Staying Alive

The distinction between states of living and states of death is one of the fundamental binaries that organise western thought with regard to the nature of human existence. For all its apparent self-evidence, however, that crude split between living and dead has never fully captured the complexity of the possibilities where, at the very least, the category of not-yet-born throws into relief both the problematic relation of a functioning organism to notions of the self and to the question of temporality and spatiality. Whether it is at the beginning or the end of the conventional life span, the moment and indeed the place in which life can be said to exist has always been highly contestable. In the contemporary context, the binary of life and death has become increasingly insecure and uncertain in the face of biomedical technologies that seek to intervene in processes that once seemed natural and inevitable. In this article, I shall focus on the field of human organ transplantation, and most particularly that of heart transplantation, as the site at which the encounter not only between self and other, but between what we conventionally understand as life and death is tested to its limits. In such scenarios, the relationality of self to other is irreducibly intertwined with questions of mortality – both mine and hers – to the extent that the affective context in which transplant recipients experience and communicate an ongoing sense of self is shot through with at very least anxiety, but more deeply a profound ontological uncertainty.

While all organ transfer from a deceased donor invokes concerns about the immanence and imminence of mortality, the issue becomes particularly acute in the context of heart transplantation, where the organ itself carries all the cultural baggage of being considered not just biologically, but metaphorically, the seat of life. We are historically invested in the significance of the heart in a way that, in western society at least, does not extend to other transplantable organs such as kidneys or liver, although recent developments in the area of face transplantation seem destined to open a scenario that is equally a focal point of a public fascination that always borders on unease. Nonetheless, the authorised narrative of the transplant clinic is one in which the rhetoric of hope leaves little room for any exploration or understanding of the more negative affects and emotions that recipients may experience. ¹ Yet staying alive is no simple outcome, and the question of whose life has been prolonged is far from clear. Accordingly, I want to raise the question of how the trope of the ‘gift of life’, as the donated heart is commonly called both in lay discourse and by those engaged in transplantation procedures, imbricates with the alternative clinical term of a ‘graft’. For recipients of donor organs, the experience of living on in the face of otherwise certain death is fraught with complex emotions not only about the self and the now dead other, but about the persistence of the other within the self. In contrast to our expectations of the feel-good narrative of the gift of life, recipients are often significantly troubled by the aftermath of the procedure, which may fundamentally challenge notions of personal identity (Poole et al., 2009), as well as having deep implications for our understanding of the relation between death and ‘staying alive’. Drawing on recent research into heart transplantation, I shall theorise the field through a reflection – drawing on both Mauss and Derrida – on the meaning of the gift, before moving on to consider whether a Deleuzian approach to both the assemblage and the ‘event’ of death might offer a more productive framework. ² This is research in progress and the latter element remains in early development.

Before engaging fairly briefly with some of the empirical components that underlie my main concern with developing a theoretical framework, I want to look briefly at the historical context in which heart transplantation has emerged as a biomedical procedure that speaks to a range of both positive and negative emotions. The grounding science of cardiology is properly linked to the early 17th-century physician William Harvey, who is credited as the first to record the circulation of the blood and the function of the heart. Long before that familiar marker of the Scientific Revolution, however, the heart was seen – most famously by Aristotle – as the principal organ of the body, the centre of intelligence, motion and sensation, and human vitality. Western medicine has been even more influenced by the 2nd-century ce physician, Galen, who, though believing that the liver was the more important organ in terms of function, claimed in his treatise On the Usefulness of the Parts of the Body that the heart was most closely related to the soul. Despite increasing sophistication in portrayals of human anatomy in the early Renaissance, it was not, however, until William Harvey’s major work, De Motu Cordis (1628), that a strongly empirically based account of the cardiovascular system first appeared (Shildrick, 2012). What is significant is how clearly his then startling claims were mediated by spiritual language. As Harvey puts it:

So the heart is the beginning of life, the Sun of the Microcosm, even as the Sun deserves to be call’d the heart of the world; for it is the heart by whose virtue and pulsation the blood is moved, perfected, made apt to nourish, and is preserved from corruption and coagulation; it is the household divinity which…is indeed the foundation of life, the source of all action.

