Donated Blood, the Body and the Self: Towards a Hierarchy of the Self?

This paper examines the changes in relationship between the body, society and donated blood. Studies in this area (Waldby 2004; Tutton 2002; Scully et al., 2006; Shaw, 2010) have focused on the moral or ethical issues related to blood donation rather than corporeal and cultural issues. This paper deconstructs the impact of developments in bio-technology and commodification of blood with regard to the self, blood donation and blood products and analyses the way in which donors understand bloods’ commodification has altered meanings attached to blood and of impact of corporeal connectedness on the self as Donor. Using data from a qualitative ethnographic study, this paper concludes that the Donor Self has become formed into a hierarchy of parts, to manage the moral and ethical demands on the person when donating, as a result of the medical need for all body parts. Increasingly, blood donors feel they ‘have to give something of themselves’, it introduces the unique concepts of differing selves: the Inner Self, the Liquid and Solid Self relating this to the work of Goffman, as donors seek to rationalize what being a blood donor means for them and their blood.


INTRODUCTION
In recent years, medical sociology and anthropology discourse has become fascinated with what may be characterized as the natural body in a biomedical word, rather than lamenting its" absence as in the past it is now excited about the embodied being (Schilling, 2012;Cregan, 2012;Haraway, 1991;Lock et al., 2002;Moore and Casper, 2015) have all examined the body as a metaphor for social change and body commodification. How these processes are mediated through and by biomedical technology has been the subject of further research (Lupton and Tulloch, 2002;Turner, 2002) but with attention being focussed on what could be termed as the solid body or body parts. Other studies in this area (Waldby et al., 2004;Tutton, 2002;Scully et al, 2006;Shaw, 2009; have focused on the moral or ethical issues related to blood donation or bio banking rather than corporeal and cultural issues focussed upon here. Blood donation can be argued, to be a valuable metaphor of the impact of these changes and be emblematic of the shifting boundaries between blood, the donor body and the communal body, understood through the lens of commoditised donation rather than altruistic donation alone. The role of the donor as provider and host of the gift needs contemporary Email: patricia.mahon-daly@bucks.ac.uk. Tel: 01494 522141 ext. 2360. Authors agree that this article remain permanently open access under the terms of the Creative Commons Attribution License 4.0 International License problemetisation to reframe the blood donor as a provider of a communal resource, rather than as an altruistic lifesaver, to emerge. Changes in the relationship between the blood and the body are symbolic of the new consciousness of blood donors about what value their blood has outside of the body and what this means for themselves as blood donors. Synnott (1993) argues that the body social is both the prime symbol of the self but also of society, and also the "property of the state" (Synnott, 1993). This can now be applied to the role which blood donation and the product itself and the way in which the commodified blood becomes the property of the state. Biotechnological advances now allow this process of commodification to include donated tissues and cell lines (Busby and Kent et al., 2014). Now applying these ideas to blood and the concept of the Self as donor, in what have been termed the "Liquid body" as demands on the "Red Market" (Carney, 2014) increase, and the product of the Gift of donated blood, becomes ever more marketable. This paper presents data derived from an ethnographic study of changes in blood donation about how donors view their Gift-blood, in relation to their body. Presenting new understanding of where this once neutral and give-away able body part lies in the donors" perceptions of the newly fetishized liquid body. It aims, to assess the impact of developments in biomedicine, consumerism with regard to the Self as donor, blood donation and the ensuing array of blood products which the Gift is utilized for as found in the array of bio products created from donated whole blood available at the Bio Products Laboratory. It provides a consideration about the way in which donors understand blood as a new body part and communicates new meanings attached to it as a medicine and a product as well as a Gift, and argues that there is an emerging restructuring of the donor-self into a possible hierarchy of the self, and presents new varieties of constructions of the Self as related to blood donation : specifically the Inner self, and the Liquid self and relates these to the concept of the Self (Goffman 1963), arguing that the contemporary body has evolved becoming internally as well as externally boundary-less (Haraways,1991: 21). It begins by contextualising the body swap word and how this may be related to the sociology of donation.

