation. They must be required to divulge what is normally private information (regarding drug-taking and sexual practices), information that touches on social identity, not just individual medical history. This amounts to doubting the value of the gift and can readily lead to doubting the value of the giver. The problem is particularly delicate for homosexual donors, a group highly sensitive to anything that might look like discrimination. More generally, the fact of suspecting the unpaid volunteer donor brutally calls into question the positive image forged at the end of the Second World War. The donor was at the core of transfusion systems based on collection from unpaid volunteers, the essential link in the whole transfusion chain (Setbon, 1993, p. 90, p. 120; Hermitte, 1996, pp. 109-114, p. 191; Morelle, 1996, pp. 344-345, p. 365). Calling the donor into question threatens the very structure of the system.

9

But we must not forget the organizational and industrial components of the gesture of giving blood. As Titmuss showed, when medical use of blood soared in the 1960s, it was necessary to establish organizations to handle what had become mass, normed situations, and these had either to follow economic logic or be part of the welfare state. [11]  M. Setbon (1993, pp. 75-80) clearly presents how the... [11] What has been stressed in the French case, of course, is how inefficient the state administration proved when it came to selecting donors, namely when it decided to collect blood in prisons. Within the prisons, selection seems to have been far from rigorous, even though prison populations figure among “high risk groups” (Morelle, 1996, pp. 41-44). And this at a time when the problem of donor selection had become particularly acute, with the introduction of major new techniques for treating collected blood, included pooling (mixing the blood of several thousand donors) and breaking down blood into various stable components (albumin, fibrinogen, immunoglobin, anti-hemophiliac VIII factors), products which themselves gradually came to be categorized as medicines. Indeed, we must distinguish between blood itself, a product which cannot be kept more than a month, and the products yielded by industrial treatment of blood or plasma, which may be kept a year or more. This difference is essential. It was through technological progress and a supply of better-adapted treatments that the industrial world made its entrance into the system of blood collection and diffusion. As Luc Boltanski and Laurent Thévenot remind us (1991), economic activity is as much a part of the industrial world as the commercial one, even if the forms of “grandeur” –here, price, there optimization techniques, and performance– are not the same. In this case, it is significant that economic logic filtered in through the industrial world rather than the commercial one proper. We readily see how this happened : with its logic of technical efficiency, the industrial world is the first to be called into play when there is a need to mass-produce normed products in accordance with strict safety requirements. Behind this logic, of course, looms economic logic, whether it be profit logic in the commercial sector or non-profit logic in the transfusion system as it functions in France. [12]  Like for-prof it business es, the non- prof it s ector... [12] In the case of tainted blood in France, this technical-economic dimension is often seen to inhere in the managerial figure of Dr Garetta, then director of the National Blood Transfusion Center (Hermitte, 1996, p. 115, p. 166; Morelle, 1996, pp. 300-302), or in the sharp competitive struggle for market licenses for AIDS virus detection tests that was going on between the Institut Pasteur and the American pharmaceutical laboratory Abbott (Morelle, 1996, pp. 60-64).

10

European countries, most of whose blood collection systems are organized around the unpaid voluntary action principle (the most notable exception is Germany), are in a position to meet domestic need for blood, but not for products like plasma and stable derivatives such as Factor VIII, distributed to hemophiliacs. These products are therefore imported from countries where donors are paid for giving blood. This means that countries with unpaid action systems cannot really see this as a quality that makes them/ more virtuous than countries with paid systems. Importing plasma from the United States amounts to using blood collected in exchange for payment; meanwhile, the importing countries do not want to be responsible for deciding to set up their own paying system (Setbon, 1993, p. 124; Hermitte, 1996, pp. 177-185; Schwartz, 1999, p. 47). There thus exists in Europe and the United States a double blood circuit : blood itself is collected in most European countries through an unpaid voluntary action system and remains in the non-profit sphere, while plasma and derived products are tied to the world of industry and profit-seeking economic logic. Metaphorically, we can say that as in Austrian economic theory, the longer the path between the initial act (collecting blood) and the prescribed product (blood on the one hand, stabilized blood products on the other), the more “capitalistic” the process is and the stronger the influence of economic logic, even though that logic is masked in part by the fact that the transactions involve world market mechanisms, above all those of the industrial world, whose foremost concern is understood to be the dependabilty and safety of highly purified products.

