"A Cultural Anthropological Study of Body Techniques for Protection: The Case Study of Indonesian Minangkabau"

ISSN 2188-8175

Yosuke SHIMAZONO*

*Department of Environmental and Preventive Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan

I. Introduction

Suppose that you have undergone a kidney transplant after months or years of life on dialysis. A transplant surgeon has made an incision into your belly and, as he usually does, placed a new kidney into the abdominal cavity. He has sutured together the renal arteries and veins and iliac arteries and veins of your body; he has also connected a ureter to the bladder. A pale kidney has turned rosy, as if it has come back to life. The surgeon has stitched up the surgical incision. Now you have become a kidney recipient. Is this new kidney, which was removed from a donor's body and was once his or her organ, your kidney? Is it a part of your body? Is it a part of you?

You may feel entitled to say that it is. For one thing, the organ was already detached and separated from the donor's body and has been placed in your body. Just like any other organ of your body-your heart, liver, lungs, etc.-it lies within your skin-bound body. Furthermore, an organ has already been integrated into the physiological process of your body as an organism. A transplanted kidney "lives" and "breathes" (Moore 1955) thanks to blood that travels around your vascular body. The kidney, in turn, is cleansing your blood of toxic metabolic wastes and processing them into urine and is contributing to maintenance of the haemostatic balance of your body.

What is more, the effect of a physiological integration of a new kidney manifests in the lived body. You are liberated from agonizing and tortuous bodily distress from end-stage kidney failure: itchiness, breathlessness, sluggishness, muscle cramps, joint pain, sleeplessness, etc. As your body recovers from the operation, it is reinvigorated and pulsates with renewed strength, appetite, and sexual drive. You may feel, as many kidney recipients I have communicated with said, that you are "reborn" and relish a "new lease on life." Able to breathe, eat, and sleep without discomfort, you re-inhabit the world with a renewed sense of enjoyment, which, according to Levinas, is a primordial relationship with what nourishes life (Levinas 1961). To the extent that the body is not only what you have but what you are, then a transplant organ has also become a part of you.

However, you may hesitate to proclaim that it is truly your organ and may feel that it has not totally assimilated into your body or has become a part of you. First and foremost, a new organ is an immunological "non-self. The immune system of your body recognizes human leukocyte antigens that serve as a "signature" of "biological individuality"; it mounts an assault on the allograft, leading to graft rejection and, ultimately, to graft loss, i.e., the "death" of an organ transplanted into your body.

To maintain graft survival, it is necessary to suppress the immunocompetence of your body. This would make your body vulnerable to infections. Thus, you are warned by your doctor that you have to take due precautions ("Wear a flu mask for a few months," "Avoid cleaning the cages or litter boxes of your pet," etc.) To make the matter more complicated, immunosuppressants have a wide range of side effects; in the worst-case scenario, they can cause life-threatening disease.

Therefore, you have been prescribed several other medications in addition to immunosuppressive drugs. In adhering to your physician's prescriptions, you would thus be constantly reminded that an organ that is in your body was not originally a part of your body and still is an immunologically foreign body. So, is a transplant organ not your organ? Is it not a part of your body and part of you? If not, what is it? To whom does it belong?

What I am suggesting is that organ transplantation is an event that calls into a question of the relationship between a part and whole of the body and the body and the self. In other words, going through a transplant surgery could lead to a "complex modification of the recipient's embodied identity, as the habitual equation between the limits of the body and the contours of the ‘I' is thrown into question" (Waldby 2002: 241). The presence of a transplant organ in your body renders problematic a statement such as "I am my body" (cf. Merleau-Ponty 2002). A relationship between the bodily "I" and "my" body is encroached upon by the curiously ambiguous entity that sustains "my" bodily existence but retains otherness.

Needless to say, not all recipients face such a problematization of the identity of the bodily self in the same manner. The extent to which a patient acutely perceives the presence of a foreign organ in their everyday life may vary depending on various factors: the kind of organ one has received, the type of donor (living or dead), the relationship with the donor (intimate other or unknown stranger), how the organ is obtained (as a gift or as a commodity), a medical condition (postoperative complications, frequency of rejections, condition of graft), and so forth. Nonetheless, a transplant patient has to live, by and large, with an awareness of the presence of a foreign organ in his or her body, which, in one way or another, problematizes his or her embodied identity.

The purpose of this paper is to explore how organ transplant patients experience this unique, novel, or even extraordinary way of being and having a body. What kind of bodily experiences does an organ transplant give rise to? How do organ recipients reestablish the relationship between the body and the self or between the bodily "I" and "my" body in the face of the presence of a foreign organ inside "my" body? I address these questions with a particular focus on kidney transplantation.

The ethnographic data examined in this paper was obtained through fieldwork carried out in the Philippines from June 2004 to December 2005. My fieldwork included (i) in-depth interviews with 52 kidney transplant patients, (ii) participation of activities of patient's self-help group (Kidney Transplant Organization of the Philippines, KITAP), and (iii) informal communication with its members. Among 52 patients I interviewed, 22 have received a kidney from a living donor who is a close relative (i.e., parent, child, sibling), 8 from other relatives and 3 from an acquaintance or in-law; 9 received a kidney from a paid kidney donor with whom they had no previous relationship and 5 from cadaver [1].

In what follows, I first briefly examine psychiatric literature pertaining to the body image of the organ recipient. Then, I examine somatic experiences and bodily practices described by kidney recipients with whom I worked. In doing so, I tentatively identify three areas of bodily experiences and practices: (i) the sensuous body, (ii) imaginary body, and (iii) performative body. I illustrate how kidney recipients attend to novel bodily sensations through which foreign organs bodies forth its presence in their lived bodies. I then examine how they respond to the sensuous manifestation of a new organ with imagination and reflexive bodywork. In conclusion, I suggest that through cultivating bodily "feelings" what one may call the hospitable bodily self, accommodating a foreign organ in such a way that the otherness of a new body part has been affirmed rather than denied or suppressed.


II. Question of the post-transplant embodiment

Anthropologists and sociologists who have investigated recipients' experiences of organ transplantation did so mainly by considering organ transplantation as acceptance of a "gift." Drawing on the theory of gifts by Marcel Mauss and others, they have examined the "gift relationship," i.e., how recipients forge an actual or imaginary relationship with their living or deceased organ donors (cf. Fox and Swazey 1992; Lock 2002; Sharp 1995, 2006). They have also examined the effect of the recipient's sense of debt and obligation to give something in return to the donor and the recipient's sense of self. However, in this scholarship, the "body" and "embodiment" has been strangely neglected theme. It may be said that uniqueness of organ transplantation as giving and receiving of a gift lies in the way a thing given is received and possessed by the recipient. A fleshly gift is incorporated into the recipient's body. However, the carnality of organ exchange has not been paid sufficient attention. An organ tends to be reduced to a symbol or a sign in social scientific literature.

