The practice of eye donation in contemporary Sri Lanka
In a remote village in southern Sri Lanka, a dearly beloved father and husband passes away. The family sets about notifying relatives and turning their home into a funeral house (mala gedara), festooned with white bunting to announce their loss to those in the neighbourhood. In the coming days relatives will come from far and wide to pay their last respects. There will be mourning and remembrance in preparation for the funeral that will follow. As part of these preparations a phone call is made to the Sri Lanka Eye Donation Society (SLEDS) in the island’s capital city, Colombo, to inform them of the death.
The reason for this phone call is that in the midst of their sadness it is remembered that the man had expressed a wish that his eyes be donated for the benefit of others. This intention had been recorded some ten years earlier when the man had attended an eye-donation event at a local Buddhist temple and filled out a series of forms recording his consent to the removal of his eyes in the event of his death. This form had been displayed on the walls of his home ever since and clearly showed his signed agreement, the signatures of witnesses, and who his relatives should contact after his death.
The telephone call is received at the SLEDS headquarters and the name and reference number on the certificate is quickly matched with the records held at the society. Another phone call is triggered. The SLEDS local ‘technician’ closest to where the death has occurred is given the address and contact details of the family. Within the hour he has assembled his kit and is off on his motorcycle in search of the funeral house. When he locates it, he is welcomed and shown to the bed on which the body lies. There is minimal exchange as all know the work that he has come to do. He is left alone with the corpse, although occasionally relatives will watch the operation and sometimes children too. He works swiftly, propping up the head to restrict any blood flow, easing out each eyeball, and carefully cutting away the four extra-ocular rectus muscles before severing the optic nerve. Once removed, the eyeballs are put in solution in jars and placed in a polystyrene box packed with ice. The empty eye sockets are cleansed of blood and filled with cotton balls. Small sutures ensure that the eyes remain closed and fluid doesn’t escape. The face is adjusted so that it looks just as it was found.
The technician thanks the family and gives them a gold-embossed certificate the size of a sheet of paper. It names the donor and is signed by the president of SLEDS and its medical director who, in effusive terms, express their gratitude. The technician also leaves several posters that will be placed on and around the coffin when the body is displayed for relatives to pay their last respects. The posters again record the appreciation of SLEDS and proclaim that ‘from the immense sadness of this death comes a great pool of merit… . The Sri Lanka Eye Donation Society offers its gratitude’. At the centre of the posters is the logo of the society and a stylised image of an eye looking down into a begging bowl, cupped by two hands as it would be when offered by a monk to receive alms (dāne). [note 1]The idea of charitable giving occurs across South Asia (Heim 2004). The complex of material and spiritual relations that such transactions give rise to is typically captured in the idea of dān. Although having a common etymological route, there are slight variations in the way it is spelt and significant variations in the way it is conceived in practice. Throughout this article the usage is consistent with Theravada Buddhist ideas of meritorious giving.
The technician takes his leave and speedily returns to his hometown. Paperwork is completed, the box containing the eyes is sealed and labelled, and then it is taken to the local bus station where it is entrusted to the care of the driver of a private passenger bus. A small charge is levied and a receipt supplied. The drivers are aware of the nature of their cargo and regularly transport such packages to Colombo. They are happy to play their part in the carriage of this virtuous and merit-emanating cargo. At the main bus station in Colombo, the package is handed over to the police post for safekeeping. The police are also fully aware of what has been given over to their custody. Within the hour a representative from SLEDS comes to collect the box.
The eyes are taken to the preparation laboratory where they are cleaned. The corneas are separated and put into a solution that will preserve them for up to fourteen days. The corneas could end up being dispatched to a local hospital, but a request has recently arrived from a hospital in the Middle East. A suitable flight is identified and the following day the corneas are packaged and labelled and sent to Katunayake airport. The box is fast-tracked onto a cargo flight. The captain of the plane receives the box and, as is his airline’s practice, the corneas travel in a cold storage container in the cockpit for safekeeping. At its destination, more paperwork is completed and the package is handed over to a courier who takes it to a local hospital where preoperative preparations are underway for a cornea transplant. The hospital writes a letter of appreciation and sends a remittance to the Sri Lanka Eye Donation Society for the ‘processing charges’ incurred in getting the eyeball from a body in rural Sri Lanka to one in the Middle East. Within twenty-four to thirty-six hours the corneas of the villager enable someone in another country to see the world afresh, or possibly for the first time.
The above account is a composite. It describes the sequences in the journey of a human eye from the body of one person to another. It is assembled from interviews and conversations with the managers, technicians, and staff of the Sri Lanka Eye Donation Society, the nongovernmental organisation responsible for the retrieval, processing, and dispatch of many of the corneas that are collected on the island. [note 2]The Sri Lanka Eye Donation Society operates independently of the National Eye Bank of Sri Lanka, which is part of the country’s National Health Service and therefore under the jurisdiction of the Ministry of Health. Unlike SLEDS, the National Eye Bank procures its corneas from within the hospital system and mostly from people who pass away in hospital rather than in the community.
