*Best Paper Award for Theoretical Approach
Since the inception of the transplant era in the 1950s, the gift of life metaphor has dominated discourse in organ transplant (Gerrand, 1994; Barker & Markmann, 2013). Its pervading use is commonly seen in public awareness campaigns – primarily used in support of voluntary organ donation. The gift of life symbolically summons cultural ideals of altruism and moral responsibility that underpin transplant policy and garner positive sentiment towards organ donation with an aim to increase the pool of potential donors (Fox & Swayze, 1992; Sharp & Randhawa, 2014; Siminoff & Chillag, 1999; Shaw, 2010; Vernale & Packard, 1990). Gift of life rhetoric is also seen in the collective lexicon of both healthcare professionals and those personally involved in transplant processes such as donors, recipients, and their respective families. This long-established metaphor centres on Mauss’ (2001) theory of gift exchange where he argues that gift-giving is a form of ritual contract characterized by three implicit agreements: the obligation to give, the obligation to receive and the obligation to repay. In this sense gifts are never free, and participants are implicated in a relationship of gift-debt requiring reciprocation (Galasinksi & Sque, 2016). Many scholars have touted the Maussian gift-giving paradigm as a helpful framework in understanding the experiences and motivations of those within the transplant process (Fox & Swayze, 1999; Gill & Lowes, 2008; Vernale & Packard, 1990), highlighting “the act of living organ donation [as] analogous to giving a gift” (Gerrand, 1994, p. 129). In Canada, living organ donation is primarily comprised of kidney transplants, essentially restricting the gifting comparison to living kidney donation (Canadian Institute for Health Information [CIHI], 2019).
As such, this paper exclusively considers the gift of life discourse in the context living kidney donation. The discourse has also been predominantly framed in terms of addressing the issue of organ scarcity, as evidenced in its continued use in promoting altruistic and voluntary donation. This tendency has resulted in a contracted focus around the issue of organ shortage and the primacy of organ donors, to the exclusion of representations of both recipient experiences and other pressing issues in transplant (Kierans, 2011). For instance, the serious issue of adherence, defined as the “extent to which people follow the instructions they are given for prescribed treatments” (Low et al., 2015, p. 752), abound in organ transplant as well over half of renal recipients miss or alter their dose of immunosuppressive medications – a behaviour that carries with it an increased risk of transplant failure (Low et al., 2015).
Therefore, in an attempt to balance the lopsided accounts in extant literature, this paper investigates the gift of life discourse through the lens of the equally problematic issue of adherence among renal transplant recipients. Utilizing critical discourse analysis, this central question is considered: how does the gift of life discourse in live donation awareness and education literature influence nonadherent behaviour among renal transplant recipients? Through assessing constructs of the gift of life metaphor implanted in live donation awareness and education literature, it is my position that the inherent morality imbued within the gift of life metaphor enable obligations to give and receive while inhibiting notions of reciprocity. In doing so, the duty of recipients to care for their donated organ is diminished, potentially influencing patient behaviours that result in missed or altered doses of prescribed medication. My argument is organized as follows: i) The role of gift theory and the gift of life discourse within organ donation are outlined. ii) I discuss how the gift of life discourse, charged with moral values, is used to intensify obligations to give and receive, while hampering notions of reciprocity. iii) I also examine the absence of gift of life discourse in post-transplant contexts. I conclude by describing potential insights and avenues for future research. This paper contributes to the debates surrounding gift of life discourses in transplantation by exploring the underrepresented area of live transplantation, and in addressing important contexts that extend beyond organ scarcity.
The Context of Organ Donation
As the preferred therapeutic option for organ failure, over 2700 transplants were performed in Canada in 2018, however the demand for organ transplants far exceed availability as over 4300 Canadians remained on the waitlist at the end of the same year (CIHI, 2019). Renal transplants are some of the most needed and performed surgeries in Canada – living donation accounts for 20% of all transplants performed in the country, and the vast majority of these are kidney transplants (CIHI, 2019). Living donation is preferred over deceased donation due to superior outcomes – recipients typically do better and have greater organ longevity – as well as being more cost effective for health care systems (BC Transplant, 2015). Given these reasons most healthcare professionals and organ donation agencies favour living donation, investing more in their promotion and education efforts. Regardless, most donor awareness campaigns and materials remain concentrated on the problem of organ shortage, and ignore other vexing issues in transplant medicine, such as renal transplant patients missing or altering their doses of prescribed immunosuppressive medications.
