 Professor Crowley-Mitocca is an anthropologist who studies how the culture of medicine affects patients, healthcare providers, and society at large, taking a cross-cultural approach to studying these issues. Dr. Crowley-Mitocca has conducted a comparative research in the U.S., Mexico, and Spain. This year she published a book based on her Ph.D. work called Domesticating Organ Tramp Plant, Familiarial Sacrifice and National Aspiration in Mexico, and that's what she'll be talking to us today. Thank you. Thank you, Lainey, and it's such a deep pleasure to be here today sharing something from this book, which did such a lot of early percolating right here at the McLean Center, and through the ongoing conversations and collaborations with colleagues and friends over the years ever since. And so thank you to Mark and to the McLean's for those opportunities. The book that finally resulted draws on extensive ethnographic research in Mexico to try and examine both the intimate experiences and the kind of politics, the very complex politics and ethics of kidney transplantation in Mexico, thinking through issues of cultural variation and global interconnection, both things we've already started to hear about on this panel. And I want to pull out today just one thread from that book for our conversation today. So I am an anthropologist, which makes this slide very simple because I don't get accorded very much by pharma and biotech in my line of work. So we can take care of that very quickly. So I want to start out with a story. I'm an anthropologist. That's sort of my, the coin of my realm in a way. And it's a story that comes from actually my very first field visit to Mexico. And I found myself encountering people wanting to tell me this same case again and again. It was told to me by the transplant surgeons and transplant coordinators and nurses that I was traveling around the city of Guadalajara to meet. And with each retelling it became increasingly clear that the story sort of communicated something they really wanted to be sure that I grasped. It was emblematic for the people who were telling it to me in some important way. The story centered around the case of a young boy in need of a kidney transplant who was the son of a Mexican father and a German mother. And he was diagnosed in Guadalajara and he was told that a kidney transplant was his best chance. And his family then, they were fairly affluent and his parents decided to take him to Germany for additional consultations. They were told the same thing in terms of needing a kidney transplant in both places. In Mexico a live donor transplant was really the only thing they were offered. Seastowners were incredibly rare. They're for a complex set of reasons that I explore elsewhere in the book and we can talk about more later if anyone's interested. But in Germany the physicians really strongly advised using a deceased donor kidney and that at the time reflected a kind of local, in part historically based, reluctance to use living donors there. Now after very careful thought the parents ended up deciding to go with living donation based on the improved outcomes with live donor kidneys. They really wanted to give their son the best chance they could. And once that decision was made, so the story goes as I was told it, the German team advised the parents to take their son back to Mexico that the Mexican transplant teams were actually more experienced with the living donor procedures than they were. Now the mother's German family I was told was horrified by her decision. They were angry. They vehemently opposed her risking herself when another option existed. But she was determined and she rejected their pleas that she reconsidered. They went back to Mexico and the donation and transplant were carried out successfully. Now each telling in each time I was told this story it was invariably emphasized to me that the mother had become más mexicana. Más mexicana that is because she was willing to potentially sacrifice herself for her son. And her German family's kind of horror at her decision in the storytelling was used to exemplify what my Mexican interlocutors understood as a kind of colder, more individualistic ethos. And it was an ethos that my Mexican storytellers were themselves sort of horrified by in the telling. Now it was a story that in a lot of ways was about national identity and pride. It's one that highlights and kind of celebrates an iconic vision of this self-sacrificial Mexican mother as a key figure, a key image for thinking about living donation in that setting. And I can't go into it very deeply here but this is an image that has a very specific and rich set of cultural and religious and historical and moral associations in that setting. It's an image that really resonates in a particular set of ways. Now over time I came to see this story, the story of the German mother become más mexicana as sort of condensing one of the central questions that has always just fascinated me in living organ donation. And that is how and when do we come to understand this procedure as life-saving and how and when do we read it as life-risking. Because it is of course both. Living donor transplant is fundamentally dependent on harming one person in order to try to help another. And that's a kind of brutal way to put it, right? Obviously we do our very best to figure out how to do the least amount of harm for the greatest amount of benefit. But the bottom line remains it's an uncommonly direct form of something