What is evident is that the newly emerging empirical science was still rooted in a reliance on the same types of explanatory metaphor that flourished in lay accounts of natural phenomena, where the heart was the symbolic focus of multifarious cultural, religious and cosmological beliefs. In Catholic mysticism of the 11th and 12th centuries, for example, the so-called Sacred Heart became an object of devotion that was gradually institutionalised over the following centuries. Referring to the substantive physical heart of Christ, it represented, nonetheless, a spiritual offering, a gift to humanity that signalled Christ’s divine love for human beings (Manning Stevens, 1997). And it is this sense of the heart as a gift – effectively an object of exchange – that underlies the contemporary narratives that frame the surface acceptability of transplantation while at the same time provoking, I will argue, the unease felt by recipients. As a surgical procedure developed in the late 20th century – it is just over 40 years since the first human to human transfer – heart transplantation remains strangely intertwined with the beliefs and imagery of the past, but it is not so much the symbolic connotations that disturb the ideal functioning of a successful transplant as the way in which the biomedical imaginary itself is shot through with metaphors that express an inherent confusion about the nature of the transaction.

In wholly unproblematised terms, transplantation is the most successful treatment – often the only hope – available for those with end-stage heart failure. Those who are listed for transplantation have effectively been told they will die without the procedure, and that their only potential for prolonging life is the limited possibility of getting a replacement heart, which relies at least on tissue-matching, and a donor family willing to consent to the procedure. In most cases, the donor will have suffered fatal trauma and most likely have been kept alive temporarily on a ventilator. Once brain death has been ascertained, the heart and other organs and tissues of the body are maintained in a stable functional state until surgical procedures to remove them have begun. In most cases, the donor heart is injected with potassium chloride in order to stop it beating, before removal from the body. Once packed in ice, the donor heart can be preserved for a maximum of six hours, before implantation and electro-shocking to restart it. A newer procedure called ‘beating heart’ surgery – that allows for longer periods between excision and implantation – involves connecting the donor heart to a machine that pushes a continuous supply of oxygenated blood through it, enabling it to continue beating. In effect cardiac death never occurs. As I am focusing on the experience of staying alive, I will not address further the controversies surrounding the vexed conventional definition of death, ³ as, perhaps surprisingly, it does not appear to be a concern raised by recipients themselves.

The language surrounding transplantation procedures is uncompromising, particularly in depersonalising the source of the organs: even now the recently living source of the organ is sometimes referred to as a cadaveric donor – although the approved term is now ‘deceased’ – and most clinicians speak of organs being harvested or retrieved, as though they have been ‘grown’ for that purpose alone. Recipients clearly do recognise, however, that their own lives depend on the death of another, and that in willing the availability of a suitable organ, someone else must die. Not surprisingly, the emotions felt by recipients towards their donors are extremely complex, at the simplest level often involving guilt, as well as admiration and empathy for the donor family. Life and death are irreducibly intertwined: the death averted, the death wished for, and the life renewed, not only for the hitherto dying heart failure patient but in a powerful, albeit magical, sense for the donor too. The more the heart is seen as the metaphoric centre of an individual life, as the locus of the soul, the more likely it is that the continuing functioning of that heart will carry with it intimations of the donor’s personal characteristics. Even at its most dispassionate, biomedical terminology already picks up on something of this in the term ‘organ graft’. The term is usually associated with horticulture, where grafting is the process whereby foreign tissue is spliced into or sutured onto the structure of an existing plant, thereby producing a hybrid. Usually the ‘recipient’ host plant, called the rootstock, is selected for the strength of its roots, while the other, the scion in technical terms, is selected for its foliage and fruits.

