Population geography II

I Introduction

It would appear as if ‘death’ has escaped the clutches of population geography. Although mortality forms one of the three pillars of population geography (coupled with fertility and migration), it remains relatively marginal (though see Dorling, 2010; Ghosn et al., 2012; Norman et al., 2011; Popham et al., 2011). This in fact has been a common lament of both histories and recent commentaries on the status of population geography, namely that interest in mortality among population geographers has diminished (Boyle, 2004; Findlay, 1993). This is not to say that the geographic study of mortality has disappeared; rather, as Boyle (2004: 767) identified over a decade ago, ‘many of the contemporary geographical studies of mortality are being conducted by health geographers (or epidemiologists or medical sociologists) rather than population geographers’. Political geographers likewise have addressed mortality, including but not limited to studies of civilian- and military-related deaths (Hyndman, 2007) and urbicide (Fregonese, 2009; Graham, 2004, 2008; Hewitt, 2009; Ramadan, 2009). There is also a lengthy scholarly engagement with mortality, death, and deathscapes within geography (Francaviglia, 1971; Kniffen, 1967; Kong, 1999; Maddrell and Sidaway, 2010; Philo, 2012a; Romanillos, 2011; Teather, 2001; Tyner, 2014; Wylie, 2009; Yeoh, 1991; Yeoh and Hui, 1995; Zelinsky, 1994). Lastly, there currently exists an efflorescence of theoretical and empirical work directed toward mortality and – by extension – the vitality of the human body. This is seen, for example, in the rapidly enlarging corpus of literature addressing both biopolitics (e.g. Anderson, 2012; Braun, 2007; Coleman and Grove, 2009; Hannah, 2011; Philo, 2012a; Rutherford and Rutherford, 2013a, 2013b; Schlosser, 2008) and thanatopolitics (e.g. Ailio, 2013; Murray, 2008) – two areas that have received limited attention in population geography (cf. Legg, 2005; Philo, 2005).

In this progress report I build upon my earlier call, namely for population geographers to reflect more deeply on the ‘survivability’ of populations and to address a layered demographic question: within any given place, who lives, who dies, who decides? (Tyner, 2013: 702). Here I want to consider a corollary, one that is based on the tautology that to ‘survive’ is to live; and to survive is to not die. For one’s ability to survive – to live – is increasingly understood as a managed activity. However, it is not necessarily death in the abstract that is to be avoided, but rather ‘pre-mature death’. Indeed, for scholars such as Gilmore (2002: 16), premature deaths follow from the application of violence. In this report I take seriously the concept of premature death; I do so from the standpoint that premature death is a bio-political and bio-economic concept, one that is intimately bound to the modernist ordering of life that dominates our contemporary understanding of both bodies and populations (cf. Harrison, 2008; Romanillos, 2011). Simply put, premature death as ‘preventable risk’ originated as a bio-logical concept in the mid-17th century. According to Bayatrizi (2008: 5), this depended on the development of new scientific techniques for measuring longevity and mortality rates and for identifying the most common causes of death. Over time, however, the concept of premature death has been transformed according to bio-economic logics, whereby mortality – as something calculable and predictable – is something also that is manageable, governable, and even profitable. In short, premature death as a concept was, and is, intimately bound to the spatial and temporal regularities of mortality – the ‘stuff’ of population geography and demography.

II Embodied geographies of mortality

While there is a long tradition of studying mortality within population geography, as Young and Light (2013: 136) explain, the approach to death is largely statistical and demographic; it has not often engaged with the meanings of death and dying. Moreover, as a topic approached in the aggregate, the study of mortality within population geography has been remarkably disembodied. In this preliminary section, therefore, I reconfigure geographies of mortality within the flourishing literature on ‘the body’.

So what exactly is the body? Are we, as embodied, corporeal beings simply a collection of cells, tissues, and organs? Conversely, is there some part of ‘us’ that exists beyond our carbon-based form? A soul, perhaps? Or a small homunculus pulling the levers in our brain? Alongside these metaphysical questions, we are confronted also with common sense. After all, we all have bodies. As Rose writes, ‘We all live through our bodies: we think, touch, feel, breathe, smell, dream and sleep with our body, and we constantly encounter other bodies’ (Rose, 2003: 48). And we are all born and at some point we will all die.

