A NEW HEART:
WHAT DOES IT MEAN?
In the stories of Bernard Malamud, death comes in the form of Ginsburg … a bulky,
bearded man with hairy nostrils and a fishy smell, who explains to his victims: “My
responsibility is to create conditions. To make happen what happens. I ain‟t in the
anthropomorphic business.” But in the life and death situations of real man, things take
place more subtly. And they are often somewhat confusing … causing us, at times, to
ask: What does it mean to live?
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What does it mean to live? How can we, in the modern world with all its scientific and
technological advances come to grips with the compelling question, in scientific terms, of
when an individual is no longer to be considered alive? At present, death is assumed to
occur when the heart stops beating. Have we reached a point in the development of
civilization where society wishes to introduce a change? … for in the course of
developing new techniques and procedures for the prolongation of life, the whole process
of transplanting vital organs from one person to another has raised critical questions
regarding the life-status of organ donors. Some experimental surgeons for example, argue
that brain activity should be the new criterion -- pointing out that when the brain ceases to
function, the unique individuality of man terminates. Witness, for example, the very large
number of patients with severe retardation or in prolonged comatose conditions due to
irreparable brain damage: they merely vegetate … for weeks, for months, sometimes for
years. Can these too be considered among the living or should the term “alive” be
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redefined?
This question has always been a compelling one … but since December 3, 1967, it has
become critical…for it was on that date, in Cape Town, South Africa, that a surgical team
headed by Dr. Christian Barnard performed the first heart transplant on a human being.
Just a few days later the same type of operation was performed in Brooklyn‟s
Miamonides Medical Center by Dr. Adrian Kantrowitz and his associates. In Brooklyn,
the heart of a three-day-old infant with a fatal brain deformity was transplanted into the
body of a two-and-a half-week old boy who had a fatally defective heart. The child lived
with his new heart for six and one half hours.
Dr. Barnard‟s team in South Africa had more success. They replaced the defective heart
of a 55 year old grocer with that of a 25 year old girl who had sustained a fatal brain
injury in an auto accident. Louis Washkansky, the grocer, lived for eighteen days.
Since that time there have been further attempts in the United States, notably by Dr.
Norman Shumway of Stanford University … but these have continued to prove
unsuccessful. In Cape Town, however, Dr. Barnard appears to be making progress. Dr.
Philip Blaiberg , a South African dentist, is still alive, after almost a month.
And so it would appear that the time may well be approaching when wholly successful
heart transplants will be performed and may then become an accepted procedure in 20th
century medical practice…when we will find that at least a limited number of individuals
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who formerly would have had little or no chance for survival because of their damaged
hearts will be given a new lease on life.
But with the apparent boon to the survival-potential of severely ill heart patients comes
the application of the problem with which we began … and other problems of ethical
nature as well. At the moment, they apply both to the recipients and the donors of vital
organs. Should the operation be perfected, then our eventual concern would be only with
donor himself.
Right now, however, with heart transplant operations still in the experimental stage, when
is a heart patient to be considered critical enough to submit to such radical surgery? “To
remove [an] apparently faltering heart amounts to a substitution of a statistical certainty
for a statistical uncertainty,” states John Lear in the Saturday Review. “The statistical
certainty,” he explains, “is that a transplant recipient, in the present state of knowledge
about the body‟s immunological system, will lose to infection or rejection with a year and
a half at most, probably much sooner.” Therefore, he has, at most, an outside chance at
surviving longer with a transplanted heart than with the damaged heart he already has …
and there is no valid scientific method of determining how long a severe heart patient
may survive without corrective procedures. Many live for years and years. The gamble is
great! Who is to decide?
In a sense, perhaps, the prospective heart recipient is in the same position, without
undergoing the transplant, as many of these individuals to whom we now turn our
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attention: the heart donor. Here, all of our initial questions come back into play. When is
a potential donor ready to give up his heart? When he stops breathing? When his heart
stops beating? When his brain ceases to function? When does the modern, terminal
patient cease to be alive? Who can determine when the life of a human being is no longer
worth saving? How is the question of who shall live or who shall die to be decided? As
we said before, these questions have been with us for a long time and have always been
the focus of any discussion on euthenasia … but the situation is different now. For
successful heart transplants, doctors need hearts … hearts donated by patients who cannot
benefit from them any longer. The issue of life and death has not been a factor in those
transplant procedures perfected up to now … particularly in the areas of corneal and
kidney transplants. The donor can continue to live without a cornea or a single kidney.
No one can live without a heart … and therefore heart donors must be dead! The question
is: When is a person dead enough to be deprived of a heart which is needed to sustain the
life of another human being?
In the case of Dr. Barnard‟s first transplant patient, Louis Washkansky, the heart he
received was taken from Denise Ann Darvall. She had been fatally injured in an auto
accident; her father consented to the donation of her heart … but Denise Ann Darvall was
still alive when she was wheeled into the operating room on December 3, at 2:15 in the
morning. At the moment of her “death” her heart was removed and made ready for the
transplant to Louis Washkansky. When was she considered dead? One report stated that
she “stopped breathing”; another said “her heart had stopped”; and a reporter for
NEWSWEEK was called “impertinent” for asking for clarification of this point from the
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surgical team.
