In ending, I revisit the philosophical thought experiment of the ‘Ship of Theseus’ that was posed in the beginning. A starting point is the question: how much of The Ship can be replaced before it is no longer the same ship? I have explored how much of a human body needs replacing before it is no longer the same body, or indeed the same person. I expanded the philosophical question to include more sociological nuances such as going beyond not only how much requires replacing, but of what? Where in the body do the replacements occur? Are there different types and kinds of materials that could be used to repair and replace the body? To what effects? The technologies of human, animal and mechanical that could be used to restore the body are socially constructed within a nexus of human relationships defining them as human/non-human, male/female, natural/artificial, technological/organic, persons/species and clean/dirty. The way meanings are associated with these materials have consequences for identity and control; of reflexivity and the experiential; of matter and modality; and form and function.

A sociology of embodiment

In researching the lived forms of embodiment through the biomedical practices of organ transplantation, xenotransplantation and cyborgisation, I demonstrate how the experience of embodiment is based on a subjectivity intimately tied to an individual’s body. However, there is no paradox in experiencing being a body or having a body as embodiment is ambiguous. I began with following a philosophical path, bringing Descartes’ Cartesian Dualism which implies an individual ‘has a body’ in the same way that they might have a car into conversation with Merleau-Ponty’s ‘being a body’. Cartesian Dualism is still relevant as modern understandings of what a person is is focused on the brain as the most vital bodily part and that the self is materialised in the brain. Social understandings of self highlight the brain’s importance in the experience of cognition, for example. However, I have suggested that the experience of embodiment does not mean that identity is solely located there. Indeed, to put it another way, although I have a brain, I am not a brain.

In contrast, there is a diffuse sense of identity that is bodily located, through, for example, adding my sociological caveats such that unlike Merleau-Ponty’s ‘embodiment as experience’ I have focused upon ‘experience as embodiment’. However, Merleau-Ponty’s emphasis on the person associating themselves with their body is a key element to bring to the discussion. I have suggested the experience of embodiment is important when an individual’s body is modified through transplantation, amputation or cyborgisation. Such body modification creates a body that is no longer absent for the individual; this absence was a taken-for-granted assumption because in our daily lives our bodies have to be part of the background and not at the forefront; otherwise, the continuous focus on our bodies and our relationship to them would hinder and obstruct our day-to-day activities. The body becomes a focal point of experience, creating a reflection that causes the body to be constructed as a separate entity while also being that body. To separate it out, there was unity beforehand. The body through modification of its composition is now an ‘absent absence’. This makes the body a presence through the conditions of reflection on having and being a body. I am, and I have, an ambiguity of embodiment. Leder’s (1990) ‘absent absence’ applies as much to the integrity of the body as it does to the image. The integrity of the body’s invisible spaces is as important to identity as the visible image. The dermal layer of the body when breached by biomedical practices that insert organs or technology is marked by the entry incision on the surface that allowed the external world in, sometimes by force given how little space there is inside.

Triad of I

The outside-in is the inside-out. The body is one whose identity includes an outside image and an inside integrity and constitutes the Triad of I. Unlike the uncertainty of embodiment, beliefs about human organs are based on a shared understanding that all share the biological condition of humanness. A lived embodied approach to theoretical discussions about embodiment is a recognition of how the reflective dimensions of embodiment are implicated when changes to the interior body are made with organic materials that are similar in terms of species. Recipients know when they receive a human organ. This universality is matched with the knowledge that despite the shared human condition, there is a uniqueness to everyone, and this contributes to the narratives told about the organs, or as Parry calls it, to their ‘social life’ (Parry, 2018). These socially constructed characteristics of individuality are projected onto the outside body but also the inside of the body. The body is one whose identity includes an outer image and inside integrity. Organ transplants are fleshy. They originate from another body which was human and therefore characteristics such as gender and others such as lifestyle choices can be created about the donor by the recipient. In Chapter 1, the transference of personal characteristics from the donor’s organ alters the recipient’s subjectivity and is a finding that has been reported since the early days of organ transplantation. Female organs are said to be infused with femininity, whereas male organs are associated with ideals of strength.

Moreover, biomedical practices such as organ transplantation and cyborgisation show how embodiment extends beyond an individualised alteration of subjectivity to include living in a social world with others in it. To some extent, what is placed inside the body will affect how the person will relate to others and how they interact in the surrounding space. Body modifications and subjectivity alterations affect others such as friends and family who are close to the implanted or transplanted techno-hybrid individual. For example, the everyday cyborg is affected by other people and environments that may damage, intentionally or unintentionally, the ICD and, by implication, the everyday cyborg.