In medicine, adherence is described as the “extent to which people follow the instructions they are given for prescribed treatments” (Low et al., 2015, p. 752). Behaviours that result in missed or altered doses of prescribed medication are commonly referred to as nonadherence (NA) (Curtis, 2009). Put simply, these patients just don’t follow doctor’s orders. Given that life-long regiments of immunosuppressive medication are prescribed for transplant recipients in order to minimize the risk of rejection (the rare exception being donation from an identical twin), NA behaviours can have a devastating effect on patient outcomes, as well as further stress health care systems by requiring those patients to return to dialysis or experience lengthy hospitalizations associated with such poor outcomes (Low et al., 2015). Low et al. (2015) point out that not taking immunosuppressive medications as prescribed is not only associated “with a 60% increased risk of kidney transplant failure” (p. 752), but also that 52% to 67% of renal transplant patients are NA when it comes to taking their prescribed medications. This is poignantly illuminated in one study of transplant recipients, where nearly 10% of patients died as a result of NA (Whistsett & Levitsky, 2017).
The ubiquitous nature of this issue has resulted in myriad explorations of NA, however these studies primarily focus on assessing NA rates (patients rarely volunteer their NA behaviours to their doctors, or when they do, they often overstate their adherence) (Wang et al., 2004), or were related to drug development, assay and effect (Low et al., 2015). Few studies focus on patient beliefs and expectations, and even less – around 1% of studies included in a systematic review of NA literature – are dedicated to improving medication adherence (Low et al., 2015). This highlights that despite being a well- recognized challenge, relatively little is known about why patients miss or alter their dose of immunosuppressive medications, and that NA continues to be a “poorly managed” (Low et al., 2015, p. 760) problem in transplant medicine.
Giving, Receiving and Repaying in Organ Donation
The dominance of the gift of life discourse within organ donation is widely acknowledged. Distinct aspects of the obligation to give, to receive and to repay have been highlighted by scholars, who note that applying “Mauss’ gift-exchange paradigm to organ transplantation illuminates many of the distinctive psychological and social phenomena that donors, recipients, their families, and the transplant team mutually encounter” (Fox & Swayze, 1999, p. 33).
Vernale and Packard (1990) expand on the shared experiences of such phenomena by highlighting formidable inner and outer pressures that influence the obligation of the donor to give. Normative pressures stemming from societal beliefs that the giving of oneself to others is an ultimate act of giving, is cited as one such example (Fox & Swayze, 1999; Vernale & Packard, 1990). The symbolic meaning of live donation is also identified as a source of complementary pressures on both giver and receiver, where the symbolism of live donation “virtually obliges every family member at least to consider making such a gift” (Fox & Swayze, 1999, p. 33), whereas a refusal to accept a live donation implies a rejection of the donor and the relationship with the recipient. The unique social and cultural pressures involved in organ donation are also observed by Sharp and Randhawa (2014) who assert that altruism in the context of organ donation lies outside traditional theories of altruistic motivations in which no reciprocity is expected, since organ donation is “a unique form of gift exchange with its own set social and cultural norms” (p. 164).
While the obligation to repay has been identified across extant literature, (Fox & Swayze, 1992; Kierans, 2011; Pinter et al., 2017; Sharp & Randhawa, 2014; Siminoff & Chillag, 1999; Shaw, 2010; Vernale & Packard, 1990), debates around both the types of experiences recipients encounter in navigating this obligation, along with what constitutes appropriate forms of reciprocation, are ongoing. For example, Fox and Swayze (1992) acknowledge the multitude of ways the gift exchange and the reciprocation entailed in the exchange can be experienced – while the experience can be emotionally and spiritually enriching for some, the literal and figurative reality that a part of the giver resides in the receiver creates a bond through the act of donation which can be “unbearable” (Kierans, 2011, p. 1475) for others. This unbearable bond is described as the ‘tyranny of the gift’: a creditor-debtor vise that binds donor and recipient together due to an inherent inability to repay the gift of life (Fox & Swayze, 1992).
