Organ Rejection

In the film John Q., Denzel Washington plays a working-class dad who holds a hospital emergency room at gunpoint to get a heart transplant for his nine-year-old son. The film's critique of health care in the United States is hard to miss: The poor lack the funds and often the insurance coverage needed for organ transplants. But there's also the unspoken, murkier theme of race, which raises some unsettling questions about our ability to prolong life. The surgeons, hospital officials, and happy heart recipients depicted in John Q. are all white; the hero and his family, denied the benefits of transplantation, are black.

In real life, race and organ transplantation are seldom mentioned in the same breath, but actually a complex international history links the two. For starters, heart transplantation was born in the land of apartheid. In 1967, the surgeon Christiaan Barnard performed the world's first heart transplant in South Africa. The following year, he transplanted the heart of a young man of mixed race into the body of an older white man from the professional class -- an operation for which Barnard is known as something of an anti-racist maverick.

But as anthropologist Nancy Scheper-Hughes discovered in the 1990s while conducting fieldwork in South African morgues, blacks who lived under apartheid see Barnard's mixed-race operation as a terrifying precedent. Many of the black South Africans she interviewed told stories of young relatives who had died from poverty or violence under apartheid, and whose organs were transplanted into older, affluent whites without the donor family's consent. When Scheper-Hughes described modern transplant surgery to one elderly black woman, the informant drew a parallel to muti -- a form of witchcraft in which skulls, hearts, eyes, and genitals are taken from corpses to impart wealth, influence, or fertility. "These doctors," the woman said, "are witches just like our own."

Such fears would be preposterous in the United States, right? In fact, blacks and other minorities in this country display marked suspicion toward organ transplantation, and not just for the economic reasons John Q. encounters. Though witchcraft may seldom be the reason, religion often is. An extreme case is Louis Farrakhan, the minister of the black-nationalist group Nation of Islam, who has sometimes attributed white society's failure to stop black-on-black violence to the need for a steady supply of fresh organs. "When you're killing each other, they can't wait for you to die," Farrakhan asserted at a 1994 rally. "You've become good for parts."

Most black resistance to transplantation is less antagonistic than Farrakhan's. It can be genuinely spiritual, stemming from an African-American Christian belief that the body should remain whole after death. It also goes hand in hand with a general mistrust of the medical profession. Last summer, when the American Robert Tools received the world's first artificial heart, he was compelled to counter rumors that white doctors had used him as a guinea pig because he was black. "That's not true," Tools told The New York Times. "I came to them and I asked them to help me."

Clive O. Callender, one of a small number of black transplant surgeons in the United States and director of the Transplant Center at Howard University Hospital, has been working for decades to overcome reluctance on the part of blacks to donate and receive organs. He said, "They feel, if I am black and society has been discriminatory to me in life, why would it be any different in death?" For Callender, more transplantation is an indication of racial progress.

But now that blacks have begun to enter the transplantation mainstream, medical professionals -- who are mostly white -- are starting to question aspects of organ transplantation in a way that may vindicate some minority fears. For example, doctors are re-examining the medical and legal construct of "brain death" -- a concept that sanctioned Dr. Barnard's removal of a beating heart from a donor in 1967 and has underpinned much transplant surgery since. But Alan Shewmon, a neurologist at the University of California at Los Angeles who once approved of brain-death criteria, now thinks that the empirical evidence against them is clear: "Brain-dead patients are deeply comatose, very sick, and dying, but no more dead than many other patients who are severely disabled, very sick, and dying."

Renée Fox, a longtime expert in the social aspects of health care and a participant in the development of the artificial heart, shocked the field in the early 1990s by questioning the fairness of transplantation. "We have observed again and again," Fox wrote with her colleague Judith Swazey, "how specifically designated individuals have been privileged to obtain needed organs and funding for transplantation by wielding special emotional, media, political, and economic resources." For example, the public-relations skills of certain physicians have been shown to make a difference in securing access to organs, as has the affluence of recipients' families.

Indeed, the race to obtain organs in the United States is becoming increasingly competitive. Advocates for the outright buying and selling of organs have emerged; meanwhile, Pennsylvania recently became the first state to offer indirect monetary compensation for organ donation, and a bill has been floated in Utah that would provide a $10,000 tax credit to donors.

The experience of other countries can be both cautionary and instructive. After apartheid's end in South Africa, Nelson Mandela's government placed a moratorium on most heart transplants. The official rationale was that the operations squandered scarce medical resources. But given Scheper-Hughes's findings, it seems likely that black distrust of transplantation was a factor. In 1997, South Africa's Constitutional Court ruled against kidney transplants as well. But the result has been to shift organ transplantation primarily into the private sector, where only the wealthy can afford it.

Anxiety about transplantation remains widespread in many parts of the world besides South Africa. The harvesting of organs from executed criminals in Communist China may be the worst government-sanctioned abuse these days; but it's an issue in Brazil, too, where the state owns your corpse unless you've acquired a non-organ donor card. Poor people in India and the Philippines have sold kidneys to rich buyers from abroad.

An especially interesting case is Japan -- one of the world's most technologically advanced countries, but one of the most cautious on transplantation. Margaret Lock, an anthropologist at McGill University, attributes Japan's historical resistance -- to heart transplantation in particular -- to a mistrust of the medical profession, as well as an ethical and spiritual rejection of the notion that a person with a beating heart could be dead.

In 1968, just months after Dr. Barnard's pioneering procedure in South Africa, a Japanese surgeon attempted a similar operation. At first the transplant was deemed a victory for Japanese medicine, but soon it was revealed that the donor may not even have been brain dead and that the recipient's heart had been tampered with. The surgeon narrowly escaped prosecution on charges of murder. In 1997, the Japanese Parliament finally passed a law enabling individuals to donate their hearts by allowing them, in consultation with their families, to waive any murder charges against the surgeon. The first legal heart transplant in Japan was performed just three years ago.

When the father in John Q. decides to commit suicide so he can give his heart to his son, he elicits two reactions. A wealthy white surgeon admits that the proposal is unethical but eggs the father on. A street-smart black man -- the film's spiritual conscience -- draws the line and counsels John Q., instead, to relinquish the suicidal quest and reconcile himself to God's will.

Most parents would probably give their own life to save their child's. But in the context of organ transplantation, the decision to fight against fate at all costs is not a purely personal decision; it has social consequences, too. The demand for organs has become so intense that doctors at the University of Pittsburgh Medical Center have developed a less stringent definition of brain death in order to harvest more hearts while they're still beating.

In this light, John Q.'s threat to kill innocent hostages so his son can survive looks more than a little ironic, and the old-fashioned African-American suspicion of transplantation starts to sound downright wise. One solution might be to follow Japan's lead and allow donors and recipients to choose the definition of death that best matches their own level of skepticism or spiritual comfort. Of course, that could lead to fewer organs and more John Q.'s.