My involvement with SLEDS goes back to 2002 when I first interviewed its staff as part of research into tissue donation in Sri Lanka (Simpson 2004). During subsequent visits to the SLEDS headquarters in Colombo I met with staff and followed with interest the growth and development of this extraordinary enterprise. The organisation has operated in the field of ophthalmic services generally and corneal donation specifically since the 1960s. From small beginnings the organisation has grown so much that, as of November 2014, SLEDS had on record over 1.1 million pledges from men and women willing to donate their eyes, and in some cases other body tissues such as bone, skin, and muscle, for use in therapeutic transplantation, education, or research. Out of a population of 20.2 million (DCS 2013), the proportion of people signalling their intention to donate is worthy of explanation. It is also important to note that the vast majority of these pledges are made by Sinhala Buddhists who make up around 70 percent of the population, with Muslims, Christians, and Hindus much less in evidence in SLEDS records (less than 5 percent).
In this article, I set about unpacking what appears to be a widespread enthusiasm among Theravada Buddhists to pledge the donation of corneal tissue, if not to have this translated into an actual donation by relatives after a person’s demise. First, this enthusiasm is explored in terms of the ostensible and widespread links to Theravada Buddhist beliefs and practices that are made by SLEDS staff, as well as by those who make the pledge. Explanations of the success of the eye-donation movement are typically conveyed by SLEDS staff in terms of Theravada beliefs concerning right action and merit (pin), rebirth and its determinants (karmaya), and what people wish to happen to the body at death. In the second part of the article, these beliefs and values are situated ethnographically in the context of contemporary eye donation campaigns and accompanying celebrations. In such events, contemporary rhetorics of corporeal charity bring individuals into alignment with ideas of nation, people, and religious community, and, moreover, with how these should be thought of and lived in the context of postwar reconstruction. In 2014, when I last visited Sri Lanka in connection with the tissue donation project, the island had only recently emerged from a protracted and vicious civil war against the Liberation Tigers of Tamil Eelam (LTTE). In 2009, the government had ended the conflict with a bloody showdown on a remote beach in the northeast of the island. Both the government and the LTTE were accused of war crimes in the run-up to the denouement of the conflict and, according to which source is consulted, anything between three thousand and forty-four thousand Tamil civilians lost their lives. [note 3]Andrew Buncombe, ‘Up to 40,000 Civilians “Died in Sri Lanka Offensive”’, The Independent (London), 12 February 2010, http://www.independent.co.uk/news/world/asia/up-to-40000-civilians-died-in-sri-lanka-offensive-1897865.html; Julian Borger, ‘Sri Lanka Says up to 5,000 Civilians Died in Tigers Battle’, The Guardian (London), 4 June 2009, https://www.theguardian.com/world/2009/jun/04/sri-lanka-civilians-tigers-battle.
For the thirty years prior to this, the people of Sri Lanka had been witness to a relentless cycle of violence in which death, atrocity, and suffering had become immanent and routine. It is against this backdrop that the account that follows is set.
Crucially for the arguments developed here, opportunities for donation are linked with the possibility that a death might become differently meaningful. The difference is evident both within Sri Lankan society as well as in the country’s relationship with the world beyond. Specifically, there is an aspiration to achieve global positioning in the burgeoning market for ethically sourced human tissue. Put simply, the numbers of those intending to donate corneas in Sri Lanka translate into a supply that not only meets local needs but creates a surplus for export in a context usually characterised by shortage (Farrell, Price, and Quigley 2010; NCOB 2011). Corneas, for which there is often a particular reluctance to donate because they are synonymous with the eye and therefore ideas about appearance, identity, and inner consciousness (Hayward and Madill 2003), are not in short supply in Sri Lanka. To bring home the importance of this connection between a local surplus and international demand, a brief excursion into a different ethnographic context is necessary.
In her ethnography of organ transplantation in Egypt, Hamdy (2012) makes a compelling argument about the way that illegal organ-procurement practices spread fear among ordinary people. In response, popular opposition to organ and tissue donation on religious grounds is common despite there being no Islamic precept that explicitly forbids it; as her informants were led to conclude, ‘the body belongs to God’ (Hamdy 2012, 19). In relation to corneal transplants this finding was particularly anomalous given that in the 1960s Egyptian doctors were relatively advanced in their ability to carry out corneal grafts. Their interest in this field had come about due to the prevalence of trachoma in Egypt, which had been endemic for several hundred years (Hamdy 2012, 16). Yet, despite these early developments Hamdy records that the eye banks upon which such interventions relied were barely operational by the 1990s. Corneas could not be sourced locally.
Some years ago I was sitting across the desk from the operations manager of the Sri Lanka Eye Donation Society when I notice a striking and beautifully crafted image on the wall behind him. I asked what it was. He explained that it was a painting on papyrus of the Eye of Horus, which had been gifted to the organisation by an Egyptian hospital. The conversation moved on to the many other pennants, medals, plaques, and icons of acknowledgement for corneas supplied by SLEDS to hospitals around the world. I thought nothing more of the specificities of these gifts, only their general effect as a composite acknowledgement of gratitude from ‘the world’. It was only upon reading Hamdy’s ethnography some years later that the significance of the Eye of Horus painting leapt out. A country, Egypt, which cannot ethically procure a supply of corneas from within, because of opposition grounded in Islam, must, perforce, source them elsewhere. Another country, Sri Lanka, which appears to give such donations a powerful endorsement on the basis of Buddhist beliefs and values, seems a rather obvious one with which to cultivate good relations. In the global quest for ethically sourced human tissue, SLEDS plays a key role in bringing these ends together and articulating back and forth between local religious beliefs and values on the one hand and a cosmopolitan, global medical trade on the other. As in Copeman’s (2011, 1060) account of blood donation in India, the promoters of tissue donation in Sri Lanka draw on a religiously inspired notion of the charitable gift, that is, they operate with ‘an objectified—singularized, disambiguated, “generified”—dan’. The conflation of the gift as religious duty and as an act of corporeal charity proves remarkably successful when it comes to activating the intention to donate, if not the actual postmortem practice. Beneath these waves of benevolent intent, however, the rather more prosaic transactions of a global ‘tissue economy’ are in evidence (Waldby and Mitchell 2006). As Healy (2006, 17) points out in relation to the work of blood banks, such organisations engage in ‘both logistical and cultural effort. The result is a practical system of procurement and distribution, but also a moral order of exchange’. The practical aspects of procurement are taken up in the second half of the article. First, let us consider in more detail the distinctively Buddhist values that give the practice of eye donation its doctrinal and moral justification in Sri Lanka.
