Transplantation Through a Glass Darkly

by James Lindemann Nelson

From Hastings Center Report, Number 22, September/October 1992.

"We should reject...solving the problem of organ shortage by maintaining colonies of animals at the ready for transplantation on demand."

Bioethical problems take many different forms, and fascinate many different kinds of people. Physicians and philosophers, lawyers and theologians, policy analysts and talk show hosts are all drawn by the blend of practical urgency and moral complexity that characterize these issues.

But there seem to be only two kinds of bioethical problems that typically pull into their orbits not only theorists and practitioners, but pickets and protesters as well. When it comes to the treatment of fetuses and animals, people take to the streets. On the same day that demonstrators on both sides of the abortion issue lamented the Supreme Court's decision in Casey, representatives of PETA (People for the Ethical Treatment of Animals) gathered at the University of Pittsburgh to protest the implantation of a baboon's liver in a thirty-five-year-old man--the father of two children--whose own liver had been destroyed by hepatitis B virus (HBV).

There is, of course, a big difference in the way the disputes are perceived: abortion's bona fides as a central ethical issue are well established, but despite an upsurge of interest among ethicists over the past decade and a half, concern about animals still seems a bit quirky, too exclusively the domain of zealots who maintain the moral equality of all species, and thereby mark themselves as fundamentally out of sympathy with our basic ethical traditions. Here I try to pull moral consideration of nonhumans closer to the ethical center, arguing that thinking about the fate of nonhumans at our hands shares with abortion--indeed, with many of our culture's most difficult moral issues--a fundamental problem: we don't really know what we are talking about. More concretely, we're at a loss to say what it is about baboons that makes their livers fair game, when we wouldn't dare take vital organs from those of our own species whose abilities to live rich, full lives are no greater than those of the nonhumans we seem so willing to prey upon. Unless we're able to isolate and defend the relevant moral distinction, we should reject the seductive image of solving the problem of organ shortage by maintaining colonies of animals at the ready for transplantation on demand.

Moral Outliers

Public protest about abortion is not galvanized by concern about the quality of informed consent, or its impact on the doctor-patient relationship. What does lie at the center of the dispute is an absolutely crucial kind of ignorance. As a society, we don't know what fetuses are, and, in an important sense, we don't know what pregnant women are either. Are fetuses babies or tissue? Are pregnant women mothers bound by special duties to their unborn children, or independent adults exercising their right to make important self-regarding decisions under the protection of a mantle of privacy? Because we don't know these things, and they matter so much, we have a hard time imagining what responsible compromise might really be like.

And what gets people out into the streets in response to a daring attempt to rescue from certain death a young father of two? What, for that matter, causes medical research advocacy organizations to spend large amounts of money, not on research, but on full-page ads in the New York Times defending what scientists do? Is it concerns about justice in the allocation of medical resources? Doubts about the "courage to fail" ethos? Misgivings centered around the independence of IRB review? Surely not. The ground of protest and counterprotest is a similar kind of ignorance about the fundamental terms of the relevant moral discourse: we don't know what animals are, either. We treat them as if they were morally protean; we mold them unto anything from much-loved companions and symbols of virtue to mere machines for making food and instruments for scientific research.

The Edges of Moral Concern

Our ignorance as a society about these dark corners of our moral commitments, our lack of consensus about where outliers really fit, is extremely divisive when coupled with individual assurance that there is in fact available knowledge about these matters, that the answers are of surpassing importance, and that there is something suspicious, if not downright evil, about the people who don't get it. While such conclusions cripple civility, and should of course be resisted, our history should be making us nervous. We have so often gotten matters of who counts morally just flatly wrong, and have exacted horrible prices from those shuffled unjustly to the margins of our moral concern.

