Stem-cell alchemy: techno-science and the new philosopher's stone.

Cregan, Kate ; Warburg, James Paul

The current debate over experimentation on foetal stem cells implicitly goes to core questions about what it means to be human. When does human life begin? Is stem-cell science simply a technical matter of deploying abstracted body parts, or does it involve experimenting on potential humans? Do we continue along the path to becoming technologically maintained cyborgs, or should there be limits to the techno-scientific remaking of life? Like the splitting of the atom, there is obviously no going back to a time before the knowledge was available, but does this make its application inevitable?

Techno-science clearly has a long and gathering history. The abstraction of the human body, particularly in relation to reproduction is not new. Theodor Kerckring's anatomical atlas, Spicilegium anatomicum (1670) immortalized lovingly preserved and artfully displayed foetal skeletons in obscene ikebana. William Hunter's famous obstetrical atlas, Anatomy of the Human Gravid Uterus (1774) faithfully depicted full-term foetuses in butchered maternal carcasses. We use the term 'butchered' advisedly. By the nineteenth century much care was being given to creating a taxonomy of the embryo and foetus, indeed to inventing stratified definitions for those very terms and dividing pregnancy into developmental categories based on the careful arrangement of preserved aborted, miscarried or post-mortem human remains. (1)

It is from a rewritten version of this history that proponents of stem-cell research now draw legitimation for the relatively arbitrary distinction between a bundle of cells and a human foetus. However, human embryonic stem-cell technology goes qualitatively beyond the earlier techniques of tracking and manipulating reproduction. Together with in vitro techniques, stem-cell science heralds a level of abstraction that builds upon and is far more intense than even the most obsessive taxonomizing. It has the potential to pervert the social meaning of both human conception and human mortality. In some of its projected outcomes, such as turning embryos into transferable post-human body matter, or developing 'therapeutic cloning' as a way of industrializing the availability of transplantable body parts, it bypasses hitherto foundational assumptions by which we live and die as embodied persons. In all of this, the aim of the new technology is to satisfy individualistic desires for transcending faulty body-parts and to make market gains out of remaking life-chances. In this sense, the current debate over the limits of technological intervention is no less than a defining moment in the history of how we are to understand the meaning of living as human beings. It contributes to reducing basic ontological questions to the search for a new philosopher's stone.

Making this point is not altogether straightforward. For anyone tinder the age of twenty-five, Star Wars, Terminator, punk rock and the technological reproduction of babies have always been there. For the rest of us, the shock value of the science fiction images of cloning from Huxley's Brave New World has begun to dissipate. The first baby to be born as a result of in vitro fertilization (IVF) treatment, Louise Brown, was born in England in 1978. By 1981, embryonic stem cells were first isolated and grown in mice in the United States and the United Kingdom. In Melbourne in March 1984 the first baby brought to term as the result of the implantation of a cryo-preserved embryo was born. While it is by no means a unanimously accepted practice, IVF has come to be a normalized possibility of human reproduction. Out of these developments has emerged human embryonic stem-cell technology, with the promise of reproducing life itself. In November 1998, scientists moved into the unprecedented position of being able to control the indefinite life of human embryonic stem cells. Now, most of us are placed in the invidious position of having again to catch tip with the scientists--legally, ethically, socially, as well as in terms of just understanding the terms of the debate and the details of the new science. This article is intended as a critical response, but also as an orienting background to both the debates and the technicalities of the science.

Background Debates

In Australia--as in the United Kingdom, the United States and the European Union--the focus of attention on techno-science has emerged largely because bio-research has raced ahead of the law. Proposed legislation to refine the regulation of human embryonic research and to outlaw human cloning began in the wake of the ethical dilemmas generated by the birth of Dolly the sheep in 1997. In March 2000, in response to a request to review a major report, (2) the Australian House of Representatives Standing Committee on Legal and Constitutional Affairs into Human Cloning held a series of five public hearings. The first forum gathered in one place the most strident voices both for and against human embryonic research. It encapsulated the tenor of the ethical debate that has surrounded the issue since. Scientists argued against the cloning of human babies--saying lamely that the risks out-weighed the benefits--but they argued for the 'therapeutic cloning' of human embryos for research, and in general for ongoing research into human embryonic stem cells. First, they argued, therapeutic cloning technology gives hope of treatment or cure for many diseases; second, the embryos they would be working on are at a very early stage of development; and third, ethics bodies already allow research on embryos up to fourteen days for the improvement of IVF. These points were seen to be sufficient reason for allowing scientists to pursue their research.

