Organ transplantation is an ethically complex, deeply symbolic event which depends on a supreme human sacrifice – giving part(s) of one’s body, while alive or after death, to be placed within the body of another, a loved one or even a stranger. And yet, medical and bioethical discourse frequently reduces this field to a matter of biology and autonomous agents making decisions about bodies they own. Sherine Hamdy’s book based on an ethnographic study over two years in Egypt offers a much needed corrective lens to this view. Her book, perhaps the first of its kind from that country, weaves the historical evolution of kidney transplantation in Egypt over five decades (one chapter is devoted to corneal transplants) with in-depth interviews of patients undergoing chronic hemodialysis, their families, physicians involved in their care, Muslim jurists, and journalists.
Hamdy, an American anthropologist of Egyptian descent, paints a landscape in which the self is construed as collective, intricately bound in the lives of others, and where decisions to give or accept a kidney (or not) are shaped by kinship systems and local family norms, influenced by religious beliefs that life is transcendental and God owns human bodies. Hamdy uses a broad canvas. She examines the impact of political, social, environmental, and inadequate healthcare systems on the rising incidence of renal disease in Egypt, and explores what she terms the “crisis of authority” in medical and religious realms leading to loss of trust in the specialty and its practitioners (p. 21). In the author’s opinion a combination of all these factors, rather than fatawa of influential Muslim scholars ruling brain death and organ donation to be impermissible in Islam, lies at the root of the significant ambivalence, and even strong opposition, to kidney transplantation she finds among the public, patients, and many medical professionals in Egypt.
Perhaps the most important contribution of her book is the insight it provides to the range and depth of debates among Muslim jurists with respect to Sharia (Islamic Law) pertaining to brain death and organ transplantation, information not easily accessible in English. Since the 1980s, the majority opinion of Muslim jurists from Islamic centers in the Middle East, which is accepted as the “official” position, is that these are permissible in Sharia. However, as there is no concept of a central church requiring a uniform position, opposition to organ transplantation can be found among jurists (including from the Asian sub-continent). This is generally dismissed by Muslim physicians as “ignorance” or anti-science bias. Hamdy’s thoughtful examination (using interviews with muftis and reviewing fatawa) of the logic underlying this opposition is among the most informative, and relevant, part of her book. She refuses to be drawn into unhelpful dichotomies of the “scientific” and the “religious” or “conservative” versus “progressive” and thus avoids losing important nuances of the debate. The author contends that muftis whom the public esteems highly and perceives as “uncorrupt” are often those who oppose organ transplantation rather than state appointed jurists who rule this to be permissible in Sharia (Chapter 2).
The author narrates her fascinating interview of Egyptian grand mufti Shaykh ‘Ali Guma’a who in opposing brain death and transplantation argues that these are not merely “medical” but moral (religious) decisions that are also closely tied to the social, political and economic circumstances existing in the country (p. 73). Some of his concerns (potential for commodification of the body and commerce in human organs, loss of human dignity) echo those voiced over five decades ago by American theologian Paul Ramsey and philosopher Hans Jonas when brain death criteria were first introduced. Clearly, equating human death with “medically” defined brain death and its connections to obtaining organs from the deceased is not as universally settled a matter as medical science would wish it to be, a reality frequently ignored and unaddressed when attempting to introduce deceased donor programs in “non-Western” oriented societies.
The second half of Hamdy’s book includes narratives of patients suffering from chronic renal failure, many left with no alternative except hemodialysis, week after week, in ill equipped, poorly staffed and over stretched public healthcare institutions in Cairo and Tanta. Perceiving live kidney donation to be enormously risky – leaving donors with physical and sexual disabilities and women unable to bear children – patients are reluctant for family members to donate kidneys preferring to buy them instead (which ironically, few can afford). Hamdy argues, correctly, that unlike many Western countries, kidney donation is not seen as an “altruistic”, heroic act, or a “gift of life” heralding a “medical miracle”, but one that is so risky that it remains a last resort (p. 224). These views are not unfamiliar to physicians working in family-centered countries that share Egypt’s poor health care system and cultural and socioeconomic realities.
My own research in Pakistan (170 million Muslims compared to 84 million in Egypt), including an ethnographic study on renal transplant patients, their families and physicians, reveals similarities to but also differences from Hamdy’s findings. In Pakistan too Sharia is considered the final authority in determining what is ethical and legal in life but, as Hamdy notes, there are “myriad ways to be a Muslim”, and “no single way to interpret and live the canonical texts of Islam” (p. 18). Our studies indicate that, for many Pakistanis, “knowledge” of Sharia related to kidney donation is acquired through “informal” sources (family elders, prayer leaders, media) rather than from muftis and fatawa that appear to be far more influential among Arab speaking Muslims. Pakistanis share the concerns of Egyptians about the risk to family members from donor nephrectomy but the religious motif during discussions is the fard (obligation) of Muslims to save human life (based on well known Qur’anic verse) particularly of kin, and the sawab (God’s reward) in the hereafter for this act, rather than God’s ownership of the human body which Hamdy believes to be central for Egyptians. Moreover, unlike Egypt, the arrival of kidney transplantation in Pakistan in the mid 1980s was not met with charged religious debates in the press, public and professionals domains, or among Pakistani muftis, and neither did the country experience physician led movements against the practice.
