230 G. O’Brien
involves the receipt of a benefit that might not have come one’s way.
In a study of kidney recipients’ quality of life, Orr et al. ( 2007 ) found
that participants made downward comparisons with their pre-transplant
time on dialysis, which served to generate positive feelings of being
‘lucky’ and enabled coping with the difficulties of life post-transplant.
One of the mechanisms undergirding this effect might be a sense of
coherence, defined by Lambert et al. ( 2009 ) as an understanding that
life is manageable, meaningful and comprehensible. Lambert and col-
leagues found that gratitude is linked with increased sense of coherence,
through positive reframing (i.e. benefit-finding or positive reinterpreta-
tion). Sense of coherence, in turn, predicts a number of positive out-
comes, including enhanced coping with critical illness (Fok et al. 2005 ).
Although some participants spoke of many things for which they
were grateful, others did not mention gratitude at all. Sonia, for exam-
ple, reported the treatment she had received over a period of several
years as her kidney disease progressed, and the dialysis equipment and
supplies that had been provided so she could undertake dialysis at
home. She had not mentioned thanks or gratitude at this point, and
when asked whether there was anything in her life for which she was
thankful or grateful, she replied (after a pause): ‘No, there is, there
isn’t, no’. Gift-of-life discourse suggests that a person should be primar-
ily grateful for receipt of ‘the gift’ (an organ transplant), not necessar-
ily the medical treatment that keeps him/her alive until a transplant is
received. However, the moral imperative of gratitude suggests that it
is experienced when a valued benefit has been received, and the ben-
efit was given intentionally and at some cost or effort to the benefac-
tor (McCullough and Tsang 2004 ). It appears that for Sonia (and some
others in the study), the ‘prerequisites’ for gratitude had not been met.
This may be due to their understanding of the treatment received. That
is, it might be understood as an entitlement rather than a benefit.
Where there is a sense that one is entitled to something (health
care, or education, in societies such as Australia, for example), it might
not be understood as a ‘benefit’ per se, and consequently gratitude
might not be experienced in response to it. Even though many of the
prospective kidney recipients constructed dialysis as the gift-of-life, this
understanding is not as clearly situated within the social discourse that