There are two ways of reading the trope of the graft which I shall develop later. The first is that, as in horticulture, the human body, following transplantation, is inevitably scarred, visually testifying to the vulnerability of the body and metaphorically to the insecurity of identities. If in the general economy of grafting, the graft is enacted as an enhancement of previously atomistic elements, then it also reveals the failing of the self/other distinction. The one and the other are recovered from their binary isolation to come together in what it is hoped will be a flourishing hybrid form. For many people, that loss of distinction is already a threat, but the second reading of the graft is rather more disturbing. In horticulture, the intended outcome of grafting is the propagation of the genetic make-up of the scion, not of the rootstock, which surely makes it a strange metaphor to choose for organ transplantation. The clear implication is that it is the donor and not the recipient who lives on, making it difficult to avoid the thought that a form of parasitism is at stake.

Let me place this in tension with another phrase prevalent throughout all stages of the transplantation process – both in and out of the clinic – that makes no claims to the ostensibly technical. I refer to the ubiquitous slogan ‘the gift of life’, which is widely understood to denote not simply the transplant organ itself but the whole process by which the recipient’s life is taken back from imminent death. It is precisely the kind of good news rhetoric that recipients, donor families, transplant teams and the wider public alike feel unconstrained in using insofar as it appears to offer a wholly positive take on what is, after all, a profound and bloody assault on the much-vaunted integrity of the embodied western subject. Who would not want to give or receive the gift of life? Yet, as I understand it, that apparently uncomplicated phrase does not simply obscure the less acceptable aspects of transplantation as an advanced biomedical procedure that takes intervention into the human body to its limits, but it also produces its own layers of unintended disturbances. Not least of these, and one that is apparent to both the most casual observer and those most invested in the success of the process, is the disjunct between the routinely depersonalised language of the clinic – which buffers medical professionals and lay participants alike against the more disturbing aspects of transplantation – and the highly personal connotations of the gift of life. The authorised language of clinicians promotes an image of heart transplantation as an emotionally disengaged exercise in spare part surgery where the recipient is a quasi-disembodied and autonomous agent making rational choices about the care of her own body, and where success or failure depends largely on technical skill. In stark contrast, the rhetoric of the gift speaks to a very human provenance for the donor organ, to implied agency on the part of the donor, and to a transaction that locks the recipient into a relationship not of their own choosing. ⁴ There is then a fundamental contradiction between the messages – imperatives one might say – aimed at recipients. They are expected to treat the intervention into their bodies both as a purely technical procedure with few consequences for their sense of self and as a point of connection to an other, whose very death has given them life, and with whom they are expected to be emotionally engaged. It is little surprise that many recipients express high degrees of disturbance in the face of such incompatible demands (Ross et al., 2010).

To those familiar with the structure of the western logos, it is clear that what is at stake, and indeed what cannot hold, is a machine model of the body in which the sovereign subject merely inhabits a material housing. Biomedicine in general is deeply invested in the Cartesian mind/body split such that anatomical and physiological knowledge is supposed to have no bearing on the embodied self. The notion of spare part surgery – whereby transplantation is simply a procedure to replace a failing organ with a better functioning model – speaks ideally to bodies that are objectified, subject to external control, and divested of any emotion. The Heart Transplant Manual, for example, given to all those listed for transplant at the hospital where my research is situated, ⁵ is meticulous in providing a step-by-step guide to potential patients that takes in variously the work-up, the intensive programme during the immediate post-operative period, an explanation of multiple medications, tips on diet and exercise, a break-down of ongoing health checks, and a warning about possible physical side-effects such as cancer or diabetes. What it scarcely addresses in its 173 pages is any of the emotional effects that transplantation might be expected to evoke. A single page introduces the Transplant Psychosocial Team and makes clear that their reports on individuals form part of the initial compulsory assessment of suitability, and that they will help with stress, but the determined emphasis is on putting patient concerns ‘in perspective’. The manual does acknowledge that the indefinite waiting period may be one in which feelings of ‘fear, impatience, or discouragement – even anger – are normal’ (Heart Transplant Manual, 2000: 35), but the absence of any address to the extended post-transplant period effectively situates those feelings as short-term and easily resolved. The unavoidable implication is that emotional concerns are of limited importance to the well-balanced recipient: the heart itself is simply a pump whose function has become compromised. Given such a context, many of those listed as waiting recipients do enthusiastically adopt the machine model of the body at a surface level, though few are able to maintain it at depth or over time.

