"The Telltale Heart" by Trevor Corson was named a Notable Essay of the Year by Best American Essays. The essay originally appeared in Transition, a literary journal published at the time out of the W.E.B DuBois Institute in the Department of African and African American Studies at Harvard University.
Trevor served as the managing editor of Transition during the years it won the Alternative Press Award for International Reporting three times and was a finalist for a National Magazine Award in General Excellence.
The Telltale Heart
Death and democracy in Japan
Many Japanese Buddhists think heart-transplant surgeons are murderers. Some Black Muslims have reason to believe that organ donation is a racist plot. And a growing number of critics think Western doctors are medically advanced but ethically backward. A report from the frontlines of the free death debate.
by Trevor Corson
HAVING A KIDNEY cut out won't kill you. You can even lose both kidneys and survive, if someone plugs you into a dialysis machine in time. Kidneys can also be harvested from a cadaver: as long as they're fresh, they can be transplanted successfully. Your corneas, too, can be sliced off after cardiac arrest and grafted onto a living person's eyeballs.
But hearts and livers and lungs are another matter. They need the constant flow of warm, nutrient-rich blood a human pulse provides. These organs are useless to other people if you actually die in that old-fashioned sense of the word—if your heart stops and your soul ascends or descends or cycles on.
Time was, death meant heart failure. And even after the heart had clearly stopped, a body was often left to go cold, and stay that way for a while, before death was pronounced. In 1740 an English physician by the name of Jean-Jacques Winslow went so far as to propose that bodily putrefaction was the only sure sign of death. (As a child, Winslow had been prematurely buried. Twice.) But with the invention of the iron lung at Harvard University in 1928—and with the rise of its successor, the artificial respirator—death was subject to debate. People whom nature had slated for putrefaction could be kept alive for decades. Their organs became prime candidates for transplantation.
In 1967, when the South African surgeon Christiaan Barnard proved that it was possible to transplant the human heart, doctors in the West faced a new predicament: How could they remove a patient's beating heart without being prosecuted for murder? An ad hoc committee at Harvard Medical School examined the latest neuroscience and rejected the idea that life ended when the heart stopped. Rather, they claimed, a person was dead when higher neurological functioning ceased. The committee called the new notion "brain-death syndrome." While brain death syndrome was challenged halfheartedly in U.S. courts, as well as in the writings of a few doctors and ethicists, a presidential Commission for the Study of Ethical Problems in Medicine officially endorsed the idea in 1983. The new medical consensus had become the law of the land.
• • •
I occasionally peruse Good Housekeeping for inspiring tales of transplantation. Nurses appear as angels making miracles, removing still-beating hearts from doomed bodies to extend the lives of a chosen few. A mother suffering over her daughter's death in a traffic accident is comforted with an intimation of immortality: in accordance with the instructions on her driver's license, the daughter's corneas are removed a few hours after the accident, healing blindness in another. A year later the gift is returned. The girl's father receives a lung transplant from a young woman who has just died—another father's daughter, also killed in a car crash.
Fifty thousand Americans are waiting to receive organs, and ten of them die every day. Waiting times for organs vary widely from one region to the next, and so the federal government is trying to nationalize the American body to make availability more equitable. In retaliation, several state legislatures have outlawed the export of body parts across state lines. Pennsylvania recently became the first state to compensate donors for organs, fudging the federal law that prohibits organ sales. Across the country, large medical centers and small hospitals are vying for the lucrative transplant business.
America's organ transplant industry has earned some critics. One of the most prominent is Louis Farrakhan, head of the black nationalist Nation of Islam, who has accused the white medical establishment of harvesting body parts from young inner-city blacks. In fact, Farrakhan's numbers are backward—blacks get more organs from whites than the reverse—but his suspicions are not wholly unfounded, since minority body parts are often taken from victims of urban crime. Perhaps more troubling is the expense of organ transplants: they can cost hundreds of thousands of dollars, and no standard insurance plan will pick up the tab. The result is that profit-conscious hospitals sometimes pick wealthy patients for organs over poor ones. In 1995, the average national wait for livers was 130 days; when baseball legend Mickey Mantle got a new liver in 48 hours, the LifeGift Organ Donation Center in Texas reported a surge in cynicism among the minority donors it had been trying to recruit. Nonetheless, most Americans continue to conceive of organ donation as the pinnacle of altruism.