It has to be you or me

Partly due to the idea of donor organs being contaminated with their previous identity, replacing a human organ with another human organ brings to the fore reflective social processes by the individual about their experiential aspects of embodiment. When human organs require repair or replacement, the preferred option from human, animal or mechanical will be from human and as similar to the recipient as possible. Repair to the body through regeneration and of 3-D bioprinting maintains the boundaries of the recipient’s embodiment from others and negates any risks to subjectivity. These novel findings show the preferred option for repairing the human body is with an organ that came from the same human body (e.g. in the case of 3-D bioprinting), or from a donor who is known or related. In the survey reported in Chapter 2, young adults expressed a firm preference for organs from a known donor. This can be interpreted as an attempt to distance the recipient from possible characteristics from a deceased donor that is a stranger. The danger of an organ from a stranger is a possible subjectivity alteration via contamination but in unknown ways. Actual stories about an anonymous donor given by transplant recipients are consistent with this fear of being contaminated with unknown characteristics. Various explanations have been put forward for the mechanism of this identity transfer including biological (cell memory or as genetic composition); pharmacological (effect of immunosuppressants); and I have emphasised the process of ‘contamination’ that tells how this happens and incorporates the stories told by recipients (Sanner, 2001a, Sanner, 2001b). It is how donor recipients make the unknown known by creating narratives about a donor they have never met and know very little about.

‘Dirty pigs’

If a recipient’s subjectivity is altered through contamination from the donor’s human fleshy organs, then there is a risk that other fleshy organs might do the same. Non-human animal organs are thought to have the same potential to cause subjectivity alterations to the recipients. Like inter-species contamination between humans, intra-species procedures such as xenotransplantation make it possible to modify the integrity of the recipient’s body, altering subjectivity. Chapter 2 (the survey with young people and the focus group research) demonstrates some participants believe human and non-human organic sources, such as from a pig, not only modifies the body but can alter subjectivity. An organ from a pig placed into the human body has the potential to contaminate the body and to make the recipient like the pig (and there are beliefs about ‘dirty pigs’ for example). Fleshy organic parts, therefore, do have a story of a life previously lived and although there are specific social, cultural and religious beliefs about the consumption of meat and pork, the repugnance wisdom of a ‘yuck’ reaction to xenotransplantation I have argued, based on the findings from this aspect of the research, is more than prescriptions about vegetarianism and food consumption. Instead, the ‘yuck’ is related to fundamental questions and perceived threats to the boundaries between humans and other species. Should xenotransplantation and 3-D bioprinting prove successful, Varela suggests:

Fleshy organic parts are associated with the identity of those they were once part of.

The current challenge of overcoming biological rejection, which is slowing the progress of xenotransplanting whole animal organs appears to be matched with a cultural one. Using animal parts on a small scale is acceptable and regularly undertaken, such as porcine valves being used as heart valves. Less is enough in these situations. On the one hand, there is a reliance on the biological and physiological similarity between humans and non-human animals for the latter to facilitate therapeutic regimes and medical research.

On the other hand, there is an inherent rejection of shared resemblances when it comes to procedures such as xenotransplantation. This might partly explain why attention is increasingly focusing on the future possibilities of using bio-, nano- and info-technologies and using genetics, microbes, devices and pharmaceutical interventions, all of which appear to be moving away from the potentialities that non-human organs might afford. Indeed, part of this move away from xenotransplantation may be ideologically based, with the introduction of the term ‘non-human animals’ used by animal activists especially, to show that animals demonstrate elements of cognition and emotion. Hence, rights with such associated (human) personhood should be applied to animals. Given these countervailing tendencies (an increasing recognition of the value of non-human animal cellular materiality for human therapy, while at the same time a greater awareness of the rights of non-human animals as social beings), there may be a preference for machines in the flesh.

‘Clean machines’

In the survey conducted with young adults reported in Chapter 2, a mechanical implant was preferred to that of a non-human animal one. Some recipients were hesitant about a mechanical implant, as it was perceived as being unnatural and uncomfortable and indeed a few of the everyday cyborgs echoed this view when sharing their actual experiences. Preferring not to have a mechanical implant was related to ideas about reliable functioning, whereby machines break, rust and malfunction. Quotes such as ‘technology and machines break more often than natural things’, and ‘it could function wrong and destroy the inside of my body’, are reflective of such a stance. Indeed, in the later interviews I conducted with everyday cyborgs, exploring their love-hate relationship with their technology, ICDs do not represent a threat to subjectivity via contamination in the manner that a fleshy organ from a human or animal might; however, as reported in the interviews, the ICD does have the potential to cause infection and to malfunction.