Part of that slippage relates specifically, as I have indicated, to the gift-of-life discourse that is encouraged – as though there were no contradiction – alongside the non-emotive functional account. The Heart Transplant Manual itself opens with a note of the philosophies that guide the transplant team in which the nature of donation is given privileged place: ‘We believe that our work is only possible through the generous act of organ donation and our efforts must honour these remarkable gifts from organ donors and their families’ (2000: 7, emphasis added). In a later remark, donation is explicitly identified as ‘an altruistic act based on the kindness and generosity of the donor family consenting to donate a loved one’s organs and tissues at a time of considerable stress and grief’ and, it goes on, ‘[d]onor families gain considerable benefit from the act of donation’ (2000: 33). With the enduringly inadequate rates of organ donation in mind, it surely makes sense within the economy of transplantation to give public recognition to donors, but the remarks here, remember, are addressed not to the givers, but the potential receivers, to those facing the imminent death of end-stage heart failure. Up to one-third of those listed for transplant will die on the waiting list precisely because a matching heart was not donated. ⁶ It would be remarkable if potential recipients did not wish at some level for the death of a suitable donor. The manual has nothing to say on this point, or indeed about the death of the donor more generally, and for the most part more strictly biomedical concerns prevail until a final unexpected return to the notion of the gift on almost the final page. There the likely recipients learn that they will be ‘encouraged’ to write a letter of thanks to the donor families during the first year post-transplant. The manual recognises that the task may be a daunting one for recipients but assumes that they will in fact want to thank their donors through the proxy of the family, albeit with anonymity maintained. And to reinforce the sense not simply of gratitude, but rather of obligation, it adds: ‘such thank you notes can be a comfort to the donor families as they come to terms with their loss’ (Heart Transplant Manual, 2000: 171). In our empirical research it was found that thinking about the letter was a significant point of emotional disturbance for an overwhelming majority of recipients, whether or not they actually wrote it:

The donor letter was discussed by 24/25 recipients, 20 of whom displayed distress manifested as verbal expressions of loss, anxiety, despair as well as physical expressions such as crying, sighing, being teary eyed, suddenly dropping the tone of voice or volume and struggling to control emotions. (Poole et al., 2010: 620)

In fact a full 15 of the participants visibly cried when discussing the thank you letter. As Patient 6 explained, ‘I don’t know how to say thank you…it’s not…not enough, it’s not enough… I really owe them something.’

The situation, then, is one in which, even before transplantation, recipients are exposed to the gift-of-life discourse while at the same time being expected to view the procedure as spare part surgery. The resulting tension is compounded, not just by a wider society which eagerly adopts the feel-good narrative of the gift that trumps death with life, but explicitly within the clinic itself. For organ transplant teams, the powerful gift discourse provides both an outlet for their own emotions and a useful counter to the wider revulsion that might otherwise be invoked by the functionalist view of the graft (Joralemon, 1995). At the facility where the empirical research is grounded, all recipients must attend for a period of several years – and intensively in the immediate post-transplant period – an ambulatory clinic for regular follow up. At the entrance to the clinic stands what is known as the Transplant Wall, where previous donors are memorialised by their friends or family. The wall consists in 60 photographs of deceased donors with short accompanying texts, a great number of which refer explicitly to the gift and to the notion of living on. The note for Mike, for example, reads: ‘His gift of organ donation ensures he lives on through the lives of others’; Dawn is memorialised with the words: ‘Organ donation was her precious and generous final gift to the world’; while the family of Sam write: ‘in a way he is still living while healing other lives’ (my emphases). As is clear from these short quotes, the donor families comfort themselves not so much in knowing that the life of an anonymous third party has been prolonged, but that their own loved one is somehow staying alive.