Buddhism and the rhetorics of corporeal charity
The concept of dāne or meritorious giving provides the primary framework within which the act of cadaveric donation can be made sense of (cf. Copeman 2011; Heim 2004; Parry 1986). At the most general level, the realisation of nibbāna is the ultimate goal of all Theravada Buddhists and this is achieved through three kinds of practice: meditation (bhavanā), right actions (sīla), and the accomplishment of the ten perfections (dasāparamitā). One of the ten perfections is that of generosity (dāne paramita) which is accomplished through acts of charity or donation. These acts are preliminaries to higher and more extreme acts of selfless giving, which include the giving of body parts and, indeed, the whole body for the benefit of others. Such acts have long been celebrated in tales of Buddha’s previous lives known as Jātaka stories. In recent times, these ideas have been expressly linked with tissue donation for biomedical purposes and have become a recognised way of demonstrating virtuous action and thereby accumulating the merit necessary for rebirth into a better existence.
Accounts of giving of alms or the sacrifice of one’s own life for another are common in the teaching of many religions. What is highly unusual in the Buddhist tradition is the existence of a clearly elaborated set of practices that relate specifically to the body. In the Buddhist literary tradition and particularly in the Jātaka stories there are frequent examples of bodhisattvas giving parts of their bodies as offerings to others in what appear to be extreme ascetic, self-denying, and ultimately suicidal acts. These are known as dāna upa paramitā and signify the perfection of giving. Such practices are well established in Buddhist traditions across South Asia. Indeed, the Buddhist literary scholar Reiko Ohnumi (2007) has identified these extraordinary acts as a distinct subgenre within Buddhism across South Asia. She refers to this genre as ‘gifts of the body’ and identifies a distinctive set of reflections within Buddhist literature on the meaning and significance of the self, the body, and death. In so doing, she goes to the heart of Buddhism’s existential philosophy, social ethics, and day-to-day ritual practice. She speculates on the way that such gifts expose deep philosophical contradictions around ideas of attachment and detachment faced by practitioners of Buddhism. For example, whilst these stories depict extraordinary acts of will, which result in immense pain and suffering, they are also supposed to demonstrate acts for which there should not be a self acting on its will in the first place. The stories also explore how the selflessness and self-sacrifice of the main protagonists impact upon their day-to-day roles and relationships. These concerns are evident in the responses of people such as family members, court retinues, and the wider community who, as ‘opposers’, feel duty bound to point out the consequences of acts of extreme self-mortification (Ohnumi 2007, 91–93). Finally, the demonstrable worthlessness of the dead body is reread in terms of its value to another, thereby rendering the act of sacrifice as one tainted by intention and attachment.
A widely known jātaka story that lays out many of these contradictions is that of King Sivi. This story, as we will see, is also the one that was used to great effect to launch the first eye donation campaign back in the 1960s. The story tells of how the Bodhisattva was reincarnated as King Sivi and resided in the North Indian city of Aritthapura. As king he was both righteous and extremely generous. He was renowned for his acts of charity through which he regularly shared his wealth with the poor. Having given away large portions of his material goods, Sivi expressed discontent and a desire to give something that was not merely outside of his body but something that was also a ‘part of himself’ (Cowell 1895, 251). So, the king vowed that on his next visit to the alms hall, if anybody were to ask for any part of his body, he would willingly give it. Hearing of this pledge, Sakra, the king of the gods, appeared in the guise of a sightless old Brahmin ready to test King Sivi. Straightaway, he asked the king for one of his eyes in order that his own sight might be restored. Sivaka, the king’s surgeon was ordered to administer a powder (churnaya) via the nose, which caused the king’s eyes to pop out. In the manner of one of Ohnumi’s ‘opposers’, Sivaka repeatedly pleaded with King Sivi not to proceed – he was, after all, a king with responsibilities other than to the blind Brahmin. On the third day of pleading, however, the act was carried out. As the translation by Cowell (1895, 254; also see Simpson 2004) records:
The king endured the pain and said ‘my friend be quick’. ‘Very well my Lord’ said the physician; and with the left hand grasping the eyeball took a knife in his right and severing the tendon laid the eyeball in the Great Being’s hand. He, gazing with his left eye at the right and enduring the pain, said, ‘Brahmin, come here’. When the Brahmin came near, he went on – ‘the eye of omniscience is dearer than this eye a hundred-fold, aye a thousand-fold: there you have my reason for this action’ and he gave it to the Brahmin, who raised it and placed it in his own eye socket.