What fetuses are has at least received a thorough airing in the bioethics literature. Gravid women we still find quite puzzling apparently, as witness current concerns about "forced cesareans" and "maternal-fetal conflict," but at least there is an awareness that getting clear about the moral character of pregnancy is a key to understanding the morality of pregnancy terminations. But despite their ubiquity in medical research and practice, determining what animals are is not thought of as a paradigmatic bioethics issue. Yet seeing animals clearly is likely to be at least as difficult as the analogous tasks for fetuses and pregnant women. After all, we have a strong stake in the presumption that nonhumans are things whose moral status is at our discretion: the looser we can keep the moral constraints, the freer we are to do as we like with these extremely useful creatures. Further, there is a sense in which animals really are protean. Human beings are animals; so are protozoa. Drawing some moral distinctions is inescapable when facing such a range, and if there's to be a bright line between entities that really matter and those that don't, the human species may very well seem a reasonable place to draw it.

Choosing this line may appear suspiciously self-serving. Yet, at least at first glance, it looks as though there really could be something ethically serious to be said for us. We don't have to rely on t@e brute fact that we're got all the power; this is a comfort, as "might makes right" has a dubious history as a basis for moral distinctions. Nor do we have to resort to the bare fact of our common species membership--again, all to the good, as such purely biological bases for moral categorization also have a simply horrifying pedigree. Further, we can avoid invoking the soul as a sort of special moral talisman whose possession elevates us above all others: purely metaphysical entities aren't much use when we're trying to do ethics with an eye to public policy in a pluralistic society. Besides, imagine what we would do if someone were to argue that the subjugation of women was justified on the grounds that all and only men possess "schmouls," an empirically undetectable entity that inexplicably gives them extra moral worth.

Transplants Distract from Better Treatments

Chronic hepatitis is a serious disease. It kills about 6,000 Americans every year. While hepatitis often passes on its own with no treatment, for a fraction of patients the disease becomes chronic and debilitating.

Even so, the baboon-to-human liver transplants performed by...experimenters are not the answer. First of all, this is an experiment, not a treatment. That means the commitment of millions of dollars and many lives, both human and animal, with no clear likelihood of success. And it means the inevitable sacrifice of researchers' time and resources that are needed for other better treatments....

Cross-species transplants have been a dream of some researchers for years--an impossible biological barrier to be assaulted with a steady surgical hand and some good immunosuppressant drugs. In chasing that peculiar surgical vision, realistic medical treatments may well be lost. And that is the real tragedy.

Neal D. Barnard, San Diego Union-Tribune, January 13, 1993.

The distinction we wish to draw between humans and the rest of creation seems much more respectable than distinctions based on might, on species, or on sectarian metaphysics. One could say that the appeal to such things as the range and power of the human intellect, the complexity and depth of our interpersonal relationships, our passions, both personal and aesthetic, our sense of morality, and of tragedy makes good sense. If these abilities and vulnerabilities don't matter morally, it's hard to imagine what would.

But if these are the characteristics that matter morally, it is not only baboons who lack them; not all of us humans have them either. Many humans have lost, or will never have, powerful intellects, deep relationships, rich passions, or the intimations of mortality. Think of the profoundly mentally ill, the comatose, and those who have sustained severe brain injuries. While such humans are themselves instances of tragedy, they have no sense of what tragedy is.

Despite this sad fact, our convictions about the importance of simply being human are so strong that we hesitate to use organs from newborns with anencephaly, a condition incompatible with either sensation or life. Given this hesitation, one can imagine the response if a leading transplant surgeon were to call for the maintenance of colonies of mentally handicapped orphans, to be well cared for until needed, but whose organs would then be "humanely" harvested for use in dying but otherwise "normal" people--infants with hypoplastic left heart syndrome, young fathers with HVB. Yet this scenario--with baboons and other primates substituting for handicapped orphans--is precisely what some transplant surgeons have been advocating since at least the 1960s, and is quite explicitly part of the agenda underlying the recent effort in Pittsburgh. If we are morally repulsed by a call to use handicapped orphans, but are eager to see whether colonies of baboons mightn't become a solution to our endemic lack of transplantable organs, it surely behooves us to have a good answer to the question, "What's so different about the two kinds of creature?"