Fluidity in approaching Sharia is poignantly captured in Hamdy’s detailed narrative of young Ali who has been on dialysis for five years (Chapter 5). Ali, a “most outspoken opponent” of transplantation, adamantly refuses a kidney from his wife or siblings (who offer to donate) as haram, arguing that you “cannot give something away that you do not own”. But he has a “change of heart” after a persuasive physician convinces him that God urges Muslims not to throw themselves into destruction but to seek a cure for illness, convincing him to believe that the transplant is not only permissible but a religious duty he must fulfill. Ali agrees to his wife being tested as a donor but unfortunately she does not match. He interprets this as “a gift from God” saving him from doing something haram. Hamdy chooses to interpret Ali’s shifts as his struggle to “cultivate […] contentment with God’s will”, see it as “God’s overall plan of benevolence and compassion”, and “[work] on himself to embody the sentiment that his body indeed belonged to God” (p. 169). This may be so. But what is equally significant is Ali’s stark comment to Hamdy after a female patient tries to console him by saying that like him she too does not wish to be transplanted. Ali says, “But of course she wants a transplant and to get better, just like the rest of us. But what can we do?”
Hamdy discusses commercial organ transactions in Egypt but without the comprehensiveness and ethnographic depth she brings to other issues (chapter 7). Although she includes interviews with buyers of kidneys her study does not involve contact with any kidney vendors; thus the silence of a crucial protagonist leaves this narrative incomplete. According to the author, kidneys sales are seen as a “fact of life” by many physicians in Cairo. The author records an interview with a physician who is an enthusiastic advocate of kidney sales, owns a private dialysis unit in Cairo, facilitates contacts between kidney vendors and buyers, and interprets his colleagues’ opposition to organ markets as a reflection of “professional jealousy” because of the money he makes (p. 155). He claims that he conducted a survey with “a satisfactory response” revealing that none of the kidney vendors had suffered “medical harm”. It would have been useful to juxtapose experiences of physicians opposed to this view, perhaps from the respected Mansoura Kidney Center “determined to curb organ sales” (p. 227).
Students of commercial transactions in organs would disagree with some of the author’s conclusions on this issue. There is conclusive empirical research that this practice is harmful not only to vendors but also to recipients who have a higher incidence of life threatening infections and graft failures compared to normal. The author’s dismissal of what she terms Egypt’s “absolutist stance against organ sales” as merely “mirroring Euro-American stances articulated in the rhetoric of secular ethics” (p. 233) would come as a surprise to those in developing countries, including Pakistan (and perhaps Egypt) – physicians, public, and the press – who believe organ commerce, domestic or international, to be exploitative and demeaning to the most disadvantaged in their societies, hardly a Euro-American sentiment. And while many would agree with Hamdy’s contention that in the focus on organ trade insufficient attention is being given to factors that “[predispose] people to organ failure in the first place”, few would subscribe to a view that organ selling is considered a problem of third world nations “presumably impoverished in both ethics and medical authority” (p. 237).
The seminal reason behind sales of organs is the desperation of renal failure patients coupled with marginalized others left with no option but to sell a part of their bodies to (temporarily) obtain the necessities of life. I suppose there is logic in the preference for buying a kidney from someone in order to protect your kin from the perceived harms of a donor nephrectomy, but to suggest as Hamdy does that “allowing for paid organs is sometimes the most ethical course of action” would be construed by many as a cynical and expedient argument (p. 236). The author’s suggestion that organ transactions “be made transparent”, that sellers be provided with information about risks, compensated decently and well looked after, and that brokers be eliminated, is akin to the kidney sale program initiated by the Iranian government over twenty years ago. However, given the realities of desperate patients and socioeconomic inequalities the program has been unable to meet its objectives, and Iranian physicians are turning to transplantation with organs obtained from deceased and living related donors instead of vendors.
But these are minor quibbles that do not detract from Hamdy’s thought provoking book. She demonstrates how history, local context and realities have combined to give a particular trajectory to kidney transplantation in Egypt which is different in significant ways from that of other Muslim countries in the region. She therefore challenges notions of a monolithic “Muslim World” and a homogenous “Islamic Bioethics”. The interdisciplinary nature of this book makes it a useful read not only for ethnographers and sociologists but also scholars of Islam, those interested in cross-cultural bioethics, and professionals connected to biomedical fields including organ transplantation.