In interviews with everyday cyborgs that I discussed in Chapter 4, cybernetic modifications to the body do not result in a person being less human, because less of their body is human. Alteration of what you are (in the material bodily sense) does not affect who you are (subjectivity) in the case of creating techno-organic hybrids such as everyday cyborgs. Simply, a machine has no social history that is connected to another living being (human/non-human animal, living/dead) in the way that organs have. However, alteration of what you are (in the material bodily sense) does affect who you are (subjectivity) in the case of organ transplantation.

The machine is a different type of material made by a human but never from the body of one. The cybernetic technology is not fleshy and has no previous association with any living being. There is no risk therefore of contamination of characteristics from the source as appears to be the case with fleshy human or animal organs. Technological additions are not assumed to turn the person into a robot as would be the case when altering subjectivity in the way that another human can or non-human animal transplants are assumed to do. Mechanical augmentation has more functional implications for these dimensions of embodiment. Mechanical additions are ‘clean’ in form but may harness ‘potentiality’ to save a life and can cause pain by doing so (Helmreich, 2013).

Machines do not have a fleshy origin; they are a different type of materiality unsullied by flesh that can contaminate. The story of devices is one that highlights that machines break, parts wear out and malfunctions are common. Using cybernetics to repair human bodies alters subjectivity in a very different way than organs from human and non-human animals do. The flesh has a story that can cause contamination, whereas the machine is created that can occasionally cause infection. It can malfunction, and inappropriate shocks were said to have been experienced by some. Their implantation does not result in the identity transformations reported by some human organ transplant recipients or envisioned by views about xenotransplantation. The consequences of becoming part cybernetic do not involve any organic additions that are supposed to alter subjectivity as is the case in using a person or a pig. The machine was not previously embodied and cannot contaminate. Nevertheless, the ICD can affect identity in the social world through limiting the patient’s ability to socialise, for example. The individual has a unique identity as an everyday cyborg which has nothing in common with the celluloid monster by the technological adaptations that sci-fiction creates and popularises. The only elements that are shared between the sci-fi monster and the everyday cyborg are that they are both more likely to be male.

ICD: cybernetics (cyb) and organisms (org)

However, reliance on biomedical technologies in the form of medical devices to repair organs has been on-going for quite some time, and these technologies are arguably becoming increasingly autonomous, reactive and communicative – the C3I. The application of such smart technologies has the real potential to excite the fears cautioned by Baudrillard insofar as they necessitate the implantation of cybernetic technologies into the human body, masking and hiding what the device (or those hacking into it) might be communicating or interfering with in its commands. What greater ontological insecurity could there be than that created by a device that is in control and autonomous ironically through an intimacy that makes it outwith individual control and out of sight of others. Then cybernetic technology can give autonomy while simultaneously taking it away. This loss of control on the part of the everyday cyborg may be key to understanding their vulnerability. Unlike bionics, prosthetics and implantable medical devices, such as CIs and glucose sensors, the ICD functioning is to intervene in a specific and rare instance of an irregular heart rhythm. The everyday cyborg can do nothing either in the case of the cybernetic device functioning or indeed malfunctioning. The ICD causes vulnerability and reflects the lack of autonomy the everyday cyborg has over the ICD that essentially has the control to save his/her life.

If the ICD performs its life-saving function and discharges shocks, the event is explained retrospectively by most everyday cyborgs locating their actions as the reason for the discharge. This reasserts some control over the device (rather than acknowledging the device is in control) and they could therefore blame either themselves through emphasising excesses on their part (worry, exercise, caffeine) or the vulnerabilities in the device (the parameters for shocks are set too low; the leads have broken; the ICD mis-sensed). The everyday cyborg can offer explanations, placing themselves as an agent of the activity and not as a victim of circumstance.

Re-appropriating the term cyborg for our everyday application reinserts issues about what cyborgs need to live happy and fulfilling lives; what kind of support they and their significant others might find useful; as well as what type of information and understanding is required to acclimatise to new techno-organic hybridity. Suppose there is a need to understand and empower those with varying abilities, then a moral and political requirement needs to recognise and celebrate those that are hybrid and materially diverse. There are lessons in what active and meaningful implantation means for the individual. ICDs can cause their cyborgs and their significant others emotional, physiological, psychological and social challenges that are rarely made visible – a cyborg individual or implanted group identification thus reawakens interest in the hybrid condition, leading us to new understandings about the obstacles as well as the benefits that implants pose. There are unique biomedical challenges regarding altered subjectivities, vulnerabilities with known and unknown others and in a loss/gain of human/cybernetic autonomy.