It is difficult to generalise from culturally specific data (see Shaw, 2010a) and some empirical research from both the US (Siminoff and Chillag, 1999) and New Zealand (Shaw, 2010b) suggests that, for donor families, the notion of the gift as such is relatively unimportant. This does not appear to be the case for the public expression of Canadian donor families, though they have yet to speak of their concerns in the more intimate context of the interview, which may yet uncover a different ordering of priorities. ⁷ What all families, recipients and transplant teams have in common in the developed world is an intensive exposure to a social discourse that promotes the gift as the right and proper figure for organ donation. Rhonda Shaw (2010b) surmises that the proximate reason may be in order to draw a distinction between the supposedly altruistic act that informs unpaid organ donation and the murky world of organ trafficking, where human material is just another commodity to be traded in exchange for money or benefits. As she notes:

In distancing donation from commodification and the potential to degrade and exploit human beings, it is assumed that gift rhetoric transmits the positive message that donation is a noble and morally worthy act. (2010b: 612)

Nonetheless, the concept of the gift of life is a highly complex one that serves many other important functions.

In everyday understanding, the giving of a gift – insofar as it remains non-trivial – is often seen as a wholly commendable act of altruisim that expects no reward. ⁸ The organ donor and her proxies are thus characterised as inherently beneficent, acting for the good of others, and there is indeed little sense – in the absence of overt recompense – in which one could speculate on unworthy motives. That is not to say, however, that donors are not constrained in their supposed generosity, and several writers, from Fox and Swazey (1992) in the early work through to Scheper-Hughes (2007), have drawn attention to the so-called ‘tyranny of the gift’, whereby live donors in particular feel under some form of obligation to give up organs and tissue to kin facing serious illness or death. While we would like to suppose that donation is the altruistic free choice of a rational agent, that may not always be the case. I am more concerned, however, with the experience of receiving the gift, where the conflict of emotions is likely to be much more immediate. Regardless of the assumption of altruism, any recipient is liable to be subjected to feelings not simply of gratitude for their own death averted, but of obligation. Aside from the deep guilt that many recipients report, which locks them into a very personal response towards the now dead donor and grieving proxies – someone, after all, has had to die to provide a heart – there is a sense in which a gift must be repaid. In transplantation discourse the most usual way of theorising the nature of the gift is with reference to Marcel Mauss’s groundbreaking anthropological study of the 1920s, The Gift: The Form and Reason for Exchange in Archaic Societies (1990 [1950]). For Mauss, the gift relationship has three distinct elements – giving, receiving and reciprocity – and it is in the latter modality that difficulties arise. If the gift is one of life, how can the donee reciprocate in any adequate way? The tyranny of the gift plays out not only in relation to the donor but to the recipient, for whom the putative incommensurability of the gift relationship is always a potential burden.

In a classical gift relationship, as initially analysed by Mauss (1990 [1950]), and revisited by Derrida in Given Time (1992), the salient point is that the bond of reciprocity between giver and receiver mobilises a complex cycle of obligation and indebtedness. For the recipient to acknowledge the attribution of altruism on the part of the gifter is already an intangible – but inadequate – recompense, and she may feel obliged to express at very least gratitude, but more likely some more substantial return. In his own analysis, Mauss maintains that the gift has the necessary function of shaping societal relations through imposing a social bond, and although he is concerned with pre-technological societies, it is clear that the transfer of organs is equally caught up in a system of exchange that requires personal and communal acknowledgment of the beneficence of the donor. At the same time, the immediate problem, of course, is, as Gail Davies notes in her research on kidney donation, that ‘attempts by either donor or recipient to construct a social relationship is viewed by professionals as pathological, something to be treated through counselling’ (2006: 8). The result is an insoluble tension between the symbolic demands of the gift and the emotionless discourse of spare part surgery. In the case of cadaveric organ donation, the return is to a proxy – usually a family member of the donor – and it is far from unusual for recipients to wish for and in some cases to seek out a quasi-kin relation with the other, a move that for similar reasons is often mirrored on the donor family side. And tellingly, Derrida – to whom I will return – refers explicitly in Given Time to organ donation, and asks: ‘has the gift ever been thought without the family?’ (1992: 17, fn. 8). The assertion of putative kinship shows the depth of the emotional investment in which the organ of the deceased donor is understood to carry with it aspects of that person’s being in the world. The newly embodied recipient is not after all restored to herself as a sovereign subject, but by virtue of the gift becomes intercorporeal and may even feel that she has incorporated, not a transferable material object, but something of the donor’s essence. This should not surprise us, for as Mauss understands it, any donation exceeds its immanent materiality to figure something intrinsic to the giver herself. He writes, ‘one gives away what is in reality a part of one’s nature and substance’ (1990 [1950]: 10) and that ‘the objects are never completely separated from the men who exchange them’ (1990 [1950]: 31). ⁹