Or do we? Well into the 21st century, we can no longer presume that all bodies undergo the same processes of life and death, fertility and mortality. There are, in other words, qualitative differences in the quantification of vitality. Since 1978, for example, it has been possible to be conceived via in vitro fertilization as opposed to in vivo fertilization. In fact, worldwide, upwards of five million babies have been conceived ‘outside’ of women’s bodies. The category of death likewise has undergone numerous transformations. In the United States, as a case in point, it is possible for two ‘bodies’, each with identical vital signs, to be classified differently – one dead and the other alive – depending on where those bodies are located (see below).

The ‘human body’, as it turns out, is not so straightforward; and neither, by extension, is our understanding of ‘life’ and ‘death’. Indeed, the complexities posed by living (and dying) bodies have inspired much philosophical thinking and anthropological study (cf. Kaufman and Morgan, 2005). For example, a long-standing presumption – at least in western thought – is the separation of the ‘mind’ from the ‘body’. During the Enlightenment, it was argued that the mind was separate from – and superior to – the body. It was the mind that made possible those processes that allow us to think, to reason, and to argue; these constituted ‘active’ or ‘voluntary’ processes. Conversely, those involuntary activities, such as respiration and digestion, were located in the body (Blackman, 2008: 4). A Cartesian understanding of the body therefore holds that the body is inert, passive, and unthinking; this is in contrast to the active, thinking mind. Indeed, while the body is conceived as part of ‘nature’, a material object consisting of organs, appetites, and biological functions, the mind is the locus of one’s consciousness. It is the mind – separate from the fleshy, inert body – that is important. Feminists, and especially poststructural feminists, have challenged the perpetuation of the mind-body dualism (Rose, 1993). They have argued, in part, that it is not possible to consider a mind or consciousness that is somehow prior to or separate from the material body. Herein lies an opportune moment for population geographers, accordingly, to enter into the long-standing debates concerning both the ontological and epistemological moorings of ‘nature’ and the ‘human body’.

We cannot take for granted the existence of a body – or even the ‘mind’ (and, as I later discuss, its material form, the ‘brain’). These concepts come into existence through practice. We may agree that a ‘body’ exists – this concrete, material, animate organization of flesh, organs, nerves, muscles, and skeletal structure (Grosz, 1998: 43) – but the meanings of this body are discursive and, by extension, politically contested. As Rose (2003: 48) writes: ‘Bodies mean nothing in and of themselves. They become meaningful only when they are produced by discourse.’ This insight has broadened our understanding of the body as a knowable object – the counterpart to the aggregated concept of ‘population’. Thus, as object, the body (like ‘population’) becomes known through various knowledges (e.g. religion, medicine, law, and politics). Hence, Mol and Law write:

When it is observed with the naked eye and through microscopes, CT-scans and other visual machinery the body is an object. It is an object when it is measured in a variety of ways, from counting the pulse to determine the blood levels of haemoglobin, creatinin, calcium. (Mol and Law, 2004: 43)

The body is also ‘known’ through administrative practices, including the census, surveys, academic performance tests, and so on. With the use of Body-Mass Indexes and Quality-of-Life Scores, bodies as objects can be counted and classified, ordered and organized; bodies can be partitioned and proportioned, divided and disciplined (cf. Colls and Evans, 2013).

The ‘knowing’ of object-bodies – especially as knowledges of the ‘body-object’ are produced toward the goal of predicting and preventing premature death – is intimately associated with changing biomedical and economic practices (cf. Colls and Evans, 2013). Beginning around the 18th century, and lasting well into the 20th century, according to Rose, knowledge of the body existed at the molar level. Rose (2007: 11) explains that ‘most people … still imagine their bodies at the “molar” level, at the scale of limbs, organs, tissues, flows of blood, hormones and so forth’. It is at this level, Rose (2007: 12) writes, ‘that we act upon and seek to perfect through diet, exercise, tattooing, and cosmetic surgery’. It was also at this level that the body was ‘revealed to the gaze of the physician after death in the post mortem dissection, visualized in the anatomical atlas, accessed in life through any number of devices’ (pp. 14–15).