Acclimatisation

Becoming a cyborg in the everyday means that, for some, there is collateral damage; vulnerabilities created, skin cut and changed, body integrity breached; viscera compromised, relationships reformed, subjectivities altered. There are ways additions of new materiality can become part of the body and part of the person. A person can accept an alien part such as that of an implantable medical device or an organ. Jean-Luc Nancy in L’intrus relates his experience of receiving a heart transplant. He describes feelings of alienation created by the ‘intruder’, a deceased donor’s heart organ, supposed by Jean-Luc, to be male:

Jean-Luc Nancy discusses in detail his organ transplant, regarding the multiple intruders in his body, ranging from his own heart to the transplant he received, the immunosuppressants created from a rabbit required to stop his body rejecting the transplant, the shingles, to cancer that eventually ‘gnaws’ at this body. This is not just about one intrusion from outside but a multiplicity of intrusions by the end of his therapy (Geroulanos and Meyers, 2009). The body, as Nancy suggests, ‘is thus my self who becomes my own intrus – a self that is already profoundly divided and multiple’. ‘And yet it is also the “self”, the “I” that re-sews at the end’ (2002: 15).

Experiencing inorganic/organic hybrid embodiment is a process whereby the transplant or the implant is alien. This alienation is a different experience to the perceptual foreignness of inner organs. The foreignness of our inside organs is a frequent absence that an individual has experienced since birth. However, both transplants and implants leave marks and scars on the body as visible reminders of where breaches into the body’s inside and integrity occurred. Both human transplanted organs and implanted technology are unfamiliar alien presences with each either fully or partially disappearing into the familiar foreign space of the interior. There are differences in the depth and reach inside the body. Generally, the ICD may not be submerged to the same extent that a transplanted organ might be. Entry into the body for both, however, is permanently marked by a scar showing where the integrity breach occurred and where a place was found in the viscera for a new alien presence, visually reminding the transplant recipient or everyday cyborg that they are new organic or techno-organic hybrids.

When experience suggests that embodiment is not an event but a process and a journey that is variable in experience and relationship with others, organic transplants and cybernetic implants to the body require varying degrees of acclimatisation to the initial alienation caused by the new artefact. This is because such body modifications recreate bodies that are routinely absent as a presence (or an absent absence). This experience of the body being absent in everyday life is a state where the relationship that a person has with their body is not reflected upon; embodiment is simply forgotten. On the individual level, for the everyday cyborg at least, this is never a status but a journey of change. Their cyborgisation process, in the case of the ICD everyday cyborg, begins after their recovery from a severe illness, disease or a near-death experience. Adjusting to a technological embodiment because of ambiguous intertwinement between body and person can mean that changing a body is not an isolated incident and will have ramifications for identity.

The process of accepting the techno-organic hybrid body becoming ‘absent’ again in everyday life requires ‘acclimatisation’. Acclimatisation is one way of describing the journey of experiencing the body as a presence to an ‘absence’ once more, in Leder’s (1990) terms. Acclimatisation may be relevant for cyborgisation and in organ transplantation too. In her book, New Organs within Us, Sanal introduces the Turkish term ‘benimseme’, referring to ‘becoming familiar or feeling at ease with something by making it one’s own. It also means internalization … [and] is a powerful word used to describe how the self, ben, or the ego, can incorporate things’ (Sanal, 2011: 4). Varela, when writing about the liver donated to him, reflects on how it did not cause any lasting identity transformation:

The images of the deceased donor and the emotions that Varela felt towards them, as well as the donated organ, came to be replaced with a generalised attribution of bonds to others and an awareness of the gift given. This intersubjectivity recognises the connection between individuals that makes the offering of an organ from the deceased possible.

It is for me, not against

Growing comfortable with a hybrid techno-organic status and living with an ICD depends on the everyday cyborg experiencing the ICD as a benefit. Those around them may see the ICD as a benefit because it removes some of the responsibilities of vigilance and oversight they may have had before the cyborgisation process and over the everyday cyborg. Now that the ICD can protect the everyday cyborg from an SCA, family and friends can concentrate on protecting the everyday cyborg from harm caused by their actions. Such protection might be complained about by the everyday cyborg; however, in their accounts, they self-blame and make themselves responsible for the ICD discharging a shock.

