Coma

Author’s Note

This novel was conceived as an entertainment, but it is not science fiction. Its implications are scary because they are possible, perhaps even probable. Consider a classified advertisement that appeared in the San Gabriel (Calif.) Tribune, May 9, 1968, col. 4:

The advertiser did not specify what organ or organs, or even whose body they were to come from.

And there have been other advertisements, many others, in various newspapers across the country. Even specific offers of the hearts from living people!

As gruesome as these ads sound, they should come as no great surprise. There are plenty of precedents for the market economy in medicine. Blood—which may be considered as an organ—is routinely bought and sold. There is a commerce in semen, which, while not an organ, is the product of an organ.

Other organs have been bought and sold. In the 1930’s, a rich Italian man bought a testis from a young Neapolitan and had it transplanted into himself. (He not only wanted the product but he wanted to be a distributor as well.) In the last few years there have been episodes where families have declined to give their own kidneys to dying relatives and have sought out and paid volunteer donors. Such cases have not been common, but they have occurred.

The larger problem, the danger, arises from the simple matter of scarcity. There are thousands of people waiting for kidneys and corneas today. The reason that these two organs are particularly coveted is because they have most frequency been transplanted—successfully. Thanks to dialysis machines, potential kidney recipients (some of them… others are left to die because of shortages of dialysis machines, personnel, and funds) can be kept alive, but their lives are far from normal. In many situations they border on the desperate, so much so that kidney dialysis centers have reported a so-called “Holiday Syndrome.” What that means is that when a holiday weekend approaches, the patients’ spirits rise as they anticipate the rush of auto accidents and the victims who may supply the eagerly awaited and desperately needed organs.

The tragedy in this situation is that the solution to the problem is already within our grasp. Medical technology has advanced to the point where approximately seven percent of all cadaver kidneys are suitable for transplant (and the figure is much higher for corneas), if they are taken from the donor body within an hour of death. But instead of being put to this noble use, these organs are regularly delivered to the worms or to the fires of the crematorium because of legal mumbo jumbo whose origins lie in the dark ages of English law. For back in those times corpses came under the jurisdiction of the ecclesiastical rather than civil law. It seems inconceivable that such a legacy should limit our lives today. But it does.

However, most, if not all, states have now passed the Uniform Anatomical Gift Act. This law has helped to provide cadavers for medical schools (whose supply was already adequate), but it has not helped in rectifying the sad need for useful “live” organs for transplant purposes. An alternate approach, by which all cadaver organs would be immediately available for salvage unless the deceased or the next of kin had made prior refusal, has been proposed. But alas, the wheels of change turn agonizingly slowly, and potential recipients are allowed to die while organs are wasted in the ground. Hard questions remain to be answered: such as an acceptable definition of death, and the legal rights of an individual after death. But such difficulties should not preclude a solution to the egregiously wasteful practice of discarding valuable human resources.

The problem of organ scarcity for transplantation represents only one flagrant example of the failure of society In general and medicine in particular to anticipate the social, legal, and ethical ramifications of a technological innovation. For some inexplicable reason, society waits to the very end before creating appropriate policy to pick up the pieces and make sense out of chaos. And in the instance of transplantation, failure to recognize mounting problems and enact appropriate solutions will certainly open Pandora’s box, with its countless unconscionable possibilities: the Stark et al. of my fiction suggest only possible, execrable aberrations.

For those readers who are interested in delving into the complex problems of organs for transplantation, I recommend two excellent articles which are delightfully illuminating, despite that fact that they appeared in law journals. This is not to cast aspersions on law journals, but rather to emphasize that the lay individual will find these articles very readable: J. Dukeminier, “Supplying Organs for Transplantation,” Michigan Law Review, vol. 68 (April 1970), pp. 811-866; D. Sanders and J. Dukeminier, “Medical Advance and Legal Lag: Hemodialysis and Kidney Transplantation,” UCLA Law Review, vol. 15 (1968), pp. 357-413.

For those who are interested in medical policy and its phlegmatic character, combined with some positive suggestions for future change, I recommend: J. Katz and M. Capron, Catastrophic Diseases: Who Decides What? Russell Sage Foundation, 1975. This is an excellent, thought-provoking book, probably years ahead of its time. Its only drawback is that not enough people in positions of power in medicine will read it.

A final word about women in medicine: I must admit that the research I did on the subject (there is not much available) caused me to alter my opinions. I now have a heightened regard for female physicians and female medical students. I recognize that their training experiences are much more difficult and stressful than those of their male counterparts. Things are getting better in this respect, but at a snail’s pace. The article I found the most illuminating is: M. Notman and C. Nadelson, “Medicine: Career Conflict for Woman,” American Journal of Psychiatry, vol. 130 (October 1973), pp. 1123-1126.