How Death Becomes Life
Author: Joshua Mezrich
Organ transplantation, the life-saving procedure at the heart of this book, is reverentially conceived by the author as ‘the ultimate gift‘, and as ‘the last thing the dead can bestow upon the living’. The book depicts organ transplantation as a supreme gesture that enables the transition from death to life, as well as the opposite transition from life to death. This dualistic feature of transplantation is evident throughout the book, such as when the author remarked that it enables one person to benefit at the expense of another, the benefactor frequently being someone young in the prime of their lives; this is illustrated by the case of a 13-year old girl who died in ‘a tragic car accident’, and whose organs ‘saved at least seven lives‘. In contrast to his deferential view of organ transplantation, the author had a dimmer view of transplant surgeons who he depicted as just ‘stewards‘ who facilitate the ‘transfer’ of organs. The book’s key objectives were to celebrate the bravery and altruism of those who donate their organs, and ‘to give context for the story of the modern pioneers who made transplantation a reality’. The book is therefore replete with touching stories of patients saved from imminent death by the benevolence of people they do not know, and with inspiring anecdotes of the pioneering surgeons who established the field of organ transplantation by having the courage to fail, and the courage to succeed (pages 12-13, 199, ix-x, and 292-305).
The author’s depiction of the technical aspects of organ transplantation, the key educational theme of the book, reflected his sense of awe about the whole enterprise. He described the different phases of the operation, from the identification of potential recipients and the screening of donors, to the performance of the tests that ensure that the donor and recipient have matching blood groups and genetics. His detailed portrayal of the procedure highlighted such key operative measures, for example how the donated organ is preserved by flushing its arteries with the University of Wisconsin solution, and by pouring ‘buckets of ice‘ into the abdominal cavity. Just as the book conveyed the grandeur of organ procurement, it also highlighted its less laudable aspects such as the risk of the surgeon becoming a dispassionate practitioner who just harvests organs, and the propensity for different organ procurement teams to compete on the scene, each trying to protect its ‘turf‘ (pages 5-7).
Perhaps the most inspiring theme of the book is its portrayal of how earlier surgeons overcame the technical obstacles to transplant surgery. In this regard, Alexis Carell stood out for his ingenious vascular surgical techniques which made it possible for transplanted organs to maintain a viable blood supply. Carrell, the author recounted, was inspired to make his breakthroughs when he realised that the assassinated French president Marie-Francois Sadi Carnot died because there was no way at the time ‘to sew severed vessels back together’. The book praised Carell as ‘a natural surgeon, ambitious, driven, and hungry for fame‘ who went to great lengths to perfect his techniques; it however also condemned him for his abiding interest in eugenics, and for his subsequent fraudulent cell culture research. Another equally innovative pioneer the author celebrated was Willem Kolf, the trailblazer who conceived of the first ever dialysis machine based on the simple premise that the kidneys are just filters. It is remarkable that whilst Kolf was making his dialysis breakthrough in Nazi occupied Holland, he was ‘all the while helping the Dutch resistance against the Germans’. Other transplant pacesetters whose lives the book chronicled included Thomas Starzl who, against the antagonism of ‘fellow clinicians’, dragged the field of liver transplantation ‘kicking and screaming into a clinical reality’; and Joseph Murray who performed the first live kidney transplantation between identical twins Richard and Ronald Merrick, a feat that ‘would change the field‘ of transplant surgery (pages 21-32, 44-52, 181-192, 201-205, 83-87).
A major challenge to the development of organ transplantation was what the author referred to as the barrier of the immune system. In recounting the history of how this hurdle was overcome, the author extolled the work of Peter Medawar, the zoologist who discovered the concept of acquired immunological tolerance. The author described how Medawar, whilst researching homograft rejection and chimerism, recognised that organ rejection is circumvented by exposing recipient foetal cells to donor cells in-utero. The author attributed Medawar’s success to his personal qualities such as his readiness to admit mistakes, and his persistence in following a course of experiments ‘over months and years‘. The book however noted that the problem of transplant rejection was only surmounted when Roy Calne introduced cyclosporin into clinical practice; the author underlined the significance of this development when he asserted that on account of cyclosporine everything ‘changed‘, and ‘the world of transplantation would explode‘ (pages 52-66, 90-99 and 205).