By the latter half of the 20th century, however, knowledge of the object-body is located at the molecular level. Rose (2007: 12) explains that the ‘clinical gaze has been supplemented, if not supplanted, by this molecular gaze, which is itself enmeshed in a “molecular” style of thought about life itself’. According to Rose, now:

tissues, cells, and DNA fragments can be rendered visible, isolated, decomposed, stabilized, stored in ‘biobanks,’ commoditized, transported between laboratories and factories re-engineered by molecular manipulation, their properties transformed, their ties to a particular individual living organism, type, or species suppressed or removed. Molecularization strips tissues, proteins, molecules, and drugs of their specific affinities – to a disease, to an organ, to an individual, to a species – and enables them to be regarded, in many respects, as manipulable and transferable elements or units, which can be delocalized – moved from place to place, from organism to organism, from disease to disease, from person to person. (Rose, 2007: 14–15)

Such a perspective opens the door to studies on the relationships between, for example, migration and organ transplantation (Roberts and Scheper-Hughes, 2011), the trafficking of human organs (Hoeyer, 2009; Scheper-Hughes, 2003, 2008; Sharp, 2000, 2006), and medical tourism (Whittaker, 2008; Widdows, 2011).

Other possibilities exist for a reconfigured embodied population geography. From genetic interventions to bodily implants and enhancements, many writers – including geographers – have speculated on the ‘existence’ of posthuman bodies (Badmington, 2004; Cadman, 2009; Castree and Nash, 2006). As Castree and Nash (2006: 501) write, new biotechnologies which involve the transfer of genes or organs between species, as well as the use of artificial devices, disturb an idealized definition of the human body as separate and liberated from nature. Many of us, for example, are familiar with the use of prosthetics. However, as Blackman (2008: 117) observes, it ‘is not simply about the prosthetic (limb, teeth, glasses) as being replacements or additions to the human body augmenting and amplifying its capacities (usually framed through a loss of the original)’. It is more; it is about the biotechnological practices that blur the boundaries between the supposedly natural and the technologically manipulated or altered material body.

Well into the 21st century, ‘our bodies are increasingly being experienced as objects to be honed and worked on’ (Orbach, 2009: 2) and, in the process, to ‘avoid’ premature death. Indeed, it is significant that neoliberal medicine has arisen at the same time that an ever-growing number of people regard their bodies as projects (Frank, 2004). What is distinctive, as Rose (2007: 20) writes, is that now ‘recipients of [medical] interventions are consumers, making access choices on the basis of desires that can appear trivial, narcissistic, or irrational, shaped not by medical necessity but by the market and consumer culture’. We can reshape our eyes and noses, and lengthen our limbs and penises. We can augment our breasts, butts, cheeks, and lips. We can whiten our skin simply by swallowing a pill (e.g. glutathione) – despite the risk of liver damage or death. As Frank (2004: 18) concludes, the ‘possibility of fixing renders inescapable the question of whether or not to fix’.

Such a fixation with the ‘promise’ and ‘potential’ of embodied projects should not lose sight of the inequalities associated with producible, consumable bodies. Not all populations have access to the ‘choices’ offered on Rose’s medical buffet; there are in fact multiple and unequal geographies to object-bodies. The class-based implications of biomedical interventions, as well as the ‘vulnerability’ to ‘pre-mature’ death, for example, should not be overlooked (cf. Harrison, 2008). The growing patient-as-consumer model, in fact, establishes a situation that empowers those with sufficient resources and disenfranchises others who lack these resources (Frank, 2004). As Kaufman and Morgan (2005: 330) write, ‘choice is at best an illusion for most of the world’s peoples’.

III The meaning(s) of life and death

What is ‘life’ and, more importantly, how is life to be valued? Our understanding of this question hinges on specific bodies of knowledge and knowledges of bodies. Prior to the 18th century, most knowledges of life (and death) were located within the realm of the ‘cultural’. Anthropologists and ethnographers, in particular, ‘have long documented social practices that do not rely on the teleological assumption that human life begins with birth and ends with death’ (Kaufman and Morgan, 2005: 320). Indeed, according to Kaufman and Morgan (2005: 321), the observation that ‘newborns are considered in many cultural contexts to be unripe, unformed, ungendered, and not fully human is evidence that personhood is not an innate or natural quality but a cultural attribute’.