A significant challenge compounding how this bond and the related need to reciprocate are reconciled is the fact that appropriate forms of reciprocity are themselves highly debated. Sharp and Randhawa (2014) suggest that reciprocity in living donation could be best understood through forms of direct and indirect exchanges in which the flow of reciprocity can be channeled in a more universal sense if reciprocation to an individual is inappropriate or unfeasible – in this way, “the recipient may ‘pay-back’ in a general sense to society” (p. 166). Transplant recipients have often been documented as joining transplant support groups, volunteering for donation promotion activities and speaking engagements, as well as engaging in various forms of correspondence with their donor (Fox & Swayze, 1992; Siminoff & Chillag, 1999; Vernale & Packard, 1990). While there may remain feelings that this type of repayment is inadequate, both donor and recipient tend to find these types of reciprocation satisfying (Siminoff & Chillag, 1999). Further, Siminoff and Chillag (1999) observe that recipients make the most of a second chance at life by complying with medical instructions, such as taking immunosuppressive medications as directed. While Siminoff and Chillag (1999) are critical of the gift of life discourse, they illustrate that a direct link between the obligation to reciprocate and adherence to medications within transplant contexts exist.
Discussions of direct financial rewards for organs (such as legalizing the black market, priority systems for registered organ donors, and preferred allocation of organs) are progressing, but remain challenged as a form of acceptable reciprocity given the perceived incongruity with bioethical principles (Sharp & Randhawa, 2014).
Critical discourse analysis was performed as described by Fairclough (2001), who outlines the method as the “analysis of the dialectical relationships between semiosis (including language) and other elements of social practices” (p. 122) with a particular focus on change. Further, such analysis includes “all forms of meaning making – visual images, body language, as well as language” (Fairclough, 2001, p. 122). As such, this paper critically assesses a breadth of publicly available living donor awareness and education texts, including donor and recipient testimonial videos, images and other written texts (e.g. transplant process guides, live donor outreach letter templates, posters and other outreach materials) circulated from institutions (hospitals, foundations) and figures of authority (doctors, nurses) in the Canadian health care system. This method was chosen because “it allows symbolic, relational, and structural aspects of health research to be addressed” (Mercado-Martínez et al., 2013, p. 257).
Texts were selected based on content containing symbolism and meanings associated with the gift of life metaphor, and where live kidney donation information and processes were included. The decision to focus on texts relating to live donation, and more specifically live kidney donation, stems from the fact that live donation in Canada occurs almost exclusively in renal transplant (CIHI, 2019). Underpinning this is the understanding that “[g]ift theory has rarely been considered from the perspective of live related transplantation” (Gill & Lowes, 2008, p. 1609) despite a greater degree of similarity between live transplantation and gifting as compared to deceased donation (Gerrand, 1994; Gill & Lowes, 2008). Texts that dealt exclusively with cadaveric donation or transplant and other therapies for kidney failure (e.g. dialysis) were excluded. The texts reviewed were limited to works in English.
Finally, texts included in the study were generated by two of the largest transplant centres in Canada: British Columbia and Ontario. These centres account for the majority of transplants performed in the nation and broadly represent Canadian donation discourse. A preliminary scan of education materials from all provincial agencies indicated that the materials from these two centres captured the essence of similar literature provided in other jurisdictions across the country. Thus, the inclusion of materials from additional Canadian locations would have been redundant.
The data were analyzed for content line-by-line. The ideas and concepts raised in texts were hand coded iteratively, and were thematically analysed for meaning. Themes and concepts were inductively identified and grouped, with emerging concepts able to be classified along themes of morality, giving, receiving and reciprocating. Texts were revisited and re-read numerous times to ensure familiarization with content and to verify findings.
Findings and Discussion
The gift of life metaphor and the Maussian notion of the gift relationship are “ubiquitous in discourse around the donation of body tissues” (Shaw, 2010, p. 611). Omnipresent in Canadian examples of live renal transplant awareness and education literature, it has become so institutionalized that explicit use of the metaphor appears in titling Ontario’s government agency responsible for organ donation and transplantation: Trillium Gift of Life Network. Although organ donation has been widely represented by the gift of life metaphor, this has largely ignored key contexts and issues that occur post-transplant, such as high instances of NA behaviour expressed by renal transplant recipients. The under representation of such issues in literature has been acknowledged by Kierans (2011), noting a tendency in research “to focus on problems relating to the supply of organs across the globe [and that which] happens to those who have been transplanted has received much less attention” (p. 1970). Looking at the pervasiveness of the gift of life metaphor from contexts beyond organ shortage has revealed insights informing the four themes discussed below. These insights provide a new perspective in considering how the gift of life discourse enables transplant recipients’ sense-making of their obligation to repay, and how this in turn, may influence decisions around adherence to life-sustaining immunosuppressive medications post-transplant.