like zero-sum or maybe even sacrificial medicine. This Frito-Calo painting that I've put up here, there was a copy of it hanging very prominently in the main transplant ward in Guadalajara where I worked. And like in this painting, live donor transplant sort of makes our interconnectedness, our interdependence really dramatically manifest. It also dramatizes how those connections can be supportive and beautiful but also exploitative and maybe dangerous that they can be read as symbiotic or vampiric. And as an anthropologist I'm really intrigued by just how this pretty extraordinary act comes to seem in many places so acceptable, so ordinary and routine. And also how by in other places at other times, it does not. The story of the Mexicana, the Maas-Mexicana German mother captures this, right? The way giving her kidney was met with angry condemnation in one place and admiring celebration in another. And looking across the world we actually see a fair amount of variation in how living donation has been accepted and used from Mexico where kidney transplant depended pretty much entirely on living donors to the US where roughly half of our kidney transplants currently depend on living donation and we're constantly looking for ways to expand those numbers to places like Germany and Spain where the use of living donors had for a long time been really limited and was regarded by many as undesirable, maybe even unethical. And these differences raise really interesting, very anthropological kinds of questions I think about the social processes and the cultural framings at work here. That is, what are the images and stories and figures by which we come to imagine living donation as an acceptable act of life-saving or an egregious form of life-risking? And trying to answer some of those questions by way of my work in Mexico can I think contribute, I hope, to the conversation on this panel. Because that opening story of the German mother points us to some key features of how living donation was being talked about in Mexico, of the way the strength of Mexican families, Mexican mothers in particular was often imagined as a kind of resource in that setting that enabled transplant to succeed there. And as these quotes kind of suggest, this was a resource that was framed as both national, a point of cultural pride in some ways, and also natural, imagined as a kind of product of an innate gendered instinct. And this commonplace kind of talk really helped to create a very taken for granted sense that of course women donate more than men, a sense that was so pervasive it was literally a joke in the local transplant community. Indeed at a national conference, one nephrologist playfully remarked to the audience of healthcare workers, so you tell a family that the patient needs a donor and what do you think happens? Everyone starts sidling away and looking expectantly at the mother, of course. And it was an observation that evoked laughter in the crowd at the time. And I think that laughter signaled the way this powerful discourse that of course women donate more than men was just kind of culturally commonsensical there for many people. And that was a set of ideas that was even further strengthened by a very powerful set of analogies that were frequently drawn between this act of offering up a kidney and various aspects of women's bodies and women's work. And I'm just going to point very briefly to three here. First living donation was often likened to giving birth. It's a framing that we hear elsewhere as well, of course, but I want to highlight how this analogy makes giving a kidney just kind of continuous with women's role in bearing and raising children. The way the risks and pain of organ donation here, like those of childbirth, get folded into a notion of sacrifice as part of women's lot in life. Part of maybe an imagined biological, maybe even theological destiny. Similarly, living donation was also frequently analogized to women's work in different ways. As one transplant patient's wife rightly observed, women take care of their families. That's what they do. Men go out and earn money, but they aren't much good when someone's sick. Symbolically linking ideas about home, the division of familial labor, the care of ailing bodies, living donation here becomes just another form of nurturing and thus feminine work. And then in a third example, the penetrative act of having a kidney removed was sometimes likened to sex in maybe surprising ways where this patient told me, my sister wanted to donate to me, but they told her at the convent that she couldn't take her orders if she donated an organ. They told her she wouldn't be pure anymore. It would be like losing her virginity. And a vote here is a sense of the female body as being more open somehow, more inviting of penetration, whether sexual or surgical, than the male body. So we have this dense web of kind of commonplace expectation and analogizing and cultural logics and everyday talk in Mexico, this idea that of course women donate more than men. And what that produced was this image of the iconic living donor as a woman and more specifically as a mother. And that's one kind of social fact. It's a social fact that that is how people were talking and thinking about living donation, how they were figuring it. And yet what people say, what they do, are not always exactly the same thing, right? We know this. We need to take both as important and neither at face value. We see in the face of this kind of very dominant