by Rob Dunn
By this point, Lower and Shumway had spent longer than anyone else working toward human heart transplants. They had also performed more heart transplants than anyone, and had a much higher rate of success than anyone (about 42 percent of their patients lived more than six months, whereas less than 10 percent of heart-transplant recipients in general did). But even in their hands, more than half of recipients died within six months. And so when Lower performed another transplant and his patient, like so many others, died, it was not surprising. What was surprising was that, in the wake of that death, he found himself accused of murder.
On May 25, 1972, in Richmond, Virginia, Lower had attempted another heart transplant. It succeeded for a short time and then failed, but it was not the recipient’s death of which he stood accused. It was the donor’s.
Bruce Tucker had fallen onto the concrete at the egg-packing plant where he worked. The fall resulted in severe brain damage. Tucker was brought into the hospital, where doctors tried to relieve the pressure on his brain with a craniotomy, but there was no response. Tucker was placed on a respirator, but he seemed to be only “mechanically alive.” The next day, the hospital declared Tucker “unclaimed dead,” and the surgeons bent over him, cut his chest, broke his ribs, and opened him up. Once the chest was open, they cut out his heart and lifted it up carefully so that it might be placed in the body of another man. In the eyes of Lower, removing Tucker’s heart was the first step in saving another man.
This was not how Tucker’s family saw things.
According to Tucker’s family, Lower and his team took Bruce’s heart before he was dead; they took the heart even before his family had been found. In the family’s eyes, Lower was just waiting for a heart. He already had the body of a recipient, Joseph Klett, laid out and ready. Tucker, a fifty-four-year-old African American man, just had the bad luck to be black and show up at the hospital when Lower was waiting for a heart. The hospital did not, it seemed, expend much energy searching for Tucker’s family before pulling him off life support and declaring him dead. Tucker’s brother, a shoemaker, called the hospital repeatedly searching for his brother and was told, variously, that he was in surgery or that he was in recovery. There was no mention of a heart transplant. When a friend called the hospital, the friend was told that Tucker was not even there. Even when Tucker’s brother arrived at the hospital after the heart transplant had taken place, he was still not told of his brother’s fate. The state had a mandatory waiting period of twenty-four hours for organ harvests from brain-dead patients, which the hospital seemed to have ignored. To Tucker’s family, Lower was a modern Dr. Frankenstein, waiting for parts, ready to gather them at any cost.
Tucker’s family hired a hungry young African American lawyer, Doug Wilder, to argue their case; Wilder would later become the governor of Virginia.12 He had big ideas for his own future, and, perhaps with those ideas in mind, he made even bolder statements than the family themselves felt comfortable making, statements that played on the emotion of the Tucker’s story. He suggested that, given another day, Bruce Tucker might have started to recover. Lower, he said, killed the poor man. Lower killed him as surely as if they had met in a back alley. He had taken the most precious thing he had: his heart.
Personally, Wilder could not possibly have been more prepared to work for the Tucker family. Before Lower’s surgery, Wilder argued against heart transplants, particularly the hearts of African Americans into whites. He wrote, “They’re not going to be taking the hearts of any white mayors. You know whose hearts they are going to be taking.” Even before Lower’s surgery, the discussion of heart transplants was racially charged in Richmond. Then, under questionable circumstances, Lower took the heart of a black man and gave it to a wealthy white man.
At stake in this case was not only Lower’s future but also the future of heart transplants. A neurologist had seen Tucker after his fall, but he had not pronounced him brain-dead. He had, more casually, said that it was “very unlikely” that Tucker’s status would change. The neurologist left open some chance of hope, however remote; it was a verbal loophole that allowed Tucker’s family to imagine that he might have recovered if only he had been left alone.
