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CURRENT

ANTHROPOLOGY
Volume 35, Number 3, June I994
? I994 byThe Wenner-Gren
FoundationforAnthropological
Research.All rightsreserved
OOII-3204/94/3503-0002$2.00

BrainDeath
and Organ
Transplantation
CulturalBases of Medical
Technology'
by Emiko Ohnuki-Tierney
In theUnitedStatesand a fewotherWesterncountries,
multiple
ofhumanorgansand experimental
transplants
transplants
using
nonhumanprimateorgansare receivingmuchmediaattention,
whileimplantshave been so naturalizedthattheyareno longer
newsworthy.
However,even some so-calledadvancedcountries,
whichpossessboththefinancialand the technicalcapabilityto
adopttransplant
remainresistantto thisnew meditechnology,
cal technology.
Theirrefusalor reluctancein partderivesfrom
theculturalunderpinnings
ofthetransplant
thatare
technology
deeplyembeddedin theEnlightenment
and thusalien
tradition
to peoplesofotherculturaland intellectualtraditions.
I argue
thattransplant
leads to a seriesoftransgressions
technology
ofreceivedcategoriesin almostall cultures-lifeand death,animate
andinanimate,humanand nonhumananimal,selfand other,
andnatureand culture.It leads to the creationofthehybridhuman-a personwhoseidentityis solelybased on rationality
locatedin thebrain-and theemergenceofa new typeofculturalizednaturerepresented
in thebody-cum-nature
whichis
transformed
thoroughly
bymedicaltechnology.
The introduction
ofthisnew technology
to otherpeopleshas profound
implications,especiallywhenit is "giftwrapped"as "thegiftoflife";anthropological
studyinformsus thatdonatedorganscan neverbe
gifts.
EMIKO OHNUKI-TIERNEY iS Vilas ResearchProfessor
at theUniversityofWisconsin,Madison(Madison,Wis. 53706,U.S.A.). She
was educatedat Tsuda College and theUniversity
ofWisconsin,
Madisonand has been a fellowoftheCenterforAdvancedStudy
in theBehavioralSciences,Stanford
(i988-89), and a memberof

i. I am grateful
toRobertLevineofYale MedicalSchoolforinviting
me to the international
conference"OrganTransplantation
and
Human Rights:Cross-Cultural
Perspectives,"
held at the Orville
H. Schell,Jr.,CenterofYale Law School,whichled to thisarticle
and anotherin whichI discuss the Japanesecase in much more
detail.He also providedinvaluablecommentsand criticismof a
longerversionof this article.Jonathan
Parrysharedwithme his
insightson giftsandcharity.
JanVansinaandReneeFoxreaddrafts
in different
stagesof preparation
and offered
me detailedsuggestions.The physiciansJonTierneyand Sh6zo Ogawa reviewedan
earlierversion.Takako Kishimasuppliedme withvaluableinformationabouttheJapanesecase. One ofthetwo anonymousreferees offered
mostperceptivesuggestions.
RichardFox's gentlebut
insightful
suggestions
wereenormously
helpful.I thankall ofthem
fortheirgenerosity.
The shortcomings
ofthearticle,however,are
myown.

theInstituteforAdvancedStudy,Princeton(i986-87). Her retheansearchinterestsare symbolicand historicalanthropology,


thropology
ofpractice,theAinu,and theJapanese.Amongher
publicationsare Illness and HealingamongtheSakhalinAinu
CambridgeUniversity
Press,198I), Illnessand Cul(Cambridge:
turein Contemporary
[apan (Cambridge:CambridgeUniversity
Press,i984), TheMonkeyas Mirror:SymbolicTransformations
in [apaneseHistoryand Ritual (Princeton:PrincetonUniversity
Press,I987), and Rice as Self:JapaneseIdentitiesthroughTime
PrincetonUniversity
Press,I993). The presentpaper
(Princeton:
in finalform22 x 93.
was submitted

In the United States and a few otherWesterncountries,


multipletransplantsofhuman organsand experimental
transplantsusing nonhumanprimateorgansare receivingmuch media attention,while implantshave been so
"naturalized,"as Foucault,Bourdieu,and Bartheswould
say (e.g., Bourdieu I977 [I9721:i64), that they are no
longernewsworthy.Israel, Denmark, and Japan,however,remain resistantto this new medical "high technology."The refusalor reluctanceto pursue this technology in these so-called advanced countries,which
possess both the financialand the technical capability
to adopt it, invites anthropologicalinquiry.The foci of
thisarticleare two: the conceptualunderpinnings
ofthe
new medical technologyof organ transplantationand
the closely associated phenomenonofthe identification
of brain death as the death of a person and the farreachingimplications of transplanttechnologyforthe
concepts of personhood and humanity. I shall also
brieflycommenton some of the ethical implicationsof
introducingthis technologyto peoples with otherculturaland/orintellectualtraditionsin theWesternmoral
frameworkof the "giftof life."
The Japanesecase will be used as theprimaryexample
in supportof my general argumentthat resistance to
the medical technologyis not a matterof economic or
technologicalcapabilitiesor even a rejectionofWestern
culturalimperialism.(A detailed descriptionof the cultural reasons for Japan'srejection of the new medical
technologyper se is given separatetreatment[OhnukiTierney I994].) Japanhas eagerlythoughalways selectivelyacceptedscience and technology(Ohnuki-Tierney
i990), andits contemporary
trademark,
as it were,is its
hightechnology.It has not,however,yetpassed legislation equating brain death with the death of a person,2
and even implants and live transplantsare performed
veryinfrequentlyin comparisonwith the situation in
theUnitedStates,theUnited Kingdom,and France.3Jap2. Underinfluence
fromabroad,theJapaneseMedicalAssociation
and Japanesephysiciansand lawyershave pressuredthe governmentto pass legislationacceptingbraindeathas deathofa person.
The govemment
createda specialtaskforce,chairedbyTakeuchi
Kazuo,to developthe standardsforbraindeathknownas theTakeuchistandards.
FollowingtheUnitedStatesandCanada(butnot
the United Kingdom),its I985 reportadvocateddefiningbrain
deathas nonfunction
of the entirebrainand specifiedsix criteria
forit (Hosaka i992:6-8).
A minority
opinionsignedbyfourmembersofthetaskforceopposedthelegalrecognition
ofbraindeath.
3. The firstsuccessfultransplantation
ofa kidneyfroma live human donoroccurredin I964 and the firstsuccessfulcadaveric
in I969 (Hosaka I992:23, 24). By I989, a totalof
transplantation
6,95i kidneytransplantations
had been performed
in Japan.Be233

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234

1 CURRENT

ANTHROPOLOGY

Volume 35, Number 3, fune 1994

anese resistancederivesto a large degreefromthe fact


thatthe new technologyrepresentsconceptsof lifeand
death,the body,and personhoodthatare deeplyembedded in a Westernintellectualtraditionthatis quite alien
to Japaneseand many other peoples, perhaps even to
manyin so-calledWesterncountries.The rationalisttraditiondevelopedin certainWesternculturesis not universal; formany individuals,even in the West,identity
as a person/humanentails farmore than beingrational
and the bodyis more than an appendageof the brain.
Given the purposes of this article,I engage in bold
interpretationsand make global comparisons. I use
termssuch as "the Japanese,""the West/Western,"
and
even "non-Western"recognizingthat theyhave serious

Cultural InstitutionsunderThreat
BRAIN

DEATH

AS A NEW

CULTURAL

INSTITUTION

Althoughit is framedas if it were highlyscientificand


thus culture-free,
the notion ofbraindeath is culturally
constructed.Today thereare two types of brain death:
(i) "death" or nonfunctionof the cerebrum,which is
the center of consciousness, sensation, and voluntary
action,and (2) nonfunctionofthe entirebrain,including
the cerebrumand the brain stem (brain death in the
United States and Japan).The nonfunctionof the cerebrum leads to a "persistentvegetativestate." In other
words,braindeathis a new phenomenondeterminedby
social agentsin each culture.
and Cohn(i98o:2ii) long
problems.
Auge(I982:I0-II)
Althoughthereis considerable"confusion"or "disarago pointed out the basic issues involved in lumping ray"(Foxand Swazeyi992:59-60)
withineach country
"the rest" of the world in a residual categoryof "the on whetherbrain death should be equated with death,
non-West."By "Westernculture,"I mean primarilythe Americans on the whole seem ready to accept brain
"high culture" of the intellectualsof France,Germany, death as a medicallydefinableconditionthat can be diand the United Kingdom, a few others primarilyin agnosedwith certainty.This providesa sympatheticenWesternEurope, and the United States. More specifi- vironmentforAmericanmedical professionalsto pursue
cally,I mean the Enlightenmenttradition,both in high transplantationof organs and tissues fromthe brainculture and in its popular version. I realize that Den- dead at an ever-increasingpace. The Japanese,by conmark,a Westerncountry,partscompanywiththe others trast,refuseto recognizebraindeath as biological death
in this regard,as does Israel if it is considered"West- in part because they remain skeptical whether brain
ern."Furthermore,
I recognizethatthereare manyindi- death can be determined with certainty.Tachibana
viduals who do not subscribeto this traditioneven in (I99' [I982]:I4- 3 I), whohas ledtheopposition
tomedithe countries where organ transplantationis most cal, legislative,and other types of recognitionof brain
highlydeveloped and, conversely,many individualsin death,considerseach conditioncurrentlyused to define
othercountriesand culturaltraditionswho advocatethe braindeatha necessarycriterionbut insiststhatthe sum
new technology.I commitall the gravesins oftotalizing of these conditions does not guaranteethe permanent
and essentializing,as the postmodernistswould say,but nonfunctionof the brain.For the Japaneseand formany
anthropologistsinterestedin broad socioculturalissues otherpeoples beforethe notion of braindeath emerged,
cannot avoid some generalizations.4
the inactive brain representeda prolongationof life
ratherthan,as it has come to be viewed in some Western
countries,a prolongationof the process of dying.
were performed, There is no question thatthe need fordonatedorgans
tween i989 and i992, 50 livertransplantations
and of these 39 were from living donors (Hosaka I992:29-39).
has played a major role in the constructionof brain
The
Some Japanese seek transplants abroad (Kimura I99I:I23).
donor, death.This is a historicallynew phenomenon(cf.Becker
in I 984,involveda brain-dead
first
pancreastransplantation,

Umehara I992:2I5);j
previouslynot even
was resumedonly I992:239;
The procedure
controversy.
raisingconsiderable
in I990. BetweenI990 and i992, therewere ii cadaverictrans- physicians equated brain death with biological death.
plantations,only 5 of whichwere successful(YomiuriShinbun, Fox and Swazey(i992:62-63)
emphasizethatmedical
in i968 (known professionalscontinueto findit difficultto identifythe
October4, i992). The firsthearttransplantation,
a
drowned
as theWada case),involvedtheremovaloftheheartof
anditstransplantation brain-deadindividual as a "corpse" and are bewildered
manwhomaynotyethavebeenbrain-dead
into a man who may not have neededit and subsequentlydied as to how to treat"dead" patientsduringand afterthe
(Tachibana I99I [i982j:298-3i8). The incidentno dountcontrib- removalof organs(see also Saito I992:i5).
Youngner
in general.No et al. (i985:323)
utedto the Japaneseskepticismoftransplantation
similarlypointto this ambivalence,
in Japan,but by
has been performed
otherhearttransplantation
had receivedheartsoverseas,usuallyin mentioningthatlabels forbrain-deadorgandonorssuch
i992 about 2o Japanese
Canada, England, or the United States (Hosaka i992:52).

The numberof transplantsin Japancontrastsmarkedlywith


thosein the UnitedStates,the UnitedKingdom,and France.In
theUnitedStates,the leadingcountrynot onlyin heartbut also
thefiguresforI983 and i99i are
in otherorgantransplantations,

as follows: kidney, 6,II2/Io,o5i


(approximately2o% fromliving
relatives); heart, I72/2,i26; heart-lung, 2o/si; liver, i64/2,953;
pancreas, 6i/533; lung, -/403 (Genel I993).

4. The purposeof this articleexcludesmoresubtleand complex


and braindeath,
on the issue of organtransplantation
arguments
in manycases, the
includingthe benefitsof thisnew technology
alive,themethecostofkeepingthebrain-dead
legaldimensions,
to chooseethidia's tendencyto encouragemedicalprofessionals
thataredraquestionablecases oftransplants
callyandfinancially

as "beating-heartcadaver" or "neomort"have not been


foundemotionallyor culturallyacceptable even in the
United States. They report,however,that "most would
agree that these donors are no longer 'persons."' Con-

maticand hencenewsworthy,
and inequalityin access to thenew
bothwithina societyand acrosssocieties(fora fine
technology
expositionoftheproblemin theUnitedStates,see Rothmani992).
factors,such as the technology
that
S. Thereare otherimportant
allows themaintenanceofother"vitalfunctions"afterthedeath
ofthebrain,thatare responsibleforthe creationofthenotionof
braindeath(Levine,personalcommunication).

