The Critical Calling: Reflections on Moral Dilemmas Since Vatican II

14. "A Clean Heart Create for Me, O God." Impact Questions on the Artificial Heart

Chapter 14 "A Clean Heart Create for Me, O God." Impact Questions on the Artificial Heart On May 24, 1985, there appeared in the New York Times, under the byline of Dr. Lawrence Altman, the following statement: [This is] probably the single most expensive medical procedure available ... Yet in a report yesterday that would redirect national priorities on one of the boldest experiments in medical history, The Working Group called for a greatly expanded Federal research effort to develop a fully implantable, permanent heart.1 Altman was referring to a report of an advisory panel of The National Heart, Lung and Blood Institute ofthe National Institutes ofHealth. Albert R. Jonsen, a member of this panel (known as The Working Group on Mechanical Circulatory Support) disputes Altman's claim that the Working Group endorsed "a greatly expanded effort." It recommended, he states, only that the present effort continue.2 Whatever the case, there can be little doubt that the arrival of mechanical circulatory support (dating to December 2, 1982 and the implantation of an artificial heart in Dr. Barney Clark at the University of Utah) will function as a symbol of the way this country faces its health challenges in the next decade or so. It is an easy prediction that we will relive the debate that surrounded dialysis for end-stage renal disease. Medicare began to operate in 1967. At that time kidney dialysis was provided by law for three groups: those eligible for veterans' benefits, Medicarebeneficiaries aged sixty-five and over, beneficiaries of medicaid programs covering this expensiveprocedure. In 256 / Richard A. McCormick, SJ. 1972, Congress extended coverage for kidneydialysis to all who needed the treatment. Joseph Califano describes the discussions that preceded this congressional generosity. There was a spirited, sometimes angry, discussion around the conference table in my White House West Wingoffice. Some said it was immoral not to provide care to all who needed it. Others said even the Great Society at its peak could not provide every medical service to all who needed it. But this was a matter of life itself, another heatedly added, pointing out that just because of quirks in the law, some were eligible and others not; some had the money to pay for it, others did not. The discussion went on and on.3 Califano's brief cameo accurately identifies the two poles that also anchored the broader congressional discussion: life and money. Could the wealthiest nation in the world choose to withhold such a service from some citizens? Is it fair to let some people die when we have the means to give them added years of life? Obviously, such questions are important. But I have to wonder whether they should so dominate the policy discussion in the way they did. Many people have had long second thoughts about the end-stage renal disease program. Many of these thoughts are probably stimulated by the fat $2billion bill that it costs. But I believe that there may be more behind such second thoughts than the financial factor. Virtually every technological advancehas its costs. Benefits comewith burdens. Therefore, it is essential to an ethical analysisthat all of the possible impacts of our interventions be identified. With that in mind, I will list areas ofpossible impact as we reflect on the future ofthe artificial heart, especially the permanent use of such a device.4 It should be emphasized that I raise these as questions rather than assertions. Indeed, to stress this, each point will conclude with a question. 1. How we view life and death. How we preserve life manifests and reinforceswhat we think of life and death. In the Christian view, as I have stated already, life is a basic good, but not an absolute one. The Christian livesin faith that she/he is on apilgrimage, that death is a transition not an end, that just as Christ conquered death and lives, so will we. We organize our lives around this belief. Question: How will this faith be affected by the artificial heart? In a sense, such faith is affected by all medical interventions inprinciple. But the artificial heart might be in a category by itself. 2. How we evaluate people. In its 1972 study, the Artificial Heart Assessment Panel of the then National Heart and Lung Institute made repeated reference to a return to functionability as a possiblebenefit of the artificial heart. In a key paragraph it stated: Impact...