Journal of Religion and Health
226
A New Challenge to Ethical Codes: Heart Transplants
IRVING
S. W R I G H T
No single event in the history of medicine has aroused more widespread interest on the part of both the medical and the lay communities than has the transplantation of the human heart. It has been praised as a modern miracle and criticized in strong terms. As I write this in December of 1968, on the first anniversary of the first transplant of a human heart into the dying Louis Washkansky, the announcement of the 100th heart transplant has just been made. Dr. Philip Blaiberg still lives in the twelfth month after receiving his new heart, as the fortunate example of the potential benefits of this procedure, once the inherent difficulties have been resolved. However, fewer than half of the recipients of the hearts of others are alive today, and fewer than ten per cent of these are alive more than three months after their transplant. This is the outlook today because of the rejection mechanism by the immunological processes in each living body. W h e n the rejection risk is reduced by immunosuppressive drugs, the resistance to infection is also reduced; many of these patients have died from infection or the combination of rejection and infection phenomena. Already several patients have received their second new heart after failure of the first to function satisfactorily. laVING S. WRIGHT, M.D., is Emeritus Clinical Professor of Medicine at Cornell University Medical College, New York City; National Chairman of the Inter-Society Commissionfor Heart Disease Resources; former President of the American College of Physicians and of the American Heart Association.
Heart Transplants
227
We may ask where all this will end. The enormous resources required the skilled teams, hardware, blood transfusions, and cost of after care with immunosuppressive therapy--have been questioned. Should these resources be devoted to the treatment of diseases in which the results are more certain and where many times the number of patients can be helped for the same cost in effort and finances? Serious questions have also arisen regarding the "moment of death" for the donor. The heart must be removed without loss of time so that it can regain its function in its new host. But by what criteria shall death be determined? I shall discuss this later, but first let us review this event and the questions in some historical perspective. Radical departures from the accepted codes and mores of the past have always met resistance. This has certainly been true in medicine. Many physicians of the past have been exorcized, castigated, ostracized, and even tortured to death when they have dared to move into the future. Just 300 years ago, an example of this pertinent to our present discussion took place. Although blood transfusions between human beings had doubtless been attemped from ancient times, the first one recorded in Western civilization was performed in June, 1667, in Paris. Like the transplantation of the heart in 1967, this one took place with much publicity, excitement, and controversy over previous transfusions in animals, and whether they could be safely used in man. The reaction to this first human transfusion was such that an edict from Criminal Court in Paris as of April 17, 1668, forbade further transfusions unless approved by the Faculty of Medicine of Paris. As this approval was not granted, the procedure was virtually abandoned for two and a half centuries, when, with the development of blood typing, preservation and storage techniques, and the prevention of clotting, it became a keystone of modern medicine and surgery. About 1925, Mr. Henry Session Souttar performed the first successful operation involving the inside of the heart--a mitral commissurotomy. The patient, a young woman with rheumatic heart disease and severe mitral stenosis, recovered and survived for some years. This was even more remarkable since it preceded the discovery of the sulphonamides and antibiotics.
228
Journal of Religion and Health
In 1953, I met Sir Henry and he invited me to visit his surgery (office) on Harley Street in London. He showed me the instruments used for the first operation. They were remarkably like those developed by American surgeons twenty years later. Then he showed me the new set he had modified for the next operation. I asked, "How did they work?" "I don't know how they would have worked," he replied; "I never had the chance to use them!" The reaction in London by both the medical and lay public to his daring operation on the human heart was so severe that he was not allowed to proceed with heart surgery and was placed in a most unfortunate position professionally for some years. Two decades passed, and others began to "discover" the same technique. It then was acclaimed as a great achievement, and Sir Henry was restored to high favor, being knighted and made an honorary fellow of many medical societies, including the American College of Surgeons. He was fortunate to have lived to see his work recognized as our ethical standards progressed to the point of accepting heart surgery as a great advance rather than something associated with witchcraft. Many more examples of the constant revolutionary change in ethical judgment could be cited. Dr. Christian Barnard and the surgeons -echo have followed him in the exciting new field of human heart transplants have been praised by half the world, but regarded with skepticism by others. However, the general concept of transplantation of human organs and that of surgery of the human heart had already been quite widely accepted. Transplantation of corneal lenses, kidneys, and bone had been successfully achieved for several years. The kidney transplants brought the problem of immunological rejection of replacement organs into sharp focus. Twins or at least members of the same family proved to have the lowest immunological rejection rate, but with increased experience, the use of immunological suppressive drugs, and the better selection of patients, greater success has been achieved with the kidneys from other living donors and even fresh cadavers. In addition, artificial kidney machines have played a major role by enabling physicians to keep patients alive for weeks or even months until a suitable donor is found. Thus far no artificial hearts or heart-lung machines that can achieve such an effect
Heart Transplants
229
over such long periods have been developed. The public was in part prepared /or this next step involving the heart; b u t new problems came to the fore and, as many of these patients died, a public reaction has come about. Questions have been raised concerning philosophical, religious, and medical ethics and legal status, as well as those of a scientific nature. Dr. Irvine Page has commented with some justification that "Reporting directly to the public on an experiment in any fashion, particularly a melodramatic one, is a dangerous procedure. The public is not in a position to make judgments of its value and can easily be deceived. Despite difficulties it is not impossible to keep confidential those things that either are of no concern to the public or require both the data and the scientific acumen to interpret them. 'u As Dr. Page further states, I know many exciting and important advances that have been withheld from the public until they could be evaluated by those trained to judge their worth accurately. On the other hand, the news media almost daily carry stories of so-called "breakthroughs" or "cures" that turn out to be valueless, but not until the hopes of countless seriously ill patients have been raised only to be shattered when the original claims proved to be unjustified. There has been a feeling that far too much publicity was given to these early efforts; some have commented that the atmosphere surrounding them resembled a circus rather than a serious scientific endeavor. Dr. Barnard spent most of the months after his initial success traveling, appearing on TV, and receiving honors rather than pursuing solutions of the problems of rejection. The usually scientifically oriented Nero York Times published an editorial dated September 9, 1968, on cannibalism as follows: Cannibalizing People Dr. Philip Blaiberg's transplanted heart has now worked successfully for more than nine months, a fact that does much to explain the rapid rise of similar operations in many countries. So fast is surgery moving in this area that a heart 1. Page, I. H., "The Ethics of Heart Transplantation," 1. Am. Med. Assoc., 1969, 207, 109.