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OHNUKI-TIERNEY

traryto the view of the health professionalsreportedon


byYoungneret al., the notionofbraindeath constitutes
a radicaltransgressionof the traditionalnotion ofdeath
in most societies in that while the culturallydefined
personis not dead-that is, the body is still warm and
the heartis still beating-the personis "killed," in the,
traditionalsense, throughthe removalof organs.
THE

CULTURAL

AND

SOCIAL

DEFINITION

OF DEATH

Brain Death and Organ Transplantation1235

worship" also attests to a prolongedprocess of social


death in many societies. During this process, the deceased graduallybecomes an "ancestor," althoughthe
"ancestor"may be a deceased baby.
Of criticalimportanceforsocial death in most societies is the body of the deceased. Even in the United
States,wherebraindeath is recognizedand organtransone typeof tradiplantationsare frequentlyperformed,
tional funeral involves "viewing" the dead body-a
practicethathas led to a high degreeof commercialization by morticians.This commercializationhas been
successfulpreciselybecause of the culturalsignificance
ofthedead bodyfortheprocessofdying.Anotherindication of the importanceof the dead bodyin many societies is the common practiceof survivors'searchingfora
missingbody or fragmentsof it even many years after
the person's death. For example, under the Clinton administrationin the United States,the searchin the jungles of Vietnam for the bodies of missing American
soldiersremainsa major issue, just as the Japanesecontinued,afternearlyhalfa century,to look forthe bones
of Japanesesoldierskilled in WorldWar II. Conversely,
"biological death" is often seen as insufficientto rid
oneselfof enemies, whose dead bodies are oftenmutilated and otherwisedestroyedfarbeyondthe need simply to terminatetheirlives. Witchcraftcommonlyinvolves a practice wherebypart of a targetedperson's
body is burnt or otherwise destroyedwith the intent
thatthe personbe killed.
The Japaneseare particularlyconcernedabout the intactnessof the body,expressedas gotai, "the fivebody
parts."The notion is closely relatedto the Japanesetaboo on violence to the body which causes imbalance.
When the Japaneseadopted religions,technology,city
planning,the legal system,the imperialaccession ritual,
and many other socioculturalinstitutionsfromChina
duringthe 5thand 6th centuries,theydid not adopt ear
piercingor footbinding.Most important,theyrejected
the institution,vital in imperial China, of the eunuch.
In China, the approximately3,000 eunuchs at the imperial courtwere thoughtto be essential forthe mainte-

In most human societies death is an extremelyimportant culturaland social phenomenon,sometimesmore


importantthan birth.6It is seen as the end of a long,
oftenharsh and difficultroad; mortuaryrituals are as
much a tributeto the departedand theirlives as they
are intendedforthe survivors.
The question of when life ends and death begins is
have longemphaenormouslycomplex.Anthropologists
sized that death is always culturally defined even
thoughit may be expressedin biological terms.Culturally identifiedsigns of death-such as the cessation of
the heartbeatand the gradualdecrease ofbodytemperature-allow survivorsto observe the "process," rather
than the instant,of death. The concept of brain death
sortofdeath.It is the
has createdan altogetherdifferent
medical professionalsalone who make "death" happen,
preventingthe survivorsfromexperiencingit as a gradual process.
In everysocietythe culturallydefinedbiologicaldeath
of an individual must be acknowledged as the social
death of a memberof thatsociety(see, e.g.,Metcalfand
Huntingtoniggi). A death, especially of an important
figurein the society,initiates a cycle of shiftingroles
amongthe survivors.Beyondfunctionalreasons forthe
importanceof death,especially the death of a personof
highsociopoliticalstatus,the death of a memberof the
social groupis a significantoccasion on which cherished
values, emotions, and human relationshipsare called
forthand sometimes tested, individually and collectively.
In most societies, a death thus initiates a prolonged
institutionalizedseries of rituals,ofteninvolvingcon- nance of order(Umeharai992:2io).
Even today,ear
siderable
financialandhumancosts.Hertz(Ig60 [i909])
piercingis uncommon, although some young women
called attentionto the custom of secondaryburial. For and a smallernumberofyoungmen have latelyadopted
example,among the Olo Ngaju, seven to eightmonths this fashion. It is a radical departurefrom tradition;
some who have had their ears pierced have done so
elapsebetweendeathandfinalburial(HertzI960 [I909]:
3'). Until the early 8th century,a mourningpractice againsttheirparents'wishes or purposelynot consulted
called mogariwas performedforJapaneseemperorsand them beforedoing so. Newspapers reportedthat one of
empressesin the course ofwhich a special hut was built the qualificationsof a brideforCrown PrinceNaruhito
to contain the corpse; only aftera long period, often was thatshe not have piercedears. Owada Masako, who
several months to several years, was the secondary marriedthe princeon June6, I993, qualifiedin this reburial performed(Mace i985:58; on folk practice,see spect.Bodilytransformations
foraestheticpurposesare
Orikuchi I976a [I949-52],
I976b [I95o]; Yanagita confinedto the tattooingpracticedby some members
oftenreferred
toas "ancestor of marginalizedsocial groups.There is also an almost
I982b [i929]). The practice
complete absence of the ritual sacrifice of animals.
6. Dworkin(I993:4) arguesthatbirthis moreimportanton the Those whose gotai is missingor deformed,
termedgotai
basis of the amountof attentiongivento the abortionissue in fugu,have encounteredconsiderable cultural and sothe UnitedStates,but abortionis the most commonmethodof
cial discrimination,especially in the past. In the past,
populationcontrolin manysocieties,as in Japan(LaFleuri992,
for
example, the crippled were thought to represent
Ohnuki-TierneyI984) and Romania (Rothmanand Rothman
i990), andreceives
littlepublicdebate.
religiousimpurity(YanagitaI982c [I9331:3I7; i982a

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236

1 CURRENT

ANTHROPOLOGY

Volume 35, Number 3, June1994

is epitoBone fromBrian's legs and hips was removedso that


[I9 I71:I 37). Abhorrenceofbodilyimperfections
a I4-year-oldboy would not have to undergoamputamized in the genre of folklorecalled hitotsume kozd,
tion of a leg due to bone cancer and so that another
"the one-eyedmonster."
The Japaneseare concernedwith the intactnessofthe
child's severelydeformedface could be reconstructedby a plastic surgeon.
bodynot only duringlife but also afterdeath. This noFromthis single tragedysprungnew life,new
tion saw formalexpressionin the Confucian doctrine
health,and new hope fornine of Brian's fellowhuthatthe intactgotai guaranteedthe rebirthof the soul.
mans and fornine Americanfamilies.
(ContemporaryJapanese,to whom the notion of gotai
remainsimportant,are not usually aware of thehistory
In otherwords,virtuallynothingis leftof Brian,whose
ofthisbeliefor thereasonsforits importance.)The eager
body is hollow. At the same time, in "Renewing Life
adoptionof cremationis in part attributableto the imthroughOrganand Tissue Donation," anotherbrochure
of
portanceofgotai. It facilitatesa swifttransformation
forpotentialdonors,it is pointed out that "the funeral
the dead bodyinto ashes and thus avoids the disintegrawill not be delayed,the bodywill not be disfigured,
and
tion of gotai. The warriors'practice of taking the entheycan hold a viewing." This statementunwittingly
emy's head derivesfromthis notion as well. Beheading
acknowledges the importanceof the body of the deconstitutedthe ultimatekillingbecause byviolatingthe
ceased fora "proper"death.
integrityof the body it preventedthe enemy's rebirth.
Universally,the bodyis essentialto the lifeand death
For many Japanese,the removal of organsfrombrainof a personand to personhood.It is forthis reason that
dead bodies violates the integrityof the body of the dethe symbolic constructionand destructionof persons
ceased. The gotai notion also underliesthe Japanesereand societyare predicatedupon a ritualenactment,posiluctance to consider implants. To date, no implanted
tive and negative,on the body.Therefore,in many culpacemaker has been manufacturedin Japan.A model
turesthe removalof organsfromthe brain-deadconstiwas once presentedat an internationalconferenceby a
tutes an act of transgression-it deprivesthe deceased
large Japanesecompanyproducingwatches and clocks
ofthefinalprocessthatenables themto leave thisworld
but was never marketedforfearof its malfunctioning
withdignityand as persons-a social and culturaldeath.
and causingdeaths (Wada and Miwa i992:64). The techFrom this perspective,the removal of organsfromthe
nologyforenteroproctia(artificialanus) is also best debrain-deadis analogous to what happensin the scene in
veloped in the United States,and Japanesepatientsuse
Zorba the Greek in which the islandersbegin to graba
productsmade in the United States (Watari I992:384).
prostitute'spossessions while she is dying.
These patients are extremelyself-consciousabout it,
and Watari(I992), a popularactor,dreadedits use more
thanthe colon cancer thathe had removed.In the view
The Cultural Constructionof Medical
of these Japanese,implants remain alien to the body,
Technologyand the Technological
which is no longernaturallyintact.
The importanceof the intactnessof the body is not Constructionof "Nature"
unique to Japanese culture. The one-eyed-monster
theme is found in many other cultures (cf. Needham The primaryfoci of any medical system are life and
I963), and the crippledhave been discriminatedagainst death,healthand illness,and the body-all ofwhich are
in many parts of the world.7The followingstorywill centralto the existentialand ontologicalconcernsofthe
not be persuasiveforeveryone.Entitled"The people, collectivelyand individually.Clearly,all health
therefore
Storyof Brian,"it is partof a package providedby Eliot care systemsare deeplyembeddedin theirculturalsysHospital in New Hampshire and by UniversityHospi- tems. It is hardlynecessaryto point out to anthropolotals and Clinics in Madison, Wisconsin,to patientsbe- gists that biomedicine is not an "objective," "scienforetheyundergosurgeryto encouragethem to donate tific,"and therefore"culture-freescientific"system.I
theirorgansin the event that theydie. In the storythe firstdiscuss the culturalunderpinningsof biomedicine
enormousaltruismof "the giftof life" consentedto by and transplanttechnologyand proceedto the latter'sfarBrian's parentsis praised in termsof the use of his or- reachingimplicationsforboth human cultureand cultures.
gans and tissues forothers:
Brian'sheartwent to a 35-year-oldfatherof two.
The liverforestalleddeath in a 2o-year-oldcollege
student.One of Brian's kidneyswent to a teacher
who had been on dialysis for5 years; the otherkidney went to a youngwife and motherof threeyoungsters.
Brian's eyes were removedso that his corneas
could restoresightto two blind people. His donated
skin helped save the life of a severelyburnedbaby.

BIOMEDICINE

AS WESTERN

CULTURE

Surgeryis arguablythe most important"healing" techis based on


nique in biomedicine.Organtransplantation
the notionof surgeryand shareswith it the basic premise of modern Western medicine, a system based on
the notion of causation that views disease as located in
an organattackedby pathogenicagents (cf.Stem I977).
Surgerythat removes a diseased organ and replaces it
throughorgantransplantationis a logical solution.This
or sym- view of disease is relativelynew in Westernmedicine,
7. As in Japan,theymaybe assignedspecialsupernatural
arisingaround I 8oo in Paris and being accepted in the
bolic power,forexample,to communicatewithdeities.

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OHNUKI-TIERNEY

UnitedStatessome 50 yearslater(Levine,personalcommunication).
Althoughsurgeryas a medical technique is naturalized in the contemporaryworld, it is by no means a
universal means of restoringhealth. Anthropological
studies of humoral medicines (Currier I966, Foster
I953) in various parts of the world have introducedus
to the notion of the equation of bodily balance with
healthand ofits imbalancewith illness. Similarly,traditional Chinese medicineis based on what Porkert(I 974)
has called a "system of correspondence"ratherthan a
"system of causation." For Japanesetraditionalmedicine (kampb),derivedfromChinese medicine,the basic
premiseof medical treatmentis the restorationof the
balance of the body,which removesthe etiologicalconditionsand thereforethe pathogensas well. In this system of medical thought,surgeryis the polar oppositeof
treatmentand is seen as aggravatingthe body's imbalance. Therefore,despite the prestigeand gloryaccorded
biomedicinein Japan,the Japanesehave been cautious
and selective about adopting surgery (see OhnukiTierney I984). Although Japanese surgeons too have
considerableprestigeand power,theypale by comparison with Americansurgeons(cf.Bazell I985).8Ifsurgeryis one ofthe most basic premisesofbiomedicine, the newly emergentnotion of brain death is anotherexpressionofbiomedicineas a productofWestern
high culture.The conceptual bedrockof brain death is
the cherishedprinciple of that culture,especially the
Enlightenmentphilosophy espoused by intellectuals
since the I7th centuryprimarilyin France, England,
Germany,and the United States,wherebyrationalityis
themost importantcriterionforhumanness.As a corollary,the brain-the seat of rational thought-occupies
the most prominentplace among the bodyparts.In this
dominant"Western"philosophicalperspective,a "person" ceases to exist when the functionslocated in the
cerebrumare "irreversibly"
lost. The brain-deadindividual is, naturally,dead as a person.
The heart too is an importantorganin Westerncultures.Love has occupied a centralplace in manyWesternculturessince the time of chivalry.Commercialestablishmentsin the United States exploit the notion of
love with iconographicrepresentationsof the heart to
promotegiftgiving on Valentine's Day and Mother's
Day. While the heart is associated with the emotions,
the brain is associated with rationalityand consciousness. At least in the past, males representedrationality
and females emotionality,as in the familiarFreudian
schema. The brain,then,representedthe essence ofhumanness as man representedhumans. In this symbolic
construct,the brainis arguablythe most importantpart
of the human anatomy. It is the seat of "the mind,"
while the heartindicatesthepresenceofmerebiological
life.
FromClassical times throughDescartes, Kant, Rousseau, and othersand even morevigorouslysince the rise

Brain Death and Organ Transplantation1237

of modernscience, the notion of rationalityas the essence of humanityin the Westernintellectualtradition


has been expressed in numerous ways. For example,
ethologyin the West has focusedon whethernonhuman
primatespossess language-the tool of rationality.In
anthropology
itself,the question ofrationalityhas occupied centerstage,whetherin its relationshipto magic
and religionor in the formof "the primitivementality,"
since the time of Levy-Bruhland has been discussed by
almost everymajor figuresince. Any equation of the
rationalisttraditionwith the entiretyofthe Westernintellectual traditionwould, however, be an enormous
oversimplification.
Even within the high cultureof the
West,a farmore complex pictureof the notion of rationality must be recognized.The relationshipsbetween
rationalityand empiricismand betweenrationalityand
discursivelogic are but two ofthemanycomplexdimensions of the question (see, e.g., Gellner i992, Tambiah
I990,

WilsonI970). Nonetheless,
theimportance
ofra-

tionality in defininghumanness is widely shared in


many Westernsocieties among both intellectuals and
ordinarypeople. It is no accident that biomedicinehas
focusedon the brainas the crucial organin determining
whether"the person" is alive or dead. The readiness
with which brain death is recognizedas signalingthe
deathof and as a human is simplya corollary-without
a functioningcerebrum,the human becomes a thing,a
nonpersonand nonhuman. Brain death is the opposite
of the ideal model-the independentindividualmaking
rationaldecisions.
Rationalityas the hallmarkof humanityand the preeminenceof the brainare not universallyshared.A cursoryreviewof culturalvaluations of body partsreveals
thatthebrainand,forthatmatter,theheartdo not enjoy
similarpreeminencein othercultures.Even withinthe
so-called West we findvariations.For example, in the
OrthodoxJewishtraditionthe heart,not the brain,is
consideredthe seat of life,and OrthodoxJewsrejectthe

notionofbraindeath(RothmanI99I:I64).