For Sinhala Buddhists today, such accounts of the body and the way that it mediates between internal and external states have considerable contemporary resonance. Indeed, appeals to donate body parts draw directly on these paradigms of selfless giving as the way to achieve the perfection of generosity and the ultimate goal of nibban. It is important to stress that this avenue to salvation is one that is not dependent on wealth or status and is believed to bring significant merit to the very lowest, as well as to the very highest. For many Sinhalese, the idea of giving the body and its parts is thus a familiar one and is captured in the often repeated formula: ‘aes, his mas, lē’, meaning literally ‘eyes, head, flesh, blood’. The formula refers to the parts of the body that feature most regularly in Buddhist folk literature in which the body or its parts as gift-cum-sacrifice figure as an important form of dāne. Indeed, as we will see in the next section, the acts of eye donors have become a novel context in which to express devotion (to Buddha and the sangha, the monastic community), to transfer merit to a departed relative (and thereby ease their progress in the next rebirth) and to accumulate it for the living (in the hope of a better rebirth in the long journey to liberation). As such, the pledge to donate and its eventual realisation by the deceased’s family is articulated through a wider set of Buddhist attitudes towards death, bodily dissolution, and just what it is that abides beyond death. These attitudes anticipate and prepare for death by cultivating ‘mindfulness of death’ (maranasañña) which, as Langer (2007, 53) suggests is aimed at ‘the final liberation, disengagement from society, which, of course, does not necessarily happen at death’. For those intending to donate, the imagination of a productive and benevolent death is important to cultivate. The expression of the intention (cetanā) to donate is thus not only a meritorious act but also helps locate the person in a good frame of mind in the face of death. Whatever the circumstances of death, such reflections help, in karmic terms, to increase the likelihood of a good death (Hallisey 2000, 17). Several people who had made such pledges conveyed to me that to be able to reflect just prior to death on the fact that one’s body parts would be used for the benefit of others was also a great comfort and a reassurance about future rebirths, a comforting glimpse of something that would transcend one’s own death.
Here, we encounter one of Ohnumi’s paradoxes: it is clear that donation is not just about disengagement from this world but a very direct engagement with it. Eye donation is promulgated by representatives of SLEDS as an act of benevolent social service (sēvaya) aimed at relieving the suffering of others and thereby improving the pool of human happiness in the here and now. These acts are felt to be good for society and connect with a strong ethic of working to improve health, assist doctors, help meet the demand for transplantable tissue, and ultimately reduce the suffering of others through charitable acts. Extending this theme I now turn to other aspects of the worldliness of donation and specifically its relation to the vicissitudes of the nation state.
Eye donation in Sri Lanka
The establishment of the Sri Lanka Eye Donation Society is attributed to the work and inspiration of one man: Dr Hudson Silva. As a medical student in the 1950s, Silva recognised the need for donor corneas at the Colombo Eye Hospital. At that time there was a ‘steady but meagre supply of corneas from prisoners hanged at the gallows’ (Silva 1984, 19) but with the abolition of the death penalty in 1956 even this small supply dried up. Along with his wife and mother, Silva started a campaign to encourage people to come forward as future eye donors. The campaign began with an article published in the Sinhala daily Lankadipa (19 January 1958) in which they volunteered to donate their own eyes. Their campaign and its slogan, ‘life to a dead eye’ (mala netata pana), caught the public imagination and thousands of volunteers came forward pledging to donate their eyes. The response was such that there were soon more corneas than could be used in local hospitals. As a solution to the problem of surplus, on 25 May 1965, three pairs of eyes were sent to Singapore to mark Vesak day, an important Buddhist festival at which key events from Buddha’s life are commemorated and celebrated. As a result of this donation sight was restored to three people. From this point onwards the export of corneas began in earnest and to date 47,015 donated corneas have been used in over fifty different countries and 28,150 have been used in Sri Lanka. To generate this supply a complex retrieval network has developed such that today SLEDS has 450 branches and six centres operating in towns and villages across the island. As described in the composite narrative that opened this article, teams go out from the regional branches to retrieve corneas from the recently deceased and endeavour to return these speedily to the SLEDS headquarters for processing and dispatch.
Support for the work of SLEDS comes from many quarters. Promotional activities are carried out by businesses, state corporations, and community organisations such as the Lions and Rotarians. The bedrock of support for eye donation is to be found among Buddhists. The role of Buddhist monks in particular has been fundamental in supporting and hosting eye donation days in their temples. Such events tend to take place on full moon days (poya), such as Vesak, with monks delivering sermons that extol the virtue of giving and the meritorious nature of the intention to donate.
Since its inception, the organisation has also had high-level political patronage and involvement, and in many regards the development of the organisation is woven into the history of the postcolonial state. The land on which the SLEDS building now stands was donated by William Gopallava, the second Ceylonese governor general of Ceylon (1968–72) and the country’s first president (1972–78) following its declaration as a republic in 1972. Gopallava donated his eyes upon his death, as had his wife before him. [note 4]Richard Basnayake, ‘William Gopallava: Gentleman Par Excellence’, Ceylon Daily News, 30 January 2012, http://archives.dailynews.lk/2012/01/30/fea02.asp.
Other high-profile eye donors who were supporters of SLEDS include Mrs Sirimavo Bandarayake, the first female prime minister, and J. R. Jayawardena, the country’s president between 1978 and 1989. The present building was opened by Prime Minister Premadasa in 1984. The millionth person to pledge a donation was Mrs Rajapaksa, the wife of the former president. Eye donation thus provides a very public vehicle for the demonstration of the private virtues of Sri Lanka’s Buddhist political elites when it comes to charitable giving. Moreover, this is a form of giving in which all can, in theory, participate and that therefore demonstrates an equality of sorts. In the end, the corneas of an exalted president are no different from those of the poorest street-sweeper.