11

This situation is not specific to blood; similar phenomena may be observed in the area of organ donation. There, too, there is a difference between organs that must be used quickly [13]  No organ may be kept refrigerated beyond a certain... [13] and those that may be treated industrially by refrigeration techniques in organ banks. While in Europe and North America legislated regulations make it clear that organs can only be donated, ie, made available for free, the technical possibility of preserving tissue shifts the boundaries between gift and market. When specialized companies can preserve tissue, it is clear that “gift” logic and market logic have become intertwined – and problematic. In the United States, tissue banks are usually private businesses engaged in competition to procure tissue and sell their services to transplanter hospitals. As David A. Fragale, director of Cryolife, Inc., has unabashedly declared, these businesses must make a profit, and the distinction between for-profit and non-profit activities becomes blurred as soon as such businesses intervene between donor and recipient. [14]  “This competition is occurring in a manner which blurs... [14] Of course, as Fragale underlines, commercialization is prohibited by law and there can be no financial incentives in the matter of organ donation, but “financial resources play a large part in the development of marketing strategies used by organ and tissue banks. While not directly offering financial incentives for organ and tissue donation, the banking organizations are continually seeking ways to remove financial disincentives for hospitals, physicians, medical examiners, coroners and funeral homes involved in the donation process” (Fragale, 1996, p. 200).

12

In sum, the industrial dimension of blood transfusion and organ transplantation, closely linked to the technological content of medical therapy, profoundly modifies the terms of the gift/market debate. To characterize the system as a whole, therefore, we cannot focus attention exclusively on the donor and donor motivation. The organizational and industrial aspects that have filtered in between giving and the market are now decisive for assessing the relation or confrontation between the two.

The social construction of the gift

13

Titmuss’ work is related to that of Polanyi and Mauss. In underlining the fact that blood is collected, Titmuss indicated that it is not a produced good, that it is closely tied to what makes us human, and that when commercialized, it falls into the category of “fictitious commodity” –like work, money, and land, according to Polanyi. In agitating for the “right to give”, even though the gift he was interested in had little to do with Mauss’s threefold obligation of giving, receiving, and giving in return, Titmuss was in fact working directly in the wake of Mauss and Mauss’ call for us to remember “a longforgotten dominant motive” (Titmuss, 1970, ch. 17; Mauss, 1980, p. 262). [15]  The author is aw are that blood donation does not... [15]

14

All three of these authors were reflecting on the links between market relations and those values that seem essential to the continuance of social life. The particularity of Titmuss’ work is that it concerns contemporary society alone. I am certainly not claiming that anthropology and history have no important contributions to make about modern society; Polanyi’s and Mauss’ work prove the contrary. But it should also be kept it mind that long, careful empirical and analytic study is often necessary to make this anthropological research relevant to contemporary societies. Rather than measure Titmuss’ loyalty to Polanyi and Mauss, his contribution should be evaluated in terms of the light it sheds on how contemporary societies function in situations where axiological demands collide with economic rationality. [16]  Titmuss made no particular effort to relate his thinking... [16]

15

While it is quite common to discuss the importance of unpaid voluntary action and giving versus self-interested behavior and the market, usually with a concern to magnify the pure, fundamental drive understood to be reflected in the first (Godbout and Caillé, 1992; Godbout, 2000), Titmuss’ work, which certainly expressed the idea that humans are moved by a fundamental drive to give, is part of a sociological tradition in which the central question is why and how such a drive takes the particular social forms it does, what its place in the social system is, and how it functions. [17]  Reference may be made here to two classical sociologists,... [17] And here Titmuss put his finger on an important, often neglected idea : the gift is a product of social construction. This can be shown by examining facts and developments in the area of organ donation over the last two decades.