230
Journal of Religion and Healtb
transplant alone is becoming too limited a challenge. The new trend is toward proving that every healthy younger person who dies in an accident is a spare parts bank. Doctors in Houston, Texas, and S~o Paulo, Brazil, have recently provided vivid examples of what can be done in cannibalizing people. The Texas surgeons transplanted a deceased young woman's heart, two kidneys and one lung into four different men, while sending the donor's two corneas to an eye bank for future use. Their Brazilian colleagues did the same with a suicide's heart, two kidneys and pancreas. Since surgeons, like other men, prefer success to failure, this surge of organ transplants testifies that mounting experience has induced growing confidence. The tissue rejection problems have by no means been entirely solved, but there is growing evidence that they can be overcome in many, if not all, cases. Earlier it could be argued that Dr. Blaiberg's survival was an accident, but that view grows steadily weaker as more data accumulate. But precisely because the surgeons and the biochemists are making such rapid progress, it is dismaying that legal and other social controls have still not been adjusted to the new realities. The vast possibilities for good in these new capabilities of surgery make the need greater than ever for appropriate rules to protect the rights of potential donors and their families and also to set up socially justified priorities among potential beneficiaries. (9 1968 by The New York Times Company. Reprinted by permission.) T h e use of the term cannibalizing seemed so unwarranted that I forwarded the following comments: The editorial columns of the New York Times have slipped from their usual high standards with the recent piece under the headline, "Cannibalizing People," September 9, 1968. This editorial dealt with one of the most remarkable scientific and medical achievements of all times, the use of organs transplanted from individuals living or dead to prolong the lives of patients afflicted with fatal diseases. It is true that these highly technical procedures are still in an early stage but those responsible for their development are entitled to the encouragement and support of the intelligent public. To even suggest a similarity to cannibalism represents the misuse of editorial license. Webster's new International Dictionary defines cannibalism as (1) "the act or practice of eating human flesh by mankind or of any animal by
Heart Transplants
231
its own kind; the use of human flesh as an ordinary article of food is very rare and is confined to the lowest savage, hence murderous cruelty, bloodthirsty barbarity." Random House Dictionary defines cannibalism as "a practice of eating one's kind, savage cruelty, barbarism; the ceremonial eating of human flesh or parts of the human body for magical or religious purposes." It is true that this term has sometimes been applied to removal of parts from an object such as an airplane in order to replace them in another object. However, this is a new and little understood connotation. Any attempt to associate the sacrifices and efforts of donors and their families, the patients who are the recipients, and the biomedical and surgical personnel involved in this great effort to move forward with the term "cannibalism" is not only scientifically unacceptable but in poor taste. Apparently the editor was unwilling to accept this criticism; the letter was not published. Nevertheless, we have seen no further reference to cannibalism in this context. T h e problems that remain before this operation can be applied widely are many.
The moment of death T h e determination of the m o m e n t of death is essential to successful transplantation. T h e operation must precede the m o m e n t of death for the recipient and must not precede the m o m e n t of death of the donor. H o w should this be determined? It has been recognized for centuries that the " m o m e n t of death" is uncertain. Persons thought and declared to be dead have arisen to the mourner's surprise, and sometimes consternation; m a n y such "miracles" are a matter of record. N o w , however, we are entering a n e w era. N o longer does the stopping of the heart signify death. Resuscitations b y the hundreds are taking place daily in coronary care units as a result of m o d e r n techniques. One patient w h o "died" by the old definition more than ninety times is, five years later, carrying on with a very active schedule, his pacemaker insuring satisfactory function of his heart. T h e fact that he was a professor of medicine with a devoted staff and fine facilities at instant command for several months made this possible, but it demonstrates what can be done. As a further demonstration of this phenomenon, m a n y of the newer
232
Journal of Religion and Health
surgical procedures involving the heart call for artificially stopping it during the critical steps and then restarting it. Even more remarkable is the fact that a patient can now live briefly without a heart. In fact, this must happen, in a heart transplant, between the time when the patient's heart is removed and the donor's heart is inserted and actually begins to function. During that period, the artificial pump insures adequate circulation, especially to the vital areas of the brain. It is hoped, but as yet far from achieved, that in the future an artificial heart may be implanted to carry the load of the circulation with its enormously varying demands. There is at present, however, real need for caution against claims that such an achievement is "just a few years off." The complications, both immediate and late, that we are encountering from such simple mechanical gadgets as artificial heart valves should serve as warning in this matter. While the stopping or even removal of the heart for appreciable periods when a replacement pump is available is possible, the same cannot be said of the brain. Survival in the face of total removal of the brain is not even a reasonable dream at this time, and even six to one minutes of deprivation of adequate blood flow results in a permanent vegetative state, or more blessed death. Cessation of function of the brain is now a far more critical index of the "moment of death" than that of the heart. The criteria for the determination of death should, therefore, be as outlined in Table 1. TABLE 1 The Determination of Death 1. Total lack of response to external stimuli--even pain 2. Absence of spontaneous muscular movements, especially breathing 3. Absence of all reflexes, including full dilatation of pupils, response to ice water in ears, and deep tendon reflexes 4. Total collapse of arterial blood pressure 5. Flat electrocardiogram 6. Flat electroencephalographic tracings* * These criteria may not be absolute for children, or for adults in a state of hypothermia or severe intoxications, especially from drugs. On January 3, 1969, a patient's heart
Heart Transplants
233
All of this has become enormously important with the development of heart transplantation as a technique of the present and of the future. It is essential that the heart to be transplanted be as fresh as possible, but removal from a living person is not acceptable by any code of ethics. Delay, on the other hand, increases the danger of failure of restoration of heart action or later survival of the patient. At the assembly of the W o r l d Medical Association in August, 1968, in Sydney, Australia, the Medical Ethics Committee pointed out that "A complication is that death is a gradual process at the cellular level with tissues varying in their ability to withstand deprivation of oxygen, but clinical interest lies not in the state of preservation of isolated cells, but in the fate of a person. Here the point of death of the different cells and organs is not so important as the certainty that the process of life has become irreversible by whatever techniques of resuscitation may be employed. ''~ Here is the crux of the problem. A w r o n g decision m a y result in either the actual death of the donor or the death of the donee by failure. T h e r e are other equally perplexing probIems involved in heart transplantations. A m o n g them a major one is the decision as to which of the m a n y candidates w h o desperately need a n e w heart will receive one of the few acceptable hearts that become available through the sudden death of an otherwise healthy person. T h i s will be discussed later. T i m e and proper matching of donor versus recipient are the keys to success. Success requires both luck and a constantly alerted, highly skilled team ready to judge and act. W h o should make these decisions? At present there and circulation were kept going with the use of a respirator and appropriate medications for eight hours after an electroencephalographic tracing indicated total cessation of brain function. This provided time for Dr. Gary Zucker to transport the patient from the Beth Israel Hospital to the New York Hospital, where Dr. Walton LBlehei and his surgical teams transplanted the heart to one patient, each kidney to a separate patient. The lenses also were saved. (A fund to honor the donor, Dr. Melvin Boigon, a psychoanalyst who died of a succession of strokes, has been established by his colleagues in the American Academy of Psychoanalysis.) 2. "The Declaration of Sydney." (World Medical Association Releases Statement on Death.) Medical Times, Dee., 1968, p. 1243.