Untilthein-

troductionof modernmedical science, forthe Japanese


the seat of the soul-which includes both the mind and
theheartin the Westernsense-was the stomach.Thus
warriorscommittedsuicide by cuttingopen theirstomachs to release their souls (cf. Chiba I98I). Tamashii
(soul) is closer to spiritualityor emotionalitythan to
rationality.This can,be seen in such expressionsas wakon kansai (Japanesesoul and Chinese brilliance)or wakon yosai (Japanesesoul and Westernbrilliance)-two
phrasesused to identifythe Japaneseselfin its encounter.with the "other." When the Japaneseencountereda
highlydevelopedChinese civilizationin the 5th through
the 6th centuryand Westerncivilization at the end of
the igth century,theyeagerlyadoptedtheseforeigncivilizations. But in an effortto protectJapaneseidentity
and pride theyidentifiedthemselveswith the Japanese
soul and creditedthe Chinese and the Westernerswith
brillianceand rationality,in this way achievingthe best
of both worlds.
Several Japanesecultural institutionstestifyto the
8. In theUnitedStates,however,thelargenumberofunnecessary
has invitedsharpcriticismin recentyears.
importanceof affectivityand emotionality.Of all the
surgeries

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238

1 CURRENT

ANTHROPOLOGY

Volume 35, Number 3, JuneI994

emotions, sadness has been particularly important


throughouthistory,and the sheddingof tearsis considered a uniquely human behavior.9For example, in the
contextof a querywhetherhumans alone are capable of
sheddingtears,we find in medieval literaturedebates
over whetherthe moistened eyes of cows and horses
representedcrying(Endo and Kasuga I 967: II9-2 I). Although aesthetic, philosophical, and ontological concepts such as yugen (grace)and monono aware (pathos
in all things)are difficultto translateinto English,they
containelementsofpathosand are the definingqualities
of the noh and of the Buddist arts. Kabuki theater,a
much more plebeian performing
art than the noh, also
emphasizes sadness and crying.A number of stylized
ways of cryingare a regularpart of the kabuki repertoire.10The traditionalrepertoireof the monkeyperformance,"1duringwhich a trainedmonkeyperformshuman dances, includes imitatingvarious typesof crying
performed
in thekabukitheater.Since monkeysare consideredclosest to humans,theirabilityor,alternatively,
inabilityto cry answers the question whetherhumans
are unique in theircapacity foremotion and therefore

toall otheranimals(Ohnuki-Tierney
superior
I 987:

200).

I 9 I,

12

The Japaneseconception of humanness, then, contrastswith the Westernconception.In the absence ofan
exclusiveemphasison rationality,equatinglifewiththe
functioningof the brainis alien to many Japanese.I believe thatthis view is alien to many othernon-Western
peoples,as well as to many individualseven withinthe
Westernworld.
The notion of informedconsent also relates to the
rationalistview ofpersonhood.Referring
to the NuremburgCode,Levine(i988:esp. I2I-27)
emphasizesthat
the idea of informedconsent is underlainby the concepts of autonomy and free choice and warns that it

maynot applyto othercultures(Levinei99i).

Indeed,

in many othersocieties, individualsare conceptualized


and the deathofa personis a commuas interdependent,

nal affair.For these people, then, informedconsent to


organdonationis not a familiarproposition.In Islamic
countries,forexample,the rightsofthe communitytake
precedenceover the rightsof the individual,according
to Daar (I989:I403). Islamic law dictatesthat the body
ofthe deceased be buriedon the day ofdeath.Thus individuals in these countries are not free agents making
independentdecisionsabout the disposal oftheirbodies.
Daar further
points out thatif a person's organis transplantedto anotherindividual-which is sanctionedunder Islamic law-it must neverthelessbe buried accordingto Islamic law when the recipientdies. This
poses problemsif the recipientbelongs to anotherreligion,in which case the transplantedorganmust be removed so that it can be buriedon the day of the recipient's death. Donors may offertheir organs, but the
organs donated remain under the jurisdictionof their
communitiesand thus underIslamic law.
Needless to say,the contrastjust drawnis too simplistic. The notion of informedconsent is not always the
model in the United States.Fox and Swazey (1992) mention several cases in which the donation and receiptof
organswere farfromfreechoices. For example, citing
the American Council on Transplantation(I989), they
describea case in which a young woman who had received one of her brother'skidneysfelt tremendously
guiltyand resentedthe decision to accept the kidney
as "just anotherdecision made forme by my family."
Conversely,thereare Japanesewho make theirown decisions about organdonationthat are respectedby their
familiesat the time of theirdeath. For example, a 53year-old Japanese woman potter,Akiko Ogawa, had
made a livingwill to donate her eyes and kidneys.On
October i6, I993, aftershe went into a coma on being
stung by a bee, her kidneys were transplantedto two
individuals (Yomiuri Shinbun, October i8, I993). Her
case was widely reportedby the mass media, and she
was heraldedas an unselfishindividualby supportersof
euthanasiaand of organtransplantationinvolvingbrain
death.In additionto individualdifferences
withina society,we must also take changesin attitudeinto account.
In fact,the notion of braindeath and organtransplantationcan be expectedto make significantinroadsin most
societies. In the past decade alone, significantlymore
Japaneseare leaning towardthe new technology.'3

9. The importanceof emotionalityis also recognizedin many


bythehealingpowerassigned
Westerncultures,as is exemplified
to thetearsoftheVirginMary(R. KenjiTierney,personalcommunication)and the commonlyacknowledgedtherapeuticeffectof
crying.
characterized
io. In contemporary
enka,a genreoffolksongs
Japan,
popular.Moviesare classified
bypathosand sadness,is extremely
into threecategoriesaccordingto the numberof handkerchiefs I3. Opinionpolls publishedin Yomiuri(DecemberII, i992) and
movie" summarizedbelow show an increaseamongthegeneralpublicin
requiredto soakup thetears,withthe"three-handkerchief
The
andorgantransplantation.
forthebraindeathcriterion
support
beingthebest.
i i. After
GeorgeBush,thenpresidentoftheUnitedStates,threw figures
thefirstin each instancebeingthat
percentages,
represent
in Octoberi982 (forquestionsA-C), NovemberI985 (for
up at thedinnertableduringhis visitto Japan,one groupoftrain- surveyed
ers,whichlatertouredthe UnitedStates,stagedan imitationof questionD), or NovemberI987 (forquestionE) and the second
(afterthediagonal)thatsurveyedforNovemberi992:
Bushbya monkey.
ofthemonkeyperformance, A. At presentin Japansomebelievethatwhenthebrainis dead
repertoire
I2. As partofthetraditional
his monkeys,sings a song that laments, thepersonis dead,whileothersholdthatevenifthebrainis dead
a trainer,representing
faceis red,myeyesare the personshouldnot be pronounceddead untilthe heartstops.
"Becauseofthekarmaofmyparents,mny
round,and,in addition,mynose is flatand ugly"(Yamaguchiken Whatis youropinion?Braindeathshouldbe judgedas death,I 5.2/
song, 32.4; braindeathis death,if we must decide,I3.4/I9.8; hardto
thetrainer's
Ky6ikulinkaiBunkakaI980:4I). Accompanying
the monkeyimitatesweeping,coveringits eyes with a hand- say,23.4/22.4; inclinednotto equatebraindeathwithdeath,I4.7/
no anembodiescomplex IO.7; braindeathshouldnotbe judgedas death,24.8/ii.9;
This seeminglysimpleperformance
kerchief.
symbolsthatallow us swer,8.5/2.8.
workingsofthefaceand eyesas polytropic
some doctorsask
B. Whena personis pronouncedbrain-dead,
to tap the core of the Japanesecosmologicalscheme,whichinbetweenhumansand animals.
survivingrelativesforthe deceased'sorgans.Choose one of the
volvestherelationship

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Brain Death and Organ Transplantation1239

OHNUKI-TIERNEY

At any rate, the refusal by the Japaneseand many


otherpeoples to accept brain death as biological death
and theirresistanceto organ transplantationis related
largely to the basic premise of the new technology,
which is a product of the rationalisttraditionin the
West and is alien to the conceptionsof life and death,
thehuman,personhood,and the bodyofmanyindividuals in both "Western"and "non-Western"societies.

Transgressionof Basic Cultural Categories


and the Emergenceof a New "Nature"
In the intellectual historyof humanity,we have witnessed major revolutions,such as relativism,that have
turnedthereceivedwisdom upside down. The new medical high technologyof organ transplantationand the
equation of the nonfunctionof the brainwith the death
of a personis, however,arguablythe most fundamental
such revolution.It may, if successful,lead to the systematic overthrowof almost all of our cherishedculturalcategories:life and death,human and nonhuman,
animate and inanimate,self and other,natureand culture.These symbolicoppositionsare sharedby all cultures, although each culture assigns them specific
meanings.
Transplanttechnology,carriedto its logical conclusion,presentsthe alarmingpossibilityof the creationof
a new human with some artificialorgans,otherorgans
fromnonhumananimals,and still othersfromotherhumans-only the cerebrumremainingfromthe original

body. If the new culturalized nature-the human


body-representsthe preeminenceofthe brain,withthe
heartas a replaceableorgan,then it reinforcesthe argument that rationality,located in the brain,ratherthan
emotionality,located in the heart,is the criticalpartof
the anatomyfordefiningthe self.If so, the new medical
technologysignals the ultimate triumphof rationality
and representsa new resolutionof the Cartesian dualism. This technological revolution will accomplish
whattheEnlightenment
stroveforwith onlypartialsuccess.
LIFE

AND

DEATH

Never beforein human historyhave there been such


drasticattemptsto alterlifeand death.Biomedicaltechnologyhas usheredin a new era in which the beginning
of life is being altered by techniques such as artificial
insemination and in-vitrofertilization.Organ transplantationfromthe brain-deadenables what Rothman
(i9i) calls "life throughdeath"-a life saved by the
deathofanother.These techniquesamountto the emergence of a historicallyunprecedentedcultural device
forcreatinglife-at its various stages-that otherwise
would not exist.
Therehave always been culturallysanctionedways of
terminatinghuman life,includingwars and otherpurposefulkillings.Abortionhas been and is widely practiced in almost everysociety.Culturalinstitutionsthat
sanctionterminatingthe lives of the elderlyare not unknown; forexample, among Eskimos the elderlysometimes staybehindwhen theirmove to anotherlocation
offersthem no alternative(Graburnand StrongI973:
Will
yourfeelings:
responsesthatmostclearlyrepresents
following
In Japan,obasuteyama (literally"the mountain
areclose I64).
will agreeiftherecipients
agreeto giveorgans,I3.2/2i.8;
relativesor friends,i2.8/7.0; will agreeonlyif the deceasedhad where old women are deserted")is a genreof folktales
in which elderlyparentsare carriedto the mountainto
will continuecareuntilthe heartstops,-/4.6;
agreed,i5.i/28.2;
willrejecttherequest,8.7/II.2; cannottelluntilone facesit, 47.0/
be leftthereto die. It is not certain,however,if these
25.7; no answer,3.2/I.5.
folktalesin fact referto an actual practice (Yanagita
C. Ifyouweretoldthatyourlifemightbe savedbytransplanting
Choose one ig5i:83-84).14 Even more prevalentis the symbolicresomeone'sorgan,would you requestthe transplant?
yourfeel- birththroughdeath which underliesnumerouscultural
ofthefollowingresponsesthatmostcloselyrepresents
will accept organs institutions,
ings: Will accept anybody'sorgan,I3.3/23.9;
includingritesofpassage (van Gennep I96I
and othersclose to me, 25.9/
onlyfromparents,siblings,friends,
[I909], Turner I967) and divine kingship(see OhnukiI2.3; will absolutelyrefuse,I9.9/ I9.3; cannottell untilthe time
Tierney199I, I993).
3.0/I.5.
comes,37.9/43.0; no answer,
The technologyof organ transplantationand its acD. Unlike the kidney,the heartand the livermust be transDo you thinkJapanshouldcontinue companyingnotion of brain death are, however,fundaplantedfromthebrain-dead.
hearttransplantation?
Yes, 63.I/73.8;
to movetowardperforming
mentally differentfrom these cultural practices. The
no,I6.4/I4.0; noanswer,
2o.5/I2.2.
new technologyenables a literal rebirththroughdeath
Yes, 72.4/
E. ShouldJapanmove towardlivertransplantation?
(see, among others,Haraway I989, I99I).
no answer,I4.6/II.9.
76.4; no, I3.0/II.7;

ofdeatharedividedamongscholF. Opinionson thedefinition


forbraindeathvaryamongmediarsandspecialists.The standards
criteDo you favorlegalizationofthebrain-death
cal institutions.
ria? Yes, 64.5; no. I8.6; other,I.I; no answer,I5.7. There was
from
considerable
regionalvariationon thislast question,ranging
to 69.o% in Chuibu(YomiuriShinbun,Decem59.9% in Kyuishui
ber II, i992) in favor.
Japaneseattitudesmayeventuallychangeto accommodatethis
justas theydidwithregardto blooddonanewmedicaltechnology
tion.Fromstubbornresistanceto blood donationJapannow has
one of the highestratesof blood donationin the world(Kimura
has made significant
inroads,
I99I: i28). Cornea transplantation
betweenI963 and i992 (KoseishoHakusho
with24,784 transplants
I993:30I).

HUMAN

AND

NONHUMAN

Organ transplantationviolates the human and nonhuman animal distinction.Transplantsurgeonshave long


experimentedwith organsfromvariousanimals,includI4. Obasuteyamais a nicknameforthemountainKamuriki-yama,
in Nagano prefecture.
The parentis seldomleftbehindbecause,
forexample,theson cannotbearthethoughtofleavinghis parent.
The legendbecameknownabroadthroughthefilmNarayamabushik6(The BalladofNarayama).