Organ donation and the problem of collection

16

Since the late 1960s, with the improvement of medical techniques and drugs to prevent tissue and organ rejection, entire swaths of the human body have been receiving close, ongoing attention from the medical world. European Community data give a clear, if only partial, idea. In 1992 approximately 27,000 tissue and organ transplants were performed (2,000 bone marrow, 10,000 cornea, 10,000 kidney, 2,500 heart, and 2,800 liver transplants), not including figures for similar bone and cardiac valve operations. At the same date, nearly half a million Europeans had received some kind of transplant (Englert, 1995). The need for organs increases with technological progress and the greater possibilities for medical treatment that such progress provides. Meanwhile, since the 1990s the gap between number of transplants performed and number of patients waiting for a transplant has been growing; scarcity is a major feature of the issue raised by organ collection. [18]  Sca rcity ma y be measur ed by waiting-list length,... [18] In the case of kidney transplants, while there were approximately 1,000 persons on the waiting list in 1982, in 1992 that number had increased to 4,000; the same for 1995 (ibid., p. 158; Carvais and Sasportes, 2000, p. 265). Being on a waiting list despite the existence of alternative treatments such as dialysis does involve some risk; an estimated 5% of waiting patients die every year. For patients with conditions that can only be treated by transplantation the situation is tragic : 25% of patients waiting for a heart or liver transplant and 50% of those waiting for a bone marrow transplant die (Englert, 1995, p. 3, p. 159).

17

The obstacle to collecting organs and tissue is, as it was for collecting blood in Titmuss’ study twenty years earlier, the lack of sufficient donors. [19]  The figures for organ transplants in France should... [19] The response to this situation in Europe, the United States, and many other countries has remained consistent with Titmuss’ understanding : altruism alone must regulate the system; there can be no commercialization. National and international organizations have regularly prohibited all market intervention. [20]  Five of the World Health Organization’s nine guiding... [20] The fact that they have done so repeatedly does not necessarily mean they cannot ensure obedience of their rules; traffic in human organs, often a national-level problem, is more a matter of rumor than hard fact proved by conclusive studies (Carvais and Sasportes, 2000, pp. 357-372), and the medical world has expressed sceptism about the existence of worldwide, organized organ trafficking, precisely because of the technological constraints involved in the different stages of the process of collecting transplant tissue and organs; also because of the complicity that would have to exist between different medical teams for such trafficking to go on (Englert, 1995, pp. 70-71). What, then, is being expressed in these repeated injunctions against commercialization of organ and tissue collection ?

Institutionalizing the “right to give”

18

We may readily think it reflects the will of those who want proponents of market and commercialization ideology to stay clear of organ donation, as suggested by Renée C. Fox and Judith P. Swazey. [21]  At the close of a chapter entitled “Alterations in... [21] This is similar to the situation which moved Titmuss to write, but it should not mask the social construction involved in blood and organ donation, namely at the political and legal levels.

19

In this connection it is instructive to look at Lorentzen and Paterson’s 1992 comparative study of France, a country where kidney donation between living persons is extremely rare, and Norway, where such donation often occurs. Whereas in France only 41% of waiting-list patients received a transplant in 1990, there was no scarcity of organs in Norway. As the authors explain, the two countries had very different organ-collecting policies. In Norway collection is highly dependent on kidney donation from patients’ relatives and friends (49% of recipients in 1990), whereas at 2.7%, France has the lowest rate for such donation of all European countries. Most organs for French patients come from deceased persons. [22]  With the exception of G reec e, Yugoslavia, and Turkey... [22] Children are the exception to this rule : a high proportion of donated organs come from parents (31% in 1989; 21% in 1990), and here France reaches a level similar to Norway’s (ibid., p. 136). The authors are quick to reject the “culturalist” explanation that Norwegians are altruistic while the French are not (ibid., p. 122), focusing instead on the ways in which the two health care systems operate. [23]  The French actually seem more altruistic than Norwegians... [23]