The Self, the Body and Blood
Blood and its component derivatives, have it argued, also entered the body swap world. Sharp (1994Sharp ( , 2000 underlines this in her work highlighting that the body is not merely a cultural entity, rather, we assign highly significant cultural and social roles to the body and therefore to body-parts such as blood, although, what role is attached to blood is unclear from her analysis on body parts, and this discussion extends this argument. So successful has technology become that whole blood is hardly ever given, and indeed some donors give components of their blood rather than whole blood (Blood 2020) 1 The ways in which blood is re-deployed after donation, needs further explanation to understand what social processes are occurring and becoming modified and how blood donors are located in the donor world set in a gifting relationship. Sharp (2007) focused on the problematic sociability of body parts and her concerns may well be echoed in future narratives of blood donors as the commoditisation process develops in relation to the blood market. The need for supply and demand in the market for blood has, it argued, influenced donors who understand the importance of their Gift Being duty bound to engage in donating pieces of the body to include blood, either in life or after death i , has created areas of tension in the Gift relationship, as espoused by both Titmuss (1970) and Mauss (1990), in relation to how this commoditisation influences the understanding of the self and the communal identity and donations of blood. These tensions are evident in how donors feel obliged to donate and in doing so have, it is argued, donors are forced to conceptualise themselves as divisible, in a ranking hierarchy of donatable elements. Weiner (1992:36) argued all personal possessions invoke a connection with their owner, which symbolises the personal experience and adds to their overall identity, so do blood donors recognize blood as a part to give away or do they link themselves with it after and during donation. Blood donation is an example of this, as blood is increasingly seen as a body part and as a result part of what Dickenson (2008) has called the body swap world; its donation or giving can tell us about what the action of giving holds for them, and about the relationship of blood to the late postmodern body. Donors" thoughts about the changed nature and value attributed to their gift of life, and how this impact on notions of the body and identity are vital in understanding the new gift relationship. Increasing use and reuse of a wider range of body parts and organs and blood products has created a growing percentage of the general population joining the ever growing donor fraternity as a result of receiving or donating donor body parts through the impact of rapid technological advances. This has led to a change in the way the donated blood is perceived as a quasi-body part in the consumer world, and has influenced the ways in which both lay and professionals conceptualise the body and its parts. With a background percentage of around 3% of the population as donors, the role is onerous and totally voluntary.
ii I will now illustrate that donors are reflective in their behaviour as a donor, understanding that change in the value of donated blood. This data was gathered at sessions in the national blood service in southeast during to 2008 In discussing the issue of giving blood with donors, data was gathered which concluded that a self-reflexive 1 COPY Blood 2010 from other paper process was present when thinking about whether blood was part of the Self as what this meant for the action of giving away a part of the Self and body. It provided narrative from donors who configure a new self to deal with the pre-understood modern-day commitment that the body in late modernity is for sharing (Powell et al., 2006;Snelling 2014). Donors" reflections on the changing landscape of perceptions of how blood is both part of you and a replaceable fluid can therefore be helpful in reconceptualizing blood as a body part no longer alienable., blood therefore could be perceived as a new spare part, rather than a replaceable neutral part of the body and with a changed bio-capital value as a result. The study was ethnography and allowed for on-going collection of reflection and comments by donors and provided the opportunity to reflect on how donors understand themselves as donors rather than givers. Waldby (2002 p.240) makes a good argument for blood within this commodity model when she says "to give an organ, blood, ova, embryos, sperm or cells is to be caught up in a social and embodied circuit in which the significance of one"s personhood imbues the fragmented" Donors expressed a range of views about how they feel they have to, should (do), need to and ought to, about becoming and more importantly remaining an active blood donor. This was especially important if the donor had a rare or desirable blood type. Lock (2001 p.69) also argues that market forces make blood donating particularly vulnerable to exploitation due to the fact that donors are made to feel that blood is both renewable resource from the body and easy to donate and that it is vulnerable to fetishisation (Scheper-Hughes and Wacquant (2006, pp1). Donors seemed to understand this relationship between the Public need and their blood, understanding that blood was needed expressing a variety of ideas: "Blood donation is a necessary social responsibility and I can"t really understand why more than 5% of the country doesn"t do it [donate blood]. It is just something you give without noticing." Waldby (2002, p.240) drew attention to the impact of medicalization of body parts and the inter-corporeality transplantation and transference creates. Weiss" (1999) concept of "intercorporeality" can be applied to the relations created by the donating and distribution of the specialist components of blood. Some donors did refer to special components of blood being sold to other countries, in particular Factor 8. Blood Donors also reflected that there might be some link between themselves and their donated blood rather than in the past the donated blood was alienated from them; Towards Hierarchy of the Self. Weiss argues that no one is discrete in their identity as the new person or I is becoming mediated by interdependence of what Waldby (2002 p239) has called "biotechnical fragmentation".