More directly related to the subject matter of this paper are works by psychiatrists who, based on their liaison work with organ recipients, examined the issue of the transplant patient's postoperative body image (Muslin 1971; 1972; Basch 1973; Castelnuovo-Tedesco 1973, 1978; Lefebvre, et al. 1973;Viederman 1974). According to them, the task that a transplant patient faces in his or her postoperative life is how to integrate, assimilate, or accommodate the organ into his or her body image. For example, Castelnuovo-Tedesco draws attention to research indicating the higher rate of depression among kidney recipients than among patients who had undergone other major surgeries and states that "there is also substantial evidence that the patient may be responding to the presence within him of what is to him psychologically a foreign body" (Castelnuovo-Tedesco 1973: 351). Therefore, a successful integration of a transplant organ into the body image is an important factor affecting the emotional and psychological wellbeing of an organ recipient.

According to a widely accepted view, there are two dimensions involved in an organ transplant: psychological and physiological. The previously cited psychiatrist states:

In attempting to understand the psychological vicissitudes of transplantation, it may be helpful to consider certain physiological analogies. Surgeons have found that the success of transplantation depends upon the immunologic similarity of the tissues of donor and recipient....If the match is not close enough, the transplant fails to be "taken in" and is rejected as a foreign body. In a similar way the self must come to terms psychologically with the newly acquired organ, making it an integrated, functioning part of its body image rather than experiencing it as something alien and dangerous, or perhaps even as simply inassimilable (Castelnuovo-Tedesco 1973: 360).

This formulation of the problem of an organ recipient's body image has an unduly dualistic overtone. It therefore should be noted that there is more than parallelism between psychological and physiological dimensions of an organ transplant. Some researchers suggest that patients who feel difficulty in regarding a transplant organ as a part of the self tend to be poorer in their physiological outcomes as well. It is said that there is anecdotal evidence indicating that psychological "rejection" of a psychologically foreign organ may be linked to the immunological "rejection" of an allograft (Ricchione 1989; Schlitt et al. 1999).

How does incorporation of what is psychologically a foreign body part into the body image take place? What facilitates or hinders the process of inclusion of a foreign organ into the patient's body image? A psychodynamic model of "internalization" of a foreign organ put forward by Muslin partly gives us answers to these questions (Muslin 1971; 1972). According to the model, which is mainly based on the author's clinical observation of kidney transplant patients, an internalization of a kidney takes place in a stepwise manner. At the initial stage-"foreign object stage"-the transplanted organ is not yet regarded as an integral part of the patient's body. Patients at this stage represent an allograft as an object or "not-me" existing separately from the self. They may report strange and uneasy feelings. At the next stage ("the stage of partial incorporation"), the organ occupies an intermediary state between a part of "me" and "not me." The psychic status of a transplant organ at this stage is comparable to a "transitional object," which, according to child psychoanalyst Winnicott, occupies the middle ground between the bodily self and the world; for an infant in its early stage of development of bodily self-awareness, it is a continuation of its body as well as an external object (Winnicott 1953). At the final stage of "complete internalization," the organ is no longer an object. Patients no longer pay attention to the new body part except in times of crisis, such as acute rejection episodes. The organ is completely dissociated and disentailed from the donor in whom it originated; the graft is fully incorporated into the body image of a recipient.

The problem with this model of internalization is that it is not clear whether the model is intended as descriptive or evaluative. Descriptively, this model of stepwise and linear progression to the complete internalization of a foreign body part is questionable; it is observed that patients' reactions vary, depending upon medical sequelae, personalities of patients, type of organs and donors, and so forth (Castelnuovo-Tedesco 1973, 1978; Basch 1973; Schlitt et. al 1999). As an evaluative model, the following questions arise: How practicable is complete internalization for an organ recipient living with an immunosuppressed body? Why is it more desirable than, say a partial stage of internalization?

Noteworthy in this regard is the claim made by some psychiatrists that the "graft and donor denial" is an "adaptive response" (Mai 1993). Patients' distress may be derived from their concerns about changes in personality (Kuhn et. al 1988: 620-621) or from thoughts about the donor's tragic death by accident, gunshot, suicide, etc. (Kaba et al. 2000, 2005) [2]. In this context, turning attention away from the presence of a "foreign" organ and its origin is an important coping mechanism in the face of emotional distress. Here, an analogy between immunological "rejection" and psychological "rejection" takes on another dimension. If the solution to immunological rejection is "suppression" of the immune system, the solution to psychological "rejection" is, as it were, "suppression" of psychological awareness of the presence of something alien beneath the scar on the traumatized body.

An idea that graft and donor denial is an adaptive response might explain a common endorsement of the metaphor of "the body as machine" (Sharp 1995, 2001, 2006, 2007). While a ‘fantasy' that an incorporation of an organ may change one's own personality is pathologized as a sign of ‘regression', a heart recipient, for example, is often told that what he or she will receive or has received is a "pump," not a "bearer of life" or "a seat of emotion" (cf. Castelnuovo-Tedesco 1973). Why is this mechanical metaphor privileged despite its obvious conflict with what a transplant patient would experience? Is not an organ "the insubstitutable other that has nonetheless been replaced" (Nancy 2008: 165)? Whether and how this mechanical metaphor works therapeutically is an empirical question. However, a presumption underlying an idea that the mechanical image of the body, say, "a heart as a pump," has a therapeutic effect and that it fosters an integration of what is foreign to oneself is not hard to understand.

The work of a metaphor in general rests on "commonsense associations" that are carried over from one semantic field to another (cf. Black 1962). Insofar as a "pump" is concerned, it is an "industrial" product and an "anonymous" and "impersonal" commodity; it is a "fungible" part of a machine and is "replaceable" without changing the nature of a machine as a whole. Such associations may facilitate integration of a transplant organ into a recipient's body image. Embodying of the disincarnating metaphor marginalizes the presence of the "foreign" organ inside the body.

A brief summary of psychiatric discourse on the problem of post-transplant body image hardly does justice to detailed analysis of psychodynamic process of introjection, projection and identification that they present. However, in the psychiatric discussions of the psychological incorporation of a transplant organ, there are two dominant tendencies that I find problematic.

First, a predominant tendency in liaison psychiatric discourse on the post-transplant embodiment is that the notion of body image is narrowly conceived as the "psychic body" (Sartre 1966) or the body as an object of representation (Csordas 1994). Waldenfels writes, "our bodily experience would by far exceed the experience of the body" because "the experience of our body would presuppose the corporeality of experience itself" (Waldenfels 2007: 71). In the psychiatric investigation of the post-transplant body image, a dualistic tendency obliterates the body as the "pre-objective" source of experience or carnal dimension of post-transplant experiences (Csordas 1993, 1994, Merleau-Ponty 2002).

Second, psychiatrists seem to take for granted what may be called the individualistic view of the bodily self that is prevalent in Western culture and dominates contemporary academic thought. It seems to be taken for granted that the presence of a "foreign" organ inside the body is threatening to the integrity and autonomy of the bodily self. It disturbs a patient's relationship with his or her body. Whether the body is what one has or what one is, the body in its entirely has to belong exclusively to oneself. Organ transplantation thus gives rise to a deviation from the normal and normative state of the bodily self. Just like the surgical wound that does not vanish, the psychological wound may not be completely healed. Nonetheless, the norm of self-mastery and self-possession dictates that it is desirable for a patient to conceal this wound-to live as if his or her body were a "normal", "untraumatized" body.

