Awake! June 8, 1968 p. 17 - 22
Heart Transplants Pose Staggering Problems
IT IS difficult to portray accurately all the moral and legal implications of heart transplants. For example, there is the question of who is qualified- to perform the operation. Thus one press dispatch told that, "fearing a mass rush to the operating table by unqualified surgeons who want to join the heart transplant club, the American College of Cardiology urged today that doctors take a go-slow attitude toward the procedure." 1
This "College," which consists of America's foremost heart surgeons, announced that it would be setting guidelines as to who is qualified to transplant hearts. Skill no doubt had something to do with the measure of success that Dr. C Barnard had. He not only received much training in the United States in transplanting hearts but also, in South Africa, made fifty transplants on dogs in the past three years. However, let it be noted that fortuitous circumstance also entered into the matter, for example, the fact that Clive Haupt's blood and tissue matched Philip Blaiberg's.
Then there is also the question: Who is to benefit from the available heart? Will it be the most urgent heart case, or the one of greatest value to the community, or the one with the most dependents, or the one with the most money? On this matter Dr. A. Senning, professor of surgery, University.Hospital, Zurich, and an outstanding heart surgeon, stated: 'Se are afraid of doing a :transplantation. Where would you stop once you started? There are so many people with damaged hearts. To whom would you give the one available heart? To someone who would pay a million dollars?"2
There is also the human element to consider. On this aspect of the matter the remarks of one of America's leading openheart surgeons, Dr. E. M. DeBakey, are apropos: "The surgeon must scrupulously guard against taking inadvertent advantage, for purely experimental purposes, of the eagerness of a desperately ill patient to consent to almost any procedure suggested. The surgeon must be certain that the proposed transplantation"2 has possibilities of success and for improving the patient's condition and chances for life. This sets up an exceedingly high standard. Who wot21d be charged with the responsibility of seeing to it that doctors meet it?
Dr. C. Barnard, it is reported, claims that 'the authority to decide legal and ethical implications in cardiac transplants rests the medial profession alone.' But not so! In the Jewish Chronic Disease Hospital case, although three doctors resigned in; protest, it was a lawyer who forced with the result that two highly reputed doctors were found guilty of 'fraud and deceit.' By the very nature of their profession some surgeons are likely to become limited in their view of the issues.
If this were not so it would be impossible to explain the facts that came to light at the Nuremberg Medical Trials. Among those sentenced to death for their experiments on humansnone of which resulted in any benefit to medicine- was Dr. Karl Gebhardt, a professor of medicine,-head physician of the Hohenlychen Sanitorium and president of the German Red Cross. Though some of these experiments were reported in the medical press, the profession by and large remained silent, even as it greeted with silence the book that catalogued them: Doctors of Infamy (1949), a revised edition appearing in 1962 under the name The Death Doctors. However, the World Health Organization highly praised the authors of these books, Dr. Mitscherlich and F. Mielke, for bringing these facts to the attention of the German medical profession.
When Does Death Take Place?
But perhaps the most staggering question or problem facing the heart transplant surgeon is, When does death take place? Yes, just what is death, medically speaking? According to one dictionary, death is "the total and permanent cessation of all the vital functions of an animal or plant." But it has been averred that there is no legal definition of death. Thus Dr. N. Bricker, a pioneer in kidney transplants, observed: "An acceptable, legal, medical and moral definition of death is needed.''3 Yes, just when does the dying patient the potential donor, become a corpse whose organs can be used? These are among the most disturbing questions that the spate of modern heart transplants has raised.
Up until now doctors had their greatest tension when trying to decide whether a person should be kept alive artificially or allowed to die peacefully. It was also held that a doctor should do all in his power to restore the heartbeat to the patient, as by artificial respiration by heart massage, or by other methods. All this was well and good, the only question involved being the life of the dying man. But with heart transplants this question has become highly charged with tension, for now the life of one patient is pitted against the life of another! A truly terrible predicament for the doctor to face!
In fact, this is one of the reasons why Russian doctors have not-yet proceeded with heart transplants. As an American doctor who recently worked with them reported: "When is the patient dead? When should heart or kidney be removed from a patient? These two questions are as unsettling in the U.S.S.R. as they are elsewhere. The Soviet scientists I worked with were reluctant to accept the proposals put forth in other parts of the world for using 'death of brain' as the moment of death rather than 'death of heart.' They are troubled by their experience with the famous physicist Dr. Lev Landau, whom they succeeded in rescuing from 'clinical death.'* A doctor working to save a life until all hope is gone now passes well beyond the point in time at which organs are salvageable for transplantation. He experiences severe tensions when he decides to abandon his efforts. The Soviets believe that these tensions will become nearly unbearable if, as he fights to save a patient's life, he must consider surrendering early enough to salvage a transplantable heart."4 Yes, deciding how long he should try to save a dying man is enough of a burden for the doctor without having the added responsibility of making a choice between two lives!