In the rest of the world, however, anxieties about transplantation are widely held. With good reason, perhaps: the harvesting of organs from executed criminals in Communist China may be the most obvious medical abuse, but there is also Brazil, where the government owns your corpse after death unless you acquire a non–organ donor card. And while Brazilians battle the bureaucracy for the coveted right to ascend to heaven intact, poor people in India and the Philippines often sell their own kidneys for a dowry or a down payment on a shack. The buyers are often rich patients from abroad.
In South Africa, the birthplace of heart transplantation, the story is even more disturbing. Christiaan Barnard's pioneering procedure matched a black donor with a white recipient. In an era when hospitals and morgues routinely helped cover up police killings, many wondered whether the bodies of murdered black activists were being secretly recycled for body parts. Soon after Nelson Mandela came to power in 1994, his government introduced a moratorium on most heart transplants, on the grounds that the operations squandered scarce medical resources. In 1997 South Aftrica's Constitutional Court ruled against kidney transplants as well. These days, transplantation in South Africa is for wealthy patients who can afford to pay for the procedures privately. As the anthropologist Nancy Scheper-Hughes has documented, South Africa's impoverished black communities view transplantation with suspicion. When Scheper-Hughes described modern transplant surgery to one elderly black woman, the informant drew a parallel to muti—South African witchcraft in which skulls, hearts, eyes, and genitals are taken from corpses to augment wealth, influence, or fertility. "If what you are saying is true," the woman responded, "that the white doctors can take the beating heart from one person who is dead, but not truly dead, and put it inside another person to give him strength and life, then these doctors are witches just like our own."
• • •
When I arrived in Tokyo on New Year's Day, 1999, Japan's history of heart transplantation consisted of one operation performed three decades ago. More than any other industrialized nation, Japan has proven immune to the white man's muti. In the most high-tech society on earth, one of the century's greatest medical breakthroughs was all but unheard of.
Japan's short flirtation with heart transplantation occurred just months after Barnard's successful South African experiment. An American-trained Japanese surgeon by the name of Juro Wada took it upon himself to bring this revolutionary technology to Japan. In 1968, Wada performed a heart transplant operation that was heralded as a victory for Japanese medicine. Then the controversy began. It seemed that Wada had been in charge of ascertaining the suitability of the donor, as well as the recipient's need for a heart. Soon, doubts emerged about whether the donor had been brain-dead after all. The recipient died two and a half months later, and Wada's reputation plummeted. Records indicated that the recipient might not have needed a new heart in the first place; later testimony indicated that the patient's heart had been tampered with after removal to make it appear closer to failure. Government prosecutors wanted to charge Wada with murder, and the case might well have led to an indictment but for a freak accident. The key witness, a surgeon who was with Wada during the operation, died in an automobile accident before prosecutors could gather his testimony. After six years of investigation, the charges were dropped for lack of evidence. Wada remained defiant, but public opinion had turned against him. After the briefest of honeymoons, heart transplantation was suddenly taboo in Japan.
Such a sudden and decisive backlash against medical technology didn't crystallize overnight. In fact, most Japanese have never trusted doctors; incited by Wada's transgression, they rejected the idea of brain death altogether. The doctors themselves did little to help their cause: their disdain for the spiritual culture on which most Japanese still draw for healing only served to alienate their patients. Japanese religious tradition treasures the torso and heart as the vessels of soul. Spiritually speaking, the notion that a person whose heart was still beating could be dead was ridiculous. Japanese Buddhists protect bodies for days after death, in the belief that reluctant souls linger. And hoping for the death of another to prolong one's own life can only create bad karma.