cultural image of the kind I've been talking about, it's nearly always a good idea to ask, what then becomes harder to see? That is, what does this almost hyper-visibility of the donor is this celebrated self-sacrificial mother? What does that hyper-visibility render in turn less visible? Well, here's one thing that goes unseen, or the went unseen in all that talk of how of course women donate more than men. In actual fact, it turns out men and women donated in the programs where I was studying in almost precisely equal numbers. Sounds like you were as surprised as I was when I found this out. It's not what you would have expected from everything I just laid out to you. It's certainly not what I expected. But these weren't secret numbers. They came from the transplant program's own databases. They weren't secret, but they were largely silent. They weren't part of the public discussion around donors in some interesting ways. So, that's one thing that goes unseen in the image of the donor as this self-sacrificial mother. The fact that living donation in Mexico actually depended equally on the bodies of men. There were some interesting, I should just say as an aside, there were some interesting gender differences, including the fact that men and women were equally likely to give organs, but not to get them. But clearly that's very straightforward, kind of unabashedly gendered image as self-sacrificial mothers. Not the whole story, right? And I'm struck returning to that idea of a kind of hypervisibility by how in making the expected, culturally comfortable sacrifice of mothers so visible by figuring living donation in this way, the more unexpected, more culturally maybe uncomfortable, but turns out very commonplace, sacrifice of men's bodies goes pretty unnoticed, pretty unremarked. Could it be that if those male sacrifices were more visible, we're more clearly seen as central to enabling transplant in Mexico that it might raise unsettling questions, that it might make this practice seem not quite so culturally commonsensical after all. So where does all this leave us? Why might the talk about living donation in Mexico be so heavily feminized when the act of living donation actually was not? And I've come to think about this question in terms of the idea of domestication, of the way that a particular kind of, that this particular kind of cultural analogizing of thinking living donation with the image of the self-sacrificial mother works to naturalize not just living donation by women, but living donation in general. And in the process, transplanting Mexico gets domesticated in multiple senses of the word. That is, it's made a private matter of home and family and a kind of national product of Mexican culture at the same time. And on both counts, as domestic matter and domestic product, living donation comes to seem sort of safe, homey, familiar, as well as familial. And indeed to invoke another register of the notion of domestication, living donation in this way gets tamed. It doesn't turn into that kind of controversial issue. It's become in other settings around the world. Instead, it's made to mesh almost seamlessly with long-standing cultural logics and existing social hierarchies in a way that may seem to make people able to get pretty comfortable with the idea of living donation. I want to try a little thought experiment with you guys. I want you to try to imagine how it would fly here, say in a transplant committee meeting or an information session with patients and families. If people went around making these same kind of off-hand references, these same kind of jokes to this similar sort of iconic image of the living donor as a self-sacrificial mother. If people literally made jokes about, of course women donate more than men. And my guess is that for all that we clearly have a very long way to go in terms of actual gender equality in this country in many ways, my guess is that that kind of outright feminizing framing that seemed so ubiquitous and so successful in Mexico here would probably go over like a lead balloon. Might in fact make a lot of people pretty uncomfortable, maybe even uneasy. And I think that's so because that sort of overtly feminizing framing would be pretty out of step with some elements of our own cherished national self-image. One that has, at least for many Americans, much more to do with ideas about equality and freedom than with ideas about self-sacrificial mothers as a kind of proudly national and natural resource. In fact, I want you to imagine here in this country what makes us comfortable. How do we figure the living donor in ways that seem culturally legible and thus morally acceptable? If the self-sacrificial mother is not the right image here, and I think it's probably not the right iconic vision of living donation, what is? Well, I'd say that here there are at least a few key dimensions of the way we talk about the way we frame and figure living donation. And probably a lot of these are very familiar. We've seen some of them in fact already today. The idea that donors are autonomous, that they're free to choose, that they have to be well informed, they have to make a careful rational choice and that they must themselves be unquestionably healthy, right? And I would guess that to most of us these seem pretty straightforward and self-explanatory, even kind of objective. For most of us these probably don't scream hey, there's something cultural going on here in the way that that image of the self-sacrificial