The book documented the history of the transplantation of a broad spectrum of organs, but its account of cardiac transplantation was particularly thrilling. In this narration, the book reviewed the remarkable feats that were achieved at the Minnesota cardiac surgery department which, under its chairman Owen H. Wangensteen, ‘amassed the most impressive group of cardiac surgeons the field might ever see at one institution‘. Foremost among these surgeons was C. Walton Lillehei who the author described as a ‘most fascinating, daring, inspiring, and complex character’ whose contributions advanced the field in various directions. South African Christiaan Barnard was also notable as the first person to perform a successful human heart transplantation. On one hand, the author described Barnard as driven, brash, abrasive, intense, and disliked by his colleagues, but on the other hand, he depicted him as possessing ‘an incredible work ethic, a fire in his belly, a belief in his own abilities, and a desire to do something exceptional‘. The book also detailed other qualities which propelled Barnard to make his mark, from being ‘highly detail oriented‘ and ‘meticulous‘, to possessing ‘an innate ability to anticipate problems and plan for what to do about them’. The author nevertheless considered Norman Shumway to be ‘the father of cardiac transplantation’ because he had spent far more time and effort in animal experimentation than Barnard; the author believed Shumway would have had priority in cardiac transplantation if brain death had been defined in the United States at the time (pages 121-126 and 134-157).
A salient feature of the book is the feeling which the author infused into every subject he covered, and this empathy permeated the whole of the book. This was evident, for example, in his delight that organ transplantation is ‘all about having someone else join you in your illness’, in contrast to other medical situations where the sick suffer and die alone. It is also testimony to his compassion that he recounted countless stories of the humanity of his patients. These stories included the accounts of Jason, who ‘carried his burden with grace and courage‘, and of Lisa, whose ‘eyes emitted a hint of sorrow, an understanding of what she had done to get here’. It also included the stories of Michaela, who ‘wanted to know something about the person who had saved her, whose liver sat inside her body’; and of Nate, who is ‘trying to live his life, but at the same time, he wonders about his death‘, and who, ‘despite everything he had gone through, he focused on the importance of hope‘. The author emphasised how difficult it is to nurture empathy in his field, recalling that as an intern, ‘the more efficient I got with my tasks, the less I looked at patients as human beings and the more I look at them as a list of boxes to check off‘. He also recalled how he became ‘desensitized‘ to the pain he inflicted on his patients, admitting that this was beyond the ‘element of detachment‘ that was required to prevent becoming ‘emotionally drained by each case’ (pages 20, 265, 213, 225, 244, 104-105).
This book is remarkable for covering the range of specialties that constitute the field of transplantation, and for doing so in sufficient depth as to portray its pioneering breakthroughs and its contemporary relevance. With a fine mix of archival stories and personal anecdotes, the author conveyed the excitement that trailed progressive transplant innovations, as well as the disappointment of false starts and unfulfilled ambitions. Some of the accounts, such as those of open heart surgery, were not directly relevant to the theme of transplantation, but they were fascinating on their own right. The author’s attempt to downplay the role of Christian Barnard stood out as perhaps the only sore point in what was otherwise an excellent narration.
The history and stories in this book are a close reflection of the hard work and commitment that are necessary for all scientific breakthroughs. This is particularly relevant in surgery where the price of failure is measured in unacceptably high morbidity and mortality rates. The key lessons of the book for doctors are the need to appreciate the ways in which past achievements were made, and the necessity of learning from the mistakes that presage every success. The book has eminently conveyed the beneficial impact of diverse forms of organ transplantation, and I recommend it to all doctors.
Publisher, Place, Year: Atlantic Books, London, 2019
Number of chapters: 18
Number of pages: 371
Star rating: 5