Historical Context

Robin Cook, master of the medical thriller, was born in New York in 1940, received an M.D. from Columbia University, and did postgraduate work at Harvard Medical School. He is on a leave of absence from Massachusetts Eye and Ear Institute and lives in Waterville Valley, New Hampshire, with his wife and child. He was once Jacques Cous-teau's Sea Lab aquanaut in the south of France. Since 1970 Cook has been writing about hot issues in the evolving medical field. His other novels include Outbreak (1987), VitalSigns(1991), and Toxin (1998). Cook's novel Vector (1999) about a bioterrorist anthrax attack on New York City foreshadowed the real-life event in 2001. Showing a knack for anticipating public debate on controversial topics, Cook's Shock (2001) describes the fertility industry and controversy over federal funding of stem cell research. Each novel is compelling and informing, while also exacerbating the public's fear.

The organ transplantation industry is the subject of Coma. Each day in 2001 63 people in the United States received an organ transplant; another 16 on the waiting list died because organs were unavailable. Driver's licenses and living wills may have an advance donor directive; however, family members often have the final word. Therefore, potential donors should tell family members of their wishes in advance. Living donors cannot donate if it is life-threatening, with uncoerced, voluntary informed consent required. Then there are brain dead donors whose cessation of brain stem function is indicated from an EEG test. Because the brain makes a person breathe, organ vitality is sustained by cardiopulmonary machines. Ethical concerns arise when harvesting from brain dead donors because brain death is a process without a distinctly pronounceable event like cardiac death. Hospice professionals, in particular, exercise ethical care in withholding food and liquid from and administering narcotics to a patient with auditory and visual responses. In a recent development, doctors who felt there was only a small window of opportunity for harvesting most transplant organs now look to a 2002 University Hospital Zurich study that shows transplant success even in harvesting older organs from cardiac death donors. This goes beyond the conventional wisdom that only a few organs such as corneas and kidneys remain viable for a time in cadavers. In heart transplantation, brain death as a criterion is distinctly different from cardiac death because only a recently beating heart can be harvested. Artificial, self-contained hearts only extend life until a donor heart can be transplanted. Bioengineering a human heart from stem cells triggered to become cardiac cells is decades and billions of dollars away. Existing stem cell lines used in research are declining, and President George W. Bush placed a moratorium on cloning to reap human parts.

While most industrialized nations legitimize brain death as a condition for organ harvesting, there are many cultural differences. In 1968, Dr. Juro Wada harvested Japan's first and only heart for transplant from a brain dead donor and was heralded as a hero and condemned as a murderer. China's primary source of transplantable organs comes from executed prisoners without their consent. Transplant proponents argue that fear and ignorance are great barriers to collecting transplant organs. Most major U.S. religions consider donation the ultimate act of charity and condone it; other views prohibiting donation include the religious belief that the body must remain intact in order to be resurrected in toto, the belief that organ harvesting from a viable body equates with abortion, and the belief that the soul still resides in the body with a beating heart.

Because transplant organs are so hard to get, there is a current debate over the donor's motivation or the commodification of tissues. The U.S. Organ Procurement and Transplantation Act makes it illegal to buy and to sell human organs. Because of the great gap between supply and demand, wealthy recipients would have inequitable access to donor organs. Right now only a donor's medical and funeral expenses are paid, so an American Medical Association ethics group sug gested a small payment of $300 to $500 or tax credits to increase donation. Organ transplant organizations claim it is an urban myth that in foreign countries poor people are waylaid, drugged, and surgically relieved of their organs; nonetheless, an advertisement appears from time to time offering a kidney for sale from $1,000-$10,000. Pirated organs may be a rarity because complex donor-recipient matching, the required surgical skill, and follow-up care are essential. Other myths include the recipient acquires the donor's desires (liking certain foods, for instance), the donor is limited by age (minors need guardian consent), donation mutilates the body prohibiting open-casket funerals, and the donor's estate pays the medical costs. Potential donors may fear indicating their wishes to donate will forestall efforts to save their lives, but safeguards are in place because the donor's medical team and the transplant team are two separate entities. Besides, the organ procurement organization is not notified until brain death is determined. Kidneys and corneas are the most transplanted organs, largely because of progressive surgical skills and fewer rejection factors. Other organs and tissues transplanted are the heart and heart valves, liver, pancreas, lungs, intestines, eyes, skin, bone and bone marrow, and tendons. A national organ donation network matches donors and recipients for blood type, medical urgency, geographical location, and time on waiting list.

Because many people die waiting for a suitable organ, recent developments in transgenic cloning are making it more feasible to transplant modified animal organs into humans with fewer rejection problems and cross-species diseases (xenotransplantation). In another advance, Dr. Anthony Atala of Harvard Medical School in 2002 took a donor steer's skin cells and created functioning tissues that were transplanted into the donor steer. Three months later the implanted tissues remained healthy and were performing their respective functions. In the case of humans these same principles should apply to growing body parts using a person's own DNA, or body parts may derive from human embryonic stem cells, an issue mired in abortion politics. President George W. Bush's Council on Bioethics in 2004 only approved of therapeutic stem cell research on existing lines, limiting research potential. Public opinion is sharply divided on these issues.

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