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240

1 CURRENT

ANTHROPOLOGY

Volume 35, Number 3, JuneI994

ing such "lowly" animals as pigs. For a long time they


have regularlyreplaceddiseased heartvalves with heart
valves taken frompigs (Levine, personal communication). At present,the mass media, ignorantof this history,are eagerlyawaitinganotherbreakthrough
in organ
transplantation-thetransplantation
ofthe organsofbaboons and other nonhuman primates into humans.
Theirenthusiasticwelcomingofthe new ape-mansheds
lighton the relationshipbetweenreligionand science in
the West. In the Judeo-Christian
tradition,an ape-man
would be a blasphemous transgression.In Genesis God
createdthe binarydivision of humans and nonhuman
animalsjust as he creatednightand day,land and water,
and so on. The line dividinghumans fromnonhuman
animals is thereforenot just importantbut sacred,and
its transgressionis taboo. Thus, in Westernfairytales
such as those ofAesop, no truemetamorphosisbetween
humans and nonhuman animals takes place-animals
simplydon human attire.
This traditionhas been challengedsince the Igth centurybyDarwinian evolutionism,which has been a powerfulforcenot only among the intellectual elites but
also amongthe folk.ThroughDarwinismthe evolutionaryproximityand affinity
betweenhumans and apes became a scientific"truth."The currentwelcomingattitude towardthe new literal ape-man,then,signals the
ultimatetriumphof Darwinism and scientificrationalityin generalover religionin the West.
In the cosmologiesofmanypeoples,includingtheJapanese, many deities are animals-thus, human metamorphosisinto animals is transcendental(fordetails,
see Ohnuki-TierneyI987). The notionoftransmigration
in East Asian religionsalso denies a hard-and-fast
line
between humans and nonhuman animals. Despite the
continuumwhich the Japaneseand many otherpeoples
see betweenhumans and nonhumananimals, theyneverthelessestablish a delicate demarcationline between
the two categoriesof beings. It is forthis reason, as I
have explained elsewhere (Ohnuki-TierneyI987), that
the monkey in Japaneseculture poses a threatto humans, who must ensure human superiorityover the
monkeybynot allowingit to crossthe line. Amongpeoples forwhom scientificrationalityhas not yet become
hegemonic,theircosmologies may insist on a sensitive
line betweenhumans and nonhumananimals.

ANIMATE

AND

INANIMATE

Artificialorgansand tissues or "implants"have become


so common that most Americans do not give much
thoughtto this curious combinationof the inanimate
(implants)with the animate (the human body). Ever
since the time of now-defunctJarvik7, the artificial
hearthas arguablybeen the most importanttypeof artificialorgan.The animate-inanimatehybridis now seen
as "natural" and even as representinga healthierand
thus betterhuman body without the diseased organor
tissue.

SELF AND

OTHER

For the self-identity


of individuals in all cultures,the
body holds intense emotional power. The existential
seat of personhood is the body. "I" is experienced
through"my body" in relationshipto othersand their
bodies. Organor tissue transplantationcreatesa human
body in which "my brain" coexists with "his, her, or
even its heart." The self/otherdistinction is transgressedin a most immediateand psychologicallypowerfulway. If body partsare freelyreplaceable,then "I" or
"me," which is existentiallyrepresentedin every cultureby the body,loses its identityand permanence."I"
witha partof "his/her/its"bodyis no longerthe unique
person.Given that the self is unique fromthe perspective of the person in every culture,the new potential
hybrid self offeredby Westernbiomedicine threatens
the personhoodexperiencedthroughthe body by each
individual.
In particularcases this helps explain how the giftof
self-the most inalienable giftof all-may sometimes
be rejected.Hosaka (i992:28) describesa Japaneseman
who receiveda kidneyfroma livingdonorand regained
his bodily"health" but lost his mind-he was readyto
knifehis doctorbecause, he said, "My bodyis no longer
mine." An additionalfactorinvolvedin such a rejection
is the impuritythat is almost universallyassigned to
the dead body. The transplantedorganin one's body is
not only "not mine" but also impure,the defilingbody
partof a dead person (on the notion of impurityin Japanese culture,see Ohnuki-TierneyI987).
NATURE

AND

CULTURE

In the Westerntraditionthe human body has occupied


an ambivalentposition in the symbolicdyad of nature
and culture.It representshumannessand human culture
but is also the seat of the "beast in everybody"-the
uncontrollablesexualityand animalityof humans,representing"nature." The new technology-the epitome
ofculture-has createda new vision ofpersonhoodthat
is located in the brain,therebyeliminatingthe ambivalent or dual nature of humans expressed throughthe
body. The new body, synthesizedby the new technology,is thenatural bodypurgedof "nature" and become
(I am temptedto add) "pure reason." The beast has been
eliminated,although,ironically,literalbeasts,forexample,baboon hearts,are allowed to enterthehumanbody.
The new human body representsanotherround of the
culturalconstructionof nature.

The GiftWrap: Introductionof the New


Technologyto Non-WesternPeoples
Justas biomedicine has been deliveredto the farthest
cornersof the earth,the new medical technologyis rapis correct,
idlybeing disseminated.If my interpretation
the concepts of brain death and organ transplantation

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OHNUKI-TIERNEY

Brain Death and Organ Transplantation124I

are deeply embeddedin the Westernintellectualtradi- ual. Furthermore,


the currentpolicy of not disclosing
tion,and thereforethe introductionof the new technol- the donor's identityand the enormous bureaucracyof
ogyis an introductionofthe coreprinciplesofthe domi- organand tissue procurementagencies tum organdonanant philosophical traditionof the West to peoples of tion into a transactioncompletelydevoid of social relaentirelydifferentintellectual and cultural traditions. tionships.The currentsituationis closer to charity,and
There is an additionalmoral dimensionto this process. in fact the Japanesereluctance to accept organ transThe idea of donatedorgansas "the giftof life,"the defi- plantationfromthe brain-deadhas been suggestedto
nitionoforganand tissue donationsin the United States derive fromthe weak developmentof "altruistic givsociety(Lockand Honde I990). How(Foxand SwazeyI992:39-40), is also themoralframe- ing"in Japanese
fromcharityin one sigworkwithinwhich this practiceis introducedto other ever,organdonationis different
peoples. Organ and tissue donation is the ultimate ex- nificantdimension-in charitythe objects, including
pressionof Judeo-Christian
values or, in less religious money,donatedare alienable fromthe donor.
It is theabsence ofa social relationshipbetweendonor
terms,an act of ultimatevirtueor altruism.
When the Japaneseand other peoples are presented and receiverthat leads to the commercializationof orwith the new medical technology,theiradoptionor re- gan donation.Withoutthe social contextin which real
jection of it ofteninvolves the broadercontextof sym- social agentsengagein a transaction,the organ-or any
bolic inequality. Japanese who advocate its adoption object,forthat matter-becomes a candidate forcomtherefore
put the argumentin such a way thatnot adopt- moditization.Withouta social agent,an object has no
ingthe transplanttechnologyis "backward,"suggesting meaning.No restrictionis placed upon theway in which
that Japanlags behind otherindustrializednations not its value is interpretedby the recipient.The most inonlyin advancedmedical technologybut in the morality alienable of all inalienable giftsthus easily turnsinto a
thatpreventsthem fromembracingthe "superior"mo- commodity.
ralityof the West. Japanesewho reject the technology
This is happeningin the "organmarket,"and in addioftencounterthe chargeby stressingtheirown cultural tionwe are witnessingthe rapiddevelopmentof a black
and moral superiority.'5
marketin organs,possiblyinvolvingchildren(MuntarbYet, donatedorgans-"the giftof self,"literally-are hornI993). For example,Bombayhas become the internot and cannotbe the giftofselfbecause organdonation nationalcenterforthe black marketin organs,ofwhich
lacks the most critical element of giftgiving and ex- one in ten is HIV-infected(Daar I989). Even "donors"
change:social relationship.Whetherbetweenindividu- themselvesare willingto sell organs.The coverstoryof
als or between social groups,giftexchange facilitates the JulyI990 issue of India Today, by Raj Chengappa,
interdependencyamong individuals in transaction,in is repletewith storiesof Indians' sellingtheirorgansin
contrastto commoditytransactions,which take place order,forexample,to build brickhouses. The magazine
betweenindependentindividualswithoutsocial ties. As cover featuresthe sale prices of various body parts: a
Mauss's(I966 [i925]) originalinsightindicated,
there- "live" eye for8o,ooo rupees,a kidneyfor27,ooo rupees,
turngiftis a criticalelement in turninggiftgivinginto and skin for 300 rupees per square inch. The author
gift exchange, thereby creating social relationships warnsthat "the nightmareof 'human organfarms'may
among strangers.In Japan,fine-tunedrules govem the soon become reality."A similar dehumanizationof the
flow of giftsand returngifts.Who initiates the cycle, human body is involved in the removal of organsfrom
when the returngiftshould be made, the value of the executed criminals in the People's Republic of China
gift,etc., are all prescribed.The cardinalrule is thatthe (SouthChinaMorning
Post,May ii, i99I). The use of
giftand returngiftbe exchanged in such a way that termssuch as "organfarms"and "harvestingof organs"
one remains indebted to the other,causing the social signalsan increasingimpersonalizationof the organdorelationshipto continue.The Japanesedescribethisrule nation process and decreasingresistance to commodas "We don't balance our abacus each time." itizationon the partof donorsand recipients.Thus the
figuratively
One should never repaya giftat its full value-which
giftof self is in imminentdangerof being transformed
would cancel out the debt,therebyclearingthe two of into the sale of self.
any relationship.The establishmentand maintenance
It is, then,extremelydangerousto cloak organdonaofhuman relationshipsis what distinguishesa giftfrom tion in giftwrappingnot only because it misrepresents
a commodity.
the practice but also because the moralityof this gift
In organdonation,the givingis of necessityone-way; wrappingfurtherrestrictsthe freedomof choice of the
one cannotoffera countergift
with a lesser organ.One's people to whom the technologyis introduced.To put
bodypartis invaluable,and thereis no way of repaying it anotherway, when the new medical technologyis
thegiftofit even to thefamilyofthe brain-deadindivid- introducedto othercountriesit is not a neutralitem-it
representsnot only the technical expertisebut the moralityof Westerncivilization.Because biomedicinehas
i5. I do not wish to conveythe notionthatI see "non-Western" previouslybroughtmiracles such as the eradicationof
peoplesas simplyhelplessvictimsof culturalimperialism.They
have takenan active role in the historicalprocesswherebythe epidemics and dreadeddiseases, the new technologyis
of Westerncivilizationbecame effectively
superiority
appropri- seen as yet anothermiracle epitomizingthe superiority
ated.
of Westerncivilization. Furthermore,
it is presentedas

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242

CURRENT

ANTHROPOLOGY

Volume 35, Number 3, June1994

an altruisticpractice,an expressionof Christianlovethe superiormoralityof the West.

upon other peoples as ultimate scientific"truth" and


universalmorality.That indeed would be an act of culturalimperialism.

Summary
The new hybridhuman is an apt symbolofthepostmodem world, in which intellectual identityrests on the
negationof cherishedculturalcategories.The postmodern world also insists on plurality and multiplicity,
whetherin the form of the resurrectionof Bakhtin's
(I98I [I975]) polyphonyor of the more sociological recognitionofthe diversitywithinsocial groupscreatedby
ethnicity,gender,class, etc. Indeed, the hybridhuman
embodies multiplicityofa sort.It is, however,"a literal

Comments
MICHAEL

V. ANGROSINO

DepartmentofAnthropology,Universityof South
Florida,Tampa,Fla. 33620, U.S.A. I7 XII 93

Ohnuki-Tierneyaptlyremindsus that science does not


transcendculture-it is, in fact,embeddedin theculture
an assem- thatproducesit. The currentWesterninterestin organ
i992:i83),
assemblageof parts"(Strathern
blage aftera thoroughprocess of dehumanization.The transplantationrequiresan ever more stringentdefiniorganis divorcedfromthe originalbody and placed in tion of death,and so the principleof "brain death" has
anotherby a thirdparty,none of whom have or retain been seized upon as a solution to a vexing ethical and
relationshipswith one another.This processhas, in my medical problem.The essay makes it clear that this soview, reduced earliermultiplicity-a humanitywith a lution is not one of neutralbiomedical technologybut
beastlynaturethatalso reachesout forthe transcendent, an extensionofWesternculture'sexaltationofthe brain
(the seat of "reason") as the definingcharacteristicof
be it rationality,love, or deities.
Anthropologicalreaders need not be remindedthat personhood.
but embeddedin its cultural
science is not culture-free
I agree with these general principlesbut think it is
tradition.BeforeKuhn (i962) articulatedthat science worthnotingthat biomedical opinion (let alone "Westand its paradigmsare constructsof cultureat a particu- ern culture" in general)is farfroma monolithon this
lar historicalperiod,Marx (Marx and Engels n.d.:I56- issue. As a medical anthropologistI would argue fora
57; see also i 965:53I) observedthatDarwin saw a repre- more dynamicview of the situationin which the critesentationof English society in the behavior of beasts rionofbraindeath has attainedits ascendancy.The traand plants,that is, nature. Darwin's science, therefore, ditionalcriterionfora declarationof death emphasized
embodied culture (English society).In Sahlins's (I976:
the cessation of circulatoryand respiratoryfunction.
io6) view, sociobiologyrepresentsa "scientifictotem- The emergenceof organ transplantationresearch and
ism." The new medical technology,then,continuesthis technology,however, seemed to require greaterprecitraditionin expressingWesternmodes ofthought.It also sion, and in I:968 an ad hoc committeeof the Harvard
continues another importantWestern tradition-the Medical School produced a report defining "brain
controland conquest ofnature,thatis, "nature"embod- death." The committee borrowedthe concept froma
ied in the body.
Frenchstudy(Mollaretand Goulon I959), thefirstscienContemplatingthe penetrationof Westernizationin tificdiscussion of "irreversiblecoma," but substituted
generaland Westernmedicinein particular,Auge (i985:
the term "brain death." The Harvard Criteria,as they
ii) identifiesthe strengthof traditionalmedicine: "alcame to be known, were offeredwithout supporting
the so-calledMinnethoughwesternizationmay make these methods lose clinical data,but shortlythereafter
theirphilosophical and psychologicallogic, theynone- sota Criteria(Mohandas and Shelley I971), based on a
theless clearlyretainsomethingof theirultimatelogic; studyof25 patients,were published.By I978 therewere
theycontinueto respondto a desireforthe individual's morethan 30 nonidenticalsets ofcriteria,none ofthem
existentialautonomyin relationto which the bodymay binding(Black I978); a patientcould have been declared
seem paradoxicallyto be alternatelyan obstacle and a dead by one set but not by another(Byrne,Evers, and
stake." The foci of any medical systemare human lives Nilges I993). In an attemptto clear up the confusion,
and theirbodies-central to theexistentialand ontologi- the President's Commission for the Study of Ethical
cal concernsofanypeople,bothcollectivelyand individ- Problems in Medicine and Biomedical and Behavioral
ually. These concerns are not abstractbut immediate, Researchin I:98I promulgatedthe UniformDeclaration
with strongaffectivepower. For any medical systemto of Death Act (UDDA), which was recommendedfor
cease to address these issues is a serious transgression adoption in all jurisdictionsof the United States. The
ofhumanity.Perhapsit is time forWesternmedical sci- UDDA specifiesthat all functionsof the entirebrain
ence to slow down in its quest forthe ultimatetriumph must have ceased beforethe declarationof braindeath;
of rationalityand the conquest of nature embodied in it is neithersufficientnor satisfactory
to hold thatsuch
the body,lest the apotheosis of rationalityboomerang cessationis "imminent."
and bringback the "beast" in us all. At the veryleast,
Leavingaside thepurelypracticalquestionofwhether
the modes of thoughtembeddedin the new transplant the averagehospitalhas the facilitiesto testall thefunctechnology,which is so Western,should not be forced tions ofthe entirebrain,even ifthe attendingphysician

