Were Transplants Premature?

Criticism and caution about heart transplants have been welling up for weeks. So, as Capetown Surgeon Christiaan N. Barnard began his second U.S. tour, he tackled the issue headon. Barnard chose the title "Was Human Cardiac Transplantation Premature?" for his presentation to the American College of Cardiology in San Francisco. Emphatically, he said that it was not.

Other opinions varied widely. Most sensible and restrained was a report by the Board on Medicine of the National Academy of Sciences. Investigational transplants are now "appropriate" in man, said the board, but surgical teams with insufficient experience and facilities should not be permitted to attempt them. It thereupon laid down a set of guidelines. But even in hindsight, they were guidelines that had already been observed by Barnard and the two U.S. teams that have transplanted hearts.

Fearsome Specter. More drastic were the objections of a few eminent cardiologists at the San Francisco meeting. New Orleans' Dr. George E. Burch, the college's new president, joined Los Angeles' Dr. Eliot Corday and Manhattan's Dr. Simon Dack in calling for at least a three-month moratorium on heart transplants. The college's outgoing president, Philadelphia's Dr. William Likoff, announced a conference of leading physicians, lawyers and theologians, to be held late this month in Bethesda, Md., to discuss the legal, ethical and practical aspects of transplants. And then there is the resolution, proposed to the Senate by Minnesota Democrat Walter F. Mondale, to set up a presidential commission to study and evaluate scientific research in medicine. In some surgeons' minds, Mondale's proposal has blurred into the fearsome specter of having a commission decide on each individual transplant and establish the death of the donor before the transplant team can be called in.

Asked whether he would observe the proposed moratorium, Barnard answered with an unhesitating "No, I would not." If other surgeons wished to, he suggested, that was their business. He insisted that he was guided by his own conscience, based on principles as old as the Hippocratic oath--that the physician must do everything in his power to save life, to restore health, and at the very least to alleviate suffering. Barnard conceded that in the case of Louis Washkansky he did not save life. But "in the case of Dr. Philip Blaiberg, I can say unhesitatingly that we have alleviated suffering. This man is now up and around, able to shave himself, and to feed himself sitting up--things that he could not do before."

Self-Appointed Critics. Any further restrictions on surgeons seemed unnecessary and unwise to Barnard. The death of a heart donor is already certified by the most experienced neurosurgeons and neurologists, he said. As for the radical nature of the operation, Barnard felt that the decision to remove a dying man's heart "may not be as difficult as the decision to remove a young woman's breast because of a lump."

Dr. C. Walton Lillehei, who was one of Barnard's teachers at the University of Minnesota and is now chief of sur gery at New York Hospital and Cornell University Medical College, was more caustic. "Decisions regarding transplantation," he said, "are better left to those who are doing the work rather than to self-appointed critics who are better versed in the art of criticism than in the field under study. In many cases, they are people who are frustrated by their own inability to create."

Barnard himself traveled to Washington last week to testify before a Senate subcommittee holding hearings on Mondale's resolution. Beside him sat another of his University of Minnesota teachers, Dr. Owen H. Wangensteen, now retired, who has probably trained more great surgeons and professors of surgery than any other man living. Wangensteen staunchly opposed the Mondale resolution, arguing that investigators receiving U.S. Government research funds are already subject to supervisory committees, which must give advance approval of any new "surgical ventures involving patients."

Barnard, not being a U.S. citizen, felt at first that he could not advise Congress and should content himself with describing how things are done in South Africa: "We already have what amounts to a commission, in effect, in our own transplant teams, comprising senior doctors of many specialties." But he was soon drawn into emotion-laden arguments. Nebraska's Carl T. Curtis cross-examined him, prosecutor style, on who decided, and when, to shut off artificial respiration for Denise Darvall, history's first heart donor. Barnard won that round by pointing out that her body was kept on the respirator for two hours after the neurosurgeons had declared her dead--"So we were on the safe side."

Connecticut's Abraham Ribicoff was worried about letting doctors make all the decisions regarding immensely costly operations paid for by the public through government financing of research. Barnard fired back: "Who pays for war? The public! But who makes the decisions in war? The generals--not the public!" That drew applause and silenced Ribicoff. Barnard was relentless. "If you feel you have to have a commission to control your doctors in this country, I feel that would be an insult to your doctors," he declared, then added: "While I am not in com petition with my colleagues here, I would say that if you set up such a commission, within a few years they would be so far behind that they would never be able to catch up with me."

This week Barnard is scheduled to fly back to Capetown. There, he predicts, he will do his next heart transplant --probably within a month--after Dentist Blaiberg goes home and releases the sterile quarters needed for the patient's recovery. And far from lowering his sights, Barnard believes: "Eventually we shall have to consider transplanting a heart and a lung together."

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