Throughout the 17th and 18th centuries, a new demographic approach to the concept of life – and of death – emerged, a transformation that coincided with the political economic transition from feudalism to mercantilism and, eventually, to capitalism. For our present purposes, the most salient aspect is necessarily on the practices – the calculations – by which governments rule and regulate, discipline and control, the populations within their territorial domains. As Crampton and Elden (2006: 682) write, ‘Forms of organizing, conceptualizing and managing the population can be seen in technologies such as the census and representational discourses, statistics, planning and cartography, as well as political expressions such as geopolitics, government and colonial ordering’. However, these calculations may also be seen as the state’s right to intervene in matters of life and death.

The elaboration of a concept of ‘population’ was a gradual process, one that was both technical and theoretical, relying on the development of statistics and census taking, and the techniques of epidemiology, demography, and political philosophy (Legg, 2005; Philo, 2001, 2005, 2012b). This has significant implications for our understanding of matters of life and death, in that the political meaning of ‘population’ as concept was fundamentally transformed. With the emergence of the territorial state, populations were no longer conceived as the simple sum of individuals inhabiting a territory; instead, populations were conceived as a technical-political object of management and governance. The relationship between the sovereign and the population is therefore not simply one of obedience or the refusal of obedience. Rather, ‘populations’ become productive through state interventions – through a series of techniques, practices, and calculations (Foucault, 2007: 70–71). From this moment onward, according to Foucault, government:

has as its purpose not the act of government itself, but the welfare of the population, the improvement of its condition, the increase of its wealth, longevity, health, etc.; and the means that the governments uses to attain these ends are themselves all in some sense immanent to the population; it is the population itself on which government will act either directly … or indirectly. (Foucault, 1991: 100)

Conceptually, the idea of populations as a collective of bodies constituting some kind of definable unit to which measurements pertain emerged from the 16th century onwards (Caldwell, 2001: 20). This is seen, for example, in the writings of John Graunt, William Petty, William Farr, Johann Peter Süssmilch, and Thomas Malthus, among others. Graunt, for example, identified certain regularities within populations: that child mortality is always higher than adult mortality; that populations exhibit a slighter higher proportion of male births compared to female births, but that male mortality is higher, thus leading to a more equal proportion of boys and girls. Süssmilch, likewise, demonstrated the existence of certain statistical regularities in population data. While searching for a divine order, or evidence of God’s planning, Süssmilch – who was a clergyman and published a book titled The Divine Ordinance Manifested in the Human Race through Birth, Death, and Propagation – examined masses of demographic data. In his quest for regularities, Süssmilch discerned the balance of births and deaths and subsequently produced a life table; this knowledge was in fact used for actuarial purposes well into the 19th century (Caldwell, 2001: 22).

What might be termed a ‘bio-logic’ understanding of populations did not spell the end of the ‘body-object’. Embedded within the ‘governmentalization’ of the state, there emerged an explicit conception of ‘life’ as both object and subject. According to Foucault (1990: 142), western man [sic] was gradually learning what it meant to be a living species in a living world, to have a body, conditions of existence, probabilities of life, an individual and collective welfare, forces that could be modified, and a space in which they could be distributed in an optimal manner. What emerged was indeed a bio-logics, a specific system of thought that positioned the knowledge of life within a broader context of political economy. In fact, prior to this time, biology per se did not exist, for the simple reason ‘that life itself did not exist. All that existed were living beings, which were viewed through a grid of knowledge constituted by natural history’ (Foucault, 1994: 128).

The idea that ‘life’ could be studied, Kaufman and Morgan (2005: 328) assert, owes its emergence (in part) to the rise of theories of evolution and its expansion to concepts formed through the sciences of physiology and, more recently, of molecular biology and genetics. More broadly, we recognize that (western) societies – but especially the United States – have inherited a legacy of viewing the human body from a biomedical perspective. As Sharp (2006) explains, ‘patients’ (bodies) are generally approached as individuals and, thus, as discrete entities; understanding and treatment are made possible without considering the significance of large social milieus. This is because, Sharp (2006: 10) argues, ‘the body itself is viewed as a sophisticated organism whose splendor stems from its physiological complexity’.