The benefit of a hybrid existence through the implantation of a cybernetic device can play a crucial role in shaping how the everyday cyborg acclimatises to their new life. In contrast to the accounts offered by transplant recipients and others, modifying the interior body through transplantation causes subjectivity alterations but the opposite occurs with cyborgisation. The ICD as a cybernetic device is made part of the everyday cyborg – the ‘cyb’ becomes the ‘org’. If a cybernetic device is used, it is not the recipient’s subjectivity that is altered, as might be suggested in the case of human or non-human animal transplantation, instead the device becomes a part of the recipient. The ICD becomes both part of the body and the subjectivity of the cyborg.

The everyday cyborg’s successful re-acclimatisation to an altered subjectivity of techno-organic hybridity makes their experiences unique when compared to patients who have heart conditions. Living with a device requires adjustments to identity, accepting that the ICD is not an alien and can become part of the person, allowing comfortable co-habiting with cybernetics. Cyborgisation alters materiality and affects subjectivity on one level, creating a need for individuals to undertake the successful acclimatisation process involved in becoming a cyborg. On another level, however, it creates a dependency on the biotechnological fix.

A 21st-century identity crisis

There are factions or groups currently mostly in the US and elsewhere called the ‘Transhumanists’, who advocate that technoscientific innovations, such as future cybernetic devices, should be embraced because they would make a person ‘better’ (Savulescu and Bostrom, 2009). ‘Better’ in this context is used by the Transhumanists to refer to the additional capabilities that other humans do not have (such as the ability to fly). The symbol for the Transhumanist is +H and in their view, the plus sign (+H) represents an addition to the human condition. It demonstrates the possible enhancement of all humanity, despite the normativity of what is and is not ‘normal’ that arguably underlies much of this type of thinking (Parens, 1998, Baylis and Robert, 2004, Hogle, 2005, Harris, 2007, Buchanan, 2008, Gordijn and Chadwick, 2008, Bostrom and Sandberg, 2009, Savulescu and Bostrom, 2009, Eilers, Grüber and Rehmann-Sutter, 2014). The everyday cyborgs are created through therapeutic modification but not enhanced by their technological modifications (see Daniels, 2000 for a discussion of what the difference is between therapy and enhancement). The speculation in the 1970s regarding the future of the human body and the ‘anatomy of the superman’ [sic] suggested a basis for enhancing human beings based on the unique qualities of non-human animals:

It appears that current-day discussions regarding enhancing the human body take little recourse of the unique abilities of non-human animal organs – better the ‘clean machine’ than the ‘dirty animal’.

Everyday cyborgs offer a narrative of the contemporary practices of modifying human bodies through bionic, prosthetic and cybernetic technologies that invite a critical understanding of the consequences for the person and whether enhancement does make people better (Van Den Eede, 2015). Increasingly, and running parallel to such a discourse on human enhancement, is a reliance on biomedicine for technological solutions to the developed world health problems. Yet the technoscientific solutions offered in the spheres of biomedicine and enhancement feature mostly male recipients. In so far as we live in a socially structured world, we are subject to the same health and gender inequalities that may become prevalent in a future society of cyborgs that are as entrenched as inequalities are today.

Having raised the spectre of social discrimination in the processes of cyborgisation, it can also be the case that a 21st-century identity crisis is occurring with the boundaries of what is inside-out and outside-in. For cyborg scholar Chris Hables Gray, the process of cyborgisation is akin to that of dying and death as both share a variability but inevitability:

The identity crisis is created by introducing new vulnerabilities to human beings, being human. The everyday cyborg acclimatises to the fractures that placing an ICD causes in their bodies and lives. Such an ability for individuals to acclimatise to new techno-organic hybridity is a positive, but the downside is that through doing so it masks the presence and magnitude of a 21st-century identity crisis which may explain why it is going on unnoticed. ‘They got what they wanted but lost what they had’ (Richard Penniman, quoted in Winner, 1993: 371), sums up the often painful ironies of not having any choice. Biomedical nemesis, unlike medical nemesis, centres the ambivalence and vulnerabilities that biomedicine causes as the clinical gaze penetrates the body seeking to implant technoscientific fixes. Biomedical nemesis can be applied to other forms of technoscience interventions that cause unintentional ‘un-health’ (Illich, 2003). It is a vulnerability that is neither disease nor illness, neither being entirely healthy nor entirely ill, the un-health is euphemistically called the ‘new normal’ or the ‘new different’. The ICD is not only cybernetic through its closed-loop feedback system, with C3I features, but it is the ultimate biomedical nemesis sine qua non the iatrogenic device par excellence. The stakes for patient survival have never been so high – without becoming cyborg there is a significant risk of death and yet with it, for some, it can cause vulnerabilities, pain, distress and anxiety – what kind of choice can the individual make when there is no choice to be made at all?