The headquarters of SLEDS is a modern three-storey building close to the centre of Colombo. It is located at the end of Eye Donation Avenue (Aksi Dāna Māwatha). In front of the building stands a large statue of Silva, with the dedication: ‘Deshabandu Doctor Hudson Silva. In gratitude for the great international service rendered by him to the blind’. [note 5]The designation ‘Deshabandu’ is one of the highest national honours that can be bestowed and is given in recognition of ‘meritorious service’.
The plaque states that the erection of the statue was funded by ‘Japanese friends’. As in the Egyptian case referred to in the introduction, Japan is a nation that has struggled with cadaveric donation as a routine practice (see for example Lock 1995) and the acknowledgement of corneas received by hospitals there is expressed in the form of this public and iconic gift to SLEDS. More such gifts lie within the building. Inside the lobby is a reception desk and to the right the Hudson Silva Memorial Museum, a glass-fronted room in which are displayed memorabilia relating to Hudson Silva and his wife and the work of SLEDS. Several glass cases show the medals, trophies, and other gifts received from all over the world, and particularly the global South, expressing thanks and gratitude for corneas they have received over the years. The building also houses the organisation’s administrative offices, ophthalmic clinic, and the labs where the corneas are processed and stored. The building is also where the all-important records section is located. Here are to be found the thousands of signed forms indicating a formally witnessed statement to the effect that in the event of that person’s death, SLEDS has informed consent for the removal of their eyes. It is to these artefacts of consent that I now turn.
Making the pledge
Riles (2006, 2) and others have drawn attention to the importance of documents as ‘paradigmatic artefacts of modern knowledge practices’ and, as such, worthy of ethnographic attention. The artefact par excellence in this regard is the ‘form’, a ubiquitous expression of the power of bureaucratic capture and one which, across South Asia, is closely tied to the operation and legitimation of weighty bureaucracies as well as ideas of the ‘public good’ and ‘utopian social contracts’ (Bear and Mathur 2016). In the SLEDS context, the consent form is crucial to the organisation’s operation. It is used to create material records of personal identifiers, past histories, and future intentions. The form used by SLEDS, however, also operates in its own right as a powerful rhetorical tool to engage people in an act of some social and moral import. At the head of the form is a logo featuring a closed eye next to an open eye and the SLEDS motto: ‘life to a dead eye’ (mala netata pana) (see figure 1 [note 6]The form displayed is in English but is also available in Sinhala and Tamil.
). In Sinhala Buddhist culture, eyes, sight, and vision provide an extended metaphorical register that attaches to ideas of life, knowledge, insight, and power; a stylised eye set in a representation of the globe features at the head of the form. At the bottom of the form there is an image of a cornucopia (pun kalasa), out of which tumble stylised leaves and flowers. The pun kalasa is a symbol of fertility and well-being that figures widely in Buddhist ceremonial. On the top left of the form is a representation of the sun and, on the right, the moon. Both are key astrological referents and figure in a person’s birth chart (kēndraya). Of particular note is the symbol of the moon, which has within it the image of a hare. This is a reference to the sasa jātaka, a widely known parable in which a wandering mendicant asks the hare for food. In order that the mendicant does not go hungry the hare leaps into the flames to cook his body so that the mendicant might eat. However, the flames do not burn the hare. The mendicant turns out to be god Sakra and the hare’s willingness to offer his body in the fulfilment of the perfection of giving (dāna paramattha paramitā) is thereafter commemorated by having his image painted on the moon. These decorative flourishes give what is otherwise merely a ‘consent form’ the appearance of a certificate which, in rhetorical terms, marks the act as something well beyond mere private transaction and as a public act of some gravity. The donor is often advised to laminate or frame the upper, decorated part of the form and place it in a prominent place in their home. Thus, not only does the donor hope to gain merit for the next life but might also gain recognition, respect, and adulation in this one too.
In recognition that there is necessarily a more prosaic and contractual element to the transaction, a person must fill out the certificate and the tear-off slip. There must be two witnesses to the signing, and they must also sign the form. The slip is then handed over to SLEDS staff so that they can match the donor to the consent form should the donation ever be activated. The portion retained by the donor, and perhaps displayed in the home, has instructions so that relatives know exactly what to do and who to contact in the event of the donor’s death. The eye retrieval teams can then proceed in the knowledge of unambiguous consent. Indeed, the form gives something of a carte blanche. It is referred to as a ‘Consent form for the donation of eyes, heart, body parts/whole body’, and what the donor is actually signing up for is only slightly more specific: ‘I the undersigned hereby consent to donate my eyes/body parts or the body for clinical use and medical research in accordance with the Cornea Graft Act No 38 of 1955 and Human Tissue Transplantation Act no 48 of 1987’. For somebody coming from a British medico-legal tradition, there is a curious reverse ordering here; the body is not the paramount entity in which various parts are contained, it is somehow secondary to the parts. This could be mere historical accident in that corneal grafting was the first significant tissue donation activity and only later followed by transactions involving other tissue. Indeed, the Corneal Graft Act was specifically introduced in order to enable the corneal retrieval activities of Hudson Silva to continue within a legal framework. This act also paved the way for the establishment of SLEDS. However, one might also speculate on some rather more fundamental corporeal logics at play here. Put simply, Western ideas of autonomy imply a person who exercises sovereignty or self-rule over their body. Within a particularly Buddhist reading of the relationship among the person, the body, and its parts, the ordering is somewhat different: the self is an illusory construct (anatta) fashioned out of conditioned responses. There is an eschewal of any abiding essence and the body is mere material form (rūpa) apprehended through sensory experience. At death the illusion of permanence is exposed; the whole is nothing more than the sum of its parts. I would argue that whilst the wording on the form might reflect the sequencing of legislation in this area, it also resonates with a Buddhist anatomo-morality that presents the body as ultimately particulate, functional and devoid of any mechanism that might hold the physical parts together. [note 7]I am grateful to Tom Widger for pointing out that the account of the body given here does not divide the body ‘at the joints’, so to speak, but separates it according to the virtues and moral possibilities of the constituent parts.