234
]ournal of Religion and Health
are many views. Modern man has found, as Solomon did, that acting as deputy for God involves a degree of responsibility for which few are prepared. Congressional action has been recommended to resolve this problem. Heaven forbid! While wise men of all disciplines may well voice their views, and even suggest guidelines for action, it would be the height of folly to develop rigid laws that might produce a rigid status at this very early stage in the new era. No one, not even the most advantaged leaders, can foresee from here where this will lead us, and nothing but high moral and ethical standards, together with the finest technical skill on the part of the participants, can be acceptable. Various organizations, including the American Heart Association, the World Medical Association, the Council for International Organizations of Medical Sciences, groups of interested surgeons, and thirteen Harvard professors have met to establish suitable criteria. The criteria presented in Table 1 summarize the results of their deliberations. These distinguished scientists a n d men of other learned professions must continue to give this matter thoughtful study. It is to be hoped that they will proceed with deliberation and caution. Moral and ethical codes that have stood the test of time have usually been developed by evolution, not by hurried conclusions arrived at under pressure. There is a need for both a national and an international registry for organ transplants in order that every detail of the data from each case be analyzed and correlated sequentially. Such a registry is now being projected for the United States by the American College of Surgeons. This will not include data on kidney transplants, since they are already recorded by the Human Kidney Transplant Registry in Boston. It will be most important for these two registries to work closely together and even to join forces. There is also need for the development of guidelines for donors and recipients in order to minimize the occurrence of injudicious selection. These guidelines will doubtless be modified as new data are evaluated by such a registry office, as well as by individual experience. Decisions involving individual life and death are the daily challenge of physicians and surgeons, who are trained to meet them to a greater degree than any other group in our society. This field is their specialty. They must continue to proceed carefully and with
Heart Transplants
235
the best possible judgment. The views of the clergy, philosophers, lawyers, and other well-motivated persons should be advanced and carefully considered, but when "the chips are down" the judgment must be made on the basis of facts relating to the individual patients involved. This should be the province of the team of physicians who will also have to bear the responsibility for the result. Often minutes make the difference between success and failure. It should be obvious that individual decisions must never be relegated to national committees. ~At this time in the framework of the state of transplantation of the heart or that of any other organ requiring the death of the donor, two independent teams should be established. The first should have the responsibility for determining when all medical or other treatment for the donor is useless because of the totally irreversible character of the loss of cerebral and other functions. The second should be responsible for all aspects of the cardiac transplantation. This is in no way intended to handicap the surgical team, but rather to protect it from unfounded accusations or insinuations of overeagerness and from possible legal consequences of this most serious act. The importance of this approach has been recently emphasized by the following sequence of events. A thirty-three-year-old man received a severe head injury in a traffic accident in Rockford, Illinois. His condition was considered so serious that he was transferred to Presbyterian-St. Luke's Hospital in Chicago for any possible treatment, but also because he might be suitable as a heart donor if treatment was of no avail. When he left the Rockford Memorial Hospital his electroencephalogram was considered as flat. However, upon his arrival at Presbyterian Hospital a neurologist checked a new EEG and found some signs of life. The transplant was therefore vetoed. Ten weeks later, the prospective "donor" was alive and awake, although he was a quadriplegic and required a respirator.
Problems of supply A m o n g the most important and immediate of problems is the supply of fresh and viable organs. (We will refer solely to hearts as a typical example.)
236
]ournal of Religion and Health
The greatest source to date and for the foreseeable future are the organs of otherwise healthy persons who die as a result of violence: suicide, homicide, or accident. These preclude pre-arrangement; therefore, chance must play a major role in such eases and chance is an unreliable mistress. There are some other causes of death, such as rupture of a berry aneurysm in an artery of the brain, that do not imply a disease process involving the heart and therefore render the organ suitable for transplant; but the total of these is relatively small in number. The resuk of the inadequate supply is that patients who need a viable heart may die while awaiting the tragic end of an unknown but suitable donor or the result of medico-legal clearance. The supply of such donors will probabty never meet the needs. Dr. Theodore Cooper of the National Heart Institute has estimated that the potential needs might require the use of every third person between the ages of fifteen and sixty-four who has met accidental, homicidal, or suicidal death. In other words, 80,000 donors will be needed in the United States each year if such a program gets into full swing. The most optimistic guess suggests 9that 40,000 might become available if all hurdles were cleared. Personally, I doubt that this figure will ever exceed 20,000, which leaves a tremendous unfilled need.
Legal aspects As mentioned above, there are legal obstacles to the rapid use of the organs of patients who die violent deaths. For example, in some states such a procedure is prohibited until the medical examiner or his counterpart has eondueted a careful investigation as to the possibility of crime and the manner of its execution, i.e., the question of homicide in what appears to be a suicide or even an automobile accident. The official may be busy on another case and many miles from the site of death. Nothing can be done until he arrives and concludes his determination. Meanwhile, the chances of a successful transplantation diminish and may be lost. Here there is a head-on conflict between the law as it has been observed for many years and the needs of the dying
Heart Transplants
237
patient, who might be saved by a successful transplant. Certainly this type of legal conundrum must be studied and resolved, but the answers do not come easily. Already the lawyers for the two men accused of beating a Houston man and killing him by injury to hisbrain are using as their defense against the charge of murder the fact that the victim's heart was later transplanted. They have contended that the beating only constituted assault, that the removal of the heart took place before the death of the patient and may have been the final step in the death of the victim. Thus the transplant team has become involved in this legal hassle that, while it may prove to have little legal validity, will at the same time conceivably raise doubts in the minds of the jurors. If this doubt is sufficient, it could change the verdict from first degree murder to manslaughter or assault, a result the defending lawyers would no doubt consider a triumph. At present, many states do not allow a person any rights regarding the disposition of his own body or the organs thereof after death, Under the law, the decision regarding dispostion is made by the nearest of kin, who may be close at hand, but also may be far away. The nearest of kin may choose to disregard the wishes the patient has expressed before death. At times it takes hours or even days to reach him and negotiate for the usual autopsy. Meanwhile, all chance of successfully transplanting the organs has been lost. This situation has always seemed both frustrating and unjust. Fortunately, in a few enlightened states steps are being taken to enact new laws permitting an adult to will his body or any of his organs for scientific or medical purposes of his own choosing. W h o should have a better right? New, carefully drawn laws to accomplish this aim should be supported and enacted at an early date throughout the country. Dr. Edward Diethrieh, Dr. John Liddieoat, and their bioengineer, Lou Feldman, of Houston, Texas, have recently developed a preservation and transplant chamber that should make it possible to move fresh heart and lung transplants over long distances from the site of accidental death to the patient in need. This should be most helpful, but movement across state lines may create legal difficulties until this whole problem is resolved by the legislators. Unfortunately, this may take many years.