Despite these objections, some Japanese were unwilling to forego modern transplant medicine. By the early eighties, wealthy patients with damaged hearts, lungs, or livers were taking matters into their own hands—going overseas in search of organs. Japanese travel agencies, known for sending Japanese salarymen on sex tours to Thailand, were soon arranging cash-for-kidney tours of the Philippines. The price tag was often high: a heart transplant abroad could run more than half a million U.S. dollars. And with a worldwide paucity of organs, the price in international goodwill turned out to be high, too: other countries resented rich Japanese snatching up their scarce organs. Back in Japan, small but vocal pressure groups began to advocate dying patients' right to organs. Japanese doctors complained that the constant threat of prosecution discouraged them from saving lives. Eventually, the government was forced to act.
The 1968 committee that endorsed brain-death syndrome in America consisted largely of physicians. But when Japan established its own brain-death committee in 1989, it included human rights activists, a Buddhist lawyer, social scientists, a writer, a newspaper editor, an environmentalist, and a labor leader. Whereas the American committee had reached consensus quickly, the Japanese committee debated for three years. Finally, in a hotly contested vote, a majority agreed that brain death was an appropriate definition of death. The government promised action.
But nothing happened. No laws were passed. The committee's recommendation settled into an uneasy political limbo. No heart transplants were performed in Japan.
Suddenly, in December 1996, brain death became an issue again. A physician-turned-parliamentarian submitted a bill to codify brain-death syndrome in Japan, and the ruling party offered its support. Resistance was immediate, but it came from an unpromising source: an obscure opposition-party parliamentarian named Takashi Yamamoto and his deputy, Hiroshi Suda.
• • •
It was a chilly Tokyo night in January 1999, when Suda's sleek purple Mercedes screeched to a halt in front of my hotel. The rear door swung open and I clambered in, only to find the car piled with papers, file folders, cellular phones, and a collection of rumpled suit jackets. On the floor, briefcases overflowed with dog-eared documents. Suda apologized—I couldn't sit up front because there was another stack of notebooks and telephones in the front seat. He gunned the sputtering Mercedes to life and we careened through the brightly-lit avenues of nighttime Tokyo. Suda wore thick rectangular glasses and brushed his greasy hair to one side; he was big-boned and gregarious, and he looked to be in his mid-thirties. Cracking jokes nonstop, he guided the Mercedes expertly through the back alleys behind Parliament, zooming up a steep hill to the Capitol Hotel, a hang-out for parliamentarians and their clientele.
Suda double-parked in front of a stretch limo and strode into the hotel like he owned it, ignoring the doorman's obsequious bow. The coffee shop was full of serious-looking dark-suited men and elegant women in brightly colored kimonos. Necktie askew, beepers strapped to his belt like magical energy packs, Suda slurped down a bowl of ice cream. Between mouthfuls, he told me how he had started down the road to battling brain death.
By the time Hiroshi Suda graduated from Tokyo's liberal Waseda University in the early eighties, he was already a rebel and an activist. Unlike most of his fellow students, who were content to ascend the corporate ladder, Suda saw Japanese society as paralyzed by inequality, parochialism, and oppressive tradition. He worked for a broad array of nongovernmental and nonprofit organizations, and in 1989, he met his future boss Yamamoto—then second-in-command at the powerful Educational Association of Traffic-Accident Orphans, one of the most successful charities in Japan. Yamamoto was so impressed with Suda that when Yamamoto was elected to the House of Representatives in 1993, he asked Suda to join his staff. "That's how I got into politics," Suda concluded, slapping some yen on the table. He looked up thoughtfully. "Little did we know that our concern for traffic-accident orphans would bring us to brain death. But most brain-dead organ donors are victims of traffic accidents."
