Wednesday, April 18, 2012

Cheney and the Undead

No. This blog is not about zombies—though in one sense it could be. It’s about the way the recent heart transplant for our beloved former VP, Dick Cheney, was trumpeted all over the world, first as a miracle of life-saving American medicine, then as a tribute to the great VP managing to survive five heart attacks and what appeared to be imminent death. But thanks to a heart transplant—the word evokes images of gardening, where we buy packets of baby plants to transplant lovingly in our backyard patch—our snarling VP has survived to hunt another day. Hosanna. Just by the way, Cheney has also thanked the donor from whom he received his heart, that donor being an unknown unperson, of course.

And that’s where things start to smell fishy. Cheney’s heart transplant, were he not on the government dole, would have cost him about $1 million. This is according to Dick Teresi, who’s written a book called The Undead (Pantheon: 2012) about precisely this transplant industry. And it is an industry—a $20 billion-a-year business at last count. Transplant surgeons make on average $400,000 a year, while procurement alone, for a heart like Cheney’s, runs about $150,000. Then all the immunosuppressant drugs for all the 30,000 or so yearly transplants come to another $1 billion a year; and the donors? the ones whose hearts and lungs and livers and kidneys and eyes and bone marrow make all these thousands of miracles possible? They get nothing. Zip. Nada. Zero. Because it’s against the law to pay them. Or even know who they were.

It’s worse than that, though--something I personally found out the hard way. Several years ago, my ex-wife was stricken with a ruptured cerebral aneurysm, which flooded her brain with blood, essentially knocking it out of commission. She was rushed to the nearby hospital and put on a ventilator and heart stimulants—life support basically—while we, her family, waited to see if a miracle might save her. It didn’t look good: though appearing to be asleep, she was nonreponsive. Still, my son was flying in from Chicago and we hoped she would survive until he could see her. That’s when the OPO ladies entered. OPO stands for Organ Procurement Organization. Until then, few of us had thought of it other than as a check-off box on a driver’s license. But suddenly these two ladies appeared and began talking to my daughter and me about organ donation. We knew my ex-wife had expressed interest in this on her will, so we were receptive—until one of the ladies mentioned “brain death.” It was the first we’d heard of this and it shocked us, me especially, since I’d had occasion to research the term due to a comp class I was teaching. The term stems from the Harvard Commission of 1968, which, with the advent of transplants, felt a need to find a new definition of death (beyond the stoppage of heartbeat and breathing) that would clarify when a patient might be a donor. As they said in their opening statement: “Obsolete criteria for the definition of death can lead to controversy in obtaining organs for transplantation.” They, and a subsequent committee, came up with the term “brain dead” to signify a person whose brain no longer maintained normal consciousness, sensory responses, motor activity, and in some cases breathing and heartbeat. Such a person could be considered, for all practical purposes (i.e. the “harvesting” of organs) dead. In our case, it was now clear that the hospital, or someone, was now considering my ex-wife brain-dead. The problem was, no one had informed us, the ones most interested in such a decision. Long story short, we exploded, roughly dismissed the OPO people, then unloaded on the surgeon who came out to explain—he was clearly worried that a breach of ethics (calling the OPO before doing the required tests to confirm brain death) had occurred.

As it turned out—though after reading Teresi’s book, I am no longer sure—my ex-wife settled things on her own. Her heart stopped and she was unable to be revived. Nor was the OPO able to “harvest” her organs. And here was the lesson we got: in order to “harvest” a “brain dead” person’s organs, that person must be kept alive or semi-alive (the language here becomes bizarre, oxymoronic). Such a person is referred to in the industry as a BHC, a “beating-heart-cadaver.” The organs, to be harvestable, must be kept irrigated by blood and oxygen; hence, the need to keep donors on ventilators and heart stimulating drugs not only up to, but including organ removal. As Teresi points out in his book, the patient who is a prospective donor gets the best medical treatment of his or her “life.” This “preharvest” treatment was being done to my ex-wife—until, that is, the possibility of organ donation had been dashed by our reaction.

Though I wrote a long essay on this (see “Ladies in Black” on my website, ) I really didn’t know the half of it. Teresi, however, has done the research, and what he has found, and what you don’t know about organ donation, can literally fill a book. Most important is the basic fact: the designation of death itself. Though the Harvard Committee, and virtually all neurosurgeons, transplant surgeons, and the people who work for OPOs will insist that the “brain dead person”—one who exhibits no reactions—is really dead, too much contrary research indicates that such a verdict rests on shaky ground. That’s because the basic test for brain death is what Teresi terms flash-splash-gasp: a flashlight is shined in the patient’s eyes to see if there’s a reaction, ice water is poured into the ears (a responsive person will shudder), and the ventilator is disconnected for a time (a normal person will attempt to gasp for air). In states like New Jersey, all these tests must be repeated twice, usually six hours apart, with two different doctors administering the tests. If the patient passes (or fails; again the language gets tricky), then brain death is confirmed. Significantly, no EEG (electroencephalograph), to test for brain wave activity, especially in the cortex, is required. That means, as Teresi humorously puts it (his sense of humor in some ways makes a grim book palatable), that a patient “could have been calculating the cross section of the bottom quark using Heisenberg’s matrices, and no amount of ice water squirted into her ear would have detected it.” In short, the standard brain-death tests focus on the activities of the brain stem (which controls basic functions), not the cortex itself.