Isn‟t this cutting things a bit close? Does it not seem somewhat ghoulish for medical men
to be standing around waiting for the moment of a patient‟s death in order to secure his
vital organs as soon as possible? And if a patient is terminal, without any hope, and his
relatives have agreed to donate his heart … what happens, or what should happen, when a
heart patient is on the verge of death unless a transplant takes place at once? Why should
the doctors then wait until the patient-donor dies, when, in the meantime the potential
recipient may also die?
In a television panel presented by PBL over channel 13 two weeks ago, entitled GIFT OF
LIFE/RIGHT TO DIE, a Catholic clergyman stated that Catholocism would allow
inaction= by the attending physician in the case of terminal illness, but not active
measures leading to the patients death. That is, the doctor could stop giving medication
… thereby hastening death.
In the press, Dr. Joseph Fletcher, spokesman for Situation Ethics at the Episcopal
Theological Seminary in Boston, is quoted as stating: “speeding up a donor‟s death, when
death is „positively‟ inevitable, may be justified if the transplant provides another human
being with valuable life.” Rabbi Emanuel Jakobovits, chief rabbi of the Brittish
Commonwealth, has said: “No one must hasten the death of a donor.”
Once again, we must ask: Who is to decide? I think that the answer should already be
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obvious … but let us continue a bit, before stating it.
First, let us not misunderstand the intent of all these questions. I, along with most of those
who would make similar observations at this time, am not opposed to the idea of heart
transplant. In fact, I view it as possibly one of the major positive breakthroughs in
modern medical research. But it gives rise to grave ethical considerations which must be
faced, dealt with and understood.
In the time of Isaiah, Jeremiah and Ezekiel, these Hebrew Prophets diagnosed the ills of
Israel and Judah as stemming from the HEART of the people. They viewed their situation
in terms of a Biblical psychology which localized feelings and emotions in the viscera
and looked to the heart as the organ of comprehension. Isael and Judah did not
understand their failings and their abandonment of the covenant. And so Isaiah said they
were sick … that “the heart of Israel had been made fat, too gross for understanding, like
veiled eyes and stopped ears.” Jeremiah agreed with the diagnosis but he held out hope
for his people through the concept of “a new covenant”, a “circumscision of the HEART”
whereby God‟s law would be written on the hearts of the people, and they would then
understand. But Ezekiel went even further than Jeremiah. He maintained that “open-heart
surgery” might have helped earlier but insisted that the disease of Israel hade gone too far
for this. Instead, he suggested the figure of God‟s actually removing “from your body the
heart of stone” and replacing it with a Layve Chodosh, with a new heart, a “heart of
flesh”.
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Today, when the heart is no longer considered the seat of the intellect or comprehension,
but is rather viewed as the most vital organ within the human body relative to the
functioning of the organism, we find that this heart too is subject to illness and
disease…and if the damage to the heart becomes too severe, the individual will die. But
now we stand on the brink of new discovery … a process of removing a damaged heart
and replacing it with a healthy one … truly a Layve Chodosh, a new heart, a heart of
flesh. No more figurative language. Twenty three hundred years later we are on the verge
of actual success.
But the illness of which Isaiah, Jeremiah and Ezekiel spoke is also with us still…not in
the heart, but now, in the mind. It is an insensitivity to ethical concerns. It is a lack of
comprehension of the implications of new miracles when they occur. These Hebrew
Prophets were the religious leaders of their day. They were concerned, primarily, with the
ethics and morality of their people. We can be no less concerned today.
Let the great surgeons of the world perfect their medical procedures … but while they
procede, let us be aware of all they do and attempt to resolve the problems that will most
certainly result from their success.
We need full and open discussion of the entire critical issue of euthenasia … both as an
issue in itself and with particular reference to those who will be needed for the donation
of vital organs required for transplant. We need advice and counsel; we need an airing of
the issues; we need to hear, in depth, from clergymen and jurists, from philosophers and
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physicians.
Jon Lear, once again, Science Editor of the Saturday Review, gives us the results today of
his attempt to receive a candid accounting of the prospects for heart transplant from the
medical profession. From the AMA, the American College of Surgeons, The American
College of Physicians, the American Hospital Association, the Board of Medicine of the
National Academy of Sciences, and the US Public Health Service he received NO
REPLY.
But there must be a reply! We need an accounting and advice. We must come to
understand this entire situation, in all its ramifications, for in the days ahead the decision
may be ours to make regarding the life or death of loved ones or of friends.
As the times have changed, so must the figurative language: for along with the possibility
of new hearts, we, the public, the concerned, the religious, the responsible ones, we
cannot afford to be afflicted with minds “made fat, and too gross for understanding” Our
minds must be opened up to the issues of our day in order that there be no impediments to
our hearing and understanding and learning in matters that so gravely affect the lives of
all mankind. This must become the dialogue in which we engage at once—for science
moves swiftly:
Lo, like clouds he goes
His chariots are like a tempest
His horses are swifter than eagles—
And continuing in Jeremiah‟s words:
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Oh, my inward parts! I writhe.
Oh, the walls of my heart!
I am deeply disturbed, I cannot keep still.
For I have heard the sound of alarm
.
Amen.
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