Traffic accidents are one of Japan's deadliest killers; perhaps most at risk are youth in bosozoku: "reckless driving gangs." A heroic racing driver used to be famous in Japan for battling villains on the open road; the cartoon morality-tale in which he starred was called Speed Racer. But by the end of the 1980s, Japan had moved from Speed Racer to Akira—a dark, psychologically complex tale of anarchist motorcycle gangs who race for control of the night streets of MegaTokyo, the city of the future. Combine Speed Racer and Akira and you get today's bosozoku, the most colorful manifestation of Japan's infatuation with American automobile culture. In low-slung sports cars adorned with spoilers and fins, neon-lighted trim and fur-lined interiors, or on insanely fast motorcycles with no mufflers, the gangs take to Japan's streets at night to carouse, take drugs, and race other gangs for territory. An underclass created more by boredom than poverty, bosozoku are seldom violent toward outsiders. But they do horrendous damage to themselves.
Thus the number of bosozoku members among the ranks of the potentially brain-dead is disproportionately high. None of them—not even the gang that calls itself the "Black Emperors"—have a Louis Farrakhan to warn of organ-transplant injustice. But the gangs do have political allies in Yamamoto and Suda. They were trying to protect the bosozoku, and other working-class Japanese—people at higher risk for accidents, people living on the margins of society. These were the potential victims of unscrupulous Japanese doctors.
Back in the car, Suda sped me through another back alley to the House of Representatives. We walked through the hallway to Yamamoto's office suite, and I asked Suda how Yamamoto had come to be such a stalwart defender of the rights of hoodlums in the first place. Suda sighed. "When Yamamoto was in junior high school, his brother was killed in a car crash. He's never gotten over it." Suda was careful to clarify Yamamoto's position. "We support people's individual right to choose to donate organs," he said. "But Yamamoto's experience has taught him that the most painful thing about losing a family member to a traffic accident is the suddenness. If you define human death as brain death and give doctors the power to demand organs, a family member might have his heart or lung ripped out before you even have a chance to mourn. And with all the secrecy surrounding doctors in Japan, it would be easy for them to make money harvesting organs from the disadvantaged—from working-class kids who die in car crashes, for instance."
Yamamoto's concerns about protecting the disadvantaged inspired him to examine the brain-death legislation that had suddenly appeared in Parliament in December 1996. He didn't like what he saw. Normally, lawmaking in Japan's parliamentary system follows a predictable pattern: the administrative branch proposes a bill; legislators in the House of Representatives debate and vote (usually along party lines); and, if the bill passes, it goes to the House of Councilors, which usually follows suit. But with the brain-death bill, the administrative branch was largely silent, and the parliamentarian sponsoring the bill claimed it as his personal project. Moreover, the political parties told their members not to vote along party lines but to vote their consciences instead. Yamamoto figured out what had happened: reacting to international embarrassment as well as aggressive lobbying by the Japan Medical Association, top bureaucrats at the Ministry of Health and Welfare had stood firmly behind brain-death legislation. The lack of ministerial backing for the bill indicated that the medical elite—eager to legalize the lucrative transplant business—had struck a deal with the ministry and the sympathetic former physician who mooted the bill in parliament. The government and the political parties would not take any heat for the controversial proposal.
"Ministries manipulating policy like this is unconscionable," Suda spat, invoking the disgust he and Yamamoto felt toward Japan's medical and bureaucratic elite. "Through elected representatives, no less! What about the will of the people? We all know that most people don't trust doctors and don't want to be declared brain-dead. The government has no business defining death. When you die is the most deeply personal matter imaginable. Legislating it would be a profound violation of the individual's right to self-determination."
Yamamoto determined that drastic action was necessary, and he decided to launch a full-fledged counterproposal. The massive undertaking was assigned to Suda. Cooperating closely with a team of human rights lawyers, Suda worked frantically to write the alternative legislation. By late March of 1997, it was ready. Where the original bill would have established brain death as Japan's official definition of death, Suda's legislation said nothing about changing the definition of death; the natural failure of the heart would remain the standard criterion. Only in cases where a comatose patient had signed up in advance to donate organs, and then passed rigorous tests to prove that he or she was brain-dead, would doctors be allowed to remove hearts or livers or lungs without being prosecuted for murder.