238
Journal of Religion and Health
The latest twist has given rise to the question: to whom does the transplanted organ really belong? Mrs. Dorothy Haupt, whose husband's heart was successfully transplanted into Dr. Philip Blaiberg, has now requested that the organ be returned to her if for any reason Dr. Blaiberg should be finished with it. Why? Because a spiritualist told her that Mr. Haupt was not resting without his heart and ought to get it back. Thus mediaeval superstitions and outmoded laws are complicating the most modern scientific achievements. History is replete with many examples of this type of conflict, the struggle of past beliefs and codes against new concepts. A 1953 law in Israel permits doctors to remove an organ without permission of the donor's relatives if it is needed for the creative treatment of another patient. So far as I know, no such law is in effect in the United States. However, when a team of surgeons in Tel Aviv under the direction of Professor Morris Lev transplanted a heart into a patient who died two weeks later, there was a hue and cry and some persons suggested that the law be rescinded. At about the same time Dr. Christian Barnard was appealing for a similar law in South Africa, urging the use of a special panel of experts to authorize the removal of organs without the consent of relatives if necessary. The fate of this proposal remains to be determined. In reaction to the excessive publicity associated with the early procedures and the question of whether the family of the donor should be reimbursed if the recipient was financially able, there is now developing pressure to preserve the anonymity of persons involved in the operations. This is in accord with the time-honored ethics of the medical profession. The violation of these ethical principles, as is usually the case, has served to re-emphasize their soundness.
Costs While t h e cost of these procedure s in terms of facilities, time, manpower, and total c a r e is high, it may seem insignificant in comparison to the budget of the space program. Yet in both cases the final value to the human race has yet to be determined. The cost must nevertheless be taken into eonsidera-
Heart Transplants
239
non in relation to our total health resources. It has been estimated that each transplant has had an average cost of up to $50,000. Obviously few patients can be expected to make more than a token payment to meet such charges, and the determination as to who receives the new heart should never rest on financial or political considerations. It has been suggested by one of the surgeons involved in this program that even a brief prolongation of life, for example up to three months, justifies the great cost and effort. While a few patients have made a brief return to a reasonably comfortable, if precarious, existence, most have failed to have even a few days or weeks of freedom from pain and constant medical supervision. T h e aim must be to prolong life rather than to prolong the death process. Dr. Blaiberg is, of course, the notable exception that still represents hope for those who are striving to solve, or benefit from, transplantation of the heart. The success with kidney transplants also encourages us to look ahead. But again it must be remembered that the problems, especially that of obtaining donors, are quite different, Unless we can do better than this, there will undoubtedly be increased feeling that these resources and talents might better be used in other directions. As immunologist James T. Nora, of Dr. Denton Cooley's team, has stated, "Unless we can induce tolerance [against immunological rejection and infection], heart transplantation has no future." If, as is the case, the objective of long-term and meaningful survival has a reasonable chance of success, then the present experimental efforts, costly as they are, can be justified until sufficient and valid data to permit a final determination of the potential value have been obtained. Dr. John J. Hanlon, Assistant U.S. Surgeon General, has pointed out that "the money used for one heart transplant could train four physicians, who, through their careers, could help many thousands of people." For all of these reasons this procedure must still be considered as a legitimate experiment rather than an established treatment. The recipient and his family must be fully informed of the risks and the doubtful outcome before entering into such a program. While as a young, virile, strong nation we stand fascinated, even trans-
240
Journal of Religion and Health
fixed, by the spectacular achievements of our moon astronauts and our transplant surgeons, we are soon to face a dilemma when cool minds must come into play. History offers many examples of the obstructing of man's progress produced by the doubters without courage or imagination to support those who sought to penetrate the unknown. Many of the explorers and scientists of the past have died o f torture or of the frustration of unfulfillment, only to have others in following years prove that they were right. W e must be careful not to set up road blocks to progress in these areas. On the other hand, there have also been many who have died and empires that have fallen when they became too involved in foolish ventures with no future, or at least none in the light of the tools or knowledge of their day. W h e n the cost becomes excessive and progress lags, it becomes advisable to set up analytical procedures, even to adopt cooling-off periods to establish both absolute and relative values. Here independent minds not too emotionally involved in the project should be used. T h e y can often detect weaknesses and lack of worth, but they may also uncover new areas of great promise that might have been missed by the closely involved workers. The time may be approaching for such a cool look at cardiac transplantation.
Summary W e have entered into a new era of medical achievement with the development of successful transplantation of human organs. The transplantation of the heart has aroused the greatest scientific interest and at the same time created serious new problems of an ethical and legal nature. It has been necessary to develop new criteria to determine the "moment of death" of the donor in order to ensure continued life for the recipient. The decision of the moment of death should be made by a small team of skilled physicians interested in furthering this important development, but not as emotionally involved as are the surgeons awaiting the chance to prolong their patient's life with a new heart. Available and suitable hearts will probably always be
Heart Transplants
241
in very short supply, and the selection of recipients will therefore become critical if the procedure proves to be widely acceptable. New laws will be essential before this process can be adopted in many states and countries. The cost in terms of total resources is so large that careful evaluation of the long-term results must be undertaken after a reasonable number of patients have been operated on and observed, perhaps at the end of the second year following the first procedure. Since the cost of each operation of this type approximates that of the education of several young physicians who could care for thousands of patients during their life span, a good hard look at the potential benefits and ultimate values is in order. At this point in time it is extremely important that this type of surgery be encouraged but limited to those prepared to undertake it with maximum skill and minimal risk. At present it must be recognized as a great experiment rather than a therapeutic triumph for general application.
