This marvelous book is concerned with what Philippe Steiner (p. 12) calls the “productivization” of death and the institutions and techniques that make it possible in contemporary societies. Sustaining this reflection is a fascinating, deeply erudite analysis of organ transplantation as a new “commerce between human beings”. The term of “commerce”, which Steiner uses in the subtitle of the book, is not innocent. In the 18^th century, the word “commerce” referred quite broadly to the way individuals became bound to one another through exchange – whether trade or conversation. In other words, commerce was civilizing (Hirschman A., 1977, The Passions and the Interests. Political Arguments for Capitalism before its Triumph) and stood in part for what Émile Durkheim would later call social “solidarity”.

Of course, by the 20^th century the original meaning had shrunk and we became used to confining the term of “commerce” to the sphere of economic exchange only. Hence the reference to a “commerce for organs” raises a much less peaceful possibility, that of a competitive market, with its associated ills of dispossession, exploitation, and moral indignity. It is between these two poles – new social bonds vs. commodification – that Steiner situates La Transplantation d’organes situates itself.

Death, Steiner reminds us, is the starting point of organ transplantation. But not any form of death: rather, it is the formalization of the very specific legal standard of “brain death” in the 1970s – a “pseudo production factor” for transplant surgeons – that made possible the procurement of large numbers of organs from dead bodies. The fact that the frontier between life and death could now be determined through technique (a flat EEG) did not necessarily make things easier. A brain dead person does not look like a corpse. His body remains warm, sometimes with slight muscle movements. Until they are forcibly removed from the body through transplantation, his heart continues to beat and his lungs continue to breathe. Transplant professionals thus find themselves in the contradictory emotional and moral location of having to turn bodies (rarely cadavers) into medically useful deaths, of, in other words, optimizing the process of death for the harvesting and use of organs. Steiner’s thesis is that if organ procurement is by and large not (yet) a fully commercial process, it is still a profoundly economic (and by necessity a political) one.

What does the economic logic consist of in this case, and what are its consequences? We may begin with the fact that if they have no price, organs still have value – if only that of the lives prolonged and saved. Correlatively, the processes surrounding transplantation also have a cost. Procurement obeys an economic logic to the extent that a whole set of activities have been organized to make the production of organs as valuable resources more successful and more efficient. Thus public campaigns have been launched to support a “politics of exhortation” whose chief purpose is to convince bereaved families and the broader public to give more organs, and a more discrete “economics of incentives” (including symbolic incentives) serves to mobilize transplant professionals toward that goal. A complex infrastructure for the coordination of clinics, hospitals and transplant centers is now in place to improve the detection of potential donors, increase the rate of donation, or target new donor populations (most countries now commonly harvest organs from older donors, aged 55 and over). Far from being about the altruism of individuals, organ procurement is first and foremost an organizational problem, as Kieran Healy (Last Best Gifts. Altruism and the Market for Human Blood and Organs, 2006) also very well saw.

But this does not mean that the moral problem disappears, far from it: the need to procure organs quickly after death (brain or cardiac) has transformed the entire set of social experiences surrounding this event. Organ transplantation profoundly disrupts the normal course of mortuary rituals. Particularly in the case of cardiac death, organ collection preparation (cooling down) may sometimes start before a patient is declared dead. And like the commotion surrounding the procedure of organ removal, the inevitable mutilation following it – even when it is hidden – remains widely disquieting to close relatives. To relieve these common anxieties, political and bureaucratic organizations in every country have thus found it necessary to produce complex rules and procedures so as to mark organ donation as a fully disinterested process for all parties concerned – families on both sides of the donor-recipient relationship, medical authorities, transplant professionals. Rationalized regulations to that effect govern the processes of collection from dead donors, presumed consent, and living organ donation, in an effort to cool down any hint of suspicious collusion. For instance, France maintains strict functional (and by some accounts inefficient) separations between the doctor who announces brain death, the doctor who harvests organs, and the transplant surgeon. And, finally, the allocation of harvested organs depends on socio-technical “dispositifs” (mostly computer algorithms) that remove the matching process as much as possible from concrete human choices and emotions.

But these careful juridical-organizational strategies, eventually, are not sufficient to increase organ supply in proportion of needs, or to quell all moral doubts. Hence these two imperatives (procure more organs and make society feel comfortable about it) come head to head in the debate over the recourse to economic incentives and the creation of biomarkets. Turning to political philosophy for guidance, Steiner carefully and equanimously reviews the different sides of this debate in the last third of the book – from libertarian, anti-paternalistic arguments in favor of the free disposal of one’s bodily “resources” to critiques focusing on the inviolable sacredness of the human body, the specter of new forms of bodily slavery, the crowding out of altruism as a result of market options, and the social stigma of using one’s body for financial profit. It turns out that there is no way out of this dilemma. If an individual’s sale of his own kidney may be consistent with the “liberal freedom” of free consent to exchange, Steiner argues, it generally does not meet the condition of “republican freedom”, or of equality between the exchange parties. The current functioning of international biomarkets matching organ consumers in rich, Western countries to organ providers in low-income countries can thus be analyzed as a form of “transplantation slave trade”, with its assorted characteristics of coordinated geographical organization, social distance between buyers and sellers, and complicit public administrations. Ultimately, Steiner takes position against biomarkets. Instead, he trusts that the politics of exhortation/economics of incentives approach will ultimately succeed in transforming social representations toward the notion that death can be “productive”. Anticipating a Durkheimian future, Steiner argues that culture will reorganize social solidarity so as to incorporate organ donation as a meaningful element of the “good death”, thereby regenerating the social bond. Going back full circle to the 18^th century philosophers who appear in his work on the history of political economy, Steiner thus exhorts us not to give up hope on the civilizing prospects of this very particular type of “commerce”.