The "Dead" Brought to Life Again
How great the danger is of deciding too soon that a person is dead and proceeding to remove his heart can be seen from the following further examples.
The New York Times, March 12, 1968, stated that heart surgery restored a marine officer who had been hit in the heart, face and legs and who "died real fast. His heart stopped. So did his breathing." Clinically he was dead, but still he-was brought to life again.
Thus also a recent London medical report showed that, of 102 patients who were unconscious for more- than a month because of brain injuries, 62 survived. Of these, 19 returned to their former jobs and 29 others returned home to lead useful lives.5 Along the same line, Professor W. Forssmann, German heart specialist, told of an American corporal who, on July 16, 1967, was the victim of a mine explosion. After doctors tried in vain for forty-five minutes to revive him through heart massage and artificial respiration, they sent him to the morgue. A few hours later, as he was to be embalmed, it was noted that he had a weak pulse, although the electrocardiogram showed no heartbeat. After three weeks of deep unconsciousness, this apparently dead man fully regained his mental faculties. 6
No question about it, heart transplantation poses staggering problems. As one British woman expressed it: "How can I ever be certain that doctors would do everything to save my life if I had a nasty accident, or a terrible disease, that they would not be influenced by what I could contribute to another person?" Apparently some doctors would have all patients entering hospitals sign statements that, in the event of death, surgeons would have the right to take any organs they chose for transplanting them into another patient! 7
No wonder that some of the more humane, more compassionate specialists are greatly concerned lest a doctor "pull the plugs' on a dying patient in order to get a needed organ. To this end they urge that the transplanting surgeon-not be the one attending the dying potential donor. Thus the British Medical Journal in discussing such problems as "when to resuscitate a patient and when to stop resuscitation once it has been started," stated: "These problems are especially acute when the patient is a potential donor of a-vital organ . .-. There is much to be said for the entire care of the potential donor being in the hands of doctors other than the transplant team until death has been finally diagnosed." 2
In the same vein Dr. DeBakey said: "The surgeon must be certain, beyond any conceivable doubts, that nothing further can be done to save the donor's life. This judgment should be made independently, by physicians who are not members of the transplant team.... The legal, moral and theological aspects of this problem are formidable."2 Yet is not the likelihood of a dying patient's having a doctor solely concerned with his well-being diminished at a hospital where every member of the staff is infected with the heart transplantation fever, as apparently was the case at the Groote Schuur Hospital? In the first heart-transplant case it was the transplant surgeons who ministered to the dying heart donor. Just what took place appears to be dubious. According- to Science News, Dr. Barnard proceeded to remove; Miss Darvall's heart when the last brain wave was seen on the encephalograph.8 However, according to Time magazine, he waited until the heart stopped beating.9 But when a reporter for Newsweek inquired as to whether Miss Darvall was taken off the resuscitation machine before her heart stopped beating, he was told: 'That is an impertinent question," and so did not get a direct answer.7 But it was a most pertinent question to everyone who may someday become a heart-transplant donor due to the assent of close relatives.
Dr. Barnard testified: "A doctor has one duty and one duty only, and that is to treat his patient until he has no means left. If we feel a heart transplant is a method for helping a patient, we must do it." But what if that 'feeling' is not based on accurate knowledge? What if helping one patient means taking the life of another? There is much discussion as to the condition of Clive Haupt, whose heart was given to Dr. P. Blaiberg. According to Boris Petrovsky, Soviet health minister, "not everything is clear in the Cape Town experiment. Many things show that a beating heart was removed for the transplant.''10 It might be said that such is implied in that we are told that the doctors "said that when they determined he could not survive, the decision was made to attempt the transplant."
Have not patients time and again been restored to life after their hearts stopped beating? Dr. Lev Landau's heart stopped four times. And as for using. 'death of brain' to determine death, patients have been restored to life after not having shown any brain activity for two hours!Particularly bothersome is the question: "If a body is all but dead, technically alive only because an artificial respiration maintains heartbeat, is it homicide to take out the heart or kidney before pulling the plug?''ll In one case in England a man who was declared dead after an accident was put on a resuscitation machine just long enough to take out his kidney and then left to die the second time.