Much depended on how one determined if a person was dead. For most of the history of medicine, beginning in ancient Greece, life ended when the heart stopped. To Christians, the Bible made clear that “the life of the flesh is in the blood.” God breathed life into man’s nostrils, which suggested the circulatory system’s activity was synonymous with life. Similar sentiments exist in the Torah and the Koran. In the United States as well as in many other countries, heart death was legal death, prior to the advent of transplant surgeries. In recognition of this history, the Americans who had been readying to do heart transplants when Barnard beat them to it assumed, for the most part, that they would have to wait for a donor heart to actually stop, for the donor’s brain and heart to die, before the heart could be harvested. Barnard, in moving forward, changed the debate, even if ambiguity about just whether and how Denise Darvall’s heart had stopped persisted. However other surgeons felt about Barnard’s achievement (and many did not feel terribly good), most credited him with changing the discussion. The heart, so long the seat of love, passion, the soul, and even thought itself, was becoming just another organ.
In response to Barnard, a dean at Harvard University convened experts to write what came to be called the Harvard Code, consisting of criteria that defined life as “life in the brain” and death as “brain death.” The Harvard Code recognized that a body without a heart could be returned to life with a heart transplant or perhaps even an artificial heart of some sort, but a body without a brain could never and would never be. Brain death was defined as the point at which a patient became unaware of his surroundings; was unable to move spontaneously; and had no activity on a brain tracing, an electroencephalogram (EEG), which measured the brain’s electrical activity. In response to the Harvard Code and changes in how surgeries were being done, many hospitals began using brain death as the criterion for the end of life. But any such code is ultimately cultural, a definition of life with fuzzy boundaries, especially until it is made law, which, in Virginia at the time of Lower’s most recent surgery, it had not been.
Lower was initially optimistic about the trial. He also felt good about Tucker’s role. To his mind, he had done nothing another surgeon would not do in the same situation. Then the judge made an early and seemingly fateful decision. He asked the jury to define life as ending when the heart stopped beating, not with the death of the brain,13 based on the definition of death in Black’s Law Dictionary. To Lower and to heart surgeons around the world, this was a blow. If the beating heart was, as in ancient times, the defining feature of life, then surely Lower had killed a man, but then the same guilt would fall upon other surgeons who had performed heart transplants (if the heart was allowed to briefly stop, everyone was happier, though this was really a sort of technical work-around more than a reasonable distinction, a work-around of which Barnard had taken advantage). Lower knew the heart was just an organ. How could the judge make such an argument? The academic part of Lower’s mind wanted to argue, to plea on behalf of reason. The rest of his mind had begun to scream. It had begun to contemplate the possibility that because of his attempt to move medicine forward, he might end up in prison for life. An article in the National Observer noted that because of the use of the definition of death in Black’s Law Dictionary, “The jury would almost certainly be compelled to convict the doctors.”
Tucker’s family, who initially thought they faced an uphill battle, began to feel as though they might win. To the family, broader narratives compounded the treatment of Bruce Tucker. African Americans have a long history of terrible, tragic, amoral, and immoral mistreatment by the medical system. The family sought $900,000 for deprivation of civil rights and an additional $100,000 in wrongful death. Whatever one considered the end of life, they seemed to have a case. In this light, when Wilder told the
jury that Tucker was just another one “of the faceless blacks to the [hospital] hierarchy,” many in the black community heard a truth being spoken.
Recent legal precedent was on the family’s side too. Two and a half weeks after Lower’s team removed Tucker’s heart, Japanese surgeon Juro Wada had carried out Japan’s first successful heart transplant. The recipient, an eighteen-year-old boy named Miyazaki Nobuo died from a lung infection eighty-three days later. Upon the news of the patient’s death, another Japanese doctor at Sapporo Medical College accused Wada of having killed the donor, a man who was declared brain-dead after a swimming accident. Eventually the case against Wada was dropped, but not until long after Lower’s case had concluded, and not because he was seen as innocent but because the evidence of the medical status of the donor was too limited.14 At the time of Lower’s trial, it was not yet clear that Wada would win, though it was clear Wada’s career in heart transplants was over. Lower’s might be too.
Lower became increasingly anxious. His lawyers spoke on his behalf, but quietly, modestly. Then the judge made another announcement: the jury, he decided, could consider either definition of death. That is, they could choose to consider the possibility that death was, as Lower would have it and in line with the Harvard Code, defined by the “complete and irreversible loss of all function in the brain.” It is unknown just what made the judge change his mind15—he seems to have been influenced by the consensus that had emerged among American surgeons—but once he did, he set the stage for Lower, Hume, and their colleagues to have more of a chance to win.