Two sets of questions arise at this point. The first has to do with bodily experiences. In what way is incorporation of a foreign organ corporeally perceived and recognized? Does not a transplantation of a new organ engender sensory experiences and, if there are any, what importance do they have to the psychological internalization of a graft? The second set of questions relates to the individualistic view of the bodily self. Does this presumption impose? Does not this presupposition prematurely foreclose a possibility of cultivating the body image in which the presence of something other than me inside the body is accommodated without its otherness being denied or suppressed? In the remainder of this paper, I explore Filipino kidney recipients' accounts of their bodily experiences and practices in a view of these two sets of questions.


III. The sensuous body: Feeling the presence of a new organ

The subcutaneous touch: Contact beneath the skin

"I could feel that I have a [new] kidney," stated Patricia, an ex-nurse who underwent a kidney transplant with her younger brother as the donor. Recalling when she woke up from anesthesia, she further explained: "Before, you had it at the back. You can now feel that your kidney is here. Something is in front of you!" She also vividly remembered a strange feeling she had when she stood up for the first time after the operation: "It was as if the kidney were falling down! So, I tried to hold it in place with my palm. My doctor told me that it would not fall. But I continued to hold up the kidney whenever I walked. I did that for about a month."

Emerson, whom I interviewed two months after a kidney transplant he had undergone with his cousin as a kidney donor, reported his experience in a somewhat different manner: "I felt very strange. After the operation, when I woke up, I felt pressure right here [placing his palm over the surgical scar at the lower abdomen]. It felt very tight. When I breathed, it was as if it were going to explode! I tried to breathe little by little so as not to press it too hard. I got worried. So, I asked other patients who visited me in my ward; I asked them a lot of questions. They kindly explained me everything. So I was able to know that it was just an ordinary thing. There was nothing to be worried about. Then, I was relaxed and was able to breathe with ease."

As Patricia's and Emerson's accounts indicate, a transplanted kidney bodies forth its presence in the sensuous body of patients at the early post-operative stage. They often feel the presence of their grafted kidney through novel bodily sensations, which may be called subcutaneous touch. A recipient's body comes into physical and sensuous contact with a newly inserted mass of flesh. It touches and is touched by the organ that lies beneath the surgical scar. Sensations of friction and pressure that are localized beneath the skin announce its presence, weight, and voluminousness.

That kidney transplant patients experience new bodily sensations in their post-transplant lives is a phenomenon that has strangely been neglected by the scholars discussing the body image of kidney recipients. I take note of the fact that it is apparently related to surgical aspects of the operation. The ordinary procedure of kidney transplantation is not a straightforward replacement of an "old" organ with a spare part. Since the first clinically successful kidney transplant between genetically identical twins, it has become the standard surgical procedure to place a kidney in a cavity at the lower right or left abdomen. The patient's own kidneys are not removed unless there is a special indication for doing so. A kidney transplant thus involves a surgical reconstruction of the anatomical body that generates a change in a sensuous dimension of the lived body or the sensuous body. The modification of the anatomical body is insignificant from the physiological viewpoint. However, my ethnographic data suggests that they are often not trivial from kidney recipient's point of view; a substantial number of my interviewees eagerly paid attention to them and incorporated them into their post-operative sense of the bodily self.

The transformation of the sensuous body can be characterized in the following phenomenological terms: In contrast to the familiar remoteness of native kidneys, a transplant kidney manifests itself in unfamiliar closeness. Let me explain.

In everyday life, we incessantly perceive our bodies; as Merleau-Ponty shows, any perception is intertwined with the perception of the body's movement, posture, etc. The perception of "functioning body", however, remains in a "tacit dimension." It is "absent" from thematic attention (Leder 1990, Sartre 1966). When we attend to our bodies and render a thematic object of perception, we realize that "it is remarkably incompletely constituted thing", as Husserl states (1989: 159). Not all parts of the body are uniformly accessible to our senses. Especially, the interior of the body, or what Leder calls the "visceral body," presents itself to us with a characteristic opacity and density (Leder 1990: 37-68). Moreover, within this layer of the body, there is also a scale of "decreasing nearness" and "increasing remoteness" (Waldenfels 2007: 80). Namely, some other organs, such as heart, lung, stomach and bladder are given to introceptive or visceral senses; the presence of these organs are continuously or intermittently felt in our everyday life, However, other organs are more silent or absent in our bodily life. I do not feel my pancreas; neither do I feel my spleen. I know its presence through biological representation of the body, i.e., by internalizing the "anatomical gaze," but I do not have any sensory experiences that can directly link to it. Arguably, the kidney is one of these imperceptible organs [3]. In the "normal" bodily existence, the bodily "I" am thus separated thus from "my" kidney by its familiar remoteness. What a transplant patient experiences is that, having awakened from sleep after the operation, he or she is also awaken to the tangible presence of a new organ inside the body. Its foreignness is manifested with its unfamiliar closeness.

Kidney recipients respond to such transformations with bewilderment and amazement. The tactile manifestation of a new organ could be felt as threatening and repulsive for some kidney patients. To illustrate this, I refer to Roberto's case. During ten months of undergoing dialysis treatment, he desperately searched for a kidney donor among laborers on sugarcane haciendas owned by his wife, but no suitable donor was found; one of six maids working in his palatial residence then asked him to help her start up a business in exchange for her kidney donation, and Roberto accepted the proposal. After the operation, his maid left his house, together with a man who also worked for Roberto as a driver, and Roberto had not seen her again. Asked about how he had felt about the presence of a new organ inside the body after the operation, he explained, "my initial feeling was ‘yuck'! Disgusting." In talking about his affective response to the subcutaneous contact with a new body part, Roberto used an analogy of sexual intercourse with a prostitute. "I would say, it's like having a sex with a prostitute. Sometimes you have sex with prostitute even if you don't like her or even loathe her. You have intercourse but you are still disgusted. It was like that." Aversive feeling caused by the subcutaneous contact with his donor's body part provoked him to use an analogy of sexual contact that occurs at the body's orifices. It is not surprising that to be comfortable with a new post-transplant body, the subcutaneous contact should no longer disturb him and the presence of a foreign kidney in his phenomenal and sensuous body should be marginalized.

Feeling a life

The accounts of my informants about their sensory experiences pertaining to a transplant kidney did not show uniformity, but some commonly reported experiences could be identified. The first class of accounts has to do with the bodily sensations that seemed to be particularly felt during the early post-operative phase. Many kidney recipients told me that they felt that their kidneys became "part" of their bodies in the sense that they were more firmly attached to the body and no longer stand out from the rest of the visceral body via their peculiar mobility.

Other commonly reported sensory experiences were "throbbing" or "pulsating" of the kidney felt beneath the incision. Ruth, an ex-nurse, explained: "A lot of transplant patients ask me questions, "Sister…you know what? I feel this kind of thing [a 'throbbing' of a kidney]. Is it okay? Is there something wrong?" Only a few don't talk about it. Most of them feel that everyday." She further stated: "So you only have to explain to them that they do not have to worry....The function of kidney is not only letting your heart beat and producing blood cells. It does a lot of work. So that's perhaps why we are given two kidneys. God has given you two. You just have to be aware that you only have one functioning kidney now."