Julian Savulescu, a bio-ethicist, went further and argued that it is immoral not to clone embryos for research, (3) and following this lead, others have shown in subsequent public debates that they are not in principle opposed to human cloning. (4) The general tenor of the 'for' case was to argue that embryos subjected to research processes are not sentient or rights-bearing individuals. Early embryos, it was argued, are of little moral significance. Therefore (double negatively), there is not sufficient reason not to proceed with treating embryos as a research resource. On balance, the protherapeutic-cloning ethicists presented a utilitarian case that if the products of human embryonic stem-cell research might potentially treat diseases such as Parkinson's, Alzheimer's and diabetes, or prevent the birth of disabled children, the decision weighs more heavily in favour of proceeding than not. This is not a strong ethical argument in itself. However, in the context of the strategies being used to naturalize techno-scientific possibilities--like naming particular individuals, for example Christopher Reeve or your grandmother, as those who might benefit--it carries considerable force in our media-saturated community.

Other (predominantly religious) ethicists argued that embryos are potential or proto-human beings, and should be respected as such: that to experiment on them is to breach the sanctity of fife. Rushing into such research, they said, takes a further step along a slippery slope that could open the way to more repellent practices, that is to say, to completely objectifying and commodifying human life while desensitizing people to ever more invasive medical science. While this is a powerful critique that deserves much more development, the religious and humanist critique of techno-science has unfortunately been bogged down in technical and reductive questions about when human life begins--at conception, at fourteen days, at viability, or with the development of consciousness? Here we can see that the ethical debates around embryonic stem-cell technology carry through the same arguments that surrounded the introduction of the regulation of IVF and other assisted reproductive technologies in the late 1970s and early 1980s. This lies parallel with the fact that cloning and embryonic stem-cell technology is dependent on the groundwork laid by the embryological research involved in veterinary and human IVF. However, this also means that the humanists and religious ethicists are still all too often caught up in the same frame of understanding that treats questions of life as based on instrumental technicalities. As one theological writer has put it, without seeing the obvious anachronism, the Bible 'offers no definition of when conception occurs'. (5) She then approvingly quotes a Catholic ethicist: 'the appearance of the primitive streak marks the formation of a multicellular human individual with a craniocaudal body axis and bilateral symmetry ... a human individual could not begin before cells of a rudimentary organism form a distinct ongoing living body at this stage'. (6) And so, blinded by science, the 'human life begins at fourteen days' argument is given credibility. (7)

With this kind of critical engagement, the irony that it is not the critical ethicists who have brought the issue to a head is easily explained. Indeed, if 'therapeutic' cloning (8) had not been threatened by the Bill on Human Cloning, the biotechnology that makes cloning possible--that is, embryonic stem-cell technology--might have continued to be used and developed in Australia untroubled by legal hindrance, as it had been since 1995.

Getting Behind the Processes Involved

What are the practicalities of the research and the surrounding circumstances that have brought us to the current moves to regulate embryonic stem-cell research? In the Standing Committee hearings it became clear that human embryonic stem-cell research was already being carried out in Australia, a fact hardly known to the wider public at the time. Australian researchers were well advanced even by comparison with many international 'competitors'. Thanks to a loophole in the Victorian Infertility Treatment Act (1995), stem cells removed from dissected embryos formed in an IVF program attached to the National University of Singapore had been imported into Victoria and experimented on at the Monash Institute for Reproduction and Development for some years. (9) The Act covers the importation, production and destruction of embryos, ova and sperm--that is, whole entities--but has nothing to say about their constitutive parts. Given that dealing in parts was not illegal, the Monash researchers had blithely imported embryonic stem cells cut out of embryos in Singapore where there was no legislation preventing it. (10) Lest you think that we are being unduly harsh here, it is worth noting that the Monash Institute is not coy about this deliberate circumvention of Australian law. 'We have always (sic) been open about the fact that the cell lines used to create specific human tissue were from Singapore because the laws in this country prevent the first stage of research,' says Alan Trounson in his own newsletter. (11) These researchers joined others in attending committee hearings to try and ensure that any new legislation did not prohibit or inhibit the techniques they hoped to be able to use. In the most recent debate in Canberra over the further legislation to regulate embryonic stem-cell research, the same faces reappeared, lobbying for all they were worth.

