A New Era For A Juggling

IF THE HEART is the source of the passions, of the emotions, what was the mechanical device implanted in Barney Clark's ribcage? It pumped blood for four months, keeping him alive. It also raised more pressing questions than this odd psychological one, especially now that medical history's second artificial heart transplant has been performed on 52-year-old William Schroeder.

A recently commissioned State of Massachusetts Task Force on Organ Transplants makes it clear that these operations, and "Baby Fae" and her transplanted baboon's heart are much more than isolated novelties created by media hype. In fact, they bring into public focus a controversy over the medical ethics and social implications of organ transplants. The task force has completed its study, addressing the problem of how to allocate organ transplants in the face of too few donor organs and too little money. Aside from this immediate concern, one of its major goals is, according to Marc S. Roberts, professor of political economy at the Harvard School of Public Health, and member of the committee, to "set a precedent" for the way the state should handle science ethics problems. Yet even this seemingly straightforward goal is itself controversial.

Organ transplantation is no isolated controversy; the issue arises as one problem in the relationship between science and public policy. Technology, whether it be artificial hearts or atom bombs, continually outruns both ethical standards and public policy in two ways. The sometimes inconceivable new power of scientific advances that give us the ability to tinker with DNA, to replace a defective heart, disrupts the ethical standards we use to judge those powers. Secondly, the sheer speed at which science forces issues upon us outstrips ethical standards. Rapid technological change leaves little time to assess consequences; we cannot know what is at stake, because science carves out new territory faster than we can discover the hidden problems. Consequently, the issues force the public to take extreme sides, to condemn or condone. In the political arena, the policy makers, also at a loss, tend either to let the new technology run wild, or cripple it with regulations and money restrictions.

The public reaction of condemning or condoning the role of technology in a disjointed consideration of each issue creates extremist factions that confuse the context in which they fight. What all of these issues cry out for is not simplistic slogans like "Ban the Bomb" or "Right to Life," but a vast reworking of the way technological change brings itself to bear on society. The point is not to abandon the condemn/condone way of dealing with science ethics issues, but to see its inadequacy, to recognize that the rapidly changing and overwhelming new powers of science radically overturn the way we make ethical choices and public policies. The Task Force on Organ Transplants is a step in this direction.

FIVE YEARS ago, if your heart had a congenital defect, you didn't have too many options. Now, the power of medical technology can turn a death bed into a hospital bed, at least temporarily. Only recent surgical and pharmaceutical advances make heart and liver transplants possible. Why is there an issue? First of all, there simply aren't enough organs to go around; how do we decide who benefits from the limited supply? Second, the transplant costs on the order of 10 times what a normal operation costs, around $300,000 for a single liver transplant. Since this money comes from insurance companies or from state Medicaid, the status quo is not a free market, but it threatens to become one, given the high financial incentives for doctors and hospitals. Clearly a laissez-faire scramble for pieces of human bodies in which the stakes are immediate life or death for the patient is an indigestible alternative; this does not mean, however, that extensive state regulation is the answer.

According to Roberts, the concern of the task force is to limit the financial scale of the organ transplant business. The committee recommends a "no new facilities" policy in which the state would use the institutions, the hospitals, to restrict the number of operations performed. "Creating a limited capacity," in which "access [is] a function of medical condition" not of ability to pay, is the solution. Such restrictions would also ensure that other state-funded programs are not strangled by high costs of transplants.

The task force is choosing among decision-making processes. Their choice is a practically informed moral judgment between what they consider better or worse ways of deciding how to allocate organ transplants. The strongest negative implication of the "limited capacity" scenario is an increased possibility that a patient who might benefit from a transplant could be denied one through lack of funds. The task force has decided that other Medicaid programs are more important; perhaps they are, though it should be noted, for example, that the kind of heart defect suffered by Baby Fae kills a substantial number of infants. The committee has implicitly decided that not all patients who might benefit from a transplant have an inalienable right to the technology. Finally, they have decided that the decision rests with the doctor.

CLEARLY VERY real limits on available organs and funds require some compromise on the issue of transplants, yet the limited capacity approach can be only part of the solution. The issue of organ transplant distinguishes itself from other pressing medical controversies, like abortion, because it creates a competition that entails the somewhat morbid prospect of the buying and selling of organs, and thus lives, for profit. The "limited capacity" scenario allows for "retrospective review," i.e. hindsight, because it slows down transplant technology. However, this slowdown could actually limit the possibility of resolving the competition by removing the constraints--by developing the technology so that organs are plentiful, and the operation is cheaper. By legislating organ transplants out of its funding, the state would clamp down on the free development of the technology that makes those transplants possible.

For the moment, the question remains of how to judge who gets the available transplants. Benefit is not a clear-cut question, yet clearcut decisions must be made. However, it would be neither ethical nor possible to create a central computer-like authority to dole out judgments of patients. The power of organ transplant technology will be controlled by somebody, be they the wealthy patients, the needy patients, the state law makers, the hospitals, or the doctors; we must decide, then, who should control that power.

By concluding that the doctor should decide for each patient's case, the task force subsumes an ethical judgment under a scientific judgment. This means enfranchising the doctor and his/her scientific procedure with the power of deciding whether or not to deny a patient a possible means of survival. Perhaps this is a solution; but, as Roberts puts it, how low do the odds of survival have to go for a doctor to say that a patient will not benefit? Roberts feels that there is "nothing novel about this" situation, that doctors are always faced with this kind of decision. There is a subtle but crucial distinction, however, between the everyday medical decision of whether or not to operate, of weighing a patient's problem against the side effects of a possible drug, and denying a patient a last resort to life. In the latter case, the situation is comparable to the problem of "pulling the plug" on dialysis machines. In decisions of these kinds, the doctor's scientific procedures for judgment do not necessarily get him off slippery ground.

What the task force wants to do is pull up on the reins of a technology that saves lives and is on its way to saving more. The limiting of organ transplants to a small scale effort solves the problem of monetary drain on Medicaid. It does not, however, solve the overall problem. This ultimate resolution of expanding transplant availability, the only resolution that satisfies the strongest ethical implications of the problem, would be delayed, perhaps indefinitely, by the group's plan. What is missing is an assessment of what the constraining effects of the task force-advocated policy would be on the medical technology's ability to eliminate the competition it created.

REWORKING OR at least reassessing the relationship between rapid technological change and social conditions means stepping in on a juggling act. It is possible to strike a balance between the "limited capacity" scenario and allowing technology to solve its own problems. What the new powers of medicine should not be is a call to take extreme sides; any scientific advance has a problem on its flip side, and by concentrating on the extreme alternatives the public confuses its dilemma. Scientific change and social change often run as two trains on independent tracks at different speeds. We tend to leap from one to the other thinking that the danger lies in one of the alternatives--but the issue is in fact in the leaping.

Politically, the question is one of power; who should make and control the set of standard procedures for deciding how to allocate organ transplants. Since voting majorities of the public often take sides by condemning or condoning the role of technology, legislators and policy makers respond to these extremes. Though perhaps inevitable, this response need not preclude reassessment of the relation between science and public policy. What is obvious is that science expands the frontier of our living conditions. What needs to be recognized is that science is an ethical frontier, rapidly outmoding our ways of making decisions. As a society, we are like a child with a powerful new set of hands--a toy about which we can neither recognize all the dangers involved, nor decide who gets to hold it.Harvard-affiliated Brigham and Women's Hospital