226
A New Challenge to Ethical Codes: Heart Transplants
IRVING
S. W R I G H T
No single event in the history of medicine has aroused more widespread interest on the part of both the medical and the lay communities than has the transplantation of the human heart. It has been praised as a modern miracle and criticized in strong terms. As I write this in December of 1968, on the first anniversary of the first transplant of a human heart into the dying Louis Washkansky, the announcement of the 100th heart transplant has just been made. Dr. Philip Blaiberg still lives in the twelfth month after receiving his new heart, as the fortunate example of the potential benefits of this procedure, once the inherent difficulties have been resolved. However, fewer than half of the recipients of the hearts of others are alive today, and fewer than ten per cent of these are alive more than three months after their transplant. This is the outlook today because of the rejection mechanism by the immunological processes in each living body. W h e n the rejection risk is reduced by immunosuppressive drugs, the resistance to infection is also reduced; many of these patients have died from infection or the combination of rejection and infection phenomena. Already several patients have received their second new heart after failure of the first to function satisfactorily. laVING S. WRIGHT, M.D., is Emeritus Clinical Professor of Medicine at Cornell University Medical College, New York City; National Chairman of the Inter-Society Commissionfor Heart Disease Resources; former President of the American College of Physicians and of the American Heart Association.
Heart Transplants
227
We may ask where all this will end. The enormous resources required the skilled teams, hardware, blood transfusions, and cost of after care with immunosuppressive therapy--have been questioned. Should these resources be devoted to the treatment of diseases in which the results are more certain and where many times the number of patients can be helped for the same cost in effort and finances? Serious questions have also arisen regarding the "moment of death" for the donor. The heart must be removed without loss of time so that it can regain its function in its new host. But by what criteria shall death be determined? I shall discuss this later, but first let us review this event and the questions in some historical perspective. Radical departures from the accepted codes and mores of the past have always met resistance. This has certainly been true in medicine. Many physicians of the past have been exorcized, castigated, ostracized, and even tortured to death when they have dared to move into the future. Just 300 years ago, an example of this pertinent to our present discussion took place. Although blood transfusions between human beings had doubtless been attemped from ancient times, the first one recorded in Western civilization was performed in June, 1667, in Paris. Like the transplantation of the heart in 1967, this one took place with much publicity, excitement, and controversy over previous transfusions in animals, and whether they could be safely used in man. The reaction to this first human transfusion was such that an edict from Criminal Court in Paris as of April 17, 1668, forbade further transfusions unless approved by the Faculty of Medicine of Paris. As this approval was not granted, the procedure was virtually abandoned for two and a half centuries, when, with the development of blood typing, preservation and storage techniques, and the prevention of clotting, it became a keystone of modern medicine and surgery. About 1925, Mr. Henry Session Souttar performed the first successful operation involving the inside of the heart--a mitral commissurotomy. The patient, a young woman with rheumatic heart disease and severe mitral stenosis, recovered and survived for some years. This was even more remarkable since it preceded the discovery of the sulphonamides and antibiotics.
228
Journal of Religion and Health
In 1953, I met Sir Henry and he invited me to visit his surgery (office) on Harley Street in London. He showed me the instruments used for the first operation. They were remarkably like those developed by American surgeons twenty years later. Then he showed me the new set he had modified for the next operation. I asked, "How did they work?" "I don't know how they would have worked," he replied; "I never had the chance to use them!" The reaction in London by both the medical and lay public to his daring operation on the human heart was so severe that he was not allowed to proceed with heart surgery and was placed in a most unfortunate position professionally for some years. Two decades passed, and others began to "discover" the same technique. It then was acclaimed as a great achievement, and Sir Henry was restored to high favor, being knighted and made an honorary fellow of many medical societies, including the American College of Surgeons. He was fortunate to have lived to see his work recognized as our ethical standards progressed to the point of accepting heart surgery as a great advance rather than something associated with witchcraft. Many more examples of the constant revolutionary change in ethical judgment could be cited. Dr. Christian Barnard and the surgeons -echo have followed him in the exciting new field of human heart transplants have been praised by half the world, but regarded with skepticism by others. However, the general concept of transplantation of human organs and that of surgery of the human heart had already been quite widely accepted. Transplantation of corneal lenses, kidneys, and bone had been successfully achieved for several years. The kidney transplants brought the problem of immunological rejection of replacement organs into sharp focus. Twins or at least members of the same family proved to have the lowest immunological rejection rate, but with increased experience, the use of immunological suppressive drugs, and the better selection of patients, greater success has been achieved with the kidneys from other living donors and even fresh cadavers. In addition, artificial kidney machines have played a major role by enabling physicians to keep patients alive for weeks or even months until a suitable donor is found. Thus far no artificial hearts or heart-lung machines that can achieve such an effect
Heart Transplants
229
over such long periods have been developed. The public was in part prepared /or this next step involving the heart; b u t new problems came to the fore and, as many of these patients died, a public reaction has come about. Questions have been raised concerning philosophical, religious, and medical ethics and legal status, as well as those of a scientific nature. Dr. Irvine Page has commented with some justification that "Reporting directly to the public on an experiment in any fashion, particularly a melodramatic one, is a dangerous procedure. The public is not in a position to make judgments of its value and can easily be deceived. Despite difficulties it is not impossible to keep confidential those things that either are of no concern to the public or require both the data and the scientific acumen to interpret them. 'u As Dr. Page further states, I know many exciting and important advances that have been withheld from the public until they could be evaluated by those trained to judge their worth accurately. On the other hand, the news media almost daily carry stories of so-called "breakthroughs" or "cures" that turn out to be valueless, but not until the hopes of countless seriously ill patients have been raised only to be shattered when the original claims proved to be unjustified. There has been a feeling that far too much publicity was given to these early efforts; some have commented that the atmosphere surrounding them resembled a circus rather than a serious scientific endeavor. Dr. Barnard spent most of the months after his initial success traveling, appearing on TV, and receiving honors rather than pursuing solutions of the problems of rejection. The usually scientifically oriented Nero York Times published an editorial dated September 9, 1968, on cannibalism as follows: Cannibalizing People Dr. Philip Blaiberg's transplanted heart has now worked successfully for more than nine months, a fact that does much to explain the rapid rise of similar operations in many countries. So fast is surgery moving in this area that a heart 1. Page, I. H., "The Ethics of Heart Transplantation," 1. Am. Med. Assoc., 1969, 207, 109.