Not all of my interviewees attended to them in the same way. For example, Ana, who received a kidney from her half-sister, stated: "There is one thing I can never forget. After the operation, a nurse told me, "The kidney placed in you is a wonderful one. You should treasure it. It is a big one. But the one left in your sister is bigger. For me, it is really unforgettable." She also stated that she always "takes care of my kidney diligently." However, concerning pulsating movements she felt beneath her skin, she stated, "I don't pay too much attention to it. It's nothing to worry about. I just think, ‘May be I have pressed it too much.'"

However, for many other kidney recipients, sensations of pulse-like beating had significant meanings for them. For an instance, Ricardo, who had received a kidney from his sister, stated: "There's something beating here." He then added, "I believe there is a life in kidney. Imagine a kidney transferred to another person: I think it's really wonderful. On TV, I saw it beating. So it must be like a heart, and I feel that here." Teresa, who received a kidney from her sister eight years prior to the interview, also reported similar experiences: "You don't feel the old ones but new ones. Sometimes, I feel something moving very slowly here beneath the scar. It is as if it is searching for its place [laugh]. It is here, ha?. It's heavy [gesture: supporting a thing by palm]." She also stated she felt "very little pain, especially when you are feeling cold, stressed, depressed." "It also beats just like a heart. […] It is as if it has a life of its own. That's why we say, batong buhay ['a living kidney']."

In accounts of the subcutaneous sensations of frictions and pressure, a transplant kidney was commonly described as a mass of flesh; it reveals itself through its characteristic volume and weight. In comparison, in Ricarod's and Teresa's accounts, bodily sensations are associated with its vitality or liveliness. A kidney is depicted like an organism, a living being that inhabits in their bodies. It is not just a part of organism but a "part-organism" within the organism or a "part-body" within a body. It is noteworthy here that Filipino kidney transplant patients I worked with often referred to their post-transplant lives as a "second life." As the source of "a new lease on life," a transplant kidney is ascribed vital qualities.

Other kidney recipients more sensitively attended to "throbbing" and other subcutaneous sensations as an appeal, a signal, or a call. "Around here [at the lower abdomen], I sometimes feel a slight throbbing when [I am] tired, when [I] don't drink water for a long period of time, and when I do some chores at home," states Bernard, who received a kidney from his older brother eleven months prior to the interview. He further explained: "It's like my kidney is complaining. When I feel that my kidney is complaining, I stop working. I lie down and relax." Other recipients gave me similar accounts. "Sometimes I did not take more water. That's why...it's saying 'I need more water, I need more water.' It's like a heart pumping," states Sylvia. She explained: "If I feel that, sometimes I go have a check up. Some other recipients say that, even though they feel something, they still ignore it. When they go to have a check up, their creatinine is already high." Ernie also states, "They say that my kidney pulsates. My doctor said that it's like your kidney is moving. ‘Thanks, Lord! It's alive. If it does not move, that is a problem! It's alive. It throbs. If it does not move, your kidney has a problem'....It hardens when it is cold. Urine comes out only little by little. If you don't drink water, it also throbs. When it needs water, it knocks."

A transplant kidney, thus, does not only have life of its own, but also makes demands and appeals, among other things, for water intake. Such a "sense" (meaning) of bodily senses (sensations) partly arises against the background of transformation in the bodily life. Dialysis patients are normally instructed by their doctors to strictly limit fluid intake up to a glass of water a day as their kidneys lose urinary functions. A dialysis patient thus has to endure chronic thirst. This is all the more so for Filipino patients, most of whom reduce the frequency of dialysis sessions to twice a week or less. A dramatic reversal of the condition occurs through a kidney transplant. A transplant patient is now instructed to drink as much as three liters of water a day. This requires to the patient to consciously cultivate a new daily routine, drinking water even when he or she does not feel any thirst. Preoperative life with diseased kidneys of his or her own is colored by persistent feeling of thirst. In contrast, a demand for abundant fluid intake characterizes postoperative life with a foreign and active kidney. A notion that a kidney that demands water links newly felt bodily sensations with this new daily routine. Transformation in the sensuous body is thereby incorporated into the habitual body.


IV. The imaginary body: The work of metaphors and the post-transplant sense of bodily
  self

In the previous section, I illustrated how a kidney transplant brings about an array of new sensory experiences. In this section, I shall describe another dimension of post-transplant bodily experiences: the use of metaphorical imagination for constitution of the post-operative sense of bodily self.

The imagination is a "prominent modality of human creativity and a powerful self process" (Csordas 1997: 79) and has a natural affinity with metaphors (Johnson 1989). "Living metaphors," as opposed to "dead metaphors," are germinative of creative imagination, involving semantic innovation (Ricoeur 2003). The innovation is produced by "sort-crossing" of a word belonging to one conceptual domain to another. Metaphors also evoke or intimate the textual "feel" as in poetic language, by creating a fan of meanings and significances. To the extent that metaphors trigger the perception of previously unnoticed resemblances or create analogies, this can lead to discovery, revelation, or cultural invention, enabling us to understand the abstract in terms of the concrete, the unfamiliar in terms of the familiar (Black 1962; Gerhart and Russell 1985; Leatherdale 1974; Turbayne 1970).

The imagination and the metaphor are also important media through which some Filipino kidney recipients give shape and meaning to bodily experiences and bodily features and achieve qualitative transformation of the body as the basis of the self. This includes a metaphorical personification of a graft, relating to it as if to a quasi-person, a fetus, or a child. They constituted a major means through which the new bodily sensibility and body image are cultivated and developed.

The kidney as a baby

An illustrative example of a recipient who uses the reproductive imagery of a kidney as a baby is Maria, a widow with two daughters, who received a kidney from her younger brother. In her account of first few post-transplant years, she said she had been "like a pregnant woman"; she had spent most of the time at home wearing muumuus as dressing gowns and stayed day and night at home. Her body was also well-rounded partly because of an immunosuppressant. In the following passage from the interview, she explained how she got used to her "life with a new kidney."

You know, it's like in a new house. It is there [she put her two palms on the right side of lower abdomen]. I think it is already covered by tissues because it is really there....Can you imagine a baby, covered with, what do you call that? A baby in their mother's womb? I can imagine. It is just like that.…I am already used to my life with new kidney. Because the doctor told me "take good care of your golden egg," my focus was always on taking care of my "golden egg." You know what? For the first three years and slowly as if it is nothing. Actually you can press it, you know. As if it is already connected with my body, unlike before. But sometimes, it is as if it has a life. It moves like that [She used a finger to convey a pulse-like beating movement].