20

The professional ethics of doctors in the two countries are similar in that both corps are on the watch against commercialization and pressure being put on donors or potential donors; likewise they agree that organ donation could hurt donor’s health (Lorentzen and Paterson, 1992, p. 125). However, French doctors are generally opposed to donation by living donors, which they see as voluntarily harming a healthy individual. Using Jon Elster’s theory (1992), the authors underline the profound institutional differences between the two countries. The act of organ donation should not be thought of as engaging donor and recipient only, with the doctor being a mere technician who arrives on the scene only after the decision to donate has been made. On the contrary, the medical institution plays a crucial role. First, the French medical world, reluctant to approve such acts, hardly encourages kidney donation (little information is available on it in France, in contrast to information on dialysis) and is concerned that such donation would have a negative effect on the medical teams who remove healthy organs from deceased persons. Second, due to previous technological choices, France is well equipped with dialysis machines, meaning there is a tendency to want to make use of existing “supply” in the area of medical care (75% of patients are put on dialysis while 25% receive transplants), as opposed to the situation in Norway, where dialysis is considered a temporary treatment (17% of Norwegian patients are on dialysis while 83% live with a transplanted kidney) (Lorentzen and Paterson, 1992, p. 130). In other words, the institutional structure at the technological-economic level is different in the two countries (existing dialysis equipment and economic profitability of using it), as is the level of trust in transplantation in general. In Norway, contrary to France, there is unanimous support for organ donation throughout the medical system and all along the institutional chain linking donor to recipient. [24]  Describing the situation in France, the authors write :... [24]

21

A presentation of the Spanish institutional system (Matesanz, Miranda, and Felipe, 1995) confirms the results of the Norwegian system while extending the scope to include post mortem organ donation, the most current variety. In 1989, Spain set up a program to improve post mortem organ collection that involved increasing the number of doctors and nurses working to coordinate organ~procuring and transplant-performing teams. These coordination teams are regularly in contact with the institutions that exercise major influence on public opinion (the church, media, patient advocacy groups, and so forth). Lastly, there is a national structure for coordinating the work of decentralized teams throughout the country. While the results of this policy are only available for a limited period, they are crystal clear : the level of post mortem organcollecting (number of donors per 1 million inhabitants) went up continuously from 14.3% in 1989 to 17.8% in 1990,21.7% in 1992, and 25% in 1995 (ibid., pp. 106-108; Carvais and Sasportes, 2000, p. 268). This puts Spain among the most altruistic countries. Other European countries, including Scandinavia, have far lower rates. [25]  In the same year 1992, organ collecting rate s per... [25]

22

To use the kind of language current in analysis of market relations, we can say that altruism is socially constructed. The social forms that altruism or giving may take are not directly the fruit of a human drive to give; we must take into account the institutional conditions that enable this drive to express itself.

Self-interested behavior, unpaid voluntary action, and the spread of the economic vision of the social world

23

In the debate between Titmuss and the economists, a major point was whether altruism should be preserved from the market or not. Titmuss’ position was that the two were mutually exclusive : the market could only corrode social behavior. This amounted to saying that among the institutions that defined the “right to give”, there were also such things as representations and, to use Durkheim’s renowned expression, ways of acting, thinking, and feeling. Titmuss’ view does not seem to have prevailed, despite the fact that, as we have seen, international institutions have adopted a similar position on ethical grounds with their imperative to keep the human body outside the commercial sphere. However, Titmuss thesis has recently been supported, and indeed reinforced, by Bruno S. Frey (1997).