230
Journal of Religion and Healtb
transplant alone is becoming too limited a challenge. The new trend is toward proving that every healthy younger person who dies in an accident is a spare parts bank. Doctors in Houston, Texas, and S~o Paulo, Brazil, have recently provided vivid examples of what can be done in cannibalizing people. The Texas surgeons transplanted a deceased young woman's heart, two kidneys and one lung into four different men, while sending the donor's two corneas to an eye bank for future use. Their Brazilian colleagues did the same with a suicide's heart, two kidneys and pancreas. Since surgeons, like other men, prefer success to failure, this surge of organ transplants testifies that mounting experience has induced growing confidence. The tissue rejection problems have by no means been entirely solved, but there is growing evidence that they can be overcome in many, if not all, cases. Earlier it could be argued that Dr. Blaiberg's survival was an accident, but that view grows steadily weaker as more data accumulate. But precisely because the surgeons and the biochemists are making such rapid progress, it is dismaying that legal and other social controls have still not been adjusted to the new realities. The vast possibilities for good in these new capabilities of surgery make the need greater than ever for appropriate rules to protect the rights of potential donors and their families and also to set up socially justified priorities among potential beneficiaries. (9 1968 by The New York Times Company. Reprinted by permission.) T h e use of the term cannibalizing seemed so unwarranted that I forwarded the following comments: The editorial columns of the New York Times have slipped from their usual high standards with the recent piece under the headline, "Cannibalizing People," September 9, 1968. This editorial dealt with one of the most remarkable scientific and medical achievements of all times, the use of organs transplanted from individuals living or dead to prolong the lives of patients afflicted with fatal diseases. It is true that these highly technical procedures are still in an early stage but those responsible for their development are entitled to the encouragement and support of the intelligent public. To even suggest a similarity to cannibalism represents the misuse of editorial license. Webster's new International Dictionary defines cannibalism as (1) "the act or practice of eating human flesh by mankind or of any animal by
Heart Transplants
231
its own kind; the use of human flesh as an ordinary article of food is very rare and is confined to the lowest savage, hence murderous cruelty, bloodthirsty barbarity." Random House Dictionary defines cannibalism as "a practice of eating one's kind, savage cruelty, barbarism; the ceremonial eating of human flesh or parts of the human body for magical or religious purposes." It is true that this term has sometimes been applied to removal of parts from an object such as an airplane in order to replace them in another object. However, this is a new and little understood connotation. Any attempt to associate the sacrifices and efforts of donors and their families, the patients who are the recipients, and the biomedical and surgical personnel involved in this great effort to move forward with the term "cannibalism" is not only scientifically unacceptable but in poor taste. Apparently the editor was unwilling to accept this criticism; the letter was not published. Nevertheless, we have seen no further reference to cannibalism in this context. T h e problems that remain before this operation can be applied widely are many.
The moment of death T h e determination of the m o m e n t of death is essential to successful transplantation. T h e operation must precede the m o m e n t of death for the recipient and must not precede the m o m e n t of death of the donor. H o w should this be determined? It has been recognized for centuries that the " m o m e n t of death" is uncertain. Persons thought and declared to be dead have arisen to the mourner's surprise, and sometimes consternation; m a n y such "miracles" are a matter of record. N o w , however, we are entering a n e w era. N o longer does the stopping of the heart signify death. Resuscitations b y the hundreds are taking place daily in coronary care units as a result of m o d e r n techniques. One patient w h o "died" by the old definition more than ninety times is, five years later, carrying on with a very active schedule, his pacemaker insuring satisfactory function of his heart. T h e fact that he was a professor of medicine with a devoted staff and fine facilities at instant command for several months made this possible, but it demonstrates what can be done. As a further demonstration of this phenomenon, m a n y of the newer
232
Journal of Religion and Health
surgical procedures involving the heart call for artificially stopping it during the critical steps and then restarting it. Even more remarkable is the fact that a patient can now live briefly without a heart. In fact, this must happen, in a heart transplant, between the time when the patient's heart is removed and the donor's heart is inserted and actually begins to function. During that period, the artificial pump insures adequate circulation, especially to the vital areas of the brain. It is hoped, but as yet far from achieved, that in the future an artificial heart may be implanted to carry the load of the circulation with its enormously varying demands. There is at present, however, real need for caution against claims that such an achievement is "just a few years off." The complications, both immediate and late, that we are encountering from such simple mechanical gadgets as artificial heart valves should serve as warning in this matter. While the stopping or even removal of the heart for appreciable periods when a replacement pump is available is possible, the same cannot be said of the brain. Survival in the face of total removal of the brain is not even a reasonable dream at this time, and even six to one minutes of deprivation of adequate blood flow results in a permanent vegetative state, or more blessed death. Cessation of function of the brain is now a far more critical index of the "moment of death" than that of the heart. The criteria for the determination of death should, therefore, be as outlined in Table 1. TABLE 1 The Determination of Death 1. Total lack of response to external stimuli--even pain 2. Absence of spontaneous muscular movements, especially breathing 3. Absence of all reflexes, including full dilatation of pupils, response to ice water in ears, and deep tendon reflexes 4. Total collapse of arterial blood pressure 5. Flat electrocardiogram 6. Flat electroencephalographic tracings* * These criteria may not be absolute for children, or for adults in a state of hypothermia or severe intoxications, especially from drugs. On January 3, 1969, a patient's heart
Heart Transplants
233
All of this has become enormously important with the development of heart transplantation as a technique of the present and of the future. It is essential that the heart to be transplanted be as fresh as possible, but removal from a living person is not acceptable by any code of ethics. Delay, on the other hand, increases the danger of failure of restoration of heart action or later survival of the patient. At the assembly of the W o r l d Medical Association in August, 1968, in Sydney, Australia, the Medical Ethics Committee pointed out that "A complication is that death is a gradual process at the cellular level with tissues varying in their ability to withstand deprivation of oxygen, but clinical interest lies not in the state of preservation of isolated cells, but in the fate of a person. Here the point of death of the different cells and organs is not so important as the certainty that the process of life has become irreversible by whatever techniques of resuscitation may be employed. ''~ Here is the crux of the problem. A w r o n g decision m a y result in either the actual death of the donor or the death of the donee by failure. T h e r e are other equally perplexing probIems involved in heart transplantations. A m o n g them a major one is the decision as to which of the m a n y candidates w h o desperately need a n e w heart will receive one of the few acceptable hearts that become available through the sudden death of an otherwise healthy person. T h i s will be discussed later. T i m e and proper matching of donor versus recipient are the keys to success. Success requires both luck and a constantly alerted, highly skilled team ready to judge and act. W h o should make these decisions? At present there and circulation were kept going with the use of a respirator and appropriate medications for eight hours after an electroencephalographic tracing indicated total cessation of brain function. This provided time for Dr. Gary Zucker to transport the patient from the Beth Israel Hospital to the New York Hospital, where Dr. Walton LBlehei and his surgical teams transplanted the heart to one patient, each kidney to a separate patient. The lenses also were saved. (A fund to honor the donor, Dr. Melvin Boigon, a psychoanalyst who died of a succession of strokes, has been established by his colleagues in the American Academy of Psychoanalysis.) 2. "The Declaration of Sydney." (World Medical Association Releases Statement on Death.) Medical Times, Dee., 1968, p. 1243.