We can find a set of interrelated metaphors in this passage: "baby," "womb," "mother." The reference to a kidney's "new house" can also be seen as an extension of a conventional metaphor, a womb as a "baby's house" ("Bahay-bata" in Tagalog means a uterus). Her recollection of the doctor's advice ("Take care of your golden egg") and everyday life (wearing muumuus, being overweight, remaining at home, and feeling "like a pregnant woman") also echoes with this metaphorical predication of the "kidney as a baby." Maria's reproductive imagery allows her to integrate certain features of the body-the kidney located at the lower abdomen-and bodily experiences-"throbbing" sensations as a sign of the vitality of a transplant kidney-into the meaningful whole. A transplant kidney is given its place within the image of her body in its metaphorical pregnancy without its otherness denied or suppressed.

The same metaphor was also used by two female kidney recipients who received a kidney from a child, to whom they had given birth. Lucinda, a widow and a mother of three children, underwent a transplant with her son as donor three years prior to the interview. In response to my question as to if she felt her kidney in any way, she said mentioned throbbing movements and stated: "I am always attentive to it because it is from my son. They say that a [transplant] kidney is a stranger to our body. Like a foreigner. Our case is different. I don't feel like that because we are a parent and child. It's like from my own [body]." Explaining her practice of talking to the kidney, she stated: "What do I say? I say something like this. [With the gesture of stroking over the belly], ‘Are you there? Yes, you are. For you are my beloved child (anak ko). You were once there with the rest in my belly. Today, it is only you who are there. Don't miss the rest that is now outside. You are again there in my belly.' Like that." In Lucinda's account, the kidney, which was part of her son and hence was once in her belly, was imagined as having returned to its original place.

A similar trope is found in the account of Maribel, who received a kidney from one of her two children, her daughter, Bernadette. Having recovered from a kidney donation, Bernadette went abroad and started to working with her aunt, Maribel's older sister, in Japan, sending remittances for her mother to buy medicine. Maribel reported the following experiences: "Sometimes it slightly aches. When I feel that, my daughter also feels it. When I text her 'my kidney aches,' then she said, 'Yes, mammy, I had toothache.' I felt it with my kidney. She was riding a bicycle, she fell down, I can't sleep, my kidney is aching and the next morning she called up. That is why, when I go to bed, I always talk to it: 'My dear child'…[with a gesture of massaging]."

In Maribel's account, this metonymical connection is conceived through the experience of pain. Maribel felt her pain in a "daughter's" kidney or Maribel's kidney that was given by her daughter. It was not only experienced as her pain but also somehow as her daughter's pain. A kidney separated from Bernadette's body as a whole still somehow retains its connection to it. Therefore, just as in Lucinda's case, a kidney donated by her daughter is for Maribel not only a metaphorical fetus but also a metonymical child. When Lucinda and Maribel both affectionately addressed the kidneys as "anak ko" ("my dear child"), they did so partly as a kidney that was both a metaphorical fetus and a metonymical child.

The use of reproductive imagery to cultivate a post-operative sense of bodily self is by no means unique to Filipino kidney recipients, nor is it restricted to a recipient of a live donor kidney transplant. For example, two American patients who received a kidney from a deceased donor cited by Lock stated (Lock 2002: 323-4, emphasis added):

I still think of it [kidney and liver transplanted from a single donor] as a different person inside me....Is not all of me, and it's no all this other person either….You know, sometimes I feel as if I'm pregnant, as if I'm giving birth to somebody. I don't know what it is really, but there's another life inside of me, and I'm actually storing this life, and it makes me feel fantastic. It's weird. I constantly think of that other person, the donor.

Oh yes, it's part of me-it's me, it's me. I even call it my baby! I take so much care, I feel protective, it's really a special part of me. You know, at first, when I went through periods of rejection, I would pray for it. I knew it was in the Father's hands, but I felt I must be responsible for this other person's kidney.

What is noteworthy in these accounts is that they highlight and affirm the ambiguous status of a "kidney as a baby," occupying in the middle ground between the self and the other ("Is not all of me, and it's no all this other person either"). A transplant organ is said to be belonging to the self ("it's part of me"); but this belongingness does not efface its otherness ("I felt I must be responsible for this other person's kidney"). To use the analogy between the immunological and psychological process of transplantation, one may say that the psychological "tolerance" is cultivated through this metaphor of pregnancy. The "foreign" organ is "tolerated" without its otherness "suppressed" just like a fetus in the mother's womb is "tolerated" despite its being the immunological non-self [4].

Mechanical metaphor

The metaphorical imagery of pregnancy can be contrasted with aforementioned cases such as that of Jake, who was afflicted with polystic kidney diseases. Some other relatives, including his younger brother, were also afflicted with the same kidney disease. His family sought kidney donors from their paternal relatives, promising monetary compensations. Jake received a kidney first from his uncle, but he suffered from acute rejection and graft loss; then he received a kidney from his first cousin. His statement suggested that he had considerable difficulty dealing with his sense of indebtedness to his uncle:

Jake: After the first transplant, I was always worrying myself over the needs of my donor, thinking "what can I do to help him?" Not knowing that it was affecting myself, destructing my life. I found out that my kidney was failing....Now I know all the tactics. I try to be numb. The first thing I focus on is myself.
YS: So do you think rejection after the first transplant is related to a sort of disturbances you felt?
Jake: Yes. It affects you. You know, most recipients had a rejection because of depression: depression because of their donors. They say to you, "I gave you my kidney. Then right now, you cannot provide my needs?" Hearing those words, recipients let themselves down and they let themselves get depressed. That's going to damage the organ.

His reference to numbness seemed to have dual meanings. Firstly, he tried not to feel responsibility for the donor's needs. According to Jake, his cousin used up eighty thousands pesos given to him by Jake's family and his mother, Jake's aunt, complained that a kidney donation affected him badly as a rumor that he had sold a kidney spread through their neighborhood. Secondly, he was also not responsive to bodily senses, neither did he pay much attention to subcutaneous sensations nor gave much significance to them. In contrast to kidney recipients' accounts of a graft kidney's vital signs, Jake talked of his transplanted kidney in the following manner:

Jake: I always think, in my mind, "it is an alien in my body." I don't feel that it is "my" kidney 100%. It is like a battery functioning normally. You know that your body functions normally only because "it" was attached there.
YS: So in your mind, it is not totally a part of you.
Jake: Yes. It is just an appendage.

His metaphor of a kidney as a replaceable battery temporarily attached to his body reminds us of the metaphor of the "body as machine" and the "heart as a pump." Jake's case demonstrates that this mechanical imagery was employed as a technique to cultivate the "thick-skinned body," to desensitize his body to a transplant kidney and to turn attention away from a sign of an enduring debt.

The kidney as a foster child

Another set of metaphors found in several interviewees' accounts is "a kidney as a foster child." The following two cases are illustrative of how this imagery is implicitly or explicitly employed by Filipino kidney recipients to reconfigure their post-operative sense of self. Manuela, a housewife, underwent 8 months of dialysis before she underwent a kidney transplant. Knowing about the possibility of kidney transplantation, Myra, her younger sister, a public servant, expressed her wish to donate a kidney to her eldest sibling. Initially, Manuela declined her offer, but depletion of their economic resources and deterioration of her health led her to decide a on kidney transplant with Myra as her donor.