Such a view may have been considerably reinforced by the images of dead, mutilated and fragmented bodies that the violence of recent decades has brought into widespread circulation. Signing a form pledging willingness to give others access to one’s body at death is thus more than a mere medico-legal transaction; it serves to locate the intending donor within a wider set of cosmological and political practices centred on death, Buddhism, and the state.
Donation and the nation
In Sri Lanka, 18 December is now officially designated ‘National Eye Donation Day’. This date was selected because it is the birthday of Dr Silva (1929–99). For two days each year the headquarters of SLEDS is given over to activities marking National Eye Donation Day. [note 8]I was unable to be in Sri Lanka on Eye Donation Day and my gratitude goes to Waruni Chandrasena who, along with Jagath Pathirage and her team, filmed the entire event, which we then made into a film: Gifts and Visions: The Practice of Eye Donation in Sri Lanka. Many of the details in this section are drawn from the work I did with them editing the film and discussing and translating interviews and dialogue.
Participants are attracted to the event for a variety of reasons: to sign the pledge, to hear a high-profile priest deliver a sermon, to see the ministers and dignitaries who grace the event, to receive free refreshments and free spectacles.
The event typically begins with giving alms and a sermon known as a bana preaching by a contingent of Buddhist priests. In 2013 the bana preaching was given by Kolannave Sri Sumangala Thero, a well-known priest who was a founding member of the controversial National Sinhala Heritage Party (Jathika Hela Urumaya). As an elected member of parliament for the JHU in 2004, he was charged with carrying forward its founding principles of promoting Sinhala Buddhism and protecting it from the threats believed to be posed by Christian conversion and Western values (Deegalle 2006, 242). Following his resignation from Parliament in 2005, Sumanagala Thero continued to cultivate a populist Buddhism and the idea of an essentially Buddhist Sri Lankan state, ordered according to Buddhist principles and values(Bauddha rājya).
On Eye Donation Day, Sumanagala Thero’s sermon was well attended, with people having come considerable distances to hear his distinctive style of emotional preaching. The members of the congregation were mostly elderly women dressed in the white clothes of the lay Buddhist or dāyaka. In his sermon Thero extolled the virtues of eye donation:
Donating eyes fulfils the perfection of generosity as preached by the Lord Buddha. Eye donation is only second to sacrificing your life.
Knowing that someone else will benefit and gain sight from our eyes after our deaths brings immense happiness. You gain immense merit when someone else who could not see with their own eyes, sees with yours.
His sermon continued with the story of how a bodhisattva had walked through fire to offer alms to the Pacceka Buddha (compare with the story of the sasa jātaka mentioned in the previous section). When he stepped into the flames, the bodhisattva was not consumed; by the power of his virtue, he extinguished the fire.
Other events to mark the anniversary included a danē ceremony to transfer merit to Dr Silva and his wife, as well as to all of the people who had donated their eyes in the past. The celebrations were concluded with a visit from Mahinda Amaraweera, chief minister for disaster planning in the Rajapaksa government. The minister arrived to the accompaniment of Kandyan drummers and dancers as befits a guest of such high status. Once in the building, a traditional brass oil lamp was lit and the assembled guests were treated to speeches from various dignitaries including the president of SLEDS, Professor Ariyapala Perera, and the ambassador for Pakistan. Like Egypt, Pakistan is an important destination for Sri Lanka’s donated corneas and there is a long history of association. A minute’s silence was held to commemorate ‘Dr Hudson Silva, eye donors, and war heroes’. A significant linkage was here being made between the founder of SLEDS and the work he made possible, the people who donate, and those who fought against the LTTE in their bid for a separate state. In recent years, those injured in the war have themselves become a major consumer of the tissues donated to SLEDS. [note 9]On a visit to the Tissue Bank, I was treated to a YouTube promotional video of an operation in which a section of donated bone was inserted into the arm of a soldier whose bones had been shattered by a gunshot.
The chief minister in particular made a link between Sinhala Buddhists and how they had come forward to donate blood and other body parts during the war. These acts of dedication were described to the assembled congregation as being essential to the war effort and the eventual achievement of victory. Notwithstanding the large numbers of corneas that end up abroad, those donating were, just like the armed forces who fought in the war, heroes of the nation. Whatever the motives of previous donors might have been, their benevolence was fed back to the assembled audience in a rousing speech that conscripted their actions as part of the government’s response to the separatist endeavours of the LTTE. The move made by the minister was similar to the one outlined by Widger, that is, a kind of ‘assimilative philanthronationalism’ with the difference that the nationalism-charity nexus revolved not around capital and markets but human tissue and virtuous donation (Widger 2016, 13).