Costs and Benefits of Xenografting

Perhaps there is a good answer to that questions difference, or set of overlapping differences, that will end up ethically supporting our practice. Perhaps we could, without arbitrary prejudice, keep all mentally handicapped humans, no matter how damaged or how alone in the world they might be, in the ethical family, so to speak. Perhaps it's appropriate to see all nonhumans, no matter how intelligent or complex their lives might be, as largely discretionary items, to be cast into the outer darkness if anything approaching a serious purpose seems to demand it. Or perhaps the real moral of the story here is that it is not baboons we should respect more, but humans who are their emotional and intellectual peers we should respect less; consider the research and therapeutic bonanza that would yield! But defending either of these conclusions would take a powerful argument, and there's very little evidence that any of the people most enthusiastically thumping the tub for more and better xenotransplantation have come up with reasons of the kind that are needed. Typically, their strategy is simply to point to the human cost of not pushing the xenograft agenda--the "three people who die every day waiting for a necessary organ" argument--without any serious attempt to balance that cost against the debit incurred to the victims of those grafts. Nor do we see much effort to set the xenograft strategy against the costs and benefits incurred by trying to enforce the required request laws that are already on the books, or to enact "presumed consent" or "routine retrieval" policies for organ procurement.

Discernment in the Dark

This, of course, returns us to our original problem: we don't even know how to begin that balancing act, and it seems that we aren't very keen on learning. A simple reliance on our moral intuitions isn't enough. As the history of medical research in the nineteenth and even twentieth century reveals, we have been more than willing to subject those who were "clearly less valuable" to the rigors of research--only then, the ones who were obviously less valuable were Jewish, or people of color. Our gut instincts simply aren't good enough as reliable moral guides when we're dealing with those whom we've pushed to the margin of moral discourse The question is not whether we're generally able to move deftly within our ordinary understanding of morality, but whether, when it comes to the moral outliers, that ordinary understanding itself is adequate

Cross-species transplantation crystallizes a certain kind of moral conflict between humans and other animals--perhaps too sharply. Pitting the life of the father of two against that of a baboon is sure to strike most of us as no contest. The glare of the contrast distracts us from such realities as the fact that, at the point of decisionmaking, the animal's death buys only a chance, not a guarantee, or that the outcome of acting is not always better than the outcome of refraining, even when death is inevitable if we stay our hand. If we reflect about our moral duties and liberties more broadly, it may strike us that we are apparently quite comfortable allowing many tragic deaths to occur daily, when what it would take to stop them is not the life of an intelligent animal, but merely the cost of drinks after work.

On the other hand, if we do refuse to take the baboon's life in an effort to save the human's out of a sense that the moral parity between baboons and mentally handicapped humans leaves us no other option, then we need to ask what else that sense of parity implies. The animal who provided the liver in the Pittsburgh case was at least killed in an effort to save the life of an identifiable person. But most of what we do with the lives of animals is--at best--only distantly related to the lives and health of people in general. If it is wrong to kill a baboon to try to save a man's life, is it wrong to kill a pig because sausages taste so good? To kill a kid to make elegant gloves? Critics of xenograft whose main concern is with the "sacrificed" animal may find it relatively easy to adopt vegan diets and eschew wearing leather. But do they really advocate that ill people begin a wholesale boycott of a medical system in which the training and research leading up to its quite standard offerings are, as it were, drenched in the blood of nonhumans?

The implications of all this for the development of xenograft and the creation of "donor" colonies are comparatively clear. There are numerous ways in which we might strive to save and enhance lives, including many that are more efficient than killing animals who resemble us in no small degree--ways that do not burden us by reinforcing our commitment to moral positions we do not fully understand, and may not be able to maintain. If we feel morally constrained to continue organ transplantation as an important way of saving and enhancing human lives, we ought not to try to respond to that moral challenge with the technological fix of a better antirejection drug that will allow us to use nonhumans as organ sources, but rather by figuring out better ways to engage the altruism of the human community, until at last it strikes us all as mighty peculiar that anyone would want to hang on to her organs after death, when she has no conceivable use for them.

We ought to drop xenograft research and therapy, investing the resources of human effort, ingenuity, and money it consumes elsewhere. We don't now know what the judgment of history regarding our relationship with nonhumans will be, but there's no reason to be sanguine about it. What this uncertainty says for our overall relationship with animals may still be a matter for debate, but there's no compelling need to make matters any worse.