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OHNUKI-TIERNEY

Brain Death and Organ Transplantation1243

has the time to do so, there is still the problem of


whetherall the integrativeand reflexfunctionsof the
brainstemare actually lost in brain death as it is ordinarilydiagnosed.In a comprehensivereviewofthe literature,Byrneand Nilges conclude that there is all too
oftena confusionofprognosis(predictionof death)with
diagnosis (deathper se) (I993:I6).
For example,they
point out that there is a general assumption that a
"dead" brain means that the heartwill stop beatingin
a relativelyshorttime; the conventionalwisdom has it
that the heartcan beat forno more than nine days followingbraindeath (Pallis I983), but thereare certainly
cases in which theheartcontinuesto functionfarlonger
than that-in at least one documentedcase up to nine
weeks (Field I988).
In theory,it is possible fortests forbrain and brainstem activityto show no functioningeven in the absence of anatomic destruction.The integratingfunctions of the brainstem(includingcontrolof breathing,
blood pressure,heartrate,and temperature)may, however,remainintacteven in coma patientswithflatEEGs
(Ogata I988). Nevertheless,a surveyof neurosurgeons
and neurologistsconducted a decade ago revealed that
as manyas 2o% commonlyomittedone or more of the
crucialtests (Black and Zervas I984). Only 35% ofphysicians and nurses involved in organprocurementcorrectlyidentifiedthe legal and medical criteriafor determiningdeath, and only I9% had a concept of death
thatwas logicallyconsistentwith the whole-brainstandard (YoungnerI989). There seems to be a predisposition to view presentfunctioningas a more salient featurethan the potentialcapacity forfunctioning.
Despite apparentlyauthoritativestatements,themedical communitydoes not have a single,clearlydefined,
and universallyapplied standardfordefiningand diagnosingbraindeath.That diagnosisis, indeed,a resultof
negotiationamongvariousinterestedpartiesin contextspecificinteractions-the recipientof an organand his/
herfamily,transplantsurgeonsin need of organs,thirdpartypayers unwilling to pay forprolonged,intensive
careofa "dead brainin a live body" (Smithi987:27)-in
which the status of the "donor" as a potentiallyliving
entityworks against the interests of all the others.
Thereforethe decision to declare brain death is a social
act that occurs in various ways dependingon shifting
circumstances;it is not purely an exercise of neutral
biomedicaltechnology.

fiedmany of these in the Westerntraditionby examining the writingsof formerscientistsand the responses
of their contemporaries.It would be a very valuable
studyin medical anthropologyto examine the writings
ofJapanesescientistsor theirresponsesto culturallyforeign concepts.That does not happen here.
I agreewith Ohnuki-TierneythatJapaneseshould not
adopt Westernbrain-deathcriteriaat this time but for
different
reasons. I have long held that America should
not impose its medicine or its world view on the Japanese. This has rarelyhappened.In the fieldofmedicine,
at least, it is the Japanesethemselveswho have adopted
Westernmedical technologywholesale. The Japanese
themselvesdiscardedtheirtraditionsof herbal and energymedicine,ofbathsand massage,ofacupunctureand
spiritualcounseling. Even today, such traditionshave
less medical recognitionin Japanthan in California.I
have never encounteredevidence that "the modes of
thoughtembedded in the new transplanttechnology"
have been "forcedupon other peoples as an ultimate
scientific 'truth."' I oppose cultural imperialism as
stronglyas Ohnuki-Tierney.I too mournthe loss oftraditionalvalues in Japan.But the West,whoeverthatis,
is not as much to blame as is the desireof the Japanese
themselves.
It is hightime that the old cliche "Japaneseemotion,
Westernrationality"be relegatedto the historyof prewar political slogans whence it originated.Japanese
thinkershave respectedand exhibitedthe highestrationality,as seen in writingsrangingfromKukai and Dogen to Ekken and Baien, fromTominaga Nakamoto and
Minagawa Kien to Ohmae Ken'ichi and Morita Akio.
This article,however,mixes metaphor(the "beast" of
sexuality)and symbol("symbolicrebirth")withmedical
fact,confusingemotional polemic ("lowly" pigs) with
the kind of rationalityexpected in Japaneseas well as
Westernacademia. I can only praythat the authorwill
herselfbe charitableand rationalin acceptingmy commentsnot as an emotional attack on her basic position,
with which I tend to concur,but as a calmly reasoned
responseto the logic and languageof her presentation.
The purpose of Ohnuki-Tierney'sarticle is thinly
veiled in her abstract.It is to attack the institutionof
transplants.She concludes that "anthropologicalstudy
informsus thatdonatedorganscan neverbe gifts."This
is surely a misunderstanding.In fact, anthropological
theorytakes no stand on medical issues. It informsus
that cultures can use anythingthey please as gifts:
mountains, symbols, daughters,heads, blood, organs,
anything.What informsus that "donated organs can
CARL BECKER
neverbe gifts"is the author'sindeliblyJapaneseconvicDepartmentof Human Sciences, Kyoto University,
tion.This articleinformsus more about thatconviction
Yoshida Nihon Matsu-cho,Sakyoku,Kyoto,Japan
and the episodes and correspondencewhich informit
6o6oI. 22 XI 93
thanabout culturalbases ofmedicine or JapanesemediI wantto thankOhnuki-Tierneyforherprovocativearti- cal ethics.
Ohnuki-Tierneyrepeatedlyanalyzes the "Western"
cle. Millions of Japaneseare wrestlingtoday with the
issues she discusses,and bioethicsin Japanis myprofes- position as (Wi) rationality is the criterion of humanhood/personhood;
(W2) rationalityis located in the
sional scholarlyconcernas well.
Of course medical technologyhas culturalbases and brain; (W3) if the brain is dead, the person cannot be
baggage.Scholarslike Durkheim and Kuhn have identi- rational;(W4) ifpersonscannot be rational,theyare not

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244

CURRENT

ANTHROPOLOGY

Volume 35, Number 3, June1994

humanbut dead; (W5) therefore


the brainis the criterion
ofpersonaldeath; (W6) when personsare dead, theirorgans may be harvested.In contrastto this straw man,
she seems to feel that (0i) soul (emotion?)is the criterionofhumanhood/personhood;
(02) soul (emotion?)is
located in the stomach/gut(Japanesehara); (03) even
witha dead brain,a personcan be ensouled (emotional?);
(04) even ifpersonsare not rational,theymay be living
humans; (05) thereforethe brain should not be a criterion(butthe stomach?);(06) organsshould neverbe harvested (until stomach death?).
Againstthis curiouspositionI should proposethe following, which is held by many Japanese as well as
"Westerners":(Bi) Detectable consciousness,not rationality,is the criterion;(B2) consciousness is identified
with the head; (B3) if the brainis dead, consciousnessis
elsewhere;(B4) deathis the state ofconsciousnessbeing
elsewhere;(Bs) braindeathmay failto detectpossibility
of consciousness; (B6) organ harvestingmay lead to
abuse ofbraindeathin Japan.I would hope thatOhnukiTierneywould agreewith me on this analysis.Ifnot,at
least this formulationshould enable a clarificationof
our positions and reasoning.There is no time or space
herefora fulldiscussion of these issues (but see Becker
I993, I994); I shall simply adduce a few pieces of evidence to supportthe points just made.
In the West, the criterionof personal existence is
clearlyconsciousness,not rationality.Referencesare legion,but one locus classicus is surelyDescartes's Meditations.In his searchforcertainty,
Descartes admitsthat
he may be deluded or mistaken in his doubt. That he
cannotdoubthis consciousnessofdoubtingis his reason
foraffirming
his certainknowledgeof the existence of
a thinkingconsciousness. Throughouthis Meditations,
Descartes recognizesconvictionto be ultimatelyimportant; he uses rationalityonly to identifythe level of
probabilityof each conviction. Sociologists of knowledge hold similarpremises.The fact that rationalityis
not the criterionforpersonhoodis obvious in the Western treatmentof infants,the comatose, and the insane.
In Japanas well, consciousnesshas been the dividing
line betweenlife and death. In traditionalShintoproceduresto detectwhethera personis dead or not,all sorts
ofsensoryappeals are made: incense is lit,his/hername
is called, food is cooked. Buddhists too treated consciousness as a primarycriterionforpersonhood.The
if there is one, between the Cartesian and
difference,
Japanesepositions is that in Japanthereis a generalreluctance to believe that the consciousness of the departed has finallydeparted.This too is evidenced in
countlesspracticesdesignedeitherto call the soul back
to the dyingbody or to communicatewith the souls of
the deceased long afterthey are cremated.Oversimplified,theJapaneseand theWesterneragreethatthepossibilityof communicatingwith the consciousness of the
patient is a critical factor.They disagree about when
this is no longerpossible: the Westernertendsto think
it impossiblewhen the patient'sbrainis irreversibly
isoelectric;theJapanesetendsto thinkit possible formany
days thereafter.
In Japan,bodies are treatednot on the basis of their

potentialforconsciousness or interactionalone but on


the basis ofwhat is "owed" to them,as Ohnuki-Tierney
well recognizes.The reason Japaneserespectvegetative
grandparents
is not thattheirgrandparents
are conscious
(althoughthis too is oftenbelieved) but that we "owe"
themrespectforall the care theyhave taken forus.
All the evidenceon death ritualand religiouspractice
in Japanindicates that the head, not the stomach, is
respectedas the seat of consciousness. The veryword
for"soul," tama, mitama, or tamashi,is etymologically
fromthe same rootas the wordfor"head," atama. Japanese took the heads, not the stomachs,of theirenemies
in battle.The cuttingofthe stomach(seppuku)bysamurai was not to let the soul freebut to show the observers
thatone's blood and gutswere red ("honest") or,in Japanese metaphor,that one was not a "backstabber"but
could die straightforwardly.
It was recognized that it
wouldnot kill the cutterbut showed thathe could tolerate greatpain while alive, beforethe soul leftthe head,
sometimesmercifullyfacilitatedby a head-cuttingassistant (kaishakunin).
Countless Japanesepaintings of people dying show
theirsouls being escortedfromthe head to heaven or
the Pure Land ofAmida. In deathbedsituations,theface
is oftenslapped or pillows kicked out fromunder the
head, givinga shock to the head. The head is the first
partofthe bodyto be washed and the last to be covered.
Funerarysketchesor photos are ofthe head, and a piece
ofthehead (skull or tooth)is oftenpreservedas a memorial. Japaneseghosts are oftenbodiless heads; the most
are sometimesfaceless (nameless) heads. Anterrifying
thropologicalstudies of Japanesepractices surrounding
deathdemonstratethatthe head and not the stomachis
the vehicle throughwhich consciousness is communicated and respected.I am well aware ofthe literatureon
Japaneselinguisticmetaphorsabout the stomach(hara).
I would be deeplygratefulifOhnuki-Tierneycould point
to any anthropologicalresearchon Japanesedeath and
dyingshowing that the stomach was ever taken as a
criterionof life or death.
Ohnuki-Tierneyascribes the Western use of brain
death as a criterionof personal life to the centralityof
"rationality."I would agreethat manyhumans are irrational, awake as well as asleep or permanentlycomatose. But the reluctance to admit the decease of one's
dearones is not new to artificialrespiration(brain-death)
situations.For centuries Japanesehave acted as if the
deceased were still presentin the room even afterpronouncingthe patientdead by cardiac criteria.Rituals of
mourningtended to be as long as one's resourcesand
statuspermitted.
The visceral reluctanceto deface the body of the deceased is due not to the notion thatemotionor the soul
may still reside in the stomach of the corpsebut rather
to the idea that the now out-of-body
soul will be upset
ifits old bodyis disrespected.That thesoul is considered
to be out-of-body
is shown by numerous funeralpractices such as calling the soul fromthe rooftopor the
gardenwell; in some districtsI have even foundpractices designedto trapthe soul in a garmentat the ceiling
and bringit back to the body. The literatureon the re-