Can someone who is comatose still have cortical activity? Here Teresi narrates some cases of coma, locked-in syndrome and persistent vegetative state (PVS), and what he finds is startling. In one famous case from Belgium, Rom Houben had been apparently comatose for 5 years after a car accident. But then an fMRI showed that he had significant brain activity, so much so that he soon learned to imagine playing tennis, and by using that as a “yes” response, was able to answer questions about himself and his family with 100% accuracy. Clearly, while apparently ‘brain dead’ (at least insofar as his brain stem functions), Houben was alive and very conscious. Teresi comments: “The netherwolds of coma reveal our profound ignorance about what the mind is and what constitutes consciousness…it may even be possible to have consciousness without a working brain” (197). When we consider that the verdict “brain dead” focuses specifically on consciousness as the sine qua non of being alive, we see that this is no idle debate. It is also quite relevant to some of the more horrifying information Teresi provides—i.e. that so-called brain dead patients have been recorded as having reacted to the initial surgery that takes their organs. Dr. Andrew Shewmon of UCLA takes very seriously these “stress responses” exhibited by patients when transplant surgeons cut into their bodies to remove organs. One observer, Kathleen Stein wrote an article in Omni magazine (“Last Rights,” Sept. 1987) in which she saw a donor’s heartbeat accelerate from 100 to 200 beats per minute with the beginning of the “harvest” procedure—at which point the alarmed surgeons shocked it back to normalcy. Teresi comments that anesthesiologists “are beginning to wonder about those racing heartbeats and other suspicious symptoms exhibited by donors. What does a “pretty dead” patient experience during a three- to five-hour harvest sans anesthetic?” (150) One hardly wants to know.

Teresi’s information on NDEs (near-death experiences) only adds to the puzzle (i.e. what is “alive” and what is “dead”? what is “conscious” and what is not, and is it solely located in the brain?) One case in particular is stunning (remembering always that the NDE is by nature anecdotal): a woman Teresi calls ‘Pam’ (a pseudonym) had an operation to remove a brain aneurysm which required that she be frozen (to 60 degrees F), her brain emptied of blood, and her heart stopped for 60 minutes—minimal blood flow being maintained by a bypass machine. Pam had a lengthy and detailed near-death experience whereby her ‘consciousness’ left her body and observed the entire operation from above—all details being precise and true to what was done to her body. She also says she saw the usual white light, and met relatives who nourished her and convinced her she had to go back to her body. The point of these experiences (of 334 patients with cardiac arrest Dr. Pim van Lommel found that 44 or 18% had NDEs) is not to affirm or deny life after death but just to ask the key question here: if Pam’s heart was stopped and her brain was emptied of blood for at least 5 minutes, just what was having the experience she remembered so vividly?

The answer any individual comes to is critical, not simply because it’s interesting philosophically, but because life-and-death decisions are being made every day in negligence, or ignorance of the answer. The heart Dick Cheney got came from someone—and he was probably young, with a good chance of having been treated in an inner-city hospital where, as Dr. Abraham Verghese wrote in Cutting for Stone, transplant teams from wealthy hospitals helicopter in to ‘harvest’ organs—someone whose life was judged to be over by doctors doing routine, and, possibly perfunctory tests. As I wrote nearly a decade ago in “Ladies in Black,” the least Americans can do is to become informed about what such procedures involve, what “brain death” means, and whether they are comfortable with doctors (as many as 65% being unfamiliar with precisely the tests needed to confirm brain death) deciding who is dead and who isn’t. Beyond that, Americans should know that the incentives to reaching a “brain-dead” conclusion are pretty strong—given the need for organs, and given the amount of money involved in the entire industry.

In the end, the basic conflict comes down to a basic one: on the one side, the transplant industry insisting, with Dr. Fred Plum (the neurologist who coined the term “persistent vegetative state”), that “The brain is the person, the evolved person, not the machine person. Consciousness is the ultimate.”(271) And on the other, increasing numbers of observers who, like Dr. Candace Pert (the neuroscientist who discovered opiate receptors), conclude that “Consciousness is a property of the entire body.”(272) That is, life, consciousness, personhood cannot be limited to the brain alone. To conclude that it is, and to, on the basis of that conclusion, urge more and more people to commit to procedures they are kept ignorant of, is to reduce humans and their death, like so much else in our culture, to commodities for harvest. It is the final indignity.

Lawrence DiStasi

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