According to custom, the counter-bill was introduced under the name of a parliamentarian more senior than Yamamoto. The bill made it to the floor of the House, but the forces marshaled against it were strong. The counterbill was crushed, 399 to 76. Suda and Yamamoto were devastated.
• • •
The House of Representatives passed the original brain-death bill that same day, but Suda's work began to make ripples elsewhere. The press had gotten hold of the counterbill and sparked a national debate. By the time the original bill landed in the House of Councilors at the end of April, public opposition was growing.
Yamamoto and Suda had contested brain death with the most secular of motivations—they wanted to protect human rights. "Originally Yamamoto and I took a very modern, rational approach," Suda told me, throwing up his hands and laughing. "I've fought my whole life against Japanese conservatism—against tradition, superstition, old-fashioned thinking. The crazy thing is, my greatest ally in this brain-death fight turned out to be conservative, old-fashioned religion."
Indeed, Japanese religious groups attacked the original brain-death bill quickly, and with unusual unanimity. In mid-April, thirty-one religious leaders addressed a joint declaration against brain death to all members of Parliament. The list of signatories included high-ranking representatives of traditional Buddhism, state Shinto, and "New Religion"—a wildly popular grouping of New Age Buddhist offshoots. This represented a larger constituency than the entire population of Japan, since most Japanese claim several different religious affiliations at once.
• • •
Yusho Muranaka, the president of Tokyo's most respected Buddhist university, received me in his office. Muranaka is an outspoken critic of organ transplantation and the author of a book about brain death and Buddhism. When I asked him for an explanation of Buddhism's resistance to the idea of brain death, he related esoteric theories about the four elements and the nature of existence. More interesting was his account of how he had become interested in brain death in the first place. "I can't tell you how many funerals I've conducted over the years for poor youngsters who've been killed in traffic accidents. Many of them are in bosozoku." Part of Muranaka's job was to help identify and purify bodies before cremation. "Seeing them like that is awful. These youths who suffer violent deaths in traffic accidents would become Japan's organ factories if we had America's brain-death laws. I can't bear the thought of it."
This sounded familiar. I nodded, but what Muranaka said next was more surprising. "And to think that these innocent young organs would be used to help people who don't deserve them!" Muranaka hastened to explain: "Most patients who want replacement organs are older people who have brought their condition on themselves through their destructive lifestyles. They drink or smoke too much; they destroy their bodies. In this cutthroat, dog-eat-dog, high-tech society of ours, people forget to stay healthy by cultivating their spiritual lives. If they cultivate bad karma, these people shouldn't be allowed to get off the hook by pilfering pieces of some hapless youngster."
Muranaka paused thoughtfully. "We are trying to use technology to fix these problems, when many of them are caused by technology in the first place. Many rationalists in Japan—scientists, engineers, bureaucrats, lawyers—they feel that Japanese religion has become socially irrelevant. The brain-death debate has been a rare opportunity for us to inject spiritual morality back into Japanese public life. We are trying to prove our ethical worth by offering an alternative to Western medical science."
Muranaka chuckled. "It's funny, both of my children are doctors. My daughter went to medical school in the States. She is very simple-minded about organ transplants; she sees them as a panacea. But my son has a more sophisticated, traditional Japanese awareness. He understands that there is a spiritual side to things, too."
For all of Suda's protestations, he had been closer to religion than he thought. Distrust of the medical profession, empathy for victims of traffic accidents, and a belief in the sanctity of death allied all the opponents of brain death. It was a powerful, if accidental, union. The joint declaration by religious groups came too late to influence the brain-death vote in the House of Representatives, but politicians in the upper house took notice. By the end of April, when the original bill was brought to the floor of the House of Councilors, a second bill similar to Suda's was already waiting there. Suda and Yamamoto regained hope. But then the process stalled. For weeks nothing happened. Finally, despite intense pressure from religious groups, the new counterbill was thrown out. Once again, Suda and Yamamoto had to admit defeat.