As Lower waited to hear the verdict, he was aware that he was not the only one on trial; his failings, if that was what they were, were failings of a field, failings of technology and unchecked progress. Heart transplants were on trial, as was the heart itself. For thousands of years, the beating heart had meant life. Doctors had stopped talking about the soul, but they still talked about life, and for doctors, life had moved to the brain. But in this courtroom, a jury of men, their own hearts pounding and thumping, would decide whether this was still true. If it was not, if life still resided in the heart, then every heart-transplant surgeon who had harvested a heart from a brain-dead patient was a murderer.
The jury passed slips of paper over to the bailiff, who passed them to the judge. The judge’s big hands unfolded the papers. He did this as slowly as he could, it seemed to Lower. Then he started to announce the verdict. Lower looked up. The dry lips of the judge opened, and he said, “Not liable.” In the courtroom of an aristocratic judge who styled himself as part of Old Richmond, an all-white jury had sided with the white doctor. Lower sat up straight and began to cry. The Tucker family members sank down into their chairs and began to sob. Their son and brother was dead, their case lost. In legal contexts, Lower’s name became associated with the timing of death. Death, after the Lower v. Tucker case, came to be viewed as brain death.16 The case would be revisited17 as state laws were changed to consider brain death as death, but the general societal lesson has never changed. In Richmond, consciousness and the soul were banished from the heart.18 The legal system had taken a bold step. But contrary to their natures, the surgeons pulled back. Heart transplants became taboo—not immediately, in response to Lower’s case, but in the years to follow, years of reckoning.
For surgeons, the residual possibility of legal problems remained, particularly in those states and countries in which laws clarifying the meaning of death had not been passed. The bigger problem was that, most of the time, the surgery did not work. People were reborn with new hearts, but they did not survive. They sat up, smiled, hugged their loved ones, and died. In many cases heart-transplant recipients still seemed to die sooner than they would have without the new hearts. This was enough to dissuade surgeons from continuing. More cynically, one might argue that after the first heart transplant in the world and then the first in Japan and the United States, the excitement of subsequent surgeries was diminished; what was left was the far less glamorous task of figuring out how to keep the heart from being rejected by the recipient’s body. Whether that task could be accomplished was unclear, and even those surgeons who performed multiple heart transplants eventually stopped. Dr. Michael DeBakey of the Methodist Hospital in Houston performed twelve transplants but then stopped. Dr. Denton Cooley of the Texas Heart Institute in Houston at one point led the world in the number of heart transplants but then stopped. Christiaan Barnard performed ten heart transplants, then stopped. In 1971, a cover story in Life magazine predicted heart transplants would be abandoned, and, when they were, it would conclude “an era of medical failure.”19 Whereas there were 121 heart transplants done in 1968, there were just 47 in 1969, 17 in 1970, and about 10 in 1971.
Here and there, other surgeons tried transplants, but most abandoned the procedure as quickly as they had started. Shumway and, with him, Lower persisted. The two (but particularly Shumway) came to dominate the field in the way it had long been imagined they would.20
Shumway was the first to admit that, even for him, the surgery was more often fatal than successful. Shumway had watched as, one by one, his heart recipients died (albeit after more months and years than for other surgeons). Some died because the hearts they had been given were too big or too small. Others died because their own bodies or their donor hearts were too far gone. Most died because of infection or because their own bodies ungratefully rejected the hearts they had been given.
Shumway worked to resolve the problems of infection and rejection; they were two sides of the same coin. Infections were caused by pathogens introduced during surgery or later, and they spread readily because the medications, such as steroids, used to suppress the immune system suppressed it too much and too generally. Shumway would use a series of compounds and approaches that would calm a recipient body enough for it to accept a donor heart but not so much that it would allow invasion by pathogens.21 It was not exciting science. Shumway would not be in the news again for his efforts. Yet it was the science necessary to change heart transplants from a sideshow novelty into medicine. For this, he received little credit. Even his obituary in the New York Times, before mentioning that he was the man who really made heart transplants possible, noted that it was Barnard who performed one first.