What a consideration of Mauss introduces into the equation is a complexity that entails recognising that the gift has a symbolic dimension completely at odds with both the bare positivist discourse of the sick body as a malfunctioning machine, and of disinterested altruism. In the case of heart transplantation, the gift circulates between the living and the dead and sets up an economy of exchange in which the obligation of reciprocity, and its affective correlates, shifts endlessly between donors and their proxies and recipients. Once recipients have written to donor families, for example, they usually want a response, and the desire for kinship goes in both directions. But, to return to my earlier question, how would the understanding of the transplant as a graft – the incorporation of a living and possibly dominant strangeness – imbricate with the gift. In that respect, it is Jacques Derrida’s theorisation of the gift and of the nature of hospitality that is perhaps more relevant. Where Mauss (1990 [1950]) sees the gift as the occasion of continuing obligation in the structural relation between self and other, Derrida (1992) has attempted to reconfigure its significance. The gift of a heart seems to fit well with Mauss’s observation that ‘to accept something from somebody is to accept some part of his spiritual essence, of his soul’ (1990 [1950]: 12), and it begins to explain recipient experiences of an internal otherness that may disrupt the sense of self. In contrast, Derrida rejects the notion of a sovereign self whose singular identity and integrity is compromised by acceptance of the gift unless it be remitted by reciprocity – a move that re-establishes the interval between self and other but, he says, inaugurates a ‘whole sacrificial bidding war’ (1992: 24) – and sets out an alternative that is not reliant on exchange. In the Derridean reconfiguration, a gift ‘must not circulate, it must not be exchanged, it must not in any case be exhausted, as a gift, by the process of exchange’ (1992: 7); indeed, once there is reciprocity, there is no gift. The moment a gift is recognised as such by either donor or donee, it ceases to be one. ¹⁰ In effect, the unconditional gift – the only form worthy of the name in Derrida’s understanding – is, as he acknowledges, impossible. What underlies Derrida’s approach, of course, is his familiar move to deconstruct the relation between self and other, and it is in that mode that the impossible gift may reappear as an aspect of unconditional hospitality.