The transformation from a molar to a molecular understanding of the body has been accompanied by a parallel transformation in our bio-logical understanding of life (Braun, 2007). As Rose (2007: 42) explains, ‘our understanding of life has been transformed many times since the word “biology” was first proposed for a novel science of life in 1802’. Thus, for much of the 20th century, the knowable body that we have inherited is one that was ‘visualized by such a clinical gaze, as it appeared in the hospital, on the dissection table, and was inscribed in the anatomical atlas. The body was a vital living system, or a system of systems – it was an organically unified whole. The skin enclosed a ‘natural’ volume of functionally interconnected organs, tissues, functions, controls, feedbacks, reflexes, rhythms, circulations, and so forth’ (Rose, 2007: 43–44; see also Philo, 2000).

In contemporary (and especially western) society, a bio-logics predominates our conceptual understanding of life and informs our understanding of abortion – a topic only minimally addressed by population geographers (cf. Gober, 1994). Accordingly, life is presumed to begin, to originate, at the moment of fertilization. Yet even this straightforward understanding quickly encounters problems. As McMahan (2002: 25) explains, ‘conception is not a momentary event but is instead a process lasting about twenty-four hours. The process is not complete until syngamy, the point at which the genetic materials from the sperm and egg have thoroughly fused.’ He concludes (p. 27) that it ‘is arguable that no new entity exists until that point’. The subsequent process of cell division likewise poses problems. During these first few days following fertilization, cells divide and divide again. When the initial single-celled zygote divides, it ceases to exist, replaced by a two-celled entity; when this entity divides, it also ceases to exist, replaced by a four-celled entity. Are the successive cell divisions events in the history of a single, individual or, instead, is there nothing – no individual – that persists through these transformations? If the latter, one would conclude that only when the cells begin to differentiate – around the second week following conception – and organize together in an integrated way do they constitute an individual (McMahan, 2002: 27). This is a fundamental decision that surrounds the abortion debate, and one to which ‘science’ may not provide answers. Indeed, according to McMahan (2002: 29), the ‘claim that the zygote is the earliest stage of the organism is something that we are neither rationally compelled to accept nor rationally compelled to deny’. To determine, a priori, that life only begins at birth is therefore considerably problematic and, in turn, political.

Such concerns surrounding the seeming indeterminacy of a bio-logical knowing of life has been accompanied by a bio-political conception of life (and death). Fassin (2009: 48), for example, refuses to provide a fixed definition of life; he argues instead that ‘it is to render its full meaning and its multiple senses when it is not confined to a biological phenomenon’. In other words, it is more beneficial to explore the ways in which ‘life’ (and ‘death’) is used politically. Here, ‘life’ itself is acknowledged as a social construction, its meanings and interpretations predicated on the specific political, economic, and cultural contexts in which it – the concept, the term – is articulated. To this end, a growing number of geographers and social scientists, influenced by the writings of Rose, Foucault, and Agamben, have worked to shift the terrain from a purely bio-logical discussion to that of a bio-political and bio-economic one. This is perhaps best exemplified in the transformation of knowledges surrounding death not as a biological fact but as a bio-political concept.

Consider, for example, the following pleonasm: that death is the absence of life; that death ‘begins’ when life ends. Such circular logic, however, is beset with innumerable difficulties. In western societies, for example, death and life have traditionally, conventionally, held to be mutually exclusive ‘states’ of being. One could not be both alive and dead. However, in many non-western societies, death does not coincide with the ‘destruction’ of an individual’s life; rather, death is a social event – death becomes an initiation into the afterlife (Kaufman and Morgan, 2005). This is seen clearly in the cultural practices surrounding reincarnation and resurrection. Consequently, the ‘boundary’ between life and death, and the meaning of this zone of ambiguity, has been culturally determined. Hence, how death is demarcated from life – and the meanings ascribed to this separation – has differed, and continues to differ, across time and space.

It is helpful, also, to consider the various approaches to the term ‘death’ itself. On the one hand, death may refer to a process, i.e. the act of dying, while, on the other hand, death may signify a ‘state of being’, that is, to be dead. ‘Death’ as a state of being has historically been understood as the cessation of vital signs: breathing, the beating of the heart, the decomposition of the body (cf. Fry-Revere et al., 2010; Giacomini, 1997; Lock, 2004; Powner et al., 1996). Such physical indicators seemingly provide clear-cut knowledge of the death of a body. As Whetstine writes:

the permanent cessation of heart and lung activity constituted death because the absence of heart and lung function quickly resulted in the failure of the entire organism. Thus, consensus emerged that cardiac and respiratory activities were significant for distinguishing the living from the dead. (Whetstine, 2008: 66)