Like the philosopher's stone in its time, the pluripotent stem cell lies at the core of debate over ethical questions, social life and economic return. There are significant vested interests within academic, political, commercial and medical institutions in seeing this technology progress. Put in basic terms, embryonic stem cells are the building blocks of the body. Controlling the building blocks and associated intellectual property rights is potentially associated with status and beneficence, fame and fortune. Stem cells are the base cells that form the early embryo and go on to multiply, develop and differentiate into the many cell types that it takes to form a whole being. They were first isolated in mice in 1981 in both the United Kingdom and the United States. (12) Now, these cells are being removed from early human embryos, grown on mouse embryonic 'feeder' cells, and biochemically manipulated to multiply without developing. In other words, the first step in readying these cells for their proposed specific therapeutic applications is to be able to alter the normal progressive development that would take place in an embryo--that is, to biochemically suspend life-development. The debate thus links the meaning of life to the scientific practice of the control of life-forms.

Human embryonic stem cells were first successfully isolated in 1998. For the following two years researchers were busily employed trying to culture significant banks of the cells and to control the restarting of the developmental process. This is part of the second step in the control of life-formation necessary for therapeutic practice: being able to control the forming of specific cell types (nerve, muscle, blood). Some embryonic stem-cell researchers around the world have had a measure of success in differentiating cells in some of their lines. (13) However, there are many steps to be taken before this biotechnology could even possibly be applied in practice, and many question marks over whether any of it will ever be useful in direct therapeutic applications. Having been grown on mouse tissue, virtually all the current cell lines in the world are unsuitable for implantation. Their potential for rejection in a person's body is no different from a whole-organ xenotransplant (animal-to-human transplant), and the accompanying potential problem of the introduction of cross-species diseases into recipients. Further, even if embryonic stem cells are successfully mass grown on human foetal or fallopian tissue--as recently claimed to have to have occurred in Singapore (14)--they would induce rejection even with close tissue-typing, as is the case with any human-to-human transplant. Many, if not most of the current stem-cell lines in Australia, for example, are ethnically Chinese.

One possible further leap--proposed as a way of overcoming this particular hurdle--is the technology that so vexed the Committee into Human Cloning: therapeutic cloning. Despite the humanitarian re-classification of its name and purpose, this remains human cloning, pure and simple--a fact that has led many researchers to now prefer to call the process 'somatic cell nuclear transfer' to avoid any association with cloning. Nevertheless, it is cloning. The difference is that therapeutic cloning does not progress to implanting the cells into the uterus of a human female, and therefore stops short of forming a cloned foetus. Therapeutic cloning involves removing the nucleus of an egg, fusing the nucleus of a somatic (body) cell from a person requiring treatment with the enucleated egg, and restarting the resulting embryo along its developmental process. Once the cloned embryo has developed to a stage at which stem cells could be removed, it would be dissected and the embryonic stem cells taken and differentiated to form the specific tissue required: supposedly, pancreatic cells for diabetes, nerve cells for Parkinson's, heart cells for cardiac disease. The problems inherent, even in medical theory, are serious--the possibility of the implanted cells spontaneously mutating and forming tumours being just one issue--and the ethics are fraught. For example, it would require massive harvesting of human eggs, raising the question of who would be most likely to donate and why. Poor women, quite possibly from countries with less stringent (or no) legal prohibition against such exploitation, would be the most likely candidates. (15)

On an immediate, pragmatic level then, therapeutic cloning could lead to the rank commercialization and exploitation of women, most probably poor or third world women, to provide the raw materials for the treatment of first world diseases. It would lead to a global trade in human eggs. Indeed, these processes are already subject to international interests and globalizing influences. Researchers around the world want access to US dollars from the lucrative National Institute of Health, and to enhance their chances of getting it they are tailoring their research to the standards the NIH has set. The researchers at Monash University, for example, had to go back and. re-derive their embryonic stem-cell lines to meet NIH standards. International research partnerships can motivate researchers to lend their support in lobbying each other's governments when regulatory legislation is proposed. There is the impetus of ensuring that research not be hindered, and (seemingly) contradictorily concerns, expressed as feigned nationalism, that if this technology is not allowed to proceed unfettered we will somehow lose our 'competitive edge' or 'market advantage', and that research will go offshore. Complex patent licensing agreements between international research partners rule the distribution of the financial outcomes of this research far more than regional legislation. This biotechnology is thus part of a global economic rationalizing of life.