Organ Donation is Morally Laden
The gift of life discourse is commonly used as “an ethical model for framing the understanding of organ donation and transplantation processes in jurisdictions where the commercialisation of body tissue is prohibited.” (Shaw, 2010, p. 609). With the virtually universal promotion of organ donation as altruistic and voluntary, the portrayal of donation as a social good with value placed on human life is underscored (Fox & Swayze, 1992; Gerrand, 1994; Gill & Lowes, 2008; Hansen et al., 2018; Heinemann, 2014). In this view, organ donation discourse is replete with ethical and moral meanings abounding in biomedical texts in lockstep with the gift of life metaphor. These moral signals are evident in a multitude of ways within live kidney donation awareness and education literature. Some of the strongest examples of this can be found within institutional policies highlighted in transplant process guides. For example, a policy in which donations from those 35 years and under are directed to children showcases this. As children have longer life expectancies, as well as being a particularly vulnerable medical population, this policy exemplifies a philosophy to focus on where the most good can be done. This point is also visible in institutional bodies’ displays of symbolic acts such as endorsing the Declaration of Istanbul (a policy both promoting live donation and renouncing the use of organs obtained via commercial transaction) (The Kidney Foundation of Canada, n.d.). Individual accounts from live donors also expressed the view that donation was the right thing to do, a perception that is in accord with evocations of altruism and “cardinal societal principles of voluntarism” (Fox & Swayze, 1992, p. 33) engendered by gift giving discourse.
What is interesting is not that the communal language of the gift of life metaphor exposes moral convictions inherent in the context of organ donation, but rather that these moral convictions are at odds with one another. Sque et al. (2006) point out that the gift of life discourse is not only designed to drive “altruistic donation based on valuing human life” (p. 121) but that this discourse reflects a dominant ethos that “counters commercialism and market-based exchanges” (p. 121). It is this counterpoint to the commercialisation of human organs in which the metaphorical moral friction lies: the emphasis on volunteerism and altruism in live donation awareness and education texts is counterbalanced with strong messages reminding both donor and recipient that “[i]n Canada, it is illegal to buy or sell organs.” (BC Transplant, n.d.-a, p. 4). As such, the juxtaposition of altruism in the act of giving with that of moral and legal sanctions on the sale of organs clash with views of repayment in the conjured gift giving framework.
While Maussian notions of reciprocity in organ donation are not necessarily monetary in nature – for example, championing donation initiatives and joining support groups as outlined above – it has been argued that the framework of gift-giving and its inherent obligations as defined by Mauss is now intermingled with contemporary notions of repayment, and that the fungibility of gifts erode the relationships of exchange (Shaw, 2010). Kierans’ (2011) discussion of reciprocity includes organ recipients’ need “to materially repay the gift in some way or by financially taking responsibility for the donor” (p. 1474). This showcases the challenge for recipients in conceptualizing repayment for the gift of a donated organ outside of financial terms. Given the tendency to put reciprocity into some form of financial exchange, the moral evocation in the gift of life discourse is at variance with itself when it comes to the notion of reciprocity. On one hand, the metaphor is used to elucidate organ donation as a moral act, being portrayed as a “personal responsibility” (Trillium Gift of Life Network, n.d.), while on the other hand, it is morally and legally abhorrent to provide financial compensation for a kidney given. Ultimately, the evocation of moral codes through the gift of life discourse restricts a recipient’s ability to repay based on moral principles. Put another way, a very narrow frame of acceptable forms of reciprocation are available to recipients, and as will be discussed below, the opportunity to leverage this has gone largely unheeded.
The polarities innate in the gift giving framework provides a moral backdrop to understand overarching and diverging narratives within live renal transplant awareness and education texts. Drawing on the boundaries of giver and receiver, these narratives serve to both magnify gift ideology and the feelings of indebtedness to reciprocate, and to simultaneously undermine it. It should be noted that while each are discussed separately, they are interwoven with each other intimately.