Following this strongly nationalistic appropriation of the activities of SLEDS’ eye donors, however, the celebrations concluded with the return to more detached sentiments, in the form of the ‘Eye Donation Song’, delivered by a choir of young people:
Calming the mind with compassionate loving kindness
Giving up greed, pride, and selfishness
Calming the mind with compassionate loving kindness
Giving up greed, pride, and selfishness
Donate eyes. Eye donation is a great virtue
To show light to those who are blind. Donate your eyes
It is a great virtue that would help you in the samsara journey
Donate eyes. Eye donation is a great virtue.
The Sri Lanka Eye Donation Society provides a forum in which multiple religious and political registers are at play. In the final section I consider the versatility needed to manage this complex traffic in popular rhetorics and political interests.
From local virtue to global vision
Sri Lanka Eye Donation Society is a silent institution doing a big role in serving mankind by donating Human Corneas and Tissues to the needy patients anywhere in the world irrespective of their color, race, religion etc. This small developing country of 20 million people has become a source for corneas to thousands of blind persons on this earth and our services will be continued till blindness is totally eradicated from the world, which is the main object of this society. (SLEDS website [note 10]http://www.eyedonation.slt.lk/; the text has been very slightly edited to correct grammar.
SLEDS presents itself as a nonpartisan organisation. Its donation application forms are printed in Tamil and English as well as Sinhala. For many years the post of clinical director of the organisation has been held by a devout Muslim, which was in some respects surprising given the strongly Sinhala Buddhist image that the organisation projected but less so given the extent of contact the organisation had with Muslim countries. Staff pride themselves on their ability to meet humanitarian need whenever and for whomsoever it might arise. In conversation with donors and SLEDS staff it was clear that fellow Sri Lankans whose sight might be restored as a result of a donation were foremost in their minds. Significantly, respondents were keen to point out that they were not concerned where their donations ended up and were happy for them to be used, not just by Buddhists, but to bring sight to Tamils, Muslims or Christians or whomever was in need. In short, the managers of the organisation are clear that theirs is a Sri Lankan endeavour, that is, one that is accepting of diversity, inclusive in its policies, and committed to a plural national imaginary. Yet, it is also clear that the rhetoric of corporeal charity to which the vast majority of donors enthusiastically respond is one that is firmly cast in a Buddhist idiom. This is a paradox that Widger explores in the context of charitable giving more generally (Widger 2015, 2016). Furthermore, despite attempts at a wider appeal for donors, SLEDS provides a logical and obvious appeal to Sinhala Buddhists. As suggested in the earlier parts of this article, expressing the intention to donate resonates with particularly Buddhist conceptions of the body and its meaningful disposal at death. However, the work of SLEDS also renders the act of donation a social act bringing into existence a community of donors who might share in the public virtue of imagined community (Anderson 1991). Whilst this community is likely to encompass a range of attitudes and positions, it is one that is united by the merit-making opportunities that SLEDS has created for those intending to donate, those who actually donate, and the relatives of those who donate. It is, in short, a powerful ‘field of merit’ in which a variety of devotional transactions raise the merit quotient of the whole community (Ohnumi 2007, 42–43).
Such activities are also closely aligned with a particular conception of Sinhala nationhood, one that the organisation has strategically drawn upon at various points in its development. In its origins, patronage, and appeal, SLEDS has succeeded in weaving the practice of corneal donation into the development of the postcolonial national state and in particular its attempts to realise itself as a Sinhala Buddhist state. As such, the work of SLEDS straddles a familiar fault line that goes to the heart of many of the conflicts that have ebbed and flowed since independence in 1948. Is Sri Lanka a plural democracy that is home to multiple religious identities, or one in which all other groups are simply subsumed under the hegemony of the dominant Sinhala Buddhist community (see Tiruchelvam 2000; Wickramasinghe 2007)? Following the end of the civil war in 2009 and the virtual elimination of the LTTE, the latter perspective prevailed with a resurgent Sinhala Buddhist nationalism, evident in the speeches given by politicians at the Eye Donation Day celebration. In short, to donate is not merely an act of benevolence within a wider set of Buddhist beliefs about the body, death, and rebirth as it perhaps was in the 1960s. In the postwar period, the activities of SLEDS are refracted through a much wider lens of political and economic interests out of which reconstruction and nation building is being wrought. Among the 1.1 million who have pledged to donate many have experienced the effects of austerity, unemployment, poverty, the loss of family members in the conflict, and the loss of social and other securities. The popularity of the act of pledging suggests a novel soteriology in which avenues are opened up for many who might not otherwise have access to such an esteemed and rewarding form of giving. A repeated theme among those who pledge is that their action will create significant merit and the opportunity to experience the joy (santōśaya) that comes with giving (see Widger and Kabir, n.d.). These acts of seemingly altruistic corporeal magnanimity are important because they point to a kind of transcendence in which there is an attempt to erase racial, religious, and ethnic differences. However, as Beck has shown in the context of blood donations between Turkish- and Greek-Cypriot populations, the relationship is often asymmetric with forms of ‘legitimate domination’ in play (Beck 2009 cited in Papagaroufali 2009). In the Sri Lankan context there is little possibility of corneas from minority groups ending up in Sinhala bodies and, whilst there is transcendence and an aspiration to cosmopolitanism, these gestures remain entirely consistent with a Sinhala Buddhist hegemony.