• • •
On June 16, 1997, late in the afternoon of the penultimate day of the legislative session, a senior ruling-party councilman named Noriyuki Sekine quietly introduced a slightly amended version of the brain-death bill that had already been approved by the House of Representatives. The next morning, the House of Councilors passed his amended version by a three-quarters majority. With only a few hours left in session, the amended bill was rushed back to the House of Representatives. Eager to produce a brain-death law before the session ended, the exhausted Parliament passed the altered bill.
The proponents of the original bill had sought to bring Japan into line with the West by defining brain-death syndrome as the exclusive legal criterion for Japanese death. But when they examined the law they had passed, they were aghast. Pressured by powerful religious organizations, Sekine and other senior parliamentarians had secretly lobbied key politicians to support a compromise. At the last minute, it worked. Brain death was now a legal definition of death in Japan, but not the legal definition of death. Under the amended law, only people who sign up in advance to be donors can be pronounced legally dead upon meeting brain-death criteria. For citizens uncomfortable with brain death, the age-old stopped-heart criterion remains the standard. The original bill, which would have handed transplant doctors the power to declare any patient brain-dead, had finally been scrapped. Suda and Yamamoto were beside themselves with relief.
Before I left Japan, I went for another ride in Suda's purple Mercedes. The back seat was just as crammed with detritus as before, and once again, we zoomed up the hill to the Capitol Hotel. Over cucumber sandwiches, Suda wondered whether heart transplants would ever catch on in Japan. Eighteen months after he had unintentionally kindled Japan's deepest religious passions and changed the course of Japanese medical history, Suda still had no idea what the future of Japanese organ donation would be. When the Mercedes wouldn't start after lunch, Suda apologized. I laughed and asked him what a progressive like him was doing driving a Mercedes, anyway, but he insisted it wasn't his car. "It belonged to my father. He worked for years and years so he could afford it. It was the one thing he wanted: a special-edition turbodiesel, direct from Germany." Suda sighed. "My father died right after he bought the car."
Overhead a breeze fluttered the leaves and sent dappled sunlight dancing across the dashboard. Suda stared vacantly out the windshield. "My grandmother was a convert to Methodism," he said. "Western culture was new in those days, and very cosmopolitan. But my father hated her strict Christianity. He vowed to prove that science was superior to religion." Suda and his sister were raised completely atheist. When Suda was a child, his father had told him that there was nothing spiritual about life. Nothing spiritual about a beautiful sunset. A sunset was just a nuclear explosion.
Suda turned to me with a strange expression. "My dad was a medical doctor, you know."
He cocked his head and ran his fingers over the ignition key. "He died from cancer. Multiple organ failure. I was with him. I knew that his body wasn't working anymore. But even after his heart stopped, I still didn't believe he was dead. Only after I touched his cold face with my hand."
• • •
A few weeks after I returned home from Japan, I was awakened early one morning by the telephone. It was Suda calling from Tokyo. He was so agitated he could hardly talk. "The entire country is in a frenzy!" he shouted from six thousand miles away. "We have our first brain-dead donor!" The forty-four-year-old patient was carrying her completed donor card when she suffered a stroke. A few days later her heart, lungs, and liver were transplanted by Japanese surgeons.
The tentative success of Japan's new paradigm is tantalizing. The Japanese public contested the aggressive designs of their medical profession, but we Americans have simply let doctors choose death for us. Our doctors encountered little resistance, and their demands for organs inevitably influenced decisions that should have fallen to philosophers and priests.