Blood is one aspect of this argument, as she argues that the market for health is mediated by what fragments of ourselves we can afford. One question here is related to whether donors considered blood to be a fragment of themselves or [their bodies], and whether this is a fragment to keep or give away. Where is the Self in the donor body then, what, if anything, are donors giving away? Within the new commodified corporeal cosmology, there are emergent and differing bodies with donors describing their body into both a Liquid and a Solid Self introducing a range of differing new selves and a hierarchy of how they view their body. Talking about the solid body part (organ) donors, saying that they did not consider donated blood to be still part of what they considered themselves or their body, either as it was being donated, or when it had been bagged up and sent off for redistribution. Some examples being 'Well it's not really part of your self is it?", and it's not the real you 'cos you replace it." Donors related to their blood in a different way than with the solid organs or what may be termed as the Solid self. The hierarchy of the Donor Self is constructed with the solid organs at the tip and a ranking of parts to include blood at the base. This was termed "an emerging hierarchy of the Self", and reflective of the contemporary background of the medicalization of blood and its components and the identity of the here and now donor.
Sperm in particular, according to my donors, embodies the self-more readily than blood, with donors expressing that "sperm is more part of you than blood" or Another donor: "blood is not as much a part of me as my sperm," thus, he was reviewing one body part against another, arguing that for him sperm was more part of you than your blood. This may have been influenced as a result of the rising medical need for all body parts, and increasingly blood "parts" as a result of the rise in blood component therapies focussing on segmented marketing to attract certain types of blood and with personalised blood products for those in need of blood replacement therapy iii . Therefore, as the order in the hierarchy related to the meanings attached to individual body-part capital changes, then so does the position in the hierarchy, however.

Ethics
My argument is that the donors have placed blood both in and outside this circuit; they did not think that blood was as much a part of the self when compared to other body parts that they could give away, especially reproductive tissues, breast-milk and the face. Cohen (1999, cited Shepper-Hughes andWaquant, 2006 p.1) argues that there has developed an "ethics of parts" in relation to the new divisible, commoditised late modern body. This means that ethics and ethical stances which used to apply to whole bodies now are applied part by part, thus, allowing market forces to dictate the value of individual parts. Blood has new commoditised, as well as social identity other than that imbued with the altruism of the past. Cohen (1999:pp) argued that this response to the divisible body was rational and argued that a subsequent "Ethics of Parts" has been created in rational response.
Discourse among the Donors was that they that they "have to give something" so they give what they think isn"t part of them, rather than electing to give away something else more central to their Self. "Lifesaving to all-it is something I can easily loose but makes no difference to my body". He was not the only one; others felt that blood "…Feels like a consumable. Even though, it is fundamentally part of me, I know it needs to be taken to be given to others". This implies no bodily connectedness to blood, but an understanding that blood has more value out of his body than in it. Its value for the population only occurs once donated. Copeman (2005) reminds us that the blood, when re-circulating outside the body and entering new bodies, becomes in fact more important. This allows both objectification and fetishism for those whose blood is rare for example, and as a result within the proposed hierarchy some blood is ranked higher or lower than other blood especially if it is a rare type or anti-body. There is a tension then with the donors distancing themselves from something fundamentally part of their body, in order for them to be at ease with the giving away a part of the Self to have much more intrinsic value to the recipient.