Nor is that all The potential of making heart transplants could be exploited by selfish,~ruthless men to a shocking degree. The possibilities for abuse are so vicious that they might be likened to the unforeseen consequences of the discovery of atomic power. Thus Dr. Forssmann envisions criminals sentenced to death being kept alive until their organs are needed for transplant; then they would be executed by heart-transplant surgeons. Concentration camps would be filled with undesirables who live only until- their hearts or kidneys are needed for transplant operations. He is deeply concerned lest "the doctor would finally be degraded to a hangman, a Lucifer, a fallen angel." According to Dr. Mitscherlich, that is the very use doctors were put to during the Nazi regime. They were employed to get rid of undesirables by injections of various things, such as gasoline or tubercule bacilli; in particular, were physicians on submarines used to get rid of troublemakers in this way.
The Legal Aspects
It is interesting to examine the question of the legal aspects of heart transplants. Doctors are concerned that there be new legislation to protect them from possible lawsuits because of performing heart transplants. In some lands it is unlawful to operate on any person except for that person's well-being. This would bar even kidney donors, as the taking of a kidney from a donor is not operating on him for his own benefit, but for that of another person.12
Then, again, conceivably one relative may have given consent but others may not have, and these might file a claim against the surgeon. In many states of the United States the wife as the closest of kin would have to give permission.l3 Thus because the Ochsner Clinic and Ochsner Foundation Hospital had performed an autopsy on a body contrary to the expressed wishes of the deceased and without permission of the widow, the Louisiana Circuit Court of Appeals awarded the widow $1,500 damages.14
While doctors are concerned about protecting themselves against such lawsuits, their patients are concerned lest they be murdered. Murder is the deliberate taking of the life of another; the fact that death is imminent is beside the point. The law does not distinguish between five minutes, five hours or five years yet to live. As one surgeon expressed it: "For the person who takes a vital organ too soon, society has a wordand that word is murder."15
Making a strong case for heart transplants as being murder is attorney H. M. Porter. Writing in the legal newspaper, the Los Angeles Daily Journal, February 2, 1968, he tells of being assured by a leading cardiologist that no surgeon would undertake the operation unless the person whose heart was to be used was still alive at the beginning of the operation. The heart must come from a living donor. The donor must be killed to take the heart; the taking of the heart must kill him.
Since it is deliberate killing, he argues, it must be termed murder. Murder can be defended on the basis of self-defense but in the case of the heart transplant, not the donor, but the surgeon is the aggressor. Then, again, the defense for the murder might be consent, but the law does not recognize the right of consent in the case of murder, as in suicide pacts.
The Scriptural Aspect
Not to be overlooked are the religious, the Scriptural issues involved. There are those, such as the Christian witnesses of Jehovah, who consider all transplants between humans as cannibalism; and is not the utilizing of the flesh of another human for one's own life cannibalistic? Nor are they by any means alone in this view. Thus Newsweek, December 18, 1968, stated: "An artificial heart that could be mass produced would alleviate the shortage of hearts andthe need to cannibalize bodies." And Dr. Donald F. Scott, consultant cardiologist at the London Hospital, condemned heart transplanting as "almost amounting to cannibalism . . . It is not a procedure within our bounds as doctors."'6
The same point was made in an extensive review of the heart-transplant problems by two of the editors of the Miami News, January 22, 1968. The article, several pages in length, opened with the questions: "Medical-miracle or cannibalism? New hope for man or a step to ultimate destruction? God's will or anathema?"
Truly by their heart transplants surgeons are posing moral, legal and religious problems of the greatest magnitude. And when one considers how few of all heart sufferers can hope to be helped by heart transplants, it is obvious that heart transplantation is not the solution. What each individual can do about his own heart will be considered in the succeeding article.
REFERENCES
1 New York Daily News, February 29, 1968.
2 Medical World News, February 16, 1968.
3 St. Louis Post-Dispatch, January 14, 1968
4 New York Times December 22, 1967.
5 The Saturday Review, February 3, 1968.
6 Frankfurter Allgemeine January 3, 19688 ,
7 Newsweek, December 18, 1967.
8 Science News, December 16, 1967.
9 Time December 15, 1967.
10 Toronto Daily Star, January 19, 1968
11 Science News, March 2, 1968.
12 Science News, February 11, 1967.
13 The Christian Century March 20,
14 Medical World News, September 1967
15 Trial December-January, 1968.
16 The Daily Telegraph. London, January 30, 1968.
End