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OHNUKI-TIERNEY

Brain Death and Organ Transplantation1245

organ transplantationmay lead to a confusionof the


meanings of personhood,identity,and humanity.She
analyses the ethics of introducing"Western" medical
technologyto othercultures,especiallyoftransplantsin
the guise of "gifts,"with theirattendantmoral framework which may be alien to cultures not broughtup
on Enlightenmentvalues. She is concerned about the
elevation of rationalismto the point where it has replaced otherfundamentalvalues in the West. She sees
clear problemsin the future-includingan unwelcome
redefinitionof life and death if the loss of the capacity
forrational thoughtcomes to be equated with death.
There is much to agreewith and to commentupon, but
space limitationsrestrictme here to dealing in some
detailwith only one area: the question ofbraindeath as
the death of a person. I believe there is here an unintendeddefectin her otherwisebrilliantarticle.
The perspectiveof informedphysicians,which for
brevityI must adopt here,is thatphysiologicaldeath is
and always has been brainstemdeath. This perspective
does not denythe social and culturalmeaningsofdeath;
on the contrary,it respects perspectiveson death in
many cultural and religious traditionsthat are consistentwithit (PallisI990; LambI990:24-42). The mediloss
callyaccepteddefinitionofdeathis "the irreversible
of the capacityforconsciousness togetherwith the irreversibleloss of the capacityforbreathing."The former
is as close as physicianscan get to the concept of the
"conscious soul," while the lattercertainlyequates with
the "breathof life." The loss of these two attributeshas
been widely accepted as the loss of life in many traditions, past and present,and neitherconsciousness nor
breathingis possible when the brainstemis dead.
It is an errorto talk of two different
types(neurological and cardiac) of death; thereis only one. Those who
have sustained brainstemdeath throughhead injuries,
prolongedanoxia, or major intracranialbleeds are dead
and if they were not maintained on ventilation machines would be seen to be dead by the "traditional"
criteriaofno breathand no heartbeat.The reasonis simple: the brainstem is the site of the "vital" centres
which controlbreathing,amongstotherlife-sustaining
physiologicalfunctions.Without the brainstemthere
be no breathing.The brainstemis also the
can therefore
site of the ascendingreticularactivatingsystem,without which therecan be no consciousness.The ventilator
does not restoreconsciousness, but it does effectively
keep the blood oxygenated,and this in turnenables the
heartto continueto beat. The patient,in fact,has died.
But in the intensivecare unit death needs to be established to avoid the indignityof ventilatingcorpses "to
A. S. DAAR
asystole,"a senseless act producinganxietyin relatives
Departmentof Surgery,College ofMedicine, Sultan
and unnecessaryexpenditureofscarce resourcesthatare
Qaboos University,Muscat, Sultanate of Oman.
needed to save the lives of other seriouslyinjuredpa27 XII 93
tients.Death is diagnosedin this settingby demonstratI foundthis articletimely,provocative,and disturbing. ing absence of brainstemreflexesand of the abilityto
The authoraccepts that she paints with a broad brush, breathe.'
but in my view her contributionoughtto be takenvery
seriously indeed, especially by medical practitioners. i. Testingby at least two expertsafteran appropriate
intervalis
She examines the conceptual underpinningsof modern performed
only (a) afterascertainingthe cause of the coma and
medical technologyand looks at how brain death and establishingthatthe patientis suffering
fromirreversible
strucvenge of angeredsouls is widespread throughoutNoh
dramaand probablydates back to the heavy lids laid on
kofun-periodcoffinsto preventthe soul of the warrior
fromfrequentingthe land of the living. This explains
the Japanese reluctance to transplant even corneas,
which could be done hours afterbodily death.
The Japaneserejectionof braindeath is not grounded
in any desire to keep humans artificiallyalive forever
on respirators.
It is groundedin theveryemotionswhich
Ohnuki-Tierneydisplays.There is always the hope that
the consciousnesswill returnto the head, the eyes will
focus,the personwill become himselfor herselfagain.
The desireto honor the personand the fearof angering
the person's hoveringsoul are the reasons forpopular
rejectionof brain death. This is seen in many publicationsfrompopularBuddhistmovementsand frompopular new religionssuch as Kofukuno Kagaku and Sukyo
Mahikari. Conversely,there has never been a serious
suggestionthat the stomach be treatedas the criterion
ofpersonalensouledness.
The more serious Japanesereason forrejectingbrain
death as a criterionfordeath is that the marketfororgans may provoke abuses of the systemby physicians.
Surveyshave shown that doctorsthemselveshave very
littletrustin theirown ethics.In Japan,second opinions
are rare,and suing a doctoror whistle-blowingby a doctor's inferiorsis unthinkable, as the Wada incident
shows. Since doctors will make their reputationsand
fortunesby transplantoperations,since theycould reason that they were doing it "for the good of the patients," and since they have virtuallyno fear of ever
beingdetectedor challengedformisdiagnosis,the incentive to pronounce dead someone very close to brain
death is almost irresistible.This is preciselythe situationin Japan,as Japanesedoctorsand patientsall know.
There are serious economic, educational, and cultural
barriersto Japan's adopting a Western-styleadversarial doctor-lawyerrelationshipin which lawsuits and
are commonplace.Yet withoutsuch inwhistle-blowing
stitutions,leaving the determinationof brain death to
professionalinterpretationof EEGs is tantamountto
sentencingorgan donors to a clandestinelypremature
fate.This is the one verygood reasonthatJapanesereject
brain-deathcriterianow.
I am gratefulto Ohnuki-Tiemeyforopeningthe floor
to a veryinterestingdiscussion and hope that both our
cultural sensitivitieswill be refinedby this exchange
and the scholarshipit may occasion.

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246

1 CURRENT

ANTHROPOLOGY

Volume 35, Number 3, JuneI994

There are indeed two different


types of brain death:
death of the cerebral hemispheresalone, resultingin
the "persistent vegetative state" (PVS), and either
whole-braindeath (cerebralhemispheresplus the brainstem) or brainstemdeath. The crucial difference
is that
physiciansdo not consider death of the cerebralhemispheresalone death of theperson; a personin a PVS is
alive, does not need to be on a ventilator,and provided
he or she is fed and hydratedwill live formany years.
Such personsare not consideredbyphysiciansto be suitable organ donors (see Daar I99I, Ottawa Resolutions
I99I)

and arenotused as organdonors.

Ohnuki-Tierneydoes make this distinctionbetween


types of brain death, but she inadvertentlyleaves the
impressionthatphysiciansconsiderthe death of the cerebralhemispheresalone as constitutingthe death of
the person. While there are ethicistswho have argued
that PVS patients can be considereddead (see Veatch
and may be consideredsuitable "cadaveric" doI99I)
nors,this is a view not sharedby physicians.
It is unfortunatethat the subject of brain death is so
oftendiscussed in the contextof organdonation,foralthoughit has helped transplantationand its studyhas
been stimulatedby organshortage,the issue was importantbeforeits applicationto transplantation-especially
in its role in managingseverelyinjuredpatientsin intensivecare units. Ohnuki-Tierneyis correctin saying
that a fundamentalchange would occur if death were
equated with loss of the capacityforrationalthought.It
would indeedredefinelifeifwe diagnosedthe demented,
those with Alzheimer's disease, and even those in the
PVS as being dead. In the lattercase the argumenthas
been whetherto allow these poor people to die-this is
not the same as sayingthey are dead. Even those decisions have had to be made by the courts,representing
society,and not by physicians.
Ohnuki-Tierneyposits that the bodyis importantfor
personhood.Indeed it is, but this begs the question: the
whole body? While there are traditionsthat devalue
cripplesor considerthe blindas dead, are we to consider
amputees also dead? If not, then where does essential
personhoodreside?It cannot be the (anatomical)heart,
foreven in culturesthat considerit the seat of life,it is
oftenattributedqualities rightlybelongingto the brain.2
If death is a loss, physiologicallyit is at minimum the
loss of brainstemfunction.Indeed, death may result
when the heartstops but only ifit stopslong enoughfor
vital centresin the brainstemto die, and the brainstem
is irreplaceablein a way that the cardiac pump is not.
Ohnuki-Tierney'sposition may appear different,but
this is more apparentthan real, providedwe stop at the

brainstem.Cogito ergosum is indeed true: it is perhaps


statementsevermade.
one of the most incontrovertible
Positively it defines the "examined" life; negatively,
however,it does not definedeath.I thinkthe distinction
mustbe at the rootofwhat Ohnuki-Tierneyhas so carefullytriedto show us.
I wholeheartedlyagree with Ohnuki-Tierney'swarningregarding
the dangersofthe "giftwrap" and its moral
underpinnings.
She providesus with an essentialinsight
into the distinctionbetweengiftsand commodities,and
her arguments,particularlyrelevantto transplantation
ethics (Daar i992), are surelyapplicable to many other
aspects of human interaction.She rightly,in my opinion, decries the fallacy and dangersof perpetualrapid
scientificdevelopment.It is a measure of how rapidly
biomedicaltechnologyis movingthather articleis even
morerelevantand disturbingnow than when she wrote
it: in the age of embryocloning,what will we mean
when we talk of the permanenceand uniqueness of a
person'sidentity?
Medicine cannotbe practisedwithoutreferenceto social and culturalvalues, even in this "post-modern"era.
It must never be practisedwithout humility.OhnukiTierney'sarticleoughtto stopus in our tracksand make
us examine the foundationsof our practice.We should
welcome dialogue between physiciansand anthropologists.
TAKEO

FUNABIKI

Departmentof Cultural Anthropology,Universityof


Tokyo,3-8-I, Komaba, Meguroku,Tokyo,Japan.
7 XII 93

Ohnuki-Tierney'spaper is anothergood example of her


to combine the defenceof anthropolcourageousefforts
ogy as a general science of man with unexpectedbut
acute insightinto Japaneseculture.However,in reading
anthropologicalpapers on the society and cultureinto
whichI was bornand in which I stilllive,I alwaysworry
that I may abuse my privilegedposition as a "native
informant,"thus endangeringmy professionalauthento the "intactness of the
ticity.Therefore,in referring
body" I have to refrainfromsaying,"I know thatmany
women have piercedears in Japan,while otherswho do
not have piercedears are just afraidofphysicalpain" or
"Compared with the United States,not only pacemakers and artificialanuses but most otherkindsofmedical
equipmentare less developed in Japan,and Frenchand
Britishcompaniesmay not be able to competewithU.S.
in this fieldeither."Instead,I must rely
manufacturers
on a brieffield tripto two ordinarydepartmentstores

in Tokyo,whereI foundthat30-40%

turalbraindamageand (b) establishing


thatreversible
causessuch
as toxins,drugs,metabolicderangements,
and shock have been
excluded.Supplementaltestsare also used by some units.
2. For example,in the Osirianmythit was ib, the heartin its
metaphysicalsense, embodyingthought,intelligence,memory,
wisdom,bravery,
sadness,and love,thatwas weighedagainstthe
featherofMa'at. The anatomicalheartwas something
else,and it
had a different
name:haty.

of the earrings

sold thereare forpiercedears. Even thoughpeople with


piercedears may buy more earringsthan those without,
we have to considerthat people with pierced ears also
wear earringsmade forpeople without and that heavy
earringsare usually made fornonpiercedears. Thus we
may be unable to say that ear piercingis uncommonin
Japan.I could carryout the same kind of enquiryin

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OHNUKI-TIERNEY

regardto pacemakers. However, I agree with OhnukiTierney'soverall pictureof Japaneseconcernabout the


"intactness of the body," and thereforeI wonder
whethermy puzzlement concerningsome of her examples (otherswould include "cuttingopen theirstomachs
to release theirsouls" and "threecategories[ofmovies]
accordingto the numberof handkerchiefs")is the overreactionofa native to culturalsacrilegeor the tenacious
desireofan anthropologist
fordetailedevidence.(Claiming to be a "native anthropologist"is second only to
claimingto be a "participantobserver"as a strategyin
anthropologicalhistory.)
On organdonationI findOhnuki-Tierney'sarguments
verysound but perhaps too gloomy about the current
and futuresituation.I thinkshe should have paid more
attentionto Levi-Straussthanto Mauss. Ifpeople always
gave up theirorgansto otherson theirdeaths and took
others' organswhen they needed them, it would be a
successfulformof generalisedexchange-one that has
alreadybegunto take shape. Of course,people may have
But my obserto overcometheirfeelingsofincongruity.
vationofrecentphenomenain thispost-modernage has
taughtme that humans are, thoughverygradually,becoming accustomed to the idea that they themselves
maybelongto a blurredcategory,"human-like"and possiblyincludingapes and monsters.
MARC

I. LORBER

Section of Organ Transplantationand Immunology,


Departmentof Surgery,Yale UniversitySchool of
Medicine, 333 Cedar St., FMB II2, New Haven, Conn.
o65Io, U.S.A. 3 I 94
Ohnuki-Tierneychallenges the application of organ
transplantationas a series of cultural transgressions
leadingto the creationof a "hybridhuman." Her objections focus on threemajor issues: the biological definition of death as cessation of brain function,the transplantationprocessas a violationofthe intactindividual,
to donatedorgansas "gifts,"
and thepracticeofreferring
an anthropologicallyerroneous concept. As she acknowledges,the issues raised are complex,and even in
is widelypracticed
cultureswhereorgantransplantation
consensus has not been achieved. AlthoughI make no
argumentbased upon anthropologicaltheory,perhaps
consideringthe recentexperiencehistoricallywill allow
various issues to be viewed from an alternativeperspective.
Clinical organtransplantationhas blossomed during
the late 2oth century,but the concepthas rootsin early
civilizations,Western and non-Western(Kahan I99I).
AncientHindu writingsinclude the legend of Ganesha,
upon whom the god Shiva graftedan elephant head to
impartwisdom. Egyptianand Greco-Romanmythology
are repletewith creaturespart-manand part-animal"hybrid"humans. Referenceto organ exchange is also
foundin ancient Chinese medical legend. For example,
the physicianPien Ch'iao was said to have exchanged
the heartsof Ch'i Ying and Kung He to restorebalance

Brain Death and Organ Transplantation1247

to theirenergies.Perhaps most famous in the West is


the legend of Saints Cosmas and Damian, whereinthe
diseased leg of Deacon Justinianwas replacedwith one
froma recentlydeceased Moorish peasant.
During the last quarter of the igth centurytransplantationlegendyielded to scientificexperimentation.
Advancesin surgicaltechniquepermittedtransplantoperationspreviouslyconsideredimpossible,and the discoveryof transplantrejectiongave birthto the field of
cellular immunology(Moore I964). Experimentalstudies continuedthroughoutthe early 2oth century,with
major emphasis in the West afterWorld War LI. Clinical feasibilitywas demonstratedduringthe I950S and
I960s, and the I98os realized widespreadsuccess as advancing biotechnologytransformedcenturies-oldhuman fantasyinto living reality.Collectively,the transplant experience should be considered not uniquely
Westernbut a logical extensionof a more universalhuman quest.
The issue of brain death also reflectsthe result of a
series of complex events. A more biologicallyaccurate
definitionofdeathbecame essentialto appropriatedeliveryof modernmedical technology;transplantationrepresentsonlyone example.The abilityto maintainphysiology using technologies such as artificialrespirators,
intravenousnutrition,and blood-pressure-maintaining
medications has presented medical practitionersand
theirpatientswith daily situations in which the existence oflife(orlack thereof)must be consideredoutside
of the traditionalcontext.The evolution of diagnostic
criteriaforbrain death grew as much fromthe care of
seriouslyill individuals as from the organ transplant
experience.When an individual recoversfromcritical
illness, life has been constructivelyprolonged.Alternatively,when recoverydoes not occur, it becomes
necessaryto defineend points of care. Although such
decisions must be consideredwithin a greatercultural
context,it seems difficultto envision a strategythat
medical care delivery
accepts "high-tech"-biology-based
while clingingto traditionalconcepts of death and dying. However, it is importantto acknowledgethat human thoughtsand emotions are not always based in
logic, and thereinlies the complex challenge of these
evolvingdefinitions.This discussion also highlightsa
relatively common result of rapid technological advances; analysisofthe culturaland societal implications
must follow implementation.
Ohnuki-Tierneyemphasizes a series of societal and
cultural conflictsfromthe perspectiveof "non-Western" societies, but it seems importantto stress that
similar ambivalence exists in the West. Paradoxically,
became increasinglysuccessfulin the
as transplantation
United States duringthe I98os, the anticipatedincrease
in organdonationwas not observed(U.S. ScientificRegalbeit
istryI993). A postulatethatpeople are struggling,
at times subliminally,with basic cultural concepts of
selfand humanityseems highlyplausible. Those working within the Western medical model (regardlessof
physicalresidence)focused on what appeared obvious;
organtransplantationhas become an effectivetherapy.