Myra: When I did not still know if my kidney is to be donated, I said, "sooner or later you will be moving to another house. Please be nice and do not give any problems to the recipient. I talked like that."
Manuela: Well, I say, "You are welcomed!" [laugh] It has a psychological effect too because I really haven't had any problems. It is wholeheartedly given.
YS: I heard that some recipients talk to transplanted kidneys, too.
Manuela: Yes, that's true. [With gesture of stroking the belly] "Be good there," like that.
Myra: Before the operation, I did it too. "Don't give a problem to your new home." That has an effect!

In this case, the kidney as a fetal figure inside the recipient's body is given another meaning with a kidney donation metaphorically seen as "sending a child to another house." A movement of the organ across the body boundary is conceptualized as a child moving from one house to another in a way clearly reminiscent of fosterage. The kidney donation is like a parent (donor) sending a child (kidney) to her sibling (recipient), who welcomes and takes care of the child on her behalf.

A similar metaphorical imagery is used by Nelson, who received a kidney from his younger sister. Nelson stated that his younger sister talked to one of her kidneys before the transplant. According to Nelson, his sister spoke to a kidney as if it were a child of her own who was being sent to another family member: "Before a transplant, my donor spoke to her kidney. ‘You will be moving to another place. I hope you help my brother. Please function well.'" Unlike other kidney recipients' accounts, he gave a unique account of his experience of the body sensations. The kidney throbbed when he met his sister. He explained: "It was as if my kidney was happy to meet my donor again."

An important cultural subtext is that, in lowland Philippine society, children serve as mediators or channels of exchange among adults, and this includes the practice of fosterage. In their study of kinship in Cebu, Yu and Lin report the widespread practice of fosterage. Fosterage may be requested either by an accepting family who "borrows" a child or a family who "deposits" or entrusts a child (Yu & Liu 1980: 236-262). Thus, while children are the precious "gift of God" and, hence, the most prized assets of parents, parenthood is also a bundle of claims and entitlements, which may be shared, transferred, delegated, and circulated among persons according to culturally specific rules (1980:255). Fosterage could result in differing degrees of assimilation of the foster child into a foster parent's family, but never results in severing a tie between a child and his natal family and parents by birth (and hence is differentiated from adoption).

This social and cultural practice of distributed parenthood and exchange of various parental rights to a child helps Filipino kidney recipients make sense of an unusual and novel relationship between bodies. Just as a child remains attached to a natal family and a family of birth, a kidney remains attached to a body, its place of the origin or birth. Bodies are like households between which a kidney can be moved without completely altering its affiliation. With such metaphorical imagery, Filipino kidney recipients' bodies incorporate another person's organ without completely assimilating it into their "own" bodies.


V. The performative body: On the bodywork of touching and talking to a kidney

Touching and talking to a kidney

In conjunction with cultivating the post-operative sense of bodily self through metaphorical imagination, patients who participated in my study engaged in a bodily performance of "touching" a transplant kidney, palpating, fondling, caressing it from over the skin and talking to it. As is discerned from the cases of Lucinda and Maribel, these elements are sometimes explicitly linked. Another case was Ruth, who received a kidney from her younger brother eight years prior to the interview. She summarized how the metaphor of "kidney as baby" is enacted by some recipients.

It is as if you have your baby with you. "Are you okay there?" Don't be rejected, ha?" "I am not eating too much so that you don't get so tired." Usually I do that. It is like you are taking care of your baby. It is as if you were pregnant. You talk to a baby so that it grows well. "Don't get sick, ha! Don't raise ‘crea'[a short hand used for creatinine]. You get along well there." Other people may think, "Are you talking to your kidney? Maybe you've gone mad." But I think it is one way of taking care of your kidney, too. You are like a mother. A baby you have is your kidney inside.

Fernandez writes, "metaphors are not only rhetorical devices of persuasion; they can also lead to performance" (Fernandez 1974: 125). According to his view, an enactment of metaphors in ritual involves s a process through which the "inchoate pronouns" (ibid.)-"I" and "we"-undergo a transformation and receive qualitative specifications. Csordas also argues that performance as enactment of metaphors effects a "qualitative transformation" of participants of ritual actions. "This is either 'movement' from one state to another or 'movement' from formlessness or lack of identity to definiteness and specificity" (Csordas 1987:459). If the metaphor as "rhetoric" is characterized by a transformation of perception through the operation of "seeing-as (if)," the performance of the metaphor transforms the self and subjectivity through "acting-as (if)." Ruth's act of talking to a kidney is a bodily enactment of metaphor, the bodily gesture based on the metaphorical imagery of a kidney as a baby.

While female interviewees tend to be explicit in evoking metaphors of a fetal life, talking to a kidney was no less common among male interviewees. An example of a male recipient was Ricardo, who received a kidney from his younger sister. Ricardo, whose account of a pulsating kidney as an organ that has a life of its own I have already quoted, stated: "When I'm standing, I feel there is something different in me, in my body and sometimes, I feel like it's beating, I just talk to her. I talk to my kidney. Just take good care, just easy, I feel I am only borrowing it, Sometimes I talk to this kidney and tell her, ‘Be good there, be nice.' It is only a foreign object." Another kidney recipient, Marshall, a father of two who received a kidney from his first maternal cousin, not only talked to the kidney, but also let his children talk to it: "Help my father!" Asked why he does it, he explained to me it was like a "prenatal care." He stated that he let his babies in his wife's womb hear music and observed its effects on his children's fondness for and excellence in singing and dancing.

Included among those who regularly talk to a kidney were two patients who received a kidney from cadaveric donor. One of them was Pedro, who received a kidney from a young man who died in a traffic accident. The following is an extract from my conversation with him and Maribel.

YS: Are there any times that you give thanks to donor?
Pedro: Yes! Through prayer. On the day of birthday of kidney, I pray for the donor and then . . .
YS: How do you pray?
Maribel: Sometimes talking to the kidney, right?
YS: Do you also do that?
Pedro: Oh, yes. Are you functioning well? Stay well. Don't leave me alone, like that.
YS: Why do you do that? Does anybody tell you to do that?
Pedro: No. I do that when sometimes when I feel pain, mild pain, I palpate for it.
Maribel: Sometimes when we eat too much, we ask apology of our kidney. Please be patient, I ate a lot.
Pedro: That's why on the birthday of the donor, I pray for him. I also pray for him on All Souls Day.

In all the cases of Ruth, Ricardo, Marshall, and Pedro, irrespective of the kind of donor (living/deceased), gender of the donor, and recipient/donor (male/male, male/female, female/male), they related to their transplant organ in a remarkably similar way. Whether explicit in metaphors of a baby or more vaguely in personifying metaphor, all recipients treated a kidney as an infantile figure, relating to the kidney by identifying themselves as caring and nurturing figures. Thus, they enacted the metaphorically constructed image of the body whose implication is similar to the metaphor of pregnancy.