Partly in reaction to the unpalatable nature of these possibilities, and to the practical problem of 'harvesting' what would have to amount to millions of eggs to treat the most commonly invoked diseases, like Parkinson's, a further possibility has been raised: fusing the nucleus of an adult cell with an enucleated undifferentiated embryonic stem cell. (16) That is to say, reversing the adult cell from its stable state of development and restarting it again as a stem cell of the tissue that the client desired. This, supposedly, overcomes the ethical and practical problems of using donor eggs, and coincidentally would not be covered by the legislation banning therapeutic cloning. Here we run up against a problem inherent in all the possibilities we have outlined so far. Whether in an enucleated embryonic stem cell or an enucleated donor egg, not all the DNA in the cell is removed. Mitochondria, the 'energy packs' in every cell, carry DNA. Even if the DNA from the cell of the person who is ill is compatible, as has been pointed out, (17) the mitochondrial DNA of the embryonic stem cells or the donor egg into which it is introduced, will most likely produce a rejection problem in itself.

Or turning to a social issue, ten or twenty years down the track what is to stop insurance companies refusing cover to people who cannot afford or who refuse such therapies? How are we to prevent insurance companies becoming interested in who has or has not been subject to pre-implantation diagnostic screening, who has been genetically modified at the embryonic stage, who has had cells implanted in them to treat a disease like Parkinson's? What is to stop medical insurance companies--who in the United States already tell doctors what treatments they can and cannot apply, what drugs they can administer, under given insurance cover-from restricting such therapies to those who have the appropriate cover? And we know very well, with the pressure to recoup research and development funding that those in the poorer sections of the developed world and the vast majority of those in undeveloped world will not have access to any of this technology, if it ever finds a viable application. A long history of pharmaceutical conglomerates withholding generic therapies and dumping unsafe drugs on third world markets has taught us that much.

It is not science fiction or scare-mongering to propose that what we may see is a shift from preventative medicine--the avoidance of adverse effects through the avoidance of risk factors--to the prevention of people, ensuring that risk factors do not arise. That is exactly what pre-implantation diagnostic screening is designed to do: prevent the implantation of undesirable embryos. People talk about preventing crippling genetic diseases in their child, yet again reducing the argument to an individual emotive level. Just because a person carries a gene does not mean that it will be expressed, or even if it is, that it will be fully expressed. (19) More fundamentally, just because someone has a debilitating disease it does not mean that his or her life is not worth living.

Broader Considerations

The highly emotive, and in some cases frankly exploitative use of individual sufferers of diseases--particularly by sound-bite driven politicians--obliterates the social background, the social processes and the social consequences of these proposed technologies. Is it worth fundamentally altering the way we see ourselves and the way we see each other, either on the overblown hope of satisfying individual desires to live longer or to make global pharmaceutical conglomerates a profit out of individually tailored drug-testing 'body matter'? Embryonic stern-cell technology re-presents our bodies as fetishized objects that only scientists know how to treat effectively. If we uncritically accept embryonic stem-cell technology we invite the rationalization of our embodiment. More generally, we participate in removing our bodies/ourselves from the context and the labour of our reproduction, the human setting that brings us into being in the first place.

It is hard, especially when everyone involved in these debates focuses on the microscopic matter to hand or on the immediate consequences of its use, to take a wider view of what may be the potential cultural consequences of using these cells. A parallel example of a now-normalized biotechnology--heart transplant--perhaps helps to elucidate some of the issues. The example has a double relevance here because one direction of stem-cell technology has been to project the cloning of heart-tissue cells and, more dramatically, to advocate the cloning of the organs themselves. Growing organs for transplant still may be a long way off, but techno-science is moving so quickly as to make it imperative that we now start thinking about the possible social consequences of industrializing body-parts production. For example, the US firm Advanced Cell Technology (ACT) recently announced that it had fabricated artificial kidney units. The kidneys were initiated from cells derived from eight-week-old cloned cow foetuses and grown on a synthetic structure made of 'polycarbonate membranes coated with an extract of rat's tails' placed under the skin of a cow. The Guardian's science correspondent concluded that 'it would be impossible, ethically, to use the same techniques to build artificial kidneys for humans. It is difficult to imagine any society allowing scientists to grow human embryos until eight weeks old, then destroy them to remove their growing kidney cells, as the ACT researchers did with cows'. (19) A brief detour into exploring the redefinition of human life and death that has taken place in the name of organ transplants suggests quite the opposite.