Towards a hierarchy of the donor-self
This tension has created the need to create a hierarchy of parts by the donor to accommodate this new way of giving. Earlier Sanner (2001) studied feelings and ideas about receiving and donating body parts. Her studies identified a series of patterns in attitudes to giving and receiving solid body parts, some of which have resonance for my argument here. Scanner"s study identified that the body had become objectified and conceived as "machine-like" (p.1494), whereby they were happy to give and/or receive solid parts with a view that the body was a composite of interrelated parts rather than a body conceived of as whole. There are similarities here in the way in which donors understand the relationship of rated body parts to the wider public need. Relating this re-organisation of the body and self into a hierarchy of parts theory is the core of this paper, as some the donors did not feel any association with their blood, not ascribing it [blood] with body part or fragment status, and thus, not being regarded as part of the Self in some instances. In other words has blood itself become independently active and with a new medicalised life of its own unrelated to the person from whom it came. This can related to Appadurai (1988) sociability thesis, but also we can perceive blood becoming a body fragment and as such imbued with qualities and properties normally reserved for solid body parts especially rare blood groups or types.

Donor self
This reflexivity on the part of the donor enables a postmodern interpretation of blood donation; narratives from donors developed progressed the notion that the Self has been made hierarchical to create a ranking order of parts of the Self, either solid or liquid. The ranking represents which parts would be missed or which parts were "too special to give away". The most special being related more closely with the concept of the Self as a person rather than the body. The separation or "hierarchisation" of the self into a new orientation is emerging in relation to liquid body parts such as blood. Other donors referred to breast milk as being a component of the body. They said that breast milk was more special than blood because it contained all the elements of mothering and that it was a special bond between the mother and the baby, therefore, breast milk represented all the goodness of the body. The reason blood is different is that it seems unrelated to you when you give it, and you don"t physically notice that anything has gone. One said milk is special because it is something a mother gives her child; it should not be given to anyone else, you get part of your mother that way, It is even more special a gift than blood. The separation out of key parts of the Liquid body, accords with some parts being viewed as purely mechanical and others as life giving or linked in some way to special qualities, e.g. manhood or individuality, linking it to the self as an individual, whereas, blood was more diffuse entity.

Goffman and the inner self
In describing two levels of the Self here, parts like blood which can be donated with ease and others which represent the selfthe inner Self. This next section relates these to the impact and changes on the self to Goffman"s (1990) theory of self .The emergence of this inner social self can be compared to what may now be termed the external social self. In the same way as the process of considering one"s self, the new body in society is being shaped by new technologies interfacing with separate body parts rather than interfacing with the body as a whole entity as was the case in the past. The impact of modern tissue and blood biotechnologies has, it is argued, impacted on what is considered to be the true self, with particular reference to those parts most closely associated with the Self and it is to this aspect of the presentation of the new "donor-self" that relates to the self in relation to how donors present and manage the body which was in the past a body whole, now has to be presented as a "body-in-parts". This type of narrative provides us with a debate about the way in which the body is viewed; the similarities between sperm and blood are cogent for the argument of hierarchy. This separation out of sperm is interestingly causing us to think about a  (Table 1). Blood is almost a circulating body part and, as such, not high up in the order of the outer self, which is headed by skin, tissues and breast milk-just skin is on the outside. Therefore, in the modern world of donation of blood, donors are creating a hierarchy of self which includes an inner self and an outer self, skin is part of the outer self that they are not happy to give, even though the technology is available and it would help as many unhealthy or sick people as blood, for example burns victims needing a skin graft. Breast milk and the face were regarded as highest in the hierarchy of the self. This was indicative of their link to identity and individuality, whereas blood is regarded as a diffuse part that allows it to be given away without any concern for the loss or change in identity. Therefore, the hierarchy of self, with regard to