In his later work (1993, 2000), Derrida’s focus on the gift as potentially the occasion of an ambiguous and uncertain opening to the other is extended into the modality of the host and of hospitality. In the word ‘host’, we can immediately discern the question of the graft and, as before, the analogies with organ transplantation are plain to see. The transplant recipient is indeed host to the graft, but as Derrida shows, the structure of the relation is unstable: ‘the guest becomes the host’s host’ (2000: 125). In ‘staying alive’ the donor heart nurtures the recipient’s survival. The ethical imperative of absolute hospitality, as Derrida understands it, demands that the host sets no limitations on what crosses her threshold (in our scenario, the boundaries of the embodied self), ‘but must offer an unconditional welcome, which devolves not on the claiming of a right, nor on the expectation of assimilation and possession, but on an openness to a difference that will never be an object of knowledge’ (Shildrick, 2013). Put in the material terms of transplantation, this entails that the heart recipient should acknowledge that, in incorporating the living organ of another, she cannot expect that it will become a comfortably integrated part of her embodied self. Theoretically, the other remains irreducibly other, and biomedically the difference of the donor’s DNA is never expunged. In short, the recipient must willingly accommodate the unknown other within. It is a reminder of what Derrida calls ‘the general problematic of relationships between parasitism and hospitality’ (2000: 59). In the form of unconditional hospitality, then, there can be no expectation of homogeneity, stability or certain benefit; rather, the host is radically exposed to the risk of the unknown and unforeseeable. For Derrida, hospitality is something freely given before any identification – in material terms, recipients are never told of the provenance of the graft – and it must be open to the other ‘without knowing what or whom to expect’ (Derrida, 1993: 33). Moreover, once the threshold is crossed, the boundary between self and other is displaced and the host herself is irrevocably changed. In Derrida’s words, the arrival of otherness is ‘enough to call into question, to the point of annihilating or rendering indeterminate, all the distinctive signs of a prior identity’ (1993: 34). ¹¹ On an ontological level, recipients do frequently struggle to negotiate their newly hybrid identities, while in substantive terms, even naming the transplanted organ as their own – as the authorised discourse expects – is a point of anxiety. There can be no simple assimilation: the other is both constitutive of the self and remains excessive. In material terms, the genetically different organ of the deceased donor is simultaneously the possibility of the self’s survival and the precise focus of an immunological onslaught that, if rejection succeeds, kills both the graft and the host. The relation is transformative: in opening up to an irreducible difference, the rigid boundaries that hold apart self and other, and life and death, give way to the becoming of an intercorporeal and atemporal self.

But is an intercorporeal self the limit of how we might theorise transplantation? Just as the biomedical impulse is always aligned to the desire to stave off death, it is no less committed to the preservation of the singular self. To say that something is intercorporeal, then, already strains the distinction between self and other, without entirely effacing them. The experience of organ donation suggests we might go further, however, in theorising a fundamental hybridity that in transplantation discourse is as much an anathema as the intimation of a parasitic graft. Hybrids and parasites alike challenge the established order of things, and particularly the classificatory claims of biomedicine. Yet beyond a surface acceptance of the machine model of the body in which the core self is undisturbed by the donor organ, many transplant recipients have already instinctively passed that step and express a deep disturbance with regard not simply to body parts, but to questions of self-identity (Sharp, 1995; Shildrick et al., 2009; Shaw, 2011). The problem is that, although popular culture is full of narratives and images of transferred identity, neither of the problematic discourses respectively around the gift of life or on spare part surgery enable recipients to voice their fears and anxieties with regard to that concept. Regardless of the actual lived experience of embodiment post-transplant, the organ recipient is still encouraged to say ‘I have her heart inside me.’ To make any difference in the facility of recipients to address the question of identity disturbance, what is really needed is a shift in the socio-cultural imaginary away from the standard of an invulnerable sovereign subject and towards a notion of corporeal indeterminacy. Such a realignment takes us well beyond the Derridean reworking of hospitality as a significant step that establishes the fundamental interiority of otherness, and elucidates the specific experience of heart transplantation, and moves towards the more radical break made possible by Gilles Deleuze. To contest the boundaries of embodiment in a Deleuzian way would, I suggest, equally entail a rethinking of death. I want to end then with some incautious speculations on where a Deleuzian approach might mitigate some of the damaging, and yet almost inexpressible, anxiety around both organ transplantation and the prospect of our own mortality.