24

Frey distinguishes between two types of motivation at the origin of economic behavior : extrinsic motivation, corresponding to what economists commonly reason about by means of the term price effect (a rise in prices or compensation increases supply of the good in question or incentive to act in the expected way), and intrinsic motivation, involving the actor finding within herself the resources that motivate her to make a product available or behave in a expected way. He posits that interaction between these two types of motivation may explain certain anomalies in actual behavior as compared to the expected maximizing behavior. Intrinsic motivation can be reinforced by price effect when the latter is perceived as a means of valorizing the former, as when symbolic remuneration increases effort. Conversely, intrinsic motivation may be reduced or vanquished if the latter is perceived as a failure to recognize the former. Economists usually neglect intrinsic motivation in their reasoning, because of their disinterest in the content of preferences, considered as given and invariant during the period under analysis. But if we go beyond the economist’s narrow framework and take values and axiological rationality into account (Boudon, 1998), we see that price effect can amount to the unintended effect of reducing or destroying intrinsic motivation. If this type of motivation is essential to action, effort and contribution are decreased. Frey adds that in cases where intrinsic motivation plays a major role, there can be a “spill-over effect”, with destruction of intrinsic motivation in one area spreading to others. Using language closer to economic theory, Frey thus returns to Titmuss’ argument (albeit moderating it) –the very one which the economists Arrow and Solow sought to refute. [26]  Titmuss had skillfully expanded the scope of his work... [26]

25

Once this step has been taken, economic theory no longer has the means to resist proper sociological analysis of representations of the economy and the impact of such representations on economic activity. The results of economic psychology experiments testing behavior with regard to public goods, for example, regularly fail to corroborate the notion that self-interested behavior dominates. Even when the nature of the experimental situation (the “free rider” strategy) is explained to respondents and the experimenter checks to make sure they have understood the mechanism, their choices do not really confirm the predictions of economic theory (Marwell and Am es, 1981; Palfrey and Prisbrey, 1997). Respondents test out as being much more cooperative than they would be if they were only following the dictates of rational pursuit of self-interest. It is significant that the only group of respondents who behaved in ways close to those predicted by economic theorists were students of economics. Other experiments, which took into account the effect of long education and economics professor’s reputation (personal reputation and influence) confirm the initial intuition : having studied economics limits the tendency to cooperate (Frank, Gilovich, and Regan, 1993). To use Michel Callon’s phrase (1998), it is also necessary to take into account the “economic construction of economic reality”. Titmuss’ call for protecting altruism from the market seems as extreme as before, but it is still of great empirical relevance given how, following Durkheim’s definition of institutions, representations partake of the social construction of behavior.

26

With gifts of blood and organs, giving has become institutionalized in the sense that each link in the giving chain is attended to and regulated by an imposing set of political, legal, economic, medical and relational institutions. The new technical, even mechanical aspect of such giving has made for a modern gift, one quite unlike what is brought to light in studies of ceremonial exchanges in archaic societies.

27

As if to counterbalance the cold, technical component of modern giving, institutions show constant concern for actors’ intentions. Close attention is paid to the donor (regardless of whether he is believed to have performed a positive or negative action), to the point where donor’s change in preference can explain certain legal difficulties in removing an organ post mortem, or discrepancies between a French law defining assumed consent and the actual French medical practice of questioning donor’s relatives and friends before removing the organ. Even greater concern is shown for living donors, where there are fears about mercantile pressure, risks of new forms of slavery, family vindication, and so forth. Close attention is also paid to professional practitioners. In France, the technical performers of the donation process (surgeons and their medical teams) are not allowed to be paid per medical act performed; this is meant to signify that they cannot be motivated by love of lucre. Likewise, there is a concern about the possible effects of “medical paternalism” toward potential recipients; the latter’s wishes are increasingly taken into account because of increasing respect for the individual–the object of modern religion, in Durkheim’s understanding– and about the phenomenon of moral polymorphism, where more importance is now granted to the axiological choices of any social group (Gromb and Garay, 1996). It seems fair to say that one of the fundamental reasons for this attention has to do with the surprising similarity between modern forms of giving and market exchange. In modern giving, anonymity is maintained in order to protect the recipient from the affective and symbolic burden of receiving the gift of life. The paradox is that this makes it hard for us to see such giving as a social tie, whereas that value – the affective and symbolic value of a social tie– has generally been the one associated with this form of commerce between human beings.