When someone is asked to donate their organs, or their family is approached to do so in a hospital emergency ward, we are told it will be giving 'the gift of life'. Altruism is a worthy quality in anyone. It is a social good and an ideal deeply ingrained in most cultures. But behind the pleas to 'save' individual lives through organ transplantation lies a far more complex process than that asked of an anonymous person to selflessly give blood, which one's body can replace readily without lasting effect. The gift of a heart requires the death of a person. This death, however, is not the commonly understood 'moment of death' when the heart stops beating and breathing ceases. That kind of death renders the gift worthless. The system of 'altruism' entails redefining death techno-scientifically. The so defined 'brain-dead' bodies of organ donors are kept on life-support systems and subjected to close monitoring and careful drug treatments so that their organs are kept alive. While the relatives wait to mourn the loss of a loved-one, the medical teams work to assess and remove viable parts for transplanting into other people. And then the surgeons have to 'take' the life-supported body through to the next stage of complete death. Organ transplantation is, in most Western cultures, spoken of and has been debated purely in terms of the miraculous saving of individual lives: the ethics of brain death barely rate a mention. (20) The 'miracle' argument also represses the issues of how organ transplantation requires what is in essence the dismembering of another's body; (21) that organ transplantation is temporary; that it fails inevitably and repeatedly; and that the drug regimens that recipients require induce other illnesses. Most importantly, however, in social terms organ transplantation radically alters our relation to the categorical condition of mortality, including our care of and responsibilities towards the dying, by redefining at least one aspect of the process of being human.

A similar set of unacknowledged re-definitions takes place with IVF. The implications of embryonic stem-cell technology are at least as serious. The most fervent arguments in favour of embryonic stem-cell technology centre on curing disease. The way this is presented to us is precisely at this individual level: this child has a motor neurone disease; that man Christopher Reeve is a quadriplegic; Michael J. Fox has Parkinson's disease. The fears and desires of individuals to live longer or healthier lives are not unreasonable in themselves. However, they too mask the terms of the production of what are, at best, ephemeral possibilities of treatments: they depend on a social redefinition of our historically lived understanding of what it is to be or become a human being. Like organs removed from the reality of the death of the person, embryonic stem-cell technology removes reproduction from the reality of the people who have created a life. Ova, sperm, embryos, become simultaneously fetishized and banalized objects open to rationalisation and commodification. They are removed-abstracted--from the conditions of their production: persons in relationship. We are led down the path, as we allowed ourselves to be earlier in this article, of focusing on the things that preoccupy scientific researchers, issues such as the incompatibility of mitochondrial DNA. The more important point is that that DNA came from somewhere. The bodily emissions of two people came together to create a life-form that, if left to its own devices in the appropriate environment--a woman's womb--has a good chance of becoming a new human being. The techno-scientific recreation of human embryonic stem cells overrides this basic condition even if it claims to be mere therapy.

Going with the products of techno-science, including the potential of organs grown in stem-cell laboratories, is not simply a matter of personal choice. Such 'choices' are intimately connected to how we perceive each other, how we perceive our ability to reproduce ourselves, and our societies. They are another means of re-presenting us to ourselves, distancing us from face-to-face, embodied relations. The tensions at work in this are apparent, even in the arguments that come from the mouths of scientific researchers. We are told that the human matter at stake to be experimented upon is a tenth the size of the head of a pin. It is therefore morally inconsequential. At the same time we are shown in living colour the miraculousness of the first days after conception being probed and stem cells removed. Even the researchers cannot make up their minds. On the one hand they want us to accept that 'surplus embryos' are worthless blobs of cells destined for the sink--waste cells that should be put to good use. On the other they ask us to reward their efforts in manipulating them, because they are dealing with miraculous bundles of cells that can do the most amazing things in differentiating into all the cells that make up the complete human body. Are they wondrous because they are human or is the meaning of being human in yet another area of techno-science being reduced to its wondrous manipulability?

(1.) N. Hopwood, 'Producing Development: the Anatomy of Human Embryos and the Norms of Wilhelm His', Bulletin of the History of Medicine, vol. 74, no. 1, 2000, pp. 29-79.