234
]ournal of Religion and Health
are many views. Modern man has found, as Solomon did, that acting as deputy for God involves a degree of responsibility for which few are prepared. Congressional action has been recommended to resolve this problem. Heaven forbid! While wise men of all disciplines may well voice their views, and even suggest guidelines for action, it would be the height of folly to develop rigid laws that might produce a rigid status at this very early stage in the new era. No one, not even the most advantaged leaders, can foresee from here where this will lead us, and nothing but high moral and ethical standards, together with the finest technical skill on the part of the participants, can be acceptable. Various organizations, including the American Heart Association, the World Medical Association, the Council for International Organizations of Medical Sciences, groups of interested surgeons, and thirteen Harvard professors have met to establish suitable criteria. The criteria presented in Table 1 summarize the results of their deliberations. These distinguished scientists a n d men of other learned professions must continue to give this matter thoughtful study. It is to be hoped that they will proceed with deliberation and caution. Moral and ethical codes that have stood the test of time have usually been developed by evolution, not by hurried conclusions arrived at under pressure. There is a need for both a national and an international registry for organ transplants in order that every detail of the data from each case be analyzed and correlated sequentially. Such a registry is now being projected for the United States by the American College of Surgeons. This will not include data on kidney transplants, since they are already recorded by the Human Kidney Transplant Registry in Boston. It will be most important for these two registries to work closely together and even to join forces. There is also need for the development of guidelines for donors and recipients in order to minimize the occurrence of injudicious selection. These guidelines will doubtless be modified as new data are evaluated by such a registry office, as well as by individual experience. Decisions involving individual life and death are the daily challenge of physicians and surgeons, who are trained to meet them to a greater degree than any other group in our society. This field is their specialty. They must continue to proceed carefully and with
Heart Transplants
235
the best possible judgment. The views of the clergy, philosophers, lawyers, and other well-motivated persons should be advanced and carefully considered, but when "the chips are down" the judgment must be made on the basis of facts relating to the individual patients involved. This should be the province of the team of physicians who will also have to bear the responsibility for the result. Often minutes make the difference between success and failure. It should be obvious that individual decisions must never be relegated to national committees. ~At this time in the framework of the state of transplantation of the heart or that of any other organ requiring the death of the donor, two independent teams should be established. The first should have the responsibility for determining when all medical or other treatment for the donor is useless because of the totally irreversible character of the loss of cerebral and other functions. The second should be responsible for all aspects of the cardiac transplantation. This is in no way intended to handicap the surgical team, but rather to protect it from unfounded accusations or insinuations of overeagerness and from possible legal consequences of this most serious act. The importance of this approach has been recently emphasized by the following sequence of events. A thirty-three-year-old man received a severe head injury in a traffic accident in Rockford, Illinois. His condition was considered so serious that he was transferred to Presbyterian-St. Luke's Hospital in Chicago for any possible treatment, but also because he might be suitable as a heart donor if treatment was of no avail. When he left the Rockford Memorial Hospital his electroencephalogram was considered as flat. However, upon his arrival at Presbyterian Hospital a neurologist checked a new EEG and found some signs of life. The transplant was therefore vetoed. Ten weeks later, the prospective "donor" was alive and awake, although he was a quadriplegic and required a respirator.
Problems of supply A m o n g the most important and immediate of problems is the supply of fresh and viable organs. (We will refer solely to hearts as a typical example.)
236
]ournal of Religion and Health
The greatest source to date and for the foreseeable future are the organs of otherwise healthy persons who die as a result of violence: suicide, homicide, or accident. These preclude pre-arrangement; therefore, chance must play a major role in such eases and chance is an unreliable mistress. There are some other causes of death, such as rupture of a berry aneurysm in an artery of the brain, that do not imply a disease process involving the heart and therefore render the organ suitable for transplant; but the total of these is relatively small in number. The resuk of the inadequate supply is that patients who need a viable heart may die while awaiting the tragic end of an unknown but suitable donor or the result of medico-legal clearance. The supply of such donors will probabty never meet the needs. Dr. Theodore Cooper of the National Heart Institute has estimated that the potential needs might require the use of every third person between the ages of fifteen and sixty-four who has met accidental, homicidal, or suicidal death. In other words, 80,000 donors will be needed in the United States each year if such a program gets into full swing. The most optimistic guess suggests 9that 40,000 might become available if all hurdles were cleared. Personally, I doubt that this figure will ever exceed 20,000, which leaves a tremendous unfilled need.
Legal aspects As mentioned above, there are legal obstacles to the rapid use of the organs of patients who die violent deaths. For example, in some states such a procedure is prohibited until the medical examiner or his counterpart has eondueted a careful investigation as to the possibility of crime and the manner of its execution, i.e., the question of homicide in what appears to be a suicide or even an automobile accident. The official may be busy on another case and many miles from the site of death. Nothing can be done until he arrives and concludes his determination. Meanwhile, the chances of a successful transplantation diminish and may be lost. Here there is a head-on conflict between the law as it has been observed for many years and the needs of the dying
Heart Transplants
237
patient, who might be saved by a successful transplant. Certainly this type of legal conundrum must be studied and resolved, but the answers do not come easily. Already the lawyers for the two men accused of beating a Houston man and killing him by injury to hisbrain are using as their defense against the charge of murder the fact that the victim's heart was later transplanted. They have contended that the beating only constituted assault, that the removal of the heart took place before the death of the patient and may have been the final step in the death of the victim. Thus the transplant team has become involved in this legal hassle that, while it may prove to have little legal validity, will at the same time conceivably raise doubts in the minds of the jurors. If this doubt is sufficient, it could change the verdict from first degree murder to manslaughter or assault, a result the defending lawyers would no doubt consider a triumph. At present, many states do not allow a person any rights regarding the disposition of his own body or the organs thereof after death, Under the law, the decision regarding dispostion is made by the nearest of kin, who may be close at hand, but also may be far away. The nearest of kin may choose to disregard the wishes the patient has expressed before death. At times it takes hours or even days to reach him and negotiate for the usual autopsy. Meanwhile, all chance of successfully transplanting the organs has been lost. This situation has always seemed both frustrating and unjust. Fortunately, in a few enlightened states steps are being taken to enact new laws permitting an adult to will his body or any of his organs for scientific or medical purposes of his own choosing. W h o should have a better right? New, carefully drawn laws to accomplish this aim should be supported and enacted at an early date throughout the country. Dr. Edward Diethrieh, Dr. John Liddieoat, and their bioengineer, Lou Feldman, of Houston, Texas, have recently developed a preservation and transplant chamber that should make it possible to move fresh heart and lung transplants over long distances from the site of accidental death to the patient in need. This should be most helpful, but movement across state lines may create legal difficulties until this whole problem is resolved by the legislators. Unfortunately, this may take many years.