28

Translation : Amy Jacobs

Previously published : RFS, 2001,42,2


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Notes

[(1)]

Richard Titmuss was a professor at the London School of Economics and a renowned specialist of the welfare state. He died in 1973. In addition to the original 1970 book, the 1997 reedition inc ludes f ive new texts on the author’s work, particularly his thought on giving, and on how the issue has developed with the emergence of the AIDS pandemic. A draft of this article was presented on the occasion of the seventh Colloque Polanyi (Lyon, May 1999).

[(2)]

Titmuss was responding to a work by M. H. Cooper and A. J. Culyer ( 1968) published by the Institute of Economic Affairs, founded in 1955 by Friedrich Hayek.

[(3)]

K. Dixon used this expression as the title for his 1998 work, which discusses several classic-liberal British think tanks, namely the I nstitute of Econom ic A ffairs, Titmus s’ declared enemy.

[(4)]

These philosophic al c onnections become obvious when we consider Titmuss’ definition of altruism–one is altruistic toward strangers, not close friends or relatives, not members of a network of family or friends– in conjunction with the title of his last chapter (“Who is my stranger ?”) and with Georg Simmel’s reflections on the stranger.

[(5)]

This is a literal example of what some American economists, studying the neoliberal economic policy of the Reagan era, called “inverse trickle-down economics” (Bowles, Gordon, and Weisskopf, 1983).

[(6)]

Titmuss’ two arguments in support of this radical thesis would later become a focal point of the debate (Solow, 1971; Arrow, 1972; Singer, 1973; Hausman and McPherson, 1993; Radin, 1996). First, he argued that in continental Europe, a collection system based on altruism in one country might well become destabilized if a market system were put in place in a neighboring country, especially if that country offered to pay for donations from its own citizens across the border, as was the practice in Holland and Germany in 1968 (Titmuss, 1970, p. 243). Second, it was easier to destroy values in a given society than to r evive them. Beca use of this asymm etr y, Titmuss recommended thinking twice before s ettin g up a system that c ould destroy axiologically-based behavior (ibid., p. 250).

[(7)]

Many examples of this are given in a study conducted in the mid-1980s on persons selling their plasma in the state of Texas (Anderson and Snow, 1994, pp. 29-30).

[(8)]

According to Pareto’s criterion, a social state B is superior to another state A when all agents in state B have a welfare index equal to or better than the index they had in state A. This does not at all mean that optimal state B is Pareto-superior to just any sub-optimal state. The redistribution effects necessarily created by a move from a sub-optimal state to optimal state B (at least) mean that an agent’s situation can in fact worsen.

[(9)]

Solow perspicaciously suggested that the British position may have been due to a “war effort” effect. This idea comes through clear ly in the Frenc h cas e studied by Marie-Angèle Hermitte (1996, pp. 94-106). Whereas selling one’s blood was a fairly common, positively viewed practice between the two world wars in France, it came to be sharply stigmatized after World War II. After the robust proletarian, generous with his blood (while selling it), came the infamous mercenary or the exploited person; the effect was to valorize the image of the unpaid voluntary donor.

[(10)]

The origin and development of the ta inted blood a ffair in France have been examine d in sever al studies; see Her mite (1996); Morelle (1996); Beaud (1999). For European Union-wide comparative studies, see Setbon (1993) and Steffen (2000).

[(11)]

M. Setbon (1993, pp. 75-80) clearly presents how the French blood transfusion system was organized. In the 1990s it employed some 11,000 persons.

[(12)]

Like for-prof it business es, the non- prof it s ector is held to budgetar y constraints, in this case fixed by the overseeing government ministry or agency, and it too must conduct successful research and development operations, invest, and so forth. The non-profit sector may also be involved in import and export, and thus have to deal with international market prices. It must also make choices between different alternatives, such as what types of blood products to supply and at what prices, etc. As M. A. Hermitte has shown (not without a certain bias; pp. 143-149), in making these choices, the French Health Ministry charged with overseeing blood transfusion agencies manipulated the sale prices of blood products among the different agencies. Those prices, which were of course not determined the same way market ones are, nonetheless played their role of pr oviding inf ormation a nd incentive, and system actors necessarily made de cis ions based on that infor mation a nd incentive and on how much maneuvering room they had. There can be no simple opposition between public and private sectors, since the same kind of difficulties as these arise in private companies divided into several profit centers linked together by supply of intermediate goods or finished products sold at prices de ter mined by a policy-ma king hie rarc hy without reference to the market (Eccles and White, 1988).