Throughout western Europe, the 18th century witnessed a sustained attempt to determine scientifically the threshold between life and death (Alexander, 1980). In part, this motivation for a clarification of death was an outgrowth of the scientific revolution and the constitution of ‘life’ itself. The human body was increasingly likened to that of a machine. For example, just as a machine could be disassembled and analyzed, and once its rules – its mechanics – were discovered it was possible to reconstruct and even improve the machine, so too could the human body be understood. Biomedical advances in tissue culture, anatomical dissections, and experiments in animal (and human) resuscitation throughout the 19th century further promoted the idea of the body as a composite of integrated units, each with a separable contribution to the whole (Powner et al., 1996: 1219). The practice of organ transplantation would solidify this bio-logical view of the body whereby the body itself is conceived as a highly medicalized system of interdependent parts and processes (cf. Sharp, 2006).

In parallel with the growing tolerance for the dissection of the posthumous body, medical practitioners searched for particular signs that would account for death and, if possible, identify ways to prevent premature death. A wide assortment of physical signs and tests of death were developed and utilized between the 18th and 19th centuries. In part, the necessity for improved techniques arose because of the growing knowledge of biophysical conditions that mimicked death, such as alcoholic stupor, extreme cold, opiates, hemorrhage, apoplexy, suffocation, fever, head injury, lightning strike, diabetic ketoacidosis, epilepsy, drowning, and fainting (Whetstine, 2008: 72). Consequently, a suite of practices were forwarded to assess better the ‘fact’ of death: these included means to confirm the cessation of heart action and respiration; the confirmation of the onset of rigor mortis; the lack of muscle movement after electrical stimulation; and assessing the relaxation and open state of the anus. Many tests bordered on the macabre and would certainly cause death if the unfortunate patient was not already dead (Whetstine, 2008). One physician, F.E. Foderé, proposed drawing an incision in the left chest to feel manually if the heart was still beating. Other methods included applying acid, electricity, or warm water to the soles of the feet; placing tissue paper over the nose and mouth; pumping scotch up the nose; funneling ammonia down the throat; severing the jugulars; separating the carotid arteries; cutting the medulla in half; and piercing the heart (Whetstine, 2008: 72). Frequently, however, medical practitioners simply followed the time-honored practice of waiting for the onset of the putrefaction of the body (Powner et al., 1996: 1220). Indeed, it was this latter test that led to the widespread use of mortuaries: a site in which corpses could be left to putrefy in hygienic isolation (Alexander, 1980: 29). In the process, death underwent a gradual disappearance from everyday lived experiences in the public sphere and subsequent reappearance as a proliferating subject of scientific, statistical, medical, sociological, and actuarial discourses (Bayatrizi, 2008: 6).

It was during this period that the concept of ‘pre-mature’ death became firmly entrenched in the bio-logics of governance; the moment when death as preventable risk became established. Through the writings of John Graunt and William Petty, as indicated earlier, death became something calculable and, by extension, something to be managed. As Bayatrizi explains:

physicians, environmental epidemiologists, philanthropists, and statisticians highlighted as problematic deaths caused by accidents, epidemics, malnutrition, and negligence. Although no specific term was used to designate these deaths, what they all had in common was that they were now deemed to be unnatural, that is, ultimately avoidable and therefore, in a sense, ‘premature.’ They included any form of death that could be considered preventable, depending on the state of medical knowledge and public health, as well as on the extant cultural expectations of longevity. Unnatural death was implicitly contrasted to the notion of a timely death that happened at the end of a fulfilled life and resulted from ‘natural’ causes, which meant from conditions associated with old age. (Bayatrizi, 2008: 52–53)

Over time, as medical knowledges and technologies transformed, so too did the concept of ‘natural’ death. Indeed, the most salient transformation from a purely bio-logic conception of death to a bio-politically informed understanding of death occurred in 1968 when criteria for a condition that would become known as ‘brain death’ were established. In that year an Ad Hoc Committee of the Harvard Medical School declared the non-functioning brain to be the fundamental medical criterion of death. ¹ As Kaufman and Morgan (2005: 329) attest, this single administrative action ‘moved, blurred, and troubled the traditional boundary between life and death, a boundary which had never before been publically questioned or clinically debated’. As Giacomini (1997: 1465) writes, this would transform a whole class of bodies under intensive care from ‘patients’ into ‘corpses’.