Intertwining of self and other

It is interesting to note that a similar practice was reported by one of Lock's interviewees. Robert, a psychiatrist who has received a kidney from a deceased donor himself, states:

They're self-conscious about telling me this sort of thing. Some of them are really embarrassed, but once they feel it's safe to talk then they say: "Oh, yes, I talk to it very morning. I get up and I say, ‘Oh, hi.'" And then I ask, "What do you call it?" And they're always surprised when I ask that, because they didn't think anyone else had given their organ a name!...They talk with their new organ, they try to get in touch with it, they think about it, they tell little stories about it, and exchange dialogues with it, they strike deals with it, and then, after a while they don't give a damn about it! They just make their peace, and they carry on with their lives with that all in the background. When that works well you see a comfortable patient. When it doesn't work, then you see a lot of depression (Lock 2002: 326).

There is, then, a remarkable similarity with what one of Lock's interviewees stated and what my interviewees stated. However, there are some differences. Unlike what Robert stated, a practice of touching and talking to a kidney was not straightforwardly related to the passage of time. In fact, one of my interviewees continued to do so even two and half years after his kidney was completely rejected and he had gone back to life on dialysis in the eleventh year after his transplant. Jonathan stated: "During the evening, I talk to it. ‘Thank you for working, then it's pity that you did not last very long.'" Rather, what seemed to be more important was a relationship a recipient has with a donor. Most of my informants who reported this kind of practice were those who have received a kidney from a family member or relative. Several kidney recipients were exceptions to this rule: one who received from a long-time family friend (see below), another who bought a kidney through a broker talked to the kidney and gave it the name of his donor, and two out of five patients who received a kidney from a deceased donor.

What kind of meaning does the bodywork of talking to and touching a transplant kidney have for kidney recipients? To address this question, I shall present two cases of kidney recipients whose accounts were particularly suggestive of the practice of talking to and touching a kidney. What their accounts demonstrate is that the manual tactility and speech acts intertwine two moments, namely touching/talking to a kidney as something or someone other than the self and touching/talking to oneself, and that these practices cultivate the sense of the hospitable body.

Patricia, whose account of the bizarre feeling at the early stage of post-transplant life was cited above, also elaborated on the meaning of the practice. The comments were made in an extremely sentimental mood. She could not control her sobbing; she paused for a while before she resumed talking. It was one of a few emotional climaxes of the two-and-a-half-hour interview.

I do that because, you know, joy of, you know, to remember that…it is given to me by my brother. I should take care of it like my brother took care of me. He suffered too much. He gave it to me without asking anything in return. What he has given to me is a part of me…I have to cherish [it]. It is a gift from him. Without that, I will not have another life. I will not be here today. I am so grateful to him for what he did.…It is just like cherishing a baby. You always talk to him so that, you know, he will grow.

Like other kidney recipients cited above, Patricia adopted a metaphorical image of a kidney as a fetus, accentuating its otherness. At the same time, the kidney, thus personified, is also said to be a "part of me."

Because you know, your mind is powerful. What you are thinking and how you are feeling always affect senses of your body. When you are…if you feel so dull, if you feel so depressed…it is a way of making yourself happy that he is a part of me. It is a remembrance between me and my brother. Wherever I go, I take him together. It is a reminder of how much you are loved.

In Patricia's account, the tactile and verbal acts are endowed with two senses and two significances. On the one hand, they are directed to a kidney donated to her by her brother. The words are ostensibly directed to the organ inside the belly that is metaphorically imagined as a sort of baby. The caring touch expresses her affection. On the other hand, in addressing words to the organ inside her body, she is also reflexively acting toward herself ("What you are thinking and how you are feeling always affect senses of your body"). Therefore, in placing her palm on her belly and talking to a kidney inside her body, she is also talking to herself as well as touching herself ("it is a way of making yourself happy").

The double senses give her speech act and act of touch a curiously over-determined character. It is dialogue-like in the sense that her speech act has an addressee other than herself. It is also monologue-like since her speech is directed to herself, her embodied mind or her mindful body. Yet, these elements are combined in a single act of speech and touch; they are neither pure monologue nor dialogue. To the extent that her act is that of touching and talking to herself, it is mediated by remembering the presence of her brother's gift beneath the surgical incision in her own flesh.

A similar duality is evident in Alan's account. Alan received a kidney from his father's colleague, Jean. His brothers and sisters, according to Alan, were unable to donate a kidney due to their health conditions and various other reasons. Jean, who knew Alan well through her involvement with parish activities, volunteered to look for a donor for him. She contacted various sources, including prisons, but she was not able to find a suitable donor. When she spoke to Alan's attending doctor, Jean learned that, unlike what she had assumed, she was not too old to donate a kidney. She thus offered her kidney to Alan, whom she also wanted to become a priest. Alan's family proposed that she would take a year off and offered to shoulder her daily expenses during her leave. When I asked if there was any way that he felt the presence of a kidney, he replied:

YS: Has there been any change in the way you feel the grafted kidney?
Alan: Well, during the first year of my transplant, it was a sort of heavy. So, I am not wearing my trousers. I was thinking that it might affect my grafted kidney.
YS: If not pants, what were you wearing?
Alan: Shorts. I wore only shorts! [laugh] Almost for a year I was not wearing any trousers. When I went for a check-up, I wore shorts. They told me that it was okay to wear trousers. No problem. But until now, when I am taking a bath, I always see to it, I have to rub with a soap slowly. Slowly and gently. I make sure that my grafted kidney has not changed. It is also the time that I become reflective too. I have to reflect always what happened to me. I think, according to the spiritual director too, it is good also that it happened to me. They say that sickness sometimes is an opportunity for putting ourselves in a more intimate relationship with others. I used to get easily angry. I got very irritated. But this time, I am happy because every time the anger begins to take over me and I begins to get irritated, I can more or less control it.
YS: Do you wash very carefully even up to now? .
Alan: Yes. I always talk to her. I am always talking to her. I always do that.
YS: How do you always [talk to]....
Alan : Well, I am talking with, "Okay...?," well, I gave her a name, "Jean." That is the name of [my donor]. "Mum Jean, thanks for your help. Are you okay there?" It's like you always talk to it so as to keep it in good condition, to make her feel comfortable.

His reference to the reflection clearly refers to his biographical disruption, disruption of his way to priesthood (for his anger and irritation, see chapter 4). At the time of the interview, he was still undecided about whether he would go back to the seminary, and he remained uncertain throughout my fieldwork. He stated that he still was not sure if he was really "called" by God.

Alan's account of manual touch, we find the intertwining of two orientations and two bodily senses. In gently rubbing the soup over the incision, Alan palpated a transplant organ inside the skin. However, if he "touched" a grafted kidney, he did not do so directly with his hand. In between his hand and a kidney that it seeks to touch lies the flesh of his own body as the medium and organ of tactility. His act of touching a kidney thus also involves the act of touching himself. What is touched is the incision on his skin that signified the biographical disruption caused by kidney failure.

To the extent that Alan's practice of touch is "self touch", touching of his own flesh, it was nonetheless mediated by the presence of something other than himself or his body. When Alan touches the surgical scar, the emotionally charged part of his flesh, beneath it lies a kidney that bears the name of his donor. His act of self-contact in a contemplative mood is not a solipsistic practice because, in doing so, he also inevitably touches or is touched by the other. The post-transplant sense of bodily self is cultivated by generating unique sensory experiences of touch. A kidney is made to manifest in his sensuous body in such a way that it is both presented as a "part" of his bodily self and as something alien to it.