[(13)]

No organ may be kept refrigerated beyond a certain time. For kidneys the limit is between 12 and 40 hours, 12 to 18 hours for livers, 6 for pancreases, 5 for hearts, and 4 for lungs (Nefussy-Leroy, 1999, §491).

[(14)]

“This competition is occurring in a manner which blurs a previously clear philosophical demarcation line between non-profit and for-profit organizations […]. This blurred philosophical line be tw een f or-pr ofit and non-profit behavior is becoming the accepted norm in the United States, and is leading to a great deal of debate and rethinking of health care mores in the European Community.” (Fragale, 1996, p. 199).

[(15)]

The author is aw are that blood donation does not correspond well to Mauss’ three-fold obligation (Titmuss, 1970, p. 280). He does remark that in a country where blood is collected through giving, a trace of the idea of giving something in return may be found in the donor having benefited himself or herself from a blood transfusion (ibid., p. 196). A Canadian study conducted after Titmuss’ work showed that 22% of persons questioned during blood donation say that “the feeling of giving in return for a transfusion” was either important or very important in their decision to donate blood (Lightman, 1981). References to Mauss’ concept of the gift permeate the work of socio-logists studying or gan donation (Fox and Swazey, 1972,1992). The concept is also vehemently debated for organ donation (Godbout, 2000), where Mauss’s three obligations are particularly hard to apply, some favoring Polanyi’s idea of a redistribution process that involves individuals and a political center, the idea being that where the gift-giving process occurs in organ donation is among professionals; ie, the teams that procure and transplant the organs (Paterson, 1997; Herpin and Paterson, 2000). I shall not discuss this point here.

[(16)]

Titmuss made no particular effort to relate his thinking to Polanyi or Mauss as intellectual sources, which amazed some commentator s and led others to reject his w ork (Douglas, 1971). These reactions were in large part due to the fact that he analyzed the issue without taking into account the fully developed body of thought that already existed on the question of embeddedness or disembeddedness in connection with Polanyi’s idea of blood as “fictitious commodity” and with how Mauss’ theory of the gift could be applied to Great Britain and the United States in the 1960s.

[(17)]

Reference may be made here to two classical sociologists, Weber on the profit drive and Tocqueville on individualism. While these are seen as fundamental human drives, those thinkers w ere concer ned to e lucidate the specific social forms they take in capitalism (Weber) and modern democracy (Tocqueville).

[(18)]

Sca rcity ma y be measur ed by waiting-list length, waiting time, or number of deaths among waiting-list patients (Carvais and Sasportes, 2000, p. 265, pp. 321-323).

[(19)]

The figures for organ transplants in France should be illustrative enough. Whereas over the 1980s the annual number increased regularly, from 700 in 1980 to 3,000 in 1988, culminating in 3,282 for 1992, it has dropped since, with 2,856 in 1995 and 2,839 in 1997.

[(20)]

Five of the World Health Organization’s nine guiding principles for organ transplant (1990-91) deal with the commercialization issue. Guiding Principle 5 reads : “The human body and its parts cannot be the subject of commercial transactions. Accordingly, giving and receiving payment (including any other compensation or reward) for organs should be prohibited.” (quoted in Englert, 1995, p. 90). The European Parliament resolution of Sept. 14,1993 is fully consistent with this (ibid., pp. 93-94). Between 1968 and 1973, all US states adopted one form or other of the Uniform Anatomical Gift Act (Fox and Swazey, 1992, p. 65).