The solution to the problem of rejection would be twofold. Shumway realized early on that transplants of hearts for which the blood types matched had a better chance of avoiding rejection. This would never have been resolved through the study of dogs alone, because dogs do not have as many blood types as humans. Still, even when blood types were matched, bodies rejected the new hearts they were given. Shumway needed to suppress the reaction of the immune system to the new organ; Barnard knew this too, of course, but he chose to disregard the problem’s complexities; rather than trying to circumvent the immune system, he just hoped to get lucky. Shumway hoped for nothing; Shumway planned and tested.
The immune system’s primary job is to differentiate self from other, us from them, and then to respond accordingly with war or peace. Not all others are attacked. Your body, for example, takes care of some of the bacteria on your skin and in your gut; it takes care of the many species on which you depend. But organs from other bodies are rejected, at least initially, and the more different they are, the more likely they are to be rejected. Shumway believed that if this response was pushed off for a while, the immune system might come to think of a new organ as part of the self; us, not them. The key was suppressing the initial immune response.
Shumway attempted many procedures to suppress the immune system, each resulting in rooms full of dead dogs with broken hearts. Then, in 1971, the same year that Life magazine had predicted the end of heart transplants, came the first steps of a breakthrough. While on vacation in Hardangervidda, a high and desolate plateau in Norway, a Swiss researcher at Sandoz (now Novartis), Jean-Francois Borel, decided to search in the soil for organisms capable of producing useful compounds.
Borel was particularly interested in finding
antibiotics, and soil bacteria and fungi are a rich source of antibiotics. The first samples Borel tested from a fungus he collected did not seem to produce useful antibiotics. But following company protocols, he also tested the fungus for other effects. In these later tests, some extracts from the fungus seemed to alter the behavior of immune cells grown in petri dishes. The same extracts also suppressed immune function in live mice. Borel figured out that the active compound in those extracts was cyclosporine, but the cyclosporine did not suppress all of the immune system. It suppressed just that part of the immune system whose job it is to distinguish self from nonself: the T-helper cells. It suppressed precisely that part of the immune system that causes problems for transplanted hearts; this, Borel quickly realized, was a very big deal, or it might be, anyway.
In 1973, two years after Borel discovered cyclosporine (four years after it was first collected in the field), Shumway was described in a newspaper article as a man who “still dreams of the day when the biochemists will produce an exquisitely precise antirejection drug that will protect transplanted hearts, kidneys and other vital tissues and yet leave unweakened the body’s ability to fight infection.”22 Shumway knew nothing about cyclosporine; news of it had not yet left Borel’s lab. The road from the discovery of a drug to its use, production, and approval is long and slow; in the case of cyclosporine, it took twelve years.23 Borel’s first publication on cyclosporine appeared in 1978. In 1980, cyclosporine was used experimentally in humans, and finally, in 1983, it was approved by the FDA after two clinical trials.24 In the intervening years, Shumway had perfected nearly every other element of heart transplantation he could. Cyclosporine was the last piece of the puzzle, and, almost immediately upon its approval, it became a key compound used during transplants. The use of cyclosporine is not without its challenges. Even when taking it, most patients require additional immunosuppression (often in the form of steroids). Initially, there were struggles with dosages. Also, the long-term use of cyclosporine and other immunosuppression drugs is associated with a variety of potentially serious health problems. Yet cyclosporine makes transplants that would otherwise be impossible, possible. Thanks to cyclosporine, the number of heart transplants started to accelerate again, dramatically (to a point). By 1987, there were four thousand people in the United States with transplanted hearts, many of whom would not have been alive without the transplants, and many of them Shumway’s patients. Shumway’s quest to fight rejection and Borel’s vacation in Norway had come together to yield a major breakthrough that saved lives. Here was Shumway’s victory lap, the proud conclusion to his story: the rebirth of the transplant as a real solution for desperate, brokenhearted folks. Tens of thousands of people walk around today with hearts donated by other people. They are true chimeras, and their existence is made possible by the surgeons and researchers who struggled for progress, but also by the patients who lost their lives in the process, patients such as Louis Washkansky, who gave everything for what might be.
