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75  Moribund Patient's Trust Is at Stake
    The Washington Post, December 10, 1967

     Heart Transfer Poses Grim Decisions

[Dr. Lederberg is professor of genetics at the Stanford University
 School of Medicine and director of the Lt. Joseph P. Kennedy Jr.
 Laboratories for Molecular Medicine]

     The outcome of the first heart transplantation in man, at Cape
Town, will be highly precarious for many months if it is not settled
sooner by a postoperative failure.  The immediate problem is
immunological rejection of the transplanted heart by the new host.

     Experience with other organs gives modest but definite hope
that the rejection process can be muted by the skillful use of
drugs.  With kidney transplants, the least favorable results have
been obtained with unrelated donors; the best, when transplants were
made from a mother to her daughter, since the rejection process is 
a measure of the genetic dissimilarity of the organ donor and the
new host.

     No Guiding Policy
     For at least five years, the technical feasibility of such a
transplant has been evident from trials with laboratory animals.
Meanwhile, there have been modest improvements in immunosuppressive
drugs.  The principal reason for the delay in carrying the process
to a human conclusion has been the lack of a community policy which
would justify a surgeon in taking a heart still able to beat for the
benefit of another person. 

     A kidney can be offered by a healthy donor with a minimum of risk,
since the second kidney can easily meet the body's needs.  The heart
cannot be spared.

     Besides the virtual absence of a legitimate supply, the problem
of heart transplants is aggravated by the potential demand: many more
people face early disability or death from failing hearts than from
faulty kidneys.

     Many surgeons and medical researchers who have anticipated the
technical success of heart transplantation have been deeply perplexed
how to develop a humane but rational policy.  When heart 
transplantation is more routinely feasible, the decision to bypass an 
opportunity to save a cardiac patient's life will be just as grave as 
the decision to take advantage of it.

     We must preserve the confidence of every patient that his 
physician's dedication to his welfare is uncontaminated by the patient's
utility as a biological resource for some other, possibly worthier 
patient.  In fact, this problem may be so difficult, and the new
stresses it places on the doctor-patient relationship so intolerable,
that we ought to make urgent efforts to evade it with further
technical advances.

     Priority on Prevention
     There are three general directions, the most rewarding of which
is fundamental research leading to prevention of cardiac disease. 
But we can also foresee more systematic efforts at the development of
mechanical hearts and the possible utilization of hearts from lower
animals, probably specially bred for the purpose.

     Faced with the dissipation of federal funds for other purposes,
the National Institutes of Health have been forced to make an
intolerable choice of priorities, and their policy is to concentrate
on research in prevention. Over the years, this offers the hope
of lessening the need for new hearts, but there will almost certainly
continue to be an important demand and we must still learn how to 
rationalize their supply.

     Some surgeons have talked of the need to redefine the criteria of
"death" in the light of modern biological knowledge.  Different organs
survive for different periods after the heart has unequivocally
stopped; many people have achieved a very hypothetical kind of
immortality by the cultivation of their cells in tissue culture in the 
test tube.

     The heartbeat is the traditional sign of life mainly because it
can be perceived by everyman, and then because stopping the flow of
blood to the brain results inevitably in the rapid and irreversible
decay of mental function.

     We now have artificial pumps that can take the place of the heart
for at least some hours.  A stopped heart can sometimes be restarted
by electric stimulation.  The heartbeat is therefore an obsolete 
criterion.  We ought to replace it by some measure of brain function and
certainly accept as "dead" a person whose brain has been mangled in an
accident, regardless of the condition of his heart.

     A deeper reading of contemporary biological perceptions of
"death" suggests, however, that no particular redefinition of the 
traditional concept is scientifically justifiable.  Rather than attempt
such a sweeping change of meaning, the law should simply authorize such
specific acts as removing a heart when certain procedural and medical
criteria can be certified.

     When pumps are available, taking the heart does not immediately
kill the brainless patient; at worst, it merely seals a doom that
should have been beyond any hope of averting before the procedure was
contemplated.

     A Mutual Club
     The medical technicalities are easier to rationalize than the
protection of the rights of the person.  The law governing a man's
right to dispose of his own body is confused, and the surviving 
relatives must usually be consulted, a procedure that would often
frustrate getting organs in time to be of any use.  Some states have
begun to codify specific rights of an individual to direct the 
disposition of his postmortem remains, which suggests individual consent
as the most constructive precedent for solving the heart donation
problem.

     Many people resist any rational argument for intruding upon their
warm bodies in any circumstances and few would want to disregard such
a wish.  Many more people, it may be hoped, would gladly authorize
any help that their organs might serve in another man's life if they
thought of the possibility of a tragic accident that left them in a
state of imminent death.

     The happiest solution to legitimizing the supply of human organs
for transplant would be to set up machinery to register advance, 
positive, voluntary consent, a club for mutual salvation.  The 
membership contracts could allow some range of alternative criteria for
when the "donations" would be permitted.  While this machinery was being
popularized, surviving relatives might have carefully constrained rights
to act on behalf of a severely damaged patient in a state of terminal
coma. 

     Is this macabre, to couple unavoidable death with a voluntary
gift of life?

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