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248

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Volume 35, Number 3, fune I994

Strategiesfor technologytransferwere developed, but


broadercultural implicationswere not addressed.The
reluctanceof people within Westernand non-Western
culturesto embrace concepts such as brain death provides a compellingargumentforthe importanceof the
culturalimplicationsof the transplantationprocess.
Initially,as advocates for our sufferingpatients we
seem to have unwittinglyfalleninto an importantcultural struggle.Although it seems straightforward
that
the culturalconcept of death is complex,a more accuratebiologicaldefinitionneed not precludeaccommodation ofhuman needs and emotions.People could choose
to forgotechnologicaladvances such as transplantation,
butit seems unlikelythattheywill do so. Culturaladaptation thereforeseems inevitable as conflictsbetween
traditionalconcepts of death and dyingand an evolving
biologicallybased model are resolved.

Reply
EMIKO

OHNUKI-TIERNEY

Madison, Wis., U.S.A. 25

94

The commentsof Angrosinoand Daar are most helpful


in clarifying
the definitionsand debates that are taking
place among medical professionalsin regardto brain
death. My medical knowledge is limited, to say the
least. In fact,my distinctionof the two types of brain
death was revised afterRobertLevine of Yale Medical
School had delineatedthemforme. Angrosino'sdetailed
discussion elaborates much betterthan I did my argumentthatbraindeathis a culturalconstructwith social
agents(forexample,those who have developedthe various criteria)activelyinvolvedin the process.As he succinctlyputs it, "the decision to declare braindeath is a
social act that occurs in various ways dependingon
shiftingcircumstances;it is not purely an exercise of
neutralbiomedicaltechnology."He cites studiesrevealing that 2o% of neurosurgeonsand neurologists"commonlyomittedone or more of the crucial tests" fordeterminingthe nonfunctioningof brain and that "only
35% ofphysiciansand nursesinvolvedin organprocurement correctlyidentifiedthe legal and medical criteria
fordeterminingdeath." These are the real anxieties of
people in the United States and Japanwho are hesitant
to sanctionthe transplantation
oforgansfromthe braindead wholeheartedlybecause of the absence of ioo%
proofof the determinationof the permanentnonfunctioningof the brain.
Daar, a transplantsurgeon with enormous cultural
sensitivity,expressesan anthropologicalconcernabout
of the body and
the universalityvs. culture-specificity
dying.However,I findhim wearinghis professionalhat
of a biomedical doctorwhen he sees the universalimportanceof the brainstemand its functionsand Cogito
ergosum as the universaltruth-preciselythe opposite
of my position. Even the biomedical definitionof the

brainstemas an anatomical partis arguablynot universal, not to mention its functionsas recognizedin biomedicine. In both his concernwith the dementedand
his discussion of the persistentvegetative state, an
acutely disturbingissue in the United States, I detect
Cogito ergosum as the definingfeatureof personhood.
Lorber,anothertransplantsurgeon,introducesa fascinatinghistoryfromvarious partsof the world of actual
and conceptualantecedentsfororgantransplants.A systematic study of the distinctionbetween literal and
symbolicobjects or acts would be an importantcontribution to anthropology-forexample, considerationof
a literal giftof self,that is, one's organ,vs. a symbolic

giftofself-Mauss's (I966

[I9.25])

thesis.Soimportant

have foundboththe imcalled symbolicanthropologists


portanceof classificatorysystemsand an equally strong
emphasis on their absence in almost all cultures,
therebybecoming intrigued by anomaly, liminality,
chaos,etc.,whose symbolicexpressionshave been found
in various hybridizationsand othertypesof anomalous
The
beings and objects (Ohnuki-Tierneyi98i:ii9-28).
relationshipbetweenthese symbolichybridizationsand
the literal ones now being produced by organ transplantationshould offerfascinatinginsightsinto our conceptual operation.
I hope I indicatedmy awarenessofintraculturalvariations within Western societies, but the comments of
Lorberand othersmake me aware that my strategyfor
emphasizingmy point-examining the culturalunderpinningsof the technologyand the ethical problemsinI
volved in its delivery-has invitedmisunderstanding.
had no intentionof pittingthe West against Japanor,
forthatmatter,the rest of the world.I am aware, and I
thoughtI said so, of the enormousrangeof attitudetowardthistechnologyin any societyand therapidchange
in these attitudes.Moreover,I am too ignorantin the
medical fieldeitherto advocate or to oppose this technology. Encouraged to do so by transplantsurgeons
genuinelyeager to understandthe cultural sides of the
argument,I wrotethis articlestressingthe culturalarguments-playing, as it were, a devil's advocate's role. I
cannot agree more with Lorber when he eloquently
points to the dilemma we face-the need for"cultural
adaptation"to hightechnologyand the need foraccommodationby medical specialists of human and cultural
aside, it is medineeds and emotions. Some differences
cal doctorssuch as Levine, Lorber,Daar, and William
Marks (another transplantsurgeon who attended the
conferenceand is now at the Swedish Medical Center
in Seattle) and not we anthropologistswho can make
significantchanges in the developmentand deliveryof
thenew medical technologyforthe benefitofhumanity
ratherthan forits exploitation.
Funabiki,an Oceania specialist, suggestsgeneralized
reciprocityas an alternativemodel forexplainingorgan
donation.I did not mentionit because it does not apply
to the transactionof organs. Generalized reciprocity
(Levi-StraussI969) is characterizedby both reciprocity
and personal/socialrelationshipbetweenthe donorand
the recipient.In generalizedreciprocity,"the expecta-

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OHNUKI-TIERNEY

Brain Death and Organ Transplantation1249

tion of a directmaterial returnis unseemly" (Sahlins

accompanies "the giftof life." As Bourdieuhas repeat-

example, respect,as is the case with the Ainu, whose


political leaders shared their food and wealth in exchange forrespect and support(Ohnuki-TierneyI974:
Within his theoreticalframe73-74; I976a:3I0-323).
work that the "span of social distance between those
who exchangeconditionsthe mode of exchange" (I974
[I9721:I96), Sahlins identifiesgeneralizedreciprocityas
takingplace among the closest kin or in a kin-based
society (pp. i96-204; see also Ohnuki-TierneyI976a:
3I9). These two principlesthat are definingcharacteristics ofgeneralizedreciprocityare missingin organdonation. Using the phrase "the tyrannyof the gift" (Fox
Fox and Swazey emphasize the onei989:253-56),
Fox and
sidedness of this transaction(Fox I978:II66;
Swazey i992), in which the recipient'senormousgratitude and respectforthe donor has no person to whom
to be directed(which oftencreates an enormous sense
of guilt on the part of the recipient)and does not lead
the presenceof
to any social relationship.Furthermore,
a medical and otherbureaucracyseparatesrecipientand
donoreven if alive. Althoughcharitydonorsreceiverespect fortheirgenerosity,the relationshipbetween donor and recipientsor even membersof the societyis, in
contrastto the situation with generalizedreciprocity,
not based on social/kinties. The organdonation,then,
is closer to charity,a processmediatedby organizations
thatis farmoreimpersonaland takes place in large-scale
societies,althoughthereis a criticaldifference.
On the ethnographicpoint about pierced ears-I am
not sure how 30-40% of earringssold translatesinto a
proportionof the Japanesepopulationwith piercedears,
since most individuals who wear earringsof whatever
kind own several pairs. Also, the piercedhole closes if
one does not wear an earring.Older Japanesestill do
regardear piercingas "impurity";when I broughtthis
subject up at lunch last summer, a senior editor of a
major publishersaid so to his assistant,who had just
had it done withouttellingherparents.At anyrate,this
"violence to the body"
practiceis a radicallydifferent
fromorgantransplantationand otherpractices,and, as
Funabikinotes,his informationdoes not contradictmy
claim about the importanceofthe intactnessofthebody
forthe Japanese.
Funabiki'spointneverthelessgivesme an opportunity
to elaboratemypoint on the power of culturalimperialism. Japanesewere long aware of Chinese ear piercing
without adoptingit; some even used it as a point of
distinctionbetween "us" (Japanese)and "them" (Chinese). Yet, youngJapanesetodayare eagerlyadoptingit
from"Westerners,"primarilyAmericans. This follows
the patternof a series of dramaticchanges in body aestheticssince the Japaneseencounterwith the West that
include preferencefor Western-lookinglarge eyes (for
which they engage in the "body mutilation" of plastic
insteadofthe classical narroweyes and the cursurgery)
rentfadamongyoungmen and women and olderwomen
of dyingtheirhair red. It is this symbolic violence of
WesternculturethatI am most concernedwithwhen it

whichmanagesto impose meaningsand to impose them


as legitimateby concealing the power relationswhich
are the basis of its force" (Bourdieuand Passeron I977
[I9701:4). I would arguethat symbolicviolence is a useful conceptualtool forunderstandingculturalimperialism involvingpower inequalities among states rather
thanexclusivelyin the contextofclass structurewithin
a societythat is the concern of Bourdieu and his associates.
But, in response to Becker's commentary,let me restate that my article is not about Japanesecultureper
se, and I am less concernedwith the symbolicviolence
imposedupon the Japanese,who have forcenturiesvolunteered to adopt foreign cultures (Ohnuki-Tierney

I974 [I9721:I94);

its return"gift"is in theformof,for edlypointedout, symbolicviolence constitutes"power

I990, I993; PollackI983), thanwiththe"gentle,


invisible formsof violence" (BourdieuI977 [I9721:I92) to

which economically less developed societies are subjected. My reason is the more imminentdangerof economic pressureto victimize the poor in poor countries.
I know that Japanesehave purchasedorgans,but I have
neverheardof theirsellingtheirorgansas do some people in India, whose only way of buildinga brickhouse
or accumulatingenough money fora dowryis the sale
of self (see Asahi Shinbun,January4, I994).
In response to otherpoints raised by Becker,I shall
tryto focus on theoreticaland methodologicalissues,
althoughto do so will call forfurtherdetails ofJapanese
culture.I welcome the opportunityto introducecomplexitiesand nuances of Japanesecultureand anthropological argumentswhich I could not include in the article.
AlthoughI did not belaborthe point,I have long emphasized the existence of multiple cosmologies and
structuresoffeelingsand thoughts.For example,forthe
Sakhalin Ainu, the formalizedcosmologythat empowers men is expressedin the bear ceremony,but the one
which celebrateswomen and theirpower is expressed

in shamanisticritual (Ohnuki-Tierney
I976b; I98I:
"Even" in the so-calledWesterntraditions,
I00-I03).

women's symbolic power is often "muted" (Ardener


I975) but is definitelypresent.In n. 7 I commentedon
the therapeuticpower of the tearsofVirginMaryand of
crying-untilrecentlyoftenconsideredwomen's behavior; it is an expression of the nonhegemonicmuted
structurewhich recognizesthe importanceofemotions,
includinglove. For thatmatter,thereare manyrationalist traditionsin the West,as Tambiah and Wilson (cited
in my article)detail. Similarly,thereare multiplestructuresof thought,cosmology,and ethos in Japaneseculturein any given historicalperiod.
It is, however,quite anothermatterto choose a handful of Japaneseintellectuals,rangingover thousandsof
years,who exhibited"the highestrationality"and conclude thatJapaneserationalistsare the same as Western
rationalists.Many sophisticateddebates
Enlightenment
have takenplace on the emphasis on reason and reasoning by some Japanesethinkers,but no one ever calls
them "rationalists"in the Westernsense. Scholarlyde-

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250

1 CURRENT

ANTHROPOLOGY

Volume 35, Number 3, fune I994

bates focus on metaphysicalvs. phenomenological,discursivevs. nondiscursivelogic, dualistic vs. nondualistic, and a host of other detailed distinctions in an
attempt to understand the native tradition(OhnukiTierneyI994) ratherthanreducingit to a Westerntradition as Becker does. To pick but one of Becker's earlier
"rationalists,"
Dogen(2I200-2I 3 5) emphasized
ddri(rea-

soning)(Heine I989,

I993),

buthis singlemostimpor-

tantprinciplewas shushdittd-"oneness ofpracticeand


attainment" or the collapsing of "the means-versusends" (LaFleur i983:22). That is, his fundamentalposition was thatthe "seated meditation"ofBuddhistswas
itself "the reality of enlightenment"(LaFleur I983:
"enlightenment"indeedfromthe
22o)-a verydifferent
Enlightenmentphilosophyof the West. Seated meditation and nondiscursivethought (furyhmo
i) were key
principlesof Zen, whetherDogen or some other type.
If Becker was looking for"rationalists"I am surprised
that he did not include OgyfiSorai of the Tokugawa
period, whose "rationalistic" thought has been discussed by scholars. Eisenstadt (n.d.) has succinctly
summarized this discussion: "But just because such
pragmatic and 'secular' thought, with very strong
has been free from
'Zweckrationalitat'-orientation,
metaphysicalgrounding,
it has notgivenriseto a critical
discursiveWestrationalitatdiscourse, and it has been
the non-discursive'philosophizingin the archaic' that
has become predominantin Japan." Becker includes
contemporary"rationalists"such as Omae Kenichi, an
M.I.T. graduatewhose Adam Smith economic rationality has drawn much attentionin Japan(fordetails of

