The Generosity of the Dead: A Sociology of Organ Procurement in France [Medical Law and Ethics Series] Lindsay B. Carey Graciela Nowenstein Ashgate Publishing, Surrey (2010) 202 pp., index 7 pp., 2 figures, 2 tables, A$69 ISBN: 9780754674320 Nowenstein’s text provides an informative in-depth exploration concerning organ procurement and transplantation issues within France but its relevance has international implications for law, ethics and health policy well beyond French borders. The text is divided into three parts: (i) law as policy, (ii) organ retrieval in hospitals, and (iii) law and policy. However these subdivisions are not really helpful for it gives the impression, which may be intended, that the book is predominantly about legal issues, when in actual fact health policy and ethics are just as noteworthy. Also the subheading is a little misleading, for excepting the fleeting reference to Durkheim, Parsons, Goffman, Glauss and Strauss, Foucault and Giddens, there is very little sociological analysis within the text – although the French sociologist Auguste Comte (if he were alive) may well have been impressed by the uniqueness of this research which, one could argue, fundamentally explores altruism; a Comteian- French sociological concept that the author could have further developed particularly given that the text is a sociological study of French altruism! Chapter one (‘Organ transplantation: From an eternally hopeless dream to the management of scarce resources’) presents an historical overview concerning the development of organ transplantation. Commencing with the miraculous legends of Saints such as Cosmas, Damien, Peter, Agatha and Mark (all of whom legend decrees performed primitive external transplantations, e.g. nose, leg and breast), the chapter progresses to the subsequent development of fantasy transplant literature (e.g. ‘Frankestein’, the ‘Modern Prometheus’, the ‘Fourth Hand’ and ‘Les mains d’Orlac’), to the more serious issues of defining death, transplant research, therapeutics, more effective immune suppression and (given transplantation success and the subsequent shortage of organs) there is an exploration of various systems of consent for organ donation. While there is much to learn from this foundational chapter, two key findings are clearly obvious. The first concerns the donor rate per million and consent laws. Spain (34 dpm), Austria (24 dpm) and Belgium (22 dpm) with ‘presumed consent laws’ have the highest donor rate per million whereas other countries such as England (13 dpm), Netherlands (13 dpm) and Germany (12 dpm), plus one could add Australia (9 dpm), do not have ‘presumed consent’ or ‘opt-out’ policies and have the lowest dpm rates in the Western World. However there are some countries where there is an exception, such as the USA (22 dpm) and Ireland (20 dpm) both having ‘expressed consent’ systems and yet relatively high numbers of donors per million. The second emphasis of this chapter is that while some might conclude that countries endorsing ‘presumed consent’ therefore have the highest dpm, the author argues that there is a naivety in believing that there is a correlation between presumed consent laws and the high rate of organ procurement. Rather the author notes, based on previous research, that in the case of Spain, Austria and Belgium other factors were dominant such as health care re- organisation that included trained transplant co-ordinators, plus communicational factors such as public awareness campaigns concerning the number of dialysed patients and that (despite presumed consent legislation) permission was still being sought from relatives before procurement. Chapter two (‘Law as a tool for enhancing social change: From faith to disenchantment’), explains the French Government’s first law of ‘presumed consent’ (1976) which rejected the altruistic ‘generosity of the dead’, preferring instead to put faith in various biomedical procedures and the endorsement of ‘presumed consent’ so as to gain and increase the level of organ procurement in France. Nowenstein argues that, subsequently, organ procurement shifted from ‘Heterogeneity to normalisation’ (Chapter three) but initially it was, in practice, a confusion of idiosyncratic protocols among hospitals, doctors and nurses until the 1990s whereby clinical staff in all French hospitals virtually bestowed upon relatives (for various pragmatic reasons) the right to veto any organ retrieval – despite the enacted law of presumed consent! Ultimately, argues Nowenstein, the French law of presumed consent was thus somewhat of a failure. A point which the current reviewer believes is debatable given the legal protection it provided to health professionals, allowing them to confidently seek procurement (with or without consent) and without fear of punitive professional, institutional or legal ramifications. Based on semi-structured interviews with French nurses and physicians across 13 health care centres in the Parisian region, Nowenstein summarises in Chapter four (The ‘living cadaver’), Chapter five (‘Unpredictable solutions’) and Chapter six (‘Whose gift?’) the practical complexities involved in organ recruitment such as determining and accepting brain death, the time constraints of transplantation and the pressure upon both clinicians and relatives to make speedy and sometimes unbearable decisions fraught with familial complexities, plus medical, political and health management issues – all of which (if not kept in balance) have the potential to lead to ‘social Ó La Trobe University 2011 10.1071/PYv17n1_BR 1448-7527/11/010122 CSIRO PUBLISHING Book Review www.publish.csiro.au/journals/py Australian Journal of Primary Health, 2011, 17, 122–123