On one hand, the 1968 decision can be viewed as a reflection of decades of medical advances designed to delay death. On the other hand, the decision introduced a new ‘form’ of death, one with far-reaching implications. Prior to the 19th century, for example, when a person’s heart stopped beating and/or his or her breathing stopped, death was all but inevitable. However, during the mid-19th century techniques for artificial respiration were developed, coupled with advents in resuscitation techniques. By the mid-20th century, cardiopulmonary resuscitation (CPR) became the standard practice, as artificial respiration was combined with chest compression (Fry-Revere et al., 2010: 39). The ‘Iron Lung’ was introduced in the 1950s, and the first successful organ transplant (of a kidney) was performed on a human body in 1954. Throughout the 1960s, basic research on animals explored the possibilities of transplanting a myriad of body parts, including vital organs, whole limbs, digits, breasts, teeth, uteruses, and even brains. Prospects for human clinical trials included transplantation of the liver, heart, brain parts, lungs, bone marrow, intestines, connective tissue (including skin), hair, and even the gonads (Giacomini, 1997: 1468). In short, the medical profession was prolonging life in an attempt to ‘prevent’ death.

However, biomedical advances in the realm of organ transplantation had the perverse effect of lengthening the life of one body at the ‘expense’ of another. This point cannot be overemphasized: death became relational, in that one person’s death (i.e. the taking of life or, more euphemistically, ‘letting die’) could mean another person’s life (i.e. the making of life). Whereas CPR is a practice conducted on one body, with the intent of saving that body’s life, the practice of organ transplantation is dependent upon two bodies: the organ ‘donor’ and the organ ‘recipient’. This relational component of death (and life) would have wide-ranging effects, in that it introduced a calculus into our understanding of death – a trade-off between bodies – where the disallowance of life for one body (the ‘brain dead’ patient) could give life to another body (the donor recipient).

This co-relational approach to death created (or, arguably, responded to) a ‘demand’ for organs – but also the necessity for a class of bodies that would occupy a threshold space between ‘death’ and ‘life’. Simply put, biomedical advances and the bio-technological improvement in life-support devices made open-heart surgery and heart transplants possible; likewise, the artificial kidney increased the longevity of end-stage renal disease patients, thereby increasing the demand for kidney transplants (Giacomini, 1997: 1469). However, a major cause of failure in kidney transplants (among others) at the time was the use of cadaver organs that had deteriorated during or after the conventional death of the donor. In other words, successful transplants were predicated on the ability to shorten the time (and sometimes space) between ‘death’ and ‘organ removal’. Waiting too long for dying to take place would risk damaging viable, transplantable organs. The argument was that if a patient was irreversibly ‘dead’ – although still somewhat living – it should be possible (permissible?) to retrieve those organs that might save the life of another patient. Thus, adopting a strong utilitarian position, it was determined that one patient would be disallowed life so that another may live. As Giacomini (1997: 1470) writes, ‘the brain-dead could not be allowed to become “too dead” for the purpose of organ donation’.

Since 1968 we have witnessed the confluence of both bio-political and bio-economic understandings of life, death, and the body-object in that each new technique that has been developed to ‘establish’ brain death has been accompanied by concerns to facilitate organ transplants and/or financial concerns surrounding health care spending (Giacomini, 1997: 1465). As Sharp observes, today:

the human body is a treasure trove of reusable parts, including the major organs (lungs, heart, liver, kidneys, pancreas, intestine, and bowel); tissue (a category that includes bone, bone marrow, ligaments, corneas, and skin); reproductive fragments (sperm, ova, placenta, and fetal tissue); as well as blood, plasma, hair, and even the whole body. (Sharp, 2006: 11)

Consequently, with over 150 ‘reusable parts’, the cadaveric human body is worth more than US$230,000 on the open market; these ‘parts’, moreover, circulate within a biomedical market that is worth billions (Sharp, 2006: 11).