Omae's advocacy,see Ohnuki-Tierney


I993:23-24)-a

curiousconflationindeed.
My concernis, at anyrate,not with intellectualtraditions but with the views of ordinarypeople, except for
certainpropositionsof high culturetransmittedand espoused by the folk as is the case with the rationalist
traditionin some Westernsocieties. As I stated in the
article,the Japanesecreditedthe Chinese withsai (capabilities, intellect,etc.) but identifiedthemselves with
"soul" long beforethis symbolicoppositionwas applied
to the Japanesevs. the West. The symbolicopposition
ofthe selfand a given otherexpressedas wakon kansai
(Japanesesoul and Chinese talent/brilliance)or wakon
y6sai (Japanesesoul and Westerntalent/brilliance)has

a longhistory(Ohnuki-Tierney
I993, Pollack I983)-

clearlyit did not beginwith "prewarslogans" as Becker


claims. As I have explainedelsewhere(Ohnuki-Tierney
I993), usingthe symbolismofrice as an example,a symbol or symbolicprinciplewithbothcognitiveand evocativepoweris a tool thatthe politicallypowerfulcan use
fortheirown purposes,but theiruse of it does not take
place in a vacuum. To the contrary,theycan mobilize
the power of the symbol to their advantage precisely
because it has been meaningfulto the people.
What distinguishesWesterntraditionsfromJapanese
ones is the strengthof rationalism,howevervaried its
manifestations,expressedin terms of both its history
and its acceptanceby ordinarypeople in Westernsocieties-far more so than the Japaneseon both counts. As

Thomas (I97I:646) points out, "a 'rationalist'attitude


had existedlong beforethe workofGalileo or Newton,"
and Aristotleand Cicero are but two examples of rationalists in classical antiquity.In his explanationof the
decline of "magic," Thomas arguesthat "what the scientificrevolutiondid was to supersedethis typeof reasoning and to buttressup the old rationalistattitude
with a morestable intellectualfoundation,based on the
mechanicalphilosophy."I am arguingthatmedical technology and its widespreadacceptance in certainWestern societies is evidence not only of the success of the
scientificrevolutionbut, more important,of the deep
rootsof the rationalisttraditionin the thoughtsof ordinarypeople and not just intellectualsin these societies.
As "evidence" for his Japaneserationalisttradition
Beckerpointsto the alleged importanceofwhat he calls
the "head." This raises the major methodologicalissue
of the readingof culturaltexts-written or otherwiseand requires a discussion of the body and its parts in
Japaneseculture.He points to the Amida paintings,in
which he sees "countless" instances of dyingpeople's
"souls being escorted fromthe head to heaven." It is
indeedodd thatspecialistsin Pure Land Buddhistpainting such as Okazaki (e.g., I977) have not spottedthese
"countless" instances.All of us know the famousK-uya
sculpture, which depicts six miniature Amida (not
souls) comingout of Kfuya'smouth (not head) (see Mori
I977). Beyond the question of whethersuch paintings
exist, the readingof a cultural text is an enormously
complexissue. The soul, ofvital culturalimportancein
almost every culture no matterhow it is definedand
givenmeaning,is oftenthoughtto departfromthe body
at the time of a person'sdeath. This is a common belief
acrossmanycultures.When it leaves the body,it has to
do so throughone ofthe bodyorifices-usually an upper
one because ofthe symbolicoppositionbetweenthe upper and the lower body,with the latteralmost universally receivinga negativevalence. Thus, as in some of
the Europeanpaintings,the head/faceis depictedin the
scene of the soul comingout of the mouth. But forany
culture,uses or depictionsofthe head do not constitute
evidence that the soul is located in the head, let alone
evidenceforthe importanceof the brain or rationality.
The Japaneseconceptionof the body and its partshas
undergonehistoricalchanges. In ancient Japanthe soul
was thoughtto reside in the gotai-the fivebody parts
or the body. Orikuchi (I975 [I928]) explains that the
ancient Japanese thought that the soul was located
somewhereoutside and enteredthe body when alive;
deathoccurredwhen the soul "split" and leftthe (generalized) "body" (fordetails of Orikuchi's interpretation,
see Ohnuki-Tierneyi99I, I993). Since the late medieval
period,the soul has been thoughtto be located in the
generaland broadlydefinedarea called hara (the stomach), which is the most importantpart of the gotai, althoughas with any cultureeverybodypartis significant
in some sense. Elsewhere(Ohnuki-TierneyI984) I have
extensivelydiscussed the importanceof the stomachin
the past and at present,when no Japanesebelieves that
the soul is located in the stomach (see the uneasiness

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OHNUKI-TIERNEY

Brain Death and Organ TransplantationI 25i

expressedby Funabiki).In this belief,the soul leaves via standingsof the Japaneseconceptionofthe bodyand its
the neck throughthe nostrilsor ears, establishingthe parts,a simplisticnotion of rationalityand consciouscustomofcoveringone's ears to preventone's soul from ness, a monolithic and decontextualized reading of
beinglured away at the time of death of someone close paintings,and a neglectoffolkas opposedto intellectual
(called mimifusagior tomobiki). Onryo, the soul of a culturesare presentedwithout a single citation except
deceased personwho has remorseor seeks vengeance,is of his own work-an articleand a forthcoming
book.
I cautioned that various otherdimensionsof the imbelievedto stay in the neck.
The seppuku suicide of warriorsderives from the plementationoftransplanttechnologywould not be dishunter'straditionoftakingthe slain animal's intestines. cussed (see n. 4) because my focus was on conceptual/
Medieval warriorsthrew their own intestines toward cultural/symbolic
issues, but Becker'scommentson the
the enemywhen they committedseppuku, therebyre- dangerof abuse of the technologyofferme an opportuleasing theirsouls fromtheirbodies. Japanesewarriors nityto clarifymy anthropologicalapproach.At a supertook an importantenemy's "head" because the "face" ficial level he is rightabout the absence of lawsuits
is the bodypartthat can most certainlyand easily iden- (thoughlitigationis increasingin Japan)broughtagainst
tifythe person;the intestinescan hardlyservethis pur- doctors by patients, the practice of seeking a second
pose. Furthermore,
as I said, the severingof the neck opinion,and the absence of whistle-blowingby a docbut here again I see him using a Western
accomplishedthe destructionof the gotai's intactness. tor'sinferiors,
Thus, takingthe enemy's "head" cannot serve as evi- yardstick.Anthropologistshave long been aware that
dence forbrain/head/rationality.
such cultural institutionsas taboos are an important
The sign of death forthe Japanesehas always been part of "non-Western"legal systems (see, e.g., Moore
stoppage of the breath. The word iki means both I986). Oftenordinarypeople are "actors ratherthan re"breath" and "life," and even today, as I noted, iki o actors" (Watson i993:82) skillfullyusing these day-tohikitoru(to withdrawone's breath)and iki ga kireta(the day practices. The Japanesethemselves are critical of
breathstopped)are the common expressionsfordeath. the absence of a legal verdicton Wada, the transplant
"Consciousness" (which Becker emphasizes but does surgeonwho is seen as having committeddouble murnot defineforJapaneseculture)is not the decisive crite- der in I968 (n. 3). Indeed, enormouspressurefromthe
rionfordeath, since the same expression(ishikiga na- mass media-with a whistle-blowerlike Tachibana,
kunaru [one loses consciousness]) is also used when cited in my article-and ordinarypeople have de facto
someone faints.Nor is consciousness a primarycrite- yieldeda verdictin this case; no heart transplantation
rion forpersonhoodas Becker claims. (On the impor- has since been performed.Similarly,the Takeuchi stantance ofhara and iki, see also Lock I980.)
dards,commissionedby the governmentto establishthe
A comprehensiveunderstandingofthe bodyand what medical criteriaforbraindeath (n. 2), include a minority
beinga human means to the Japanesein historicalper- opinion.In the Japanesedecision-makingprocess,votes
spectiveis clearly beyond the scope of my article and are rarelytaken,and a victoryof the "majority,"somethis reply. My argumenton the emotionalityof per- timeswith a marginof one, is not favored.Even though
sonhood in Japaneseculturewas intendedto highlight the minorityopinion was signed by only four,the Tathe point that here as in many cultures personhood keuchi standardshave acted as a deterrentto thepassage
should not and cannot be reducedto rationalityand the of legislationin favorofbraindeath as death. Similarly,
restof the body to an afterthought
of the brain.At any the legal prohibitionof traditionalmedicine has never
rate,of crucial importanceforhumans and theirlife in been effective;people have simplycontinuedto use it.
Japanesecultureis the soul, whose propertiesand func- This type of nonformalizedlegal system does allow
tions I describedin the articleas closer to emotionality roomforabuses, but we see abuses in the United States,
thanto rationality.I use the termas a roughtranslation wherelawsuits have become a routinerecourseforconand not as equivalent to the emotionalityembeddedin flict resolution. American transplantsurgeons of the
the Westernsymbolic dyad of rationality-emotionalityyoungergenerationfindit difficultto voice reservations
about this rapidlydevelopingtechnologybecause their
(Ohnuki-Tierneyn.d.a, b).
I am puzzled by Becker's insistence on whateverhe seniorshave built theirreputationson it and do not welmeans by "head," since the head simplydid not occupy come such a criticalstance.
an importantplace until the WesternrationalisttradiFinally,farfromhaving been "discarded,"the tradition became influentialamong the intellectualelite. In- tionsofherbaland energymedicine,baths and massage,
deed, among the parts included in the "head" it is the and acupunctureand spiritual counseling are thriving
kubi (neck) that was of crucial importanceforthe Japa- despiteefforts
to suppressthemtwice in recenthistory.
nese, not because of its link to the brainbut as the pas- Seekingto modernizethe nation,in I875 the Meiji govsage by which the soul leftthe body and as the tempo- ernmentrequiredkampo doctorsto pass an examination
raryseat of the onryo.In this connectionI must point in seven subjectsofWesternmedicinebeforetheycould
out that no Japanese,even today,would referto an en- practicekampo. ShortlyafterWorld War II, regarding
emy's "head"; it is always referredto as kubi. His themas "barbaricand unhygienic,"the Allied Forcesin
claim of a shared etymologyfor the Japanesewords Japanattemptedto eradicatemoxibustion,acupuncture,
forthe soul and the head is, like his claim of "count- massage, bone-setting,etc. (Ohnuki-TierneyI984:9Iless paintings,"absolutelygroundless.These misunder- 92). The Japanesefolk simply ignoredthe law, and re-

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2521

Volume 35, Number 3, June1994

ANTHROPOLOGY

CURRENT

centlykampo and these practiceshave made a phenomenal comeback. The support of the people has even
forcedthegovernmentto include thekampd treatments
of herbal medicine, acupuncture,and moxibustionin
healthinsurance.Temples and shrinesofferthe spiritual
and psychologicaldimensionsof wellness just as there
is an importanttherapeuticdimensionin, forexample,
Catholics' confessionsto priests.In additionto the daily
bathat home at bedtime(notbeforegoingout,as Americans do), onsen (hot springs)are flourishingnow that
affluent
Japaneseare able to go on holidaytrips(see Graburnn.d.).In factdomestictravel,includingvisitsto hot
springs,is the top (58%) leisureactivity,involvingsome
54 millionJapanese,the second most frequent(I 5%) besome I2 million(MorrisI990: i6ingskiing,involving
ofbaths
I7). Signs,includingubiquitous advertisement,
and traditionalmedicine are everywhere-on streetcorners,in streetcars,and in newspapers.Becker,who has
lived in Japanformanyyears,overlooksall these signs,
and it is thereforeno wonder that he projectshis own
obsession with the brain and rationalityonto the Japanese.
Daar and Lorberstressthe necessityofmutual understandingbetween biomedical professionalsand anthropologists. I have deliberatelymade my argumentpoto this end.
lemic, playingthe role of anthropologist,

stemin braindeath:A criticalreview.Issues in Law and Medicine 9:3-2I. [MVA]

BYRNE, PAUL A., JOSEPH C. EVERS, AND RICHARD G.


NILGES. I993. Anencephaly-organ
transplantation?
Issues in
Law and Medicine9:23-33. [MVA]
CHENGAPPA, RAJ. I990. The organsbazaar.India Today,July,

PP. 30-37-

CHIBA, TOKUJI. I98I.

22I.
CURRIER,

RICHARD. I966. The hot-coldsyndrome


and symbolicbalancein Mexico and Spanish-American
folkmedicine.
Ethnology5:25 I-63.
DAAR, A. S. I989. Ethicalissues: A MiddleEast perspective.
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[ASD]
I992. Rewardedgifting.
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[ASD]
RONALD.

I993. Life'sdominion:An argument


about abortion,euthanasia,and individualfreedom.New
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EISENSTADT,
SHMUEL NOAH. n.d.The Japanese
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254

1 CURRENT

ANTHROPOLOGY

Volume 35, Number 3, June1994

MARILYN.
I992. After
nature:Englishkinshipin
thelate twentieth
century.Cambridge:CambridgeUniversity
Press.

STRATHERN,

TACHIBANA,

I991 (I982).

TAKASHI.

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TAMBIAH,

STANLEY

J. I990. Magic, science, religion, and the

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THOMAS,

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MIWA.
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WADA,

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I992.

Gan senkoku,watakushino bawai

(Cancer verdict, in my case). Bungei Shunju 70:370-85.


JAMES L. I993. "Rites or beliefs? The constructionof

tion 26i:2205.
[MVA]
S. J., M. ALLEN,
YOUNGNER,

E. T. BARLETT,

ET AL.

I985.

New
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WATSON,

Prizes
The American Society forEthnohistoryannounces the
recipientsofits ErminieWheeler-Voegelinand RobertF.
Heizer AwardsforI993. The ErminieWheeler-Voegelin
Prizeforthe best book-lengthworkin ethnohistory
was
awarded to James Lockhart (Department of History,
Universityof California,Los Angeles) for The Nahuas
afterthe Conquest: A Social and Cultural Historyof

the Indians of CentralMexico, SixteenththroughEighteenth Centuries (Stanford:StanfordUniversityPress,


I993). For the best article in the field, the Robert F.
Heizer Prizewas awardedto JohnSteckly(NativeAmerican Studies, Universityof Sudbury)for "The Warrior
and the Lineage: JesuitUse ofIroquoianImages to CommunicateChristianity"(Ethnohistory39:478-509).

Wanted
Donations to the newly establishedSymbiosisFoundation of the Department of Cultural Anthropologyof
L. Eotvos Universityin Budapest to assist studentsand
youngfellowsin fieldworkand subsequentpublication.
The department'sthree main research programs-in

EasternEurope, Central Asia, and Latin America-are


froma shortfallin local funding.Contributions
suffering
by professionalorganizationsand individuals will be
gratefullyreceived. Please write: L. Boglar, L. Eotvos

Piaristakoz i,
University,

I052

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Budapest,Hungary.