The work of SLEDS, however, does not stop at the rhetorics of intranational civility, but increasingly draws on international ones too. As stated previously, to date 47,015 donated corneas have been used in more than fifty different countries. Sri Lanka has achieved global renown as a provider of corneas and is a significant player in addressing shortages experienced in many countries. As the account of the corneas’ journey given at the outset demonstrates, the work of SLEDS provides a mechanism whereby public moral virtue might be given currency in the global market for ethically sourced tissue. In this regard, the work of SLEDS is unique in the way that it articulates local ‘bioavailability’ (Cohen 2005) with global ‘biovalue’ (Waldby 2002).
SLEDS presents itself as a nonprofit, nongovernmental organisation. There are no incentives for people to sign the pledge other than perhaps hospitality and entertainment at an eye donation event. Donors or their families do not receive any financial remuneration should their pledge be realised as an actual cornea donation. Charges are not made to hospitals or clinics for corneas, though ‘processing charges’ are levied. This stance keeps SLEDS in line with Sri Lanka’s Transplantation of Human Tissues Act of 1987 that states in section 17(1) that: ‘No person shall buy or sell, dispose of, or otherwise deal in, directly or indirectly, for a valuable consideration, any body or any tissue or part thereof for any of the purposes referred to in section 2, without the prior written approval of the Minister’. There is, however, a certain opacity surrounding the nature of ‘processing charges’ and particularly when corneas are sent abroad. The typical cost given by the organisation to an international request is in the region of US$450 per cornea. The justification for processing charges is accounted for in terms of the payment of SLEDS staff (including the technicians who carry out the actual retrieval), the costs of training workers and running the headquarters and the many regional centres, the purchase of expensive preservatives, the purchase and maintenance of laboratory equipment, and the costs of transporting corneas using special air-freighting arrangements. International recipients of corneas also express their gratitude in kind through the donation of equipment, vehicles, and consumables as well as in the wide range of medals, plaques, and commemorative gifts that adorn the SLEDS headquarters.
My last visit to SLEDS was in November 2014 to present the film we had made the previous year about their work. The filmmaker, Waruni Chandrasena, and I showed Gifts and Visions: The Practice of Eye Donation in Sri Lanka to around forty staff and interested parties. The SLEDS director seemed to be impressed with the film and was keen to use it for future promotional purposes. There was talk of the World Health Organisation’s ‘VISION 2020’ programme for eradication of avoidable blindness [note 11]See ‘What Is VISION 2020?’ published by the World Health Organisation, http://www.who.int/blindness/partnerships/vision2020/en/.
and the aspiration that SLEDS would ‘put Sri Lanka on the map’ through its contribution to this global initiative. As if to drive home the geographical metaphor, a large board showing a map of the world covered one side of the hall in which we showed the film. Above it was the legend: ‘National and International Development Programme’. On the board, the island of Sri Lanka was disproportionately large and illuminated markers showed the local hospitals they had served. Across the rest of the world map were similar markers showing the international destinations for Sri Lankan corneas. One of the staff pointed out that although SLEDS supplies corneas across the world, they make sure that local needs are met first. Yet, the pitch to international audiences was clearly something of a priority for the organisation. Across the stage at the rear of the hall was a large banner on which was written: ‘Welcome to delegates from China’ and ‘friendship’. The week before, SLEDS had been visited by representatives from a Chinese eye hospital, an eye bank, and a Lion’s Club. The delegation was there to express their gratitude and solidarity as well as to negotiate an even more substantial flow of corneas from Sri Lanka. The proliferation of demand in China and other countries could far outstrip even Sri Lanka’s ability to supply, which was posing a significant practical and moral challenge for SLEDS. Could people’s corporeal beneficence be promoted even further?
Just as individuals with limited resources are able to engage in donations that carry much prestige and signal great virtue, so it would seem that a small nation with similarly limited means is able to effect the same outcome. In global terms, the export of corneas to a wide range of countries is portrayed as an act of generosity disproportionate to the scale of the country’s resources. More specifically, the traffic in corneas is emerging as part of the ongoing geopolitical positioning of Sri Lanka in the global order. Significant in this positioning are current relations of financial indebtedness with China following the building of ports, motorways, and airports during the Rajapaksha era. Likewise, there is considerable dependency on the Middle East for remittances from migrant workers. It is perhaps no accident that these countries are, at the time of writing in 2017, important destinations for Sri Lankan corneas. In the emergent thanato-politics of circulating tissue, personnel, resources, virtue, and gratitude, new possibilities open up for how citizens might be asked to write their bodies into the future of the nation as it emerges from decades of civil war and seeks to establish its place in the international order.
My thanks go to Waruni Chandrasena, Dhana Hughes, Rachel Douglas-Jones, Jagath Pathirage, Tharindi Udalagama, and Tom Widger who have helped in the development of this article. I am particularly indebted to the staff of the Sri Lanka Eye Donation Society for their support and collaboration over the years.
About the author
Bob Simpson is Professor of Anthropology at Durham University. He has carried out fieldwork in Sri Lanka and the United Kingdom, focusing on the practical and ethical implications of developments in the life sciences, such as new reproductive technologies, transplantation, and prenatal diagnosis. He convenes the interdisciplinary New Immortalities network, which is aimed at stimulating reflection on death, donation, and the complex imaginaries that are now forming around the secondary use of organs, tissues, and whole bodies in the twenty-first century. See https://www.dur.ac.uk/anthropology/newimmortalities/ for more information.
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