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Wednesday, February 1, 2023

The Capitalist Trap of Pig Organ Transplants

Dave Bennett agreed to have an experimental pig heart transplant surgery for two reasons. First, he hoped it meant he would be able to return home to his beloved dog again. And second, after being deemed a problem patient and consequently rejected from heart transplant programs, this was his only chance at life. In Bennett’s own words, he “wants a human heart.” By agreeing to the surgery, he’s hoping to convince the medical establishment that he’ll finally deserve one.

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In 2020 alone, more than 40,000 Americans waited on organ transplants. And though close to 3,000 Americans did receive replacement human hearts, as many and more remain on the waiting list—20 percent of those will likely die before they can receive one. Scientists have been working for decades to develop (through gene editing and cloning) pigs whose organs won’t be immediately rejected by the human body, all in the name of solving the problem of supply shortages. To make these organs viable for humans, scientists introduced 10 genetic modifications to the pig from which Bennett’s heart was taken. The pigs were also bred to be smaller so the heart would not continue to grow inside the human body. The resulting surgery would involve three experiments: an experimental heart from an experimental pig, an experimental surgery, and finally, an experimental anti-rejection drug. None of these procedures had been tested in a living human prior to Bennett’s surgery. There were a lot of variables—and a lot of big “ifs.”

Despite the laudatory headlines, Bennett’s surgery was not a miracle; it’s part of a long and controversial history of animal-to-human (or xeno) transplant research. In the 17th century, blood of various animals was used in transfusions; by the 19th century, the skin of frogs was used for grafts. And in the early 20th century Serge Voronoff popularized implanting baboon testicles into aging men. But the first primate-to-human heart transplant took place in 1964. The patient died within two hours. In fact, most xenotransplants have failed due to immunological and pathobiological (disease-related) problems. But increasing shortages have pushed this science forward, notwithstanding. And as with all medical “firsts,” such surgeries need their first patient, their first trial.

Bennett became first not by true choice, but by necessity: “It was either die or do this transplant,” he said before the surgery. In the race to perfect xenotransplants, we have already set up a system of haves and have-nots, of those who are considered worthy of a human heart and those upon whom we can take risks. And that's unlikely to change, no matter how common pig organs become.

Bennett spent his life doing itinerant jobs to support his family. He’d fix the pool, do maintenance on your car, or provide the occasional painting or home repair. Ten years ago, he had a decellularized pig heart valve inserted, an increasingly common procedure that doesn't actually involve introducing any pig cells into a human. After that, he had been relatively healthy, but in October, something changed. He felt fatigue, had shortness of breath, and couldn’t climb the stairs. His son David, a physical therapist, grasped the gravity of the situation, and Bennett went for care at University of Maryland Medical Center. He was diagnosed with uncontrollable arrhythmia—his heart was giving out—but it isn’t easy to get on transplant waiting lists. Especially for patients like Bennett.

Given the short supply of organs, the expense of implanting them, and the extensive recovery time following, transplant teams want patients they feel will have the best chance at success. But how do we measure this, and what ultimately makes a good patient? It helps to first understand the requirements of an organ transplant. Unless an organ is being donated from a genetic twin, the body it arrives in will see it as a foreigner. As a result, the body’s own immune system will attack and reject it unless patients take anti-rejection drugs for the rest of their lives. The new organs must be monitored through regular checkups, and patients must make significant lifestyle changes. Patients who have a history of not following a doctor’s orders or showing up for their appointments—what the medical system calls “noncompliance”—are therefore considered risky for transplants and often turned away.

But what this system misses is that noncompliance isn’t always the result of a patient being unwilling to or uninterested in following directions. A patient who is not taking medication properly, for instance, “may have forgotten the doctor’s instructions,” or patients might not follow the recommended diets because they “can’t afford to buy additional food,” explains Sue Edwards of the Center for Ethics in Washington, DC. In still other situations, the problem is the expense of medications and checkups for those with no insurance or steady work. According to Bennett’s medical records, he had missed follow-up appointments and didn't take his prescribed medication consistently after his valve implant 10 years prior. Was it because he hadn’t understood the importance of the follow-up? Was it confusion over medications? Did it have to do with cost? The notes themselves will not provide those answers because the answers will not matter; the medical establishment, says Donna McCormack, principal investigator of Transplant Imaginaries, a project on embodied ethics, “already deemed him a troublemaker.”