Some of the most visible and easily consumed renal transplant awareness and education texts come in the form of media campaigns and outreach, brochures and videos documenting living donor and recipient experiences. The highly visual nature of these texts often relies on symbolic communication in engaging in the gift of life discourse. A recurring and dominant graphic trope includes the superimposition of an illustrated kidney on an anatomically correct position on top of model’s (often an actual recipient or donor’s) body. This visual provides an easy-to-understand message at a glance, signalling the model as a transplant participant. By drawing attention to the physical location of the transplanted organ – which, for the recipient, typically sits in the lower abdomen, distinctly further down in the body from where the kidneys we are born with are located – the embodied nature of transplantation is explicitly referenced. The emphasis on the physical body, down to the correct anatomical placement, provides the viewer with a perception of transparency and the ability to look through one’s body, however the only thing worth looking at is the organ itself. In this way, donor and recipient have been reduced to their organs, and their identities exist within texts solely as the roles they play in the kidney transplant process. As there is no recipient without a donor, each is discursively positioned in relation to one another. This reductive approach in representing transplant participants functions to place the kidney at the forefront of the message in order to magnify its meaning and importance as the gift of life.
Despite the positioning of recipient and donor as paired, the relationship depicted is not equal. This is evident in videos capturing experiences of common living donation scenarios, where live donors are typically friends, family or co-workers of the recipient. In these videos, and across scenarios, the recipient and donor appear as a dyad, however the videos focus on the experience of the donor, and thus the recipient’s story is told through the donor’s experience of donation. The donor is provided with the dominant voice, relegating the recipient to the role of passive receiver of their transplanted organ and all the things it enables: career, family, time. In this narrative, through representations that further reduce the recipient, both the magnitude of the gift and the gift-giver are exalted. The centrality of the kidney as a gift highlights the inherently noble role of donor as gifter of life, the implied morality of which places the donor in an elevated position. This subtle arrangement of donor and recipient roles illustrates the pressures of the obligation to give placed on donors to live up to such elevated status.
Recipient accounts reinforce the act of donation a “giant gift” (BC Transplant, 2017c, 1: 47) but also acknowledge the feeling of being “beholden to [the donor] for the rest of [their] life” (BC Transplant, 2017b, 2:22). By focusing on the enormity of the gift and the elevated position of the gift-giver, the notion of the gift becomes inseparable from the tacit obligations of reciprocity it entails. In conflating the recipients’ identity with that of the gifted organ, feelings of indebtedness to the donor are intensified. Mauss’ (2001) gift-giving framework suggests that the obligation to reciprocate is embedded in societal structures, however the reductive nature of the recipients’ identity in live donation texts heightens this need to repay. This is captured by Gill and Lowes (2008) who state that despite the perception that reciprocation is onerous due to the magnitude of the gift of life, that “the inability to properly reciprocate does not eliminate the impulse to attempt to repay.” (Gill and Lowes, 2008, p. 1609). The result is that recipients experience a characteristic and complex mix of emotions with regard to reciprocation, ranging from gratitude to guilt (Kierans, 2011). The complexity of the transplant experience is also reflected in notions of receiving.
Donor identities and experiences of the transplant process are further contrasted with that of the recipient within live donation awareness and education texts. Donors are portrayed as ‘healthy’, and ‘normal’, with one donor even recounting her post-donation experience as relatively easy, engaging in activities like biking and hiking, and returning to life the same as it had been pre-surgery within a month. The focus on the accelerated recovery time and type of physical activities within the donor’s account portrays the event of donation as relatively minor. Even if physical recovery is successful, other impacts, such as financial losses due to time off for recovery, are unaccounted in these representations. The focus on donor health and normalcy is further illustrated in an excerpt from a live donation letter template which act as communication guides for recipients actively soliciting a live donor:
I’ve learned it’s possible for kidney donors to live a normal and healthy life with just one kidney. Donors are carefully medically screened to make sure it is safe for them to donate. The transplant team makes the donor’s health and well-being a priority. (BC Transplant, n.d.-b)
Here, the notion of ‘normal’ and ‘healthy’ are not only implicitly contrasted with an abnormal pre-transplant life for recipients which often characterized by rounds of dialysis, fatigue and other feelings of ill health, but this excerpt represents a tendency to overemphasize the health and safety of the donor. In turn, this downplays the potential risk of major abdominal surgery. Even routine surgeries like kidney transplantation carry a .03% risk of death and 1%-2% risk of serious surgical complications, which were observed in only one document in the suite of education and awareness literature analyzed (London Health Sciences Centre, 2017). Living donor accounts are awash with rhetoric around the ‘small’ risk associated with live donation, supporting the perception that the consequences of donating a kidney are minimal (LHSC Canada, 2012). This, in concert with the repeated affirmations that the donor’s health is a ‘priority’, discursively minimizes the overall impact to the donor and provides a pseudo-guarantee of a ‘full and healthy life’ that is consistently reinforced through the institutional legitimacy from which the texts originate (hospitals, agencies, health care authorities).