In short, what the seemingly merely fanciful bodily practice of talking to a kidney and fondling it is a "serious play." Through the bodywork, a transplant kidney inside the body becomes an affectively charged site of intertwining of the inside and outside of the body and "me" and "not-me." Through this unique experience, something other than "me" is enfolded into a process of embodiment, a continuous process of separation and reunion of the bodily "I" and "my" body, sentient body-subject and sensible body-object (cf. Merleau-Ponty 1968; Zaner 1981; Waldenfels 2007).


VI. Conclusion: On the tolerant mind and the hospital body

This paper only examined accounts of bodily experiences of Filipino kidney recipients. The limited amount of research done on this issue prevents us from stating to what extent findings could be generalized even among kidney recipients, let alone among recipients of other organs. It would be fruitful to carry out a similar investigation of recipients of other organs-heart, lung, liver, etc. Do recipients of different organs feel different kinds of bodily sensations? Do they improvise different sorts of metaphorical imagination and bodily performance?[5] A cross-cultural comparison may reveal various metaphors and divergent manifestations of creative imagination in remaking the body image after organ transplantation. The findings of this paper thus point to the need for a wider investigation into the role of sensuous experiences and imagination in the lives of organ recipients in different social and cultural contexts. However, it is possible to draw some tentative conclusions from the findings of this study.

In considering the meaning of the experience of incorporation of a "foreign" organ into the body, in an essay titled "The Intruder," Jean-Luc Nancy, a French philosopher who has undergone a heart transplant, offers a valuable insight.

The intruder introduces himself forcibly, by surprise or by ruse, not, in any case, by right or by being admitted beforehand. Something of the stranger has to intrude, or else he loses his strangeness. If he already has the right to enter and stay, if he is awaited and received, no part of him being unexpected or unwelcome, then he is not an intruder any more, but then neither is he any longer a stranger. To exclude all intrusiveness from the stranger's coming is therefore neither logically acceptable nor ethically admissible (Nancy 2008: 161).

The "stranger" or "intruder" in this passage has two referents: (i) a foreigner within the national border who may disturb the nation as a body politic and (ii) a transplant organ, an "immunological non-self" inserted into a patient's personal skin-bound body. A transplant organ is not an intruder in the sense that it does not forcibly introduce itself as some foreigners might. However, the heart transplanted into his body is an intruder nonetheless since it is "the insubstitutable other that has nonetheless been replaced" (Nancy 2008: 165).

The presence of the stranger inside the boundary, according to Nancy, poses a problem to the bodily self as well as the body politic: the welcoming of the stranger. The intruder problematizes the identity of the self-same "I," interrupting "its simple adequation (in its 'I = I')" (2008:168). "Between me and me there had always been some space-time," Nancy states. However, transplantation deepens and widens the fissure within the bodily self. The survival of "my" body as a living organism, on which the existence of the "I" depends, is conditioned by the "intrusion" of something other than me. The incision in "I am my body" is irredeemably open. This is the problem a transplant patient has to live through. To accommodate a stranger, one has to face the presence of something that resists being "naturalized," "assimilated," or "reabsorbed." An intruder is no longer an intruder when he (she, it) is "reabsorbed" into the personal body or the body politic. "The strangeness of the stranger would otherwise be reabsorbed-would be an issue no longer-before he even crossed the threshold." Welcoming the intruding stranger is "hard to receive and conceive" but is also "what needs to be thought through and put into practice" (2008: 162).

Nancy's essay invites us to critically examine a predominant tendency in psychiatric literature examined above. The presence of the alien thus constitutes a threat to the norm of self-mastery and self-possession prevalent in the Western individualistic notion of the self or a view of the possible individual, in which the self is seen as a master of his own body. An organ transplant traumatizes not only the body, but also the autonomous bodily self. The norm of self-mastery and self-possession dictates that the corporeally and psychologically traumatized bodily self must suppress the injury and wound so as to live as if his or her body were a normal and normative body. A deviation from such a norm tends to be pathologized (cf. Sharp 1995, 2006).

The way a transplant organ is incorporated as a part of the bodily self by kidney recipients can be seen as a patient's response to the problem of welcoming the intruder. Through attending to manifestation of a new organ in the sensuous body, cultivating the new body image with metaphorical imagination, and reflexively acting on their own bodies, many kidney transplant patients worked out a way of accommodating a foreign body part in such a way that its otherness was not marginalized or denied. On the one hand, something other than oneself inside one's own body is given a place in the lived body, and its unique presence is acknowledged. On the other hand, it is incorporated into an integral part of the bodily self. The sensuous manifestation of the "foreign" kidney is incorporated into the habitual body. It is integrated as a part of the meaningful whole of the imaginary body through metaphors of a kidney as a fetal life or a foster child. Talking to and touching a kidney while at the same time talking to and touching oneself also affirms that it is a part of the lived body. A transplant organ becomes a meaningful site of intertwining of "me" and "not-me" and is enfolded into the hospitable body. Psychological "tolerance" is achieved without its otherness "suppressed" just like a fetus in the mother's womb.

A cultivation of the "tolerant" mind and the "hospitable" body may present a significant challenge to what is widely taken for granted in psychiatric discourse on incorporation of a transplant organ. Therefore, it may appear subversive since it deviates from normalizing discourse of transplant liaison psychiatry. However, a question that has to be asked is: Is something that problematizes the "I am my body" necessarily a spoiler of the sense of bodily self? Or is it a masculinist and healthist preoccupation of the Western individual and autonomous bodily self (Young 1984; Weiss 1999)? The encroachment of "intruder" inside the body may not only be a source of estrangement, alienation, and diminishment of autonomy of the embodied selfhood, but also a source of its enrichment.


Notes

[1] One recipient who had two kidney transplants received a kidney from a mother and sister. Another recipient who had two kidney transplants received a kidney from an uncle and a cousin. Therefore, in total 54 cases of kidney transplantation.

[2] For heart recipients' experience of a change of personality, see Bunzel et. al. (1992). According to their questionnaire survey, while around a half of heart recipients acknowledged the profound effect a heart transplant had for the self-understanding, only a small minority of heart recipients (6%) reported a change of personality and ascribed this to transmission of personal traits from their donors.

[3] It is true that my back pain can be caused by inflammation of a kidney; pain, nonetheless, is still localized in the back, not a kidney.

[4] For a detailed philosophical discussion on the concept of "immune self" from a feminist perspective, see Howes' thoughtful essays (Howes 2000, 2007). Howes criticizes the urinary notion of the self assumed in the immunologic use of the notion of the self. For a historical background of the notion of the immune self, see also Tauber's work (1994).

[5] Francisco Valera has left a fragmentary memoire of his experience of a liver transplant (Valera 2001). Although the space does allow a further discussion, I note that his posthumously published essay is extremely thought provoking in this respect (see also, Waldby 2002).


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