238
Journal of Religion and Health
The latest twist has given rise to the question: to whom does the transplanted organ really belong? Mrs. Dorothy Haupt, whose husband's heart was successfully transplanted into Dr. Philip Blaiberg, has now requested that the organ be returned to her if for any reason Dr. Blaiberg should be finished with it. Why? Because a spiritualist told her that Mr. Haupt was not resting without his heart and ought to get it back. Thus mediaeval superstitions and outmoded laws are complicating the most modern scientific achievements. History is replete with many examples of this type of conflict, the struggle of past beliefs and codes against new concepts. A 1953 law in Israel permits doctors to remove an organ without permission of the donor's relatives if it is needed for the creative treatment of another patient. So far as I know, no such law is in effect in the United States. However, when a team of surgeons in Tel Aviv under the direction of Professor Morris Lev transplanted a heart into a patient who died two weeks later, there was a hue and cry and some persons suggested that the law be rescinded. At about the same time Dr. Christian Barnard was appealing for a similar law in South Africa, urging the use of a special panel of experts to authorize the removal of organs without the consent of relatives if necessary. The fate of this proposal remains to be determined. In reaction to the excessive publicity associated with the early procedures and the question of whether the family of the donor should be reimbursed if the recipient was financially able, there is now developing pressure to preserve the anonymity of persons involved in the operations. This is in accord with the time-honored ethics of the medical profession. The violation of these ethical principles, as is usually the case, has served to re-emphasize their soundness.
Costs While t h e cost of these procedure s in terms of facilities, time, manpower, and total c a r e is high, it may seem insignificant in comparison to the budget of the space program. Yet in both cases the final value to the human race has yet to be determined. The cost must nevertheless be taken into eonsidera-
Heart Transplants
239
non in relation to our total health resources. It has been estimated that each transplant has had an average cost of up to $50,000. Obviously few patients can be expected to make more than a token payment to meet such charges, and the determination as to who receives the new heart should never rest on financial or political considerations. It has been suggested by one of the surgeons involved in this program that even a brief prolongation of life, for example up to three months, justifies the great cost and effort. While a few patients have made a brief return to a reasonably comfortable, if precarious, existence, most have failed to have even a few days or weeks of freedom from pain and constant medical supervision. T h e aim must be to prolong life rather than to prolong the death process. Dr. Blaiberg is, of course, the notable exception that still represents hope for those who are striving to solve, or benefit from, transplantation of the heart. The success with kidney transplants also encourages us to look ahead. But again it must be remembered that the problems, especially that of obtaining donors, are quite different, Unless we can do better than this, there will undoubtedly be increased feeling that these resources and talents might better be used in other directions. As immunologist James T. Nora, of Dr. Denton Cooley's team, has stated, "Unless we can induce tolerance [against immunological rejection and infection], heart transplantation has no future." If, as is the case, the objective of long-term and meaningful survival has a reasonable chance of success, then the present experimental efforts, costly as they are, can be justified until sufficient and valid data to permit a final determination of the potential value have been obtained. Dr. John J. Hanlon, Assistant U.S. Surgeon General, has pointed out that "the money used for one heart transplant could train four physicians, who, through their careers, could help many thousands of people." For all of these reasons this procedure must still be considered as a legitimate experiment rather than an established treatment. The recipient and his family must be fully informed of the risks and the doubtful outcome before entering into such a program. While as a young, virile, strong nation we stand fascinated, even trans-
240
Journal of Religion and Health
fixed, by the spectacular achievements of our moon astronauts and our transplant surgeons, we are soon to face a dilemma when cool minds must come into play. History offers many examples of the obstructing of man's progress produced by the doubters without courage or imagination to support those who sought to penetrate the unknown. Many of the explorers and scientists of the past have died o f torture or of the frustration of unfulfillment, only to have others in following years prove that they were right. W e must be careful not to set up road blocks to progress in these areas. On the other hand, there have also been many who have died and empires that have fallen when they became too involved in foolish ventures with no future, or at least none in the light of the tools or knowledge of their day. W h e n the cost becomes excessive and progress lags, it becomes advisable to set up analytical procedures, even to adopt cooling-off periods to establish both absolute and relative values. Here independent minds not too emotionally involved in the project should be used. T h e y can often detect weaknesses and lack of worth, but they may also uncover new areas of great promise that might have been missed by the closely involved workers. The time may be approaching for such a cool look at cardiac transplantation.
Summary W e have entered into a new era of medical achievement with the development of successful transplantation of human organs. The transplantation of the heart has aroused the greatest scientific interest and at the same time created serious new problems of an ethical and legal nature. It has been necessary to develop new criteria to determine the "moment of death" of the donor in order to ensure continued life for the recipient. The decision of the moment of death should be made by a small team of skilled physicians interested in furthering this important development, but not as emotionally involved as are the surgeons awaiting the chance to prolong their patient's life with a new heart. Available and suitable hearts will probably always be
Heart Transplants
241
in very short supply, and the selection of recipients will therefore become critical if the procedure proves to be widely acceptable. New laws will be essential before this process can be adopted in many states and countries. The cost in terms of total resources is so large that careful evaluation of the long-term results must be undertaken after a reasonable number of patients have been operated on and observed, perhaps at the end of the second year following the first procedure. Since the cost of each operation of this type approximates that of the education of several young physicians who could care for thousands of patients during their life span, a good hard look at the potential benefits and ultimate values is in order. At this point in time it is extremely important that this type of surgery be encouraged but limited to those prepared to undertake it with maximum skill and minimal risk. At present it must be recognized as a great experiment rather than a therapeutic triumph for general application.