When the state defines death, further abuses are bound to follow. In America, organ shortages are driving the government and medical establishment to increasingly Orwellian tactics: federal agents trafficking in organs, strong-arming local officials into surrendering body parts; doctors ratcheting the standards of death down in the endless quest for organs. We are not far from the blessedly idiotic achievement of killing people to save the dying. When a young country boy in Virginia was shot in the head during a gas station holdup in 1985, the local hospital spent twenty-three hours trying to save his life. The effort failed, but the boy—an organ donor—was able to give the gift of life. Six years later, recipients of his organs began to die of AIDS. As worried officials tried to track down all the beneficiaries to warn of contamination, the mission turned into a nightmare. A total of fifty-six body parts had been harvested from the boy's corpse. The event helped persuade some American experts that the race to plunder the human body had gone far enough. Few made accusations as reckless as Louis Farrakhan's claim that, when rich whites need a kidney or heart they say, "Give us a nigger." But a number of American critics came to the same position adopted by Nelson Mandela's government in South Africa: transplantation squanders medical resources in a society where many citizens still lack basic health care.
The bureaucratic consensus that has supported America's brain-death doctrine is beginning to unravel. At one extreme, doctors at the University of Pittsburgh Medical Center—America's most aggressive organ-transplant hub—are easing shortages by extracting organs from patients who don't even meet brain-death criteria. Surgeons at the medical center use what they call the Pittsburgh Protocol, which allows organs to be harvested, under certain circumstances, during the indefinite few minutes after life support is removed but while bodily functions could probably still be revived.
Along with the threat of draconian government control, this ever more invasive presumption by medical professionals is inspiring philosophers, religious scholars, and even surgeons to reconsider brain death itself. Some of these emerging critics take a position even more cautious than that of Yamamoto and Suda in Japan—they advocate a return to the stopped-heart criterion, which would make some transplant operations impossible. Others are closer to Japanese Buddhist priests, questioning the American penchant for prolonging death at great expense to society, with considerable pain for the patient—concerns that have also inspired the hospice and right-to-die movements. Still others sound a lot like Muranaka, the Buddhist university president in Tokyo. They deplore the supremacy of technology in American culture and the misguided quest for immortality that champions organ transplants in the first place.
Meanwhile, ethical considerations aside, medical experts are beginning to question the brain-death paradigm on purely scientific grounds. Alan Shewmon, a University of California (Los Angeles) neurologist, once defended brain-death criteria, but he now argues that the empirical evidence is clear: brain-dead patients are deeply comatose, very sick, dying—but no more dead than many other patients who are severely disabled, very sick, and dying. The medical community must reach a more scientifically accurate definition of death, says Shewmon, based on what he refers to as the "thermodynamic point of no return" of microstructures throughout the body. Such a paradigm would not necessarily end the donation of vital organs like hearts and lungs. But it would, at least, end the medical fiction that donors are dead when these organs are removed.
On the horizon looms the possibility that organ shortages are a temporary problem: someday we may be able to grow livers from scratch. Growing organs like tomatoes might solve some ethical problems, but if the process turns out to require human hosts, who will play Prometheus—chained to a rock, the eagle devouring his regenerating liver each day? In any case, the prospect would not mark such a pronounced change from our contemporary consensus. Medical science—with its hosts of nursing angels—transforms our bloody offerings into the promise of immortality. But it is a false promise. The sewn-up sick simply recommence dying often just a short time later.
For now, the Pittsburgh Protocol on the one hand, and the movement to revive cardiac arrest criteria on the other, are the two extremes of death in America. By providing the option for a determined donor to offer organs when standard criteria would preclude the gift, the Pittsburgh Protocol allows patients to elect a definition of death that involves a degree of sacrifice for the sake of a social good. If the Pittsburgh Protocol were legalized and properly paired with an option to elect old-fashioned death—natural cardiac failure—a new American paradigm might end up looking a lot like Japan's brain-death law. Self-determination and spiritual sensitivity would trump medical paternalism. But first, Americans would have to wrest death away from their doctors and return it to their own hearts. ❦
vol 9, no 4 • summer 2000
Chairman of the Editorial Board
Kwame Anthony Appiah
Henry Louis Gates, Jr.
Michael Colin Vazquez
Houston A. Baker, Jr.
Micere M. Githae Mugo
William Julius Wilson