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Rapid Responses: Rapid Responses published:
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Is there a future for heart transplantation
- David W Evans (9 March 2003)
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Heart Transplant: A success story
- Kamal Kumar Mahawar (11 March 2003)
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The hearts, minds and souls of donors
- Richard G Fiddian-Green (11 March 2003)
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Organ Transplantation
- John P. Hopewell (21 March 2003)
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David W Evans, Retired physician 27 Gough Way, Cambridge, CB3 9LN
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EDITOR - The answer to your question : "Is there a future for heart transplantation?" on the cover of this week's journal is : "No". That it had no long-term future was obvious from the first, if only because the supply of donor hearts would never have been sufficient to meet demand if the procedure had proved successful and acceptable. But, as Anyanwu and Treasure point out(1), no proof of its efficacy has ever been adduced, while developments in prophylaxis and therapy now offer preferable alternatives free from the resource and ethical problems which have always dogged transplantation of the human heart. Not least among the latter is the procedure's dependence upon the idea that death of the brain stem can be diagnosed, with the necessary certainty, by means of bedside tests of some brain stem reflexes together with a (dangerous) apnoea test. This simplistic notion was challenged many years ago(2)and has now been conclusively shown to be false(3). The acquisition of donor hearts is thus seen to depend upon the misrepresentation of an imprecisely diagnosed pre- mortal syndrome as the death of the patient destined to be the donor - with all the special and general, public and professional, deceptions flowing from it. That corrupt practice can no longer be sustained. It has not borne good fruit and can never do so(4). David W Evans 1. Anyanwu A, Treasure T. Prognosis after heart transplantation. BMJ 2003; 326: 509-10 (March 8) 2. Evans DW, Hill DJ. The brain stems of organ donors are not dead. Catholic Medical Quarterly 1989; 40: 113-121 3. Facco E, Munari M, Gallo F, Volpin SM, Behr AU, Baratto F, Giron GP. Role of short latency evoked potentials in the diagnosis of brain death. Clinical Neurophysiology 2002; 113: 1855-66 4. Matthew 7: 18 Competing interests: None declared |
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Kamal Kumar Mahawar, SHO, General Surgery Caithness General Hospital, Wick KW1 5 NS
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Heart transplant is one of the biggest wonders of the last century. It would be unfair to say that it has not much made difference to the patients. Most of these patients otherwise have a very limited life span and it more than compensates for frequent visits required to monitor the immunosuppression, minor long term renal dysfunction and malignancies which are not rapidly lethal. Heart transplant has established itself and it would be sometime before an alternative finds such widespread acceptance. Competing interests: None declared |
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Richard G Fiddian-Green, None None
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Professor Christiaan Barnard's first heart transplant (1) raised one contentious issue and settled another. The first issue, that of the defintion of brain death, has yet to be settled (2). The second issue, that the heart might be the seat of the soul, was settled by the clear demonstration that the heart was no more than a pump. It is the latter that might have prompted his surprising invitation to meet with the Pope. In his book, Kiss Kiss, Roald Dahl tells a characteristically awful story about a woman who claimed that her husband had abused her when he was alive (3). In taking her revenge the woman kept one of his eyes alive in a goldfish bowl and made spiteful comments to it whenever she passed. The only reaction her husband could make in retaliation was to narrow his pupil, the implication being that his mind was still very much alive. Judging from my late father's out-of-body experience (OBE) there is a possibility that Roald Dahl's fictional account might not be too far divorced from reality (4). Indeed the Alice hypothesis provides a rational basis for a complete mind-body split (5,6). That much of the brain may be removed at surgery on occasions with remarkably few impairments of cognitive function raises the further possibility that the brain might not as important a determinant of cognitive function as is commonly supposed (7). Indeed the Alice hypothesis raises the possibility that the body might be no more than a dumb terminal for the mind (8). There is certainly nothing very special about the brain. Einstein's brain was no bigger and had some regional differences from controls, but the controls were not matched for his behaviour and intellectual interests (9). It is possible, therefore, that neither the heart nor the brain is the seat of the soul. In which case "brain dead" donors might be much more aware of their circumstances than is commonly supposed. 1. Barnard CN. The first heart transplant--background and circumstances. S Afr Med J. 1995 Sep;85(9):924, 926. 2. Is there a future for heart transplantation David W Evans bmj.com, 8 Mar 2003, rapid response to: Prognosis after heart transplantation Ani Anyanwu and Tom Treasure BMJ 2003; 326: 509-510. 3. Roald Dahl. Kiss kiss. Penguin Books, London, 1960 4. Body-mind split and brain death Richard G Fiddian-Green bmj.com/cgi/eletters/325/7378/1433#28128, 23 Dec 2002 5.. Mind-body split: the Alice hypothesis Richard G Fiddian-Green bmj.com/cgi/eletters/325/7378/1433#28056, 21 Dec 2002 6. Re: time to move beyond linear physics Richard G Fiddian-Green bmj.com/cgi/eletters/325/7378/1433#29680, 15 Feb 2003 7. Borgstein J, Grootendorst C. Clinical picture: half a brain. Lancet 2002; 359: 473. 8. Steven Hawking is a miracleRichard G Fiddian-Green bmj.com/cgi/eletters/326/7380/106/b#29066, 24 Jan 2003 9. Sandra F Witelson, Debra L Kigar, Thomas Harvey The exceptional brain of Albert Einstein Lancet 19 June 1999. Volume 353 Issue 9170 Page 2149 Competing interests: None declared |
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John P. Hopewell, retired \formerly Royal Free Hospital
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I read the editorial by Anyanwu and Treasure on heart transplantation(March 8th.)with great interest. I had just the same feeling about organ transplantation in 1959 when Roy Calne and I did the first organ (kidney) transplants using an effective chemotherapy to deal with rejection.(Brit.med.J.,1964,1,411-413) Although organ transplantation was the great new hope at the time, I felt it was too cumbersome a weapon of treatment to last for very long. Curiously, nearly all the other operations I did during my career at the Royal Free Hospital have been abandoned and become part of the history of medicine, whilst organ transplanation seems to have no immediate rival. John Hopewell Competing interests: None declared |
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