At the heart of Deleuze’s philosophy is a decisive break with the notion of an atomistic subject – the sovereign subject of modernity – that celebrates not static ‘being’, but a state of becoming. In the later work, that state tends towards the notion of becoming other/imperceptible (Deleuze and Guattari, 1987) in which any individual subject is always in a process of unravelling. Each of us is caught up in multiple and unpredictable webs of connections – what Deleuze calls assemblages – in which life itself is characterised as a non-personal vitalist force that exceeds the unique interests and experiences of each individual (see Braidotti, 2006). For Deleuze, then, life is marked by potentiality, by the generative power of connection and the unending processes of transformation. Such an approach is highly apposite for our technologised society, and may be particularly useful in rethinking deceased donor transplantation as an ongoing project, not only for the recipient but for the donor too. In Deleuzian terms, life is not a discrete essence, book-ended at the point of birth and death by non-existence, but ‘a plane of immanence’ (2001: 168), which, although it is continually actualised in the individual body where it has personal value, marks that body as simply an element in the broader cycle of becoming. The course of human life is clearly marked by discrete events where things change or transform, but in another sense, events are also incorporeal forces and intensities that are atemporal and excessive to any discrete location. In those terms, the death of a human being is both the final dissolution of a singular existence and the juncture at which the individual actualisation of life is subsumed by a non-personal vitalism. As Rosi Braidotti succinctly puts it: ‘It’s organisms that die, not life’ (2006: 143). There is no doubt that my own death marks the limit of my personal relations and the cessation of my self-identity, but it not an absolute closure. Rather, the event of dying is a further opening, another moment of becoming. As Deleuze puts it:

Death has an extreme and definite relation to me and my body and is grounded in me, but it also has no relation to me at all – it is incorporeal and infinitive, impersonal, grounded only in itself. (1990: 151)

So how would this look in terms of organ transplantation? In the liberal humanist context in which only individual identity counts, it is understandable that donor families wish to see the donor living on in another. But in the Deleuzian rethinking of mortality, individual ‘ownership’ of life gives way to the intensity of continued becoming in a process with neither beginning nor end. In that sense, the individual instance of the donor’s death continues to contribute to the ongoing flux and flow of life, temporarily manifest in one or, more likely, several recipients. Even within the current understanding of donation there is a strongly Deleuzian element insofar as each deceased donor body will provide on average organs and tissues for around seven recipients, illustrating clearly the fluid and cross-cutting power of connectivity and assemblage. In an important sense, death itself is negated, but not by the transfer of personal characteristics to another. In Deleuzian terms, what matters in the personal survival of those receiving transplants is neither guilt about the demise of the donor nor feelings of obligation, but the capacity to affirm life, both in its renewed potential and in its endurance. Success would be not about functional efficacy as such, but what Braidotti has called ‘sustainability’, ‘the very possibility of the future, of duration, of continuity’ (2006: 137), mobilised through unprogrammed becomings. It would be the desire to enhance one’s potentialities through pleasure and pain alike. The relation between recipient and donor in such a model is an impersonal one in which both giver and receiver live on, not against the horizon of individual life and death, but in a new and unpredictable assemblage. The task of the recipient, then, would be to take on both the anticipated changes and the unexpected transformations that occur as a result of transplantation without ressentiment; as Deleuze puts it: ‘not to be unworthy of what happens to us’ (1990: 149). The good life, as he and Braidotti understand it, is one that exceeds material boundaries and temporal limits and transforms itself even in the face of adversity, moving always towards new possibilities of becoming other than itself. Finally if, for transplant teams and the wider public, the event of dying were seen as simultaneously the recomposition of life under new relations of sustainability – as in a very real sense donor families already construe it – then the incipient mortality of recipients would not be deemed a threat and the impulse to save life at all costs would be lifted.

For the time being, our socio-cultural imaginary remains caught up in quasi-Cartesian conceptions of the body that both allow for the surgical onslaught of heart transplantation and generate deep anxieties when the model fails to correspond with the lived experience of those undergoing the process. Organ donation is a disturbing and potentially painful process on all sides, loosely countered by the gift-of-life rhetoric that dominates the public face of transplantation without significantly alleviating the anxieties of those directly involved. The reconfiguration that I have discussed may look like an abstract exercise in thinking otherwise, but that is to fail to consider the affective implications of extensive interventions into the body. The exposure of the inherent plasticity of the embodied self, the ever more common assemblage of hybrid bodies that supersede the distinct identities of self and other, and the blurring of the boundaries between life and death, are all already apparent within the context of organ donation. I would suggest, finally, that our time is already Deleuzian, and that the meaning and processes of transplantation must be radically reassessed.