what was being given away, had the face and breast milk higher up than blood. The donors said (asserted/reported) that breast-milk was more special than blood because it contained all the elements of mothering and that was a special bond between the mother and the baby, therefore, breast-milk represented all the goodness of the body. Another said that breast milk had a mothering link which made it extra special. This can be related to ideas of coherency in selfpresentation. Goffman (1972, cited Howson 2002 argued that we see ourselves as others do and share understandings of the expectations associated with the particular roles or encounters. The physical appearance of the body is central to the relation between virtual and actual social identities, but because blood is not visible, like the face for example, it is more easily given away. This is possible evidence supporting the notion that blood is incorporeal and is located at a lower order in the self for donation in relation to the more traditional and tangible transplant and donation of body parts in the past, such as heart and lung. The hierarchy which donors create is related to their self as a person, embodied via their body. Donors referred to the face as the "true you" and as an external self; people know you by your face. As a result it was consider the top of the hierarchy and something which donors who mentioned this would never donate. Breast-milk and the face were regarded as highest in the hierarchy of the self. This was indicative of their link to identity and individuality, whereas blood is regarded as a diffuse part that allows it to be given away, without any concern for the loss or change in identity.
The donors" thoughts about this aspect divided body parts in this new binary framework of mechanical and human. Hearts were mechanical and those body parts which were especially human were sperm and breast milk. This was because they were perceived as carrying what was termed "the true you" where as the heart was viewed just as a pump it is a developing hierarchy of self in relation to the giving and receiving of body components.
Some parts of the body have been linked to being a sort of waste product and not part of the real self. One example of this is the umbilical cord blood. Its location and relation to new life and regeneration seems a little odd. Waldby and Mitchell (2007:110) have examined the journey that one so labelled blood-related waste product, umbilical cord blood, has made. They argue that this type of blood has been reclassified as "a significant fragment of the infant", whereas it had [formerly] been classified as "waste product". This part of blood has been reclassified largely due to the further bio-technicalisation of the body, as technology finds new ways of utilising once discarded parts; such is the need to utilise all parts of the body carcass. This proves that the body has a hierarchy and that positions within it are subject to alteration depending on culture and technology as well as the market place. This paper has analysed changes in understanding of blood donation in relation to the body and the self-as donor, which, it was argued, represent a pertinent concern about the body in society and in an increasingly bio technological world. This paper extends the scope of changes in meanings attached blood donation, to enable further understanding of the changes identified in blood donation as a corporeal civic action, as well as a communal bio-resource and how Donors manage the relationship between themselves and the alienated life of the extracorporeal blood and its components.
The aim of this paper was to focus on the donating body and present data about how donors view their gift of blood in relation to their body. The impact of biotechnology on blood as a therapeutic body part has created a secondary market for blood components and latterly fragments or parts of the circulatory system such as umbilical cord blood, which was considered a waste product in the past. Moreover, the biotechnological advances have created a tension in the alienable potential of donated blood, as increasingly the donated blood is processed into parts unrecognisable and critically unrelated to the original donated blood and donor. Blood, it has been argued here, has slid down to the bottom of a self-hierarchy, which is indicative of how of donors view their blood in relation to other more significant body parts such as the face, breast milk and sperm. The impact of these techno-medical capacities on the secondary market for pooled human blood has created a dilemma for the donors in the UK. They have been socialised into regarding their donation as a unique gift, rather than "raw" body part procured for refashioning and recirculation within the public arena, with no regard or link to the donor from whom it came. The impact on blood donors in the body-part world and the rise of biomedical technology, especially in relation to donation and transplantation, is influencing the concept of the individual. In echoing Mauss (1990) therefore, the body indeed has become man"s greatest tool and central to contemporary corporeal social exchange systems.