It is precisely the ambiguous status of the living cadaver that permits the possibility of more than one calculation of its condition as either alive or dead (Lock, 2004: 137). Consequently, it is this liminal position, of bodies as being neither wholly dead nor wholly alive, which imparts their value. Kaufman and Morgan explain, for example, that there exists:

[a] growing number of liminal beings who hover in an ambiguous zone between life and death: the long-term comatose, severely demented, unconscious or minimally conscious. These states of being – not-dead-but-not-fully-alive, sustained by modern medical practices – destabilize and force a remapping of the notions of life, death, and person in different ways. (Kaufman and Morgan, 2005: 330)

The concept of ‘brain death’ therefore was not discovered; rather, it was invented to allow health-care professionals unilaterally to remove patients from life-support devices without fear of liability (Fry-Revere et al., 2010: 42). Indeed, ever since the first organ transplants were conducted, a pressing ethical concern surrounded the practice: by removing healthy organs, such as the kidney, physicians were essentially violating their ethical imperative to ‘do no harm’. Moreover, concerns remained that the removal of organs might be considered ‘murder’ (Giacomini, 1997: 1468).

At this juncture, according to Whetstine (2008: 75), we see a fundamental change from being unable to determine death due to medical inadequacy to being unable to determine death because of scientific advancement. Indeed, the efforts of the Harvard Medical School did little to clarify our bio-logical understanding of death. With the publication of the committee’s report, two definitions of death became widely recognized: the ‘traditional’ cardio-pulmonary death, and the newly invented brain death (Lock, 2004: 138). Not surprisingly, such medical confusion permeated the legal system. In 1970, for example, Kansas became the first state to pass legislation to establish the legal validity of brain death, wherein brain death was to be ‘based on ordinary standards of medical practice’ in which ‘there is an absence of spontaneous brain functions’ (Fry-Revere et al., 2010: 29). In 1972, however, Capron and Kass proposed an alternative definition: brain death occurs if and when respiratory and circulatory functions have irreversibly ceased and are only continued through artificial means. This was followed, within three years, with the establishment of the Model Definition of Death Act, developed by the Law and Medicine Committee of the American Bar Association. This definition abandoned the cardio-respiratory determination of death in favor of criteria of irreversible cessation of total brain function.

By the late 1970s there emerged a complex legal geography of death, with at least 30 different sets of criteria laid out by various advisory groups to be used when making a diagnosis of brain death. Consequently, in 1981 a special President’s Commission proposed a Uniform Determination of Death Act (UDDA), which was immediately supported by the American Medical Association and the American Bar Association (Lock, 2004: 139). Nevertheless, in the United States there is currently no medical consensus with respect to brain death – as four different criteria for ‘death’ are currently in use in the United States. The UDDA has been adopted legislatively in 38 states and two US territories, and judicially in two additional states; the remaining 10 states use one of three alternative definitions (i.e. the Uniform Brain Death Act, the Capron-Kass Model, or the Kansas Model) (Fry-Revere et al., 2010: 44). As such, when someone is pronounced dead is often a function of where they are pronounced dead. There is, in other words, a distinct bio-legal geography to the condition of mortality in the United States.

IV Conclusions

Although ‘mortality’ is somewhat off the radar screen of population geography, the study of death permeates Geography and the social sciences more broadly. In this progress report I have considered the emergent literatures that have taken seriously the embodiment of mortality and, by extension, the more fundamental – and vital – questions of life itself. I have highlighted the various and overlapping bio-logics of mortality; the advent of technologies designed both to ‘shape’ the body-object but also to ‘cheat’ death. Population geography is well positioned to contribute to these ongoing debates, for the geographic study of population was and remains pivotal in the development of bio-political, bio-economic, and bio-legal logics and the ordering of life.

The world, as Castree and Wright (2005: 4) lament, is ‘rife with fatality and almost incomprehensible suffering’. They acknowledge the existence of, among other problems, disease, starvation, malnutrition, poverty, gender inequality, sexual discrimination, and environmental degradation. These conditions, of course, are determinant of observable patterns of mortality, of the unequal life-chances of one’s survivability. These are also long-standing topics of population geography, and population geographers have made (and continue to make) significant contributions to the empirical understanding of mortality (e.g. Billingsley, 2011; de Sherbinin, 2011; Storeygard et al., 2008). It is time, however, to adopt a parallel tack, to chart new geographies of mortality and premature death; to critically interrogate those bio-logics of life that inform how certain populations have been rendered disposable, wasted, or precarious (cf. McIntyre and Nast, 2011).