mother may have. But I want to suggest that here too there's a very particular, very culturally specific way of figuring, of analogizing, of thinking living donation that's going on. Because I think it invoked in these ideas about autonomy and rationality and individual freedom is a cherished iconic figure of our own cultural and moral world. That is the liberal individual, the rational decision maker, maybe even something like homo economicus. And like the self-sacrificial Mexican mother that's a figure with particular characteristics and histories and aesthetics and assumptions that are built in and travel along with it. To name just one such feature the iconic figure of the rational decision maker for us most typically is male. And I've pulled just a couple images among many that are out there that seem to capture this. The way the autonomous rational individual is so often coded as male just kind of generally without really thinking about it. And sometimes often even explicitly in the images of living donation that we have that are out there. And that might not even register. We might not really pay attention to it much of the time. So what? Does it matter if indeed it is true that the images we often use to talk and think about living donation here are male? Maybe it does. Because it turns out that there's a pretty interesting contrast between the Mexican setting where people say women donate more than men and they don't, and our setting where it's neither a common joke nor an open expectation that women donate more than men, but they actually do. In fact, women last year accounted for about 63% of living donor kidneys in the U.S. It's an imbalance that's been pretty persistent over the years that we've been collecting visible in our own iconic image of that autonomous, rational, healthy living donor is that kind of gendered coding. But also this idea of, and we've heard a bit of this already today from Laney, that focus on the healthy living donor has made it, I think, harder to see them as themselves patients. Patients' risks and outcomes, and I've talked about this in years past here, we owe it to them to track more carefully and more concertedly than we have. And so ultimately I think the view from Mexico helps us pose a question while we're asking here too, how the particular images and figures and stories with which we figure living donation also played a role in making some things more visible and others less so. Perhaps domesticating some of the potential discomforts of this sacrificial form of medicine right here at home. And so the final thing I'm going to leave you with as an example from the book that the figures and the stories and the analogies we think with matter deeply. And then we have to pay really careful attention to what they highlight, what they make hyper visible. We have to attend to what they carry along with them, to what they tell us about what we value, about what feels culturally comfortable and thus morally acceptable. And we need also equally to pay really careful attention to what those figurings just might make less easy to see and hence less easy to value thanks. And you will tell me if there's time for questions or we can chat in the rest of the conference time if there is not. Hi, thank you so much, September Williams again. This is a question for you, but it's also a question for kind of the last three speakers. The thing that I have realized from working in geriatrics and working in long term care and end of life issues in 11 different cultures and with people with psychiatric illness as well, is that at some point I started using a paradigm in my head of what is this person's internal reasoning system. You can call it culture or you can call it whatever, but what I found really from psychiatric patients is that an individual's internal reasoning system may be very different if you're a schizophrenic, but very consistent if you know them well enough, similarly as you cross cultures. So what I'm wondering is anybody, we have the big thing of culture, but the individual cultures of people come from their big culture and their family culture and their emotional culture. Any kind of a paradigm for that? It's a tall order. As an anthropologist I can sort of sketch out the big culture which is one of the resources that we all draw on and we have our individual histories, we have the microcosm of our family, it's such a complicated complex. I don't have a here's the tool for the way to think about that. It's like this, I know it when I see it. But I can say, I mean I can say so I teach in a medical school right and so one of the things that's interesting about teaching trying to help medical students think about cultural issues as part of their practices, you always want to be on guard from the danger of sort of giving them the sense that oh I know how Mexicans think about X or I know how Chinese people think about Y because that's not how culture works but people often want a sort of easy to grab onto tool. And so the thing, I mean Kleinman and others have a sort of a list of questions that are a good starting point for how do you have a conversation that gets to whatever the person's internal system is. So I don't know that I have a name for it but I have seen some good examples of processes for getting to it with the individual patient in front of you. And I think that's the closest I can come to answering what's a very good question. You invited other earlier speakers if they want to thank them too. Thank you.