(2.) On 10 August 1999, the Minister for Health, the Hon Dr Michael Wooldridge MP, asked the House of Representatives Standing Committee on Legal and Constitutional Affairs to review the report of the Australian Health Ethics Committee of the National Health and Medical Research Council, Scientific, Ethical and Regulatory Considerations Relevant to Cloning of Human Beings (16 December 1998).

(3.) J. Savulescu, Hansard, 29 March 2000, and in 'Procreative Beneficence: Why We Should Select the Best Children', Bioethics, vol. 15, no. 5/6, 2001, pp. 413-26.

(4.) P. Singer, The Australian, 23 August 2001, p. 3: 'Cloning for reproductive purposes was temporarily problematic because of the likely spate of birth defects but, if these difficulties were rectified, cloning in limited circumstances "would not be unreasonable"'.

(5.) D. Cooper Clarke, in an otherwise sensitive article, 'Human Embryonic Stem Cell Research', Center of Applied Christian Research Ethics Newsletter, vol. 7, no. 3, 2002, p. 3.

(6.) Cooper-Clarke, citing Norman Ford.

(7.) Despite this generalization there are some effective critics, see Simon Cooper, 'The Small Matter of Our Humanity', Arena Magazine, no. 59, 2002, pp. 34-8.

(8.) In a double irony, Alan Trounson recently claimed that therapeutic cloning was now irrelevant, that the way forward is in the fusion of adult cells with embryonic stem cells, at 'Cloning and Embryonic Stem Cell Research: Does Australia Need a Moratorium?', Dean's Lecture Series, University of Melbourne University, 26 July 2002.

(9.) Serendipitously, this research partnership, between Alan Trounson (Monash University) and Professor Ariff Bongso (NUS) began in 1995, the same year as the Act. BresaGen, an American commercial venture incorporated in Athens, Georgia, has an Australian arm that backs Professor Peter Rathjen's work at Adelaide University. It is also conducting related research, mostly on mice, and in mid-2001 the parent company derived four of its own embryonic stem-cell lines.

(10.) Singapore is only now debating the ethics of these procedures under the auspices of the Bioethics Advisory Committee, set up by the Singaporean government in September 2001

(11.) Stem Cell Update, published by the Monash Institute of Reproduction and Development, winter 2000, p. 2.

(12.) G. R. Martin (UK), M. J. Evans and M. H. Kaufman (USA) cited in L. M. Silver, Remaking Eden: Cloning and Beyond in a Brave New World, London, Weidenfeld & Nicolson, 1998, p. 128.

(13.) New Scientist, 8 April 2000.

(14.) Far Eastern Economic Review, 15 November 2001. This opens out a whole new question, if this is to be carried out in Australia. Will researchers then be pushing to be able to use aborted foetuses to further their research? Or will they again threaten to take their work 'offshore'? The latter is a patent nonsense when a good deal of the work, particularly the more ethically contentious procedures, is already done offshore and has been since the beginning.

(15.) D. Dickensen, 'Commodification of Human Tissue: Implications for Feminist and Development Ethics', Developing World Bioethics, vol. 2, no. l, 2002, pp. 55-63.

(16.) The Australian, 8 June 2002, p. 3.

(17.) Dr Perry Bartlett, Head of Development and Neurobiology, Walter and Eliza Hall Institute of Medical Research confirmed this was most likely the case when asked by Nicolas Tonti-Filippini in question time at 'Cloning and Embryonic Stem Cell Research: Does Australia need a Moratorium?'.

(18.) There are Downs Syndrome people who are non-communicative, and there are those who have successfully completed university degrees: nobody could have known their outcomes from a genetic test.

(19.) J. Meek 'Scientists Claim Cloning Success', The Guardian, 3 June 2002.

(20.) See M. Lock, Twice Dead: Organ Transplants and the Reinvention of Death, Berkeley, University of California Press, 2002, throughout. She shows the deep resistance to organ transplantation in Japan and how this is affected by the widespread public knowledge about the ethics and diagnoses of brain death.

(21.) Both Lock and L. Hogle, Recovering the Nation's Body: Cultural Memory, Medicine, and the Politics of Redemption, New Brunswick, Rutger's University press, 1999, give detailed, dispassionate yet horrific descriptions of the practicalities of organ retrieval in the US and Germany, respectively.