Gill and Lowes (2008) observe this tendency, commenting that the propensity to downplay donor actions or impacts is analogous to etiquette in contemporary gift giving “whereby gift givers often try to lessen the value of their gift” (p. 1615). Phrases such as ‘it’s nothing special’ or a similarly familiar ‘its just a little something’ illustrate this point. This suggests the minimization of risk to the donor enables the recipient to enact their obligation to receive. When considering the heightened meaning attributed to the kidney as a gift, which encourages donors in performing their obligation to give, the perceived minimal impact to the health and lifestyle of the donor acts as counterbalance in order to allow the exchange to occur.
The narrow scope of reciprocation engendered by the gift of life metaphor receives little attention in live donation awareness and education texts. Where the language of the gift of life is overt in describing acts of giving and receiving in organ donation, such presence is significantly lacking in contexts discussing acts of reciprocation post-transplant (i.e. when the acts of giving and receiving have been completed). The symbolic meanings, moral references and metaphorical language of the gift of life are supplanted with biomedical dialect; the figurative focus giving way from serving a greater social good to that of individual medical necessity, the need to understand immune system responses, the types and frequency of doctors visits and the general need to “follow the post transplant clinic guidelines” (BC Transplant, 2015, 20:24). Adherence to immunosuppressive medications appears as a component of medical regimes required post-transplant, but lack the social meanings and moral connotations ascribed to activities by the gift of life metaphor. In comparison to portrayals of giving and receiving, the language of the gift of life metaphor is noticeably absent when it comes to repaying.
This fissure in the gift of life rhetoric marks a substantive departure in discourse that may provide insight into why issues of medication nonadherence is plaguing the transplant community. The gift of life, synonymous with an altruistic morality, was shown to dialogically enable donors and recipients in their respective obligations to give and receive. By leaving the element of reciprocity unacknowledged within this line of discourse means that the conflicting feelings of “gratitude and guilt” (Kierans, 2011, p. 1474) associated with giving and receiving remain unreconciled, with the onerous burden of reciprocity persisting in a heightened state.
Extending the gift of life metaphor into notions of reciprocity within live kidney donation education and awareness texts, such as highlighting adherence to prescribed medications as a form of repayment, may help to balance the moral asymmetry across giving and receiving, and repaying, that is conjured within transplant discourse. Displacing monetary conceptions of repayment and positioning adherence to immunosuppressive medications as an inherently moral and acceptable form of reciprocity would “help reduce the feelings of indebtedness the recipient felt” (Sharp & Randhawa, 2014, p. 166) and enable the recipient to enact their obligation to repay.
Ultimately, the discursive disjuncture in the use of the gift of life metaphor provides a potential explanation into why 52% to 67% of renal transplant recipients are missing or altering doses of medications (Low et al., 2015). However, there is an obvious need for more research into how the gift of life metaphor and connotations of giving, receiving and repaying may influence issues of adherence. To deepen the understanding of this phenomenon, future research should consider these results from an intercultural perspective in order to draw additional comparisons and decipher idiosyncrasies between contexts.
This study provides a nuanced understanding of the gift of life discourse within the context of live kidney donation. By showing that the morally-laden gift of life metaphor enables both donors and recipients in enacting their obligations to give and receive respectively, a confounding relationship with the obligation to repay is exposed. The ways in which the donor and recipient are discursively positioned within live kidney transplant texts serve to simultaneously magnify and undermine notions of reciprocity. Further, this study observes how the symbolic meanings associated with the gift of life are replaced by biomedical language in the post-transplant context (i.e. when the giving and receiving have been completed), leaving the recipient with restricted moral beacons with which to reconcile conflicting feelings of guilt and gratitude around the impulse to repay. Without these guideposts, the recognition and instances of adhering to immunosuppressive medications post-transplant as a form of reciprocity may be diminished. This observation provides a potential explanation of, and a possible avenue to further explore, the high instances of NA among renal transplant recipients.
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