[(21)]

At the close of a chapter entitled “Alterations in the theme of the gift”, the authors rem ark : “This mar ket vision – per meated by s upply- side econom ics and neo- conser vative political thinking– is grounded in the conviction that economic and social relations should ideally be organized around and guided by the maximization of rational, self-interested free choices and that ‘moral obligations to others can be satisfied [best] … by first satisfying obligations to the self’.” (Fox and Swazey, 1992, p. 72). and Swazey, 1992, p. 65).

[(22)]

With the exception of G reec e, Yugoslavia, and Turkey (where the absolute levels are nonetheless quite low–a total of 160 transplants in Greece in 1992– due to the difficulty these countries have organizing an organ trans plant system), the da ta show a low proportion of donation between living persons out of the total number of trans plants performed in 1992 : France, 2.5%; Greece, 42.5%; I taly, 15.2%, Spa in, 1 %; th e S ca ndinavian countries, 25.8%; Switzerland, 11.6%; United Kingdom, 4.8%, and United States 23.8% (Englert, 1995, p. 113). Japan is a separate case, with a record of 78% for 1991, but this situation is due to the fact that the notion of brain death was not accepted in Japan until 1999; the only type of donation possible was between living persons.

[(23)]

The French actually seem more altruistic than Norwegians when it comes to blood donation (7.6% of 1 million inhabitants in France donate blood, as opposed to 4% in Great Britain and 5% in Sweden). It should also be note d that volunteer donor ass ocia tions constitute a major institution in France. The authors did well, therefore, to rule out a culturalist explanation.

[(24)]

Describing the situation in France, the authors write : “Dialysis operators’ preference for keeping the system focused on dialysis, which is in turn denounced by transplant operators, is not making collaboration between specialists in the two areas any easier.” (ibid., p. 133). They then point out that “for patients, this conflictual division of labor means that 1) it is highly probable they will never be sent to a transplant service, and 2) they may well receive contradictory infor mation on pos sible treatment” (ibid., p. 134). I would suggest that just as we speak of a “prescriber market” in the case of buyers seeking access to “experts” to obtain the knowledge necessary for making decisions (Hachtuel, 1995), so we may speak of a kind of “prescriber altruism”.

[(25)]

In the same year 1992, organ collecting rate s per m illion inhabitants in Eur opean countries ranged from 5.5% (Italy) to 18.5% (Portugal). The United Kingdom, France and the Scandinavian countries were fairly close together, with respective rates of 15.5,16, and 16.8% (Englert, 1995, p. 113).

[(26)]

Titmuss had skillfully expanded the scope of his work beyond blood donation, already evoking organ donation but also less perceptible gifts such as the gif t of self involved when hospitalized patients donate their bodies to medical science (1970, p. 280). This s uggests tha t he wa s thinking of a phenomenon of the type that Margaret J. Radin (1996, pp. 95-101) has called the domino theory and Frey calls the “spill-over effect”; that is, the impact of value destruction on spheres other than those immediately implicated.

Résumé

Français

Richard M. Titmuss’ study of blood donation is still a reference on the subject of giving for medical purposes. This article reviews Titmuss’ main arguments, together with economists’ reactions to his affirmation that a system based on giving and altruism is superior to one organized around the market and self-interested action. It then shows that the gift/market opposition is a reductive one, in that it does not take into account the industrial aspect of medical donation. Lastly, on the basis of empirical information about organ donation, the article brings to light the work of social construction without which, as Titmuss clearly understood, modern forms of giving could not have been established.

Plan de l'article

  1. Giving vs the market ?
    1. Titmuss’main points and the reactions of two economists
    2. Donation, the market, and industry
  2. The social construction of the gift
    1. Organ donation and the problem of collection
    2. Institutionalizing the “right to give”
  3. Self-interested behavior, unpaid voluntary action, and the spread of the economic vision of the social world

Pour citer cet article

Steiner Philippe, « Gifts of Blood and Organs : the Market and “Fictitious” Commodities », Revue française de sociologie 5/ 2003 (Vol. 44), p. 147-162
URL : www.cairn.info/revue-francaise-de-sociologie-2003-5-page-147.htm.


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