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Bennett’s surgeon, Bartley Griffith, says he first told him about the experimental protocol in December. “We can’t give you a human heart,” he recalled for the New York Times, but they could use a pig’s heart—even though (and in some ways, because) it had “never been done before.” Griffith described it as a moon shot—where the patient is the one taking the real risks. But it’s important to note that those risks were paid for. Though neither the hospital nor the academic institution would reveal the cost of the procedure, they admitted to covering any fees not picked up by Bennett’s insurance, which, of course, would not have been the case in an ordinary procedure. In the present system, experimental surgeries rely on vulnerable patients who have no other way forward and nothing to lose.

In an unusual twist, shortly after the story of the transplant broke, the Washington Post reported that Bennett had served six years in prison for assault. The victim’s sister said he was “unworthy” of the surgery—to which the University of Maryland Medical Centre rightly replied that it was the “solemn obligation” of a hospital to provide care based entirely on medical need, not on his history. The irony—or rather, the noncompliance ethical dilemma—is that a patient’s past is never used as a reason for refusing treatment. Until it is. Bennett, by virtue of his noncompliance from years before, had already found himself on a hierarchy of care that had little to do with need, and everything to do with history.

For many who seek to further the field of xenotransplant, who justify experiments on individuals like Bennett, the point of farming organs would be to alleviate the shortage of organs for all patients. Jayme Locke of the University of Alabama at Birmingham, where a successful pig kidney was transplanted into a brain-dead patient last week, suggests pig organs will advance the entire field: “What a wonderful day it will be when I can walk into clinic and know I have a kidney for everyone,” she told the New York Times. The scientific advances, including genetic alterations, the cloning of DNA, and more, are truly remarkable, and the possibilities suggestive. But even if this works, the aspiration for “surplus” organs has its own ethical nadir.

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Simply put, “it’s a fantasy,” says MacCormack. We could build new, vast farms of genetically modified pigs (with their own climate footprint); we could perhaps develop enormous warehouses of heart-lung machines to keep the pig organs alive and viable until transplant. But the myth of indefinite supply is yet another capitalist trap we are learning to mistrust. At present, the United States has a surplus of vaccines—but anti-vax movements notwithstanding, there are still plenty who cannot get access to them. “There’s never going to be enough,” MacCormack explains, “because they will keep changing the parameters as to who can get them, how unwell you can be, under what circumstances.” There will still be the dichotomy between who gets an experimental pig heart and who gets a safer, more trial-tested human one. Our medical systems have been built on the same capitalist hierarchies of haves and have-nots. They will always serve the most privileged at the expense of the least.

For proof, we need look no further than medical history. When in 1968 Christiaan Barnard took the heart from a 24-year-old Black man named Clive Haupt and placed it in the chest cavity of Philip Blaiberg, a white dentist with chronic heart disease, he didn’t just inaugurate a new era of heart transplant—he also stoked fears among the Black community. Haupt’s doctor described the pressure put upon him to declare the patient brain dead so that his heart could be used to save a life considered, at that time in apartheid South Africa, of more value. Will they work as hard to save our lives, asked The Afro-American, a weekly newspaper in Baltimore, or will doctors be willing to let Black patients die in order to take their organs and perfect their science?

In the 50 years since the first successful human heart transplants, a great deal has changed technologically, but vulnerable people still bear more of the risk and reap fewer of the benefits. Bennett remains alive with his new heart, almost two weeks after surgery, but no one yet knows when (or if) he will be able to leave the hospital. Bennett may be moving scientific progress forward, but he does so for the benefit of patients who won’t have to take his risk.

Can we progress science without these ethical dilemmas? We can, but it would mean leaving the for-profit model of biomedicine behind. In all such cases, including the historical ones, supply and demand have meant that the best treatment options go to those who can afford them—those with the greatest financial means or personal connections. When scarcity comes, the false equivalence between money and value means the privileged get better care. It might mean they receive the scarce human organ transplants—or the expensive, cutting-edge 3D-printed organs—while others are forced to do without, or, as with Bennett, to make do with experimental pig organs.

If medical research, particularly in the United States, can divorce itself from the capitalist myth of surplus, then there is hope for a future of truly accessible transplants. In that future, Bennett would be allowed on the human heart waiting list, rather than having to prove himself through experimental surgery. Perhaps he may still have opted to have the pig heart transplant, but it would have been a free and clear choice, not made because there were no other options. In the meanwhile, Bennett waits and hopes he will be given a shot at a human heart transplant. “I want to help other people," Bennet told his son before surgery, but more than anything he wants to live.

Updated 1/27/2022 2:30pm ET: This story has been updated to correct Jayme Locke's gender pronoun.

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