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.

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]

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] 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]

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] 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]

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] 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).

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] 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] 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).

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.

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] 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] 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).

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.

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]

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] 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.

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 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] 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 ?

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] 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 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]

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]

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.

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]

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.

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.

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.

Translation : Amy Jacobs

Previously published : RFS, 2001,42,2