Who Lives?

Mr. Smith is a 58-year-old African-American male, who appears at least a decade older than his stated age. He is about 6’0, slim, and features a neatly-trimmed mustache. He sits stooped forward, and relies on a cane to get around. Mr. Smith has a pleasant affect, and even offers to get me a cup of water. His legs show moderate edema, and his eyes feature notable scleral icterus. Mr. Smith is on the list.
Mr. Smith inquires to whether I’m “also on dialysis,” and if I voted for Obama. I told him that I’m attending as a medical student, and that I don’t share my political views in public. Mr. Smith believes that Obama will bring us “back to nature” and will stop “sending jobs overseas.” I smile and tell Mr. Smith that I hope the president helps solve the economic crisis. This is no occasion for pessimism.

Mr. Smith expounds on his dating woes. His last girlfriend was “too needy,” and wanted something more permanent than Mr. Smith was able to provide. Mr. Smith implies that his misgivings were more due to his lack of emotional readiness, rather than the fact that his remaining days are contingent on a fluctuating number on a table, and that, like many of the 101,236 current Americans waiting for an organ, he may die before receiving a much-needed kidney transplant.

I met Mr. Smith, because I happened to sit next to him this past Sunday in a downtown Los Angeles theater, to view “Who Lives?,” a play Sponsored by the Renal Support Network. The production takes place in early 1960s Seattle, and explores the moral anguish afflicting a committee dedicated to choosing the lucky few who will test a curious, but experimentally promising machine, which “removes your blood, cleans it out, and then returns it to your body.”

The panel consists of a devout priest (“God has chosen us for this very important purpose”), an overwhelmed homemaker (“Father, there isn’t anything spiritual about this!”), a blue-collar craftsman (“The workers are always getting a raw deal, so what’s so wrong…”), a pedantic, neophyte doctor (“Disease is just the gross exaggeration of aging”), a pushy Jewish lawyer (“F-ck doctors”), a beautiful, liberated grad student, and some un-endearing blonde guy, who instinctually rejects Black applicants, and focuses the rest of his attention on seducing the grad-student. The group’s task involves ranking people, not merely based on medical criteria, but also each applicant’s presumed “value” to society. Thus, the committee debates the relative "significance" of musicians versus businessmen. The wealthy versus the poor versus the “rags to riches” success stories. Women versus men. Women with children versus men. Fertile women versus infertile women versus men. Blacks versus whites.

Today, such technocratic management of life and death strikes one as pretty abhorrent. Unfortunately, however, I find no solace in our contemporary method of organ allocation. Indeed, while we, as a society, have come to recognize the human infallibility inherent in prioritizing human lives, we now do something far worse, by creating an artificial shortage of life-saving organs, and banning individuals, charities, and the government from paying people for their kidneys.

We invoke all kinds of moral arguments to dissect messy commerce and greed from the prim and genteel art of uprooting a meat-sized slab of tissue, hitching it to various tubes and plumbing out a urine stream. To defend the volunteer-only status of organ donation, liberals and conservatives alike manufacture arguments that they would never entertain, when concerning other topics: “The poor will be the first to give up their organs, and this is harmful!!” (Cs: Should we prevent the needy from obtaining payday loans or eating at McDonald’s? Ls: Ought we to restrict women from obtaining abortion or birth control, even if it posed her some risk?) “It will be racist!” (Check out the demographic makeup of the waiting list.) “It will cheapen the ideal of giving from the goodness of one’s heart! “ (Ls: Do you ascribe the same logic to food stamps? More ceremoniously- “Would you like to sign up today and volunteer to save a life?! Low risk and high 'goodness of heart' satisfaction! No? I, shamefully, haven't signed up either...”) “Legalization will increase violence and coercion!” (Organ prohibition, meet drug prohibition), “Only rich people will be able afford them!” (Rich medical tourists and insurance-holders are generally the only ones who can afford obtaining organ transplants. If legalized, there may still be a disparity between the rich and poor in organ procurement, just as there is in all aspects of medicine, but this does not call for a ban on all medical procedures. However, we can legalize organ sales, and then- depending on whether you favor Heritage or TAP- accept a certain degree of inequality, or fiddle with our health care system, so that the poor can afford organs, as well).

My feeling is that most people oppose economic exchange of organs simply because the whole idea seems very, very unpleasant (yes, to me, too!). But good public policy is not constructed to convenience such a persnickety relic of natural selection as our sense of disgust. We ought to focus solely on whether we are actually helping people like Mr. Smith, who needs additional time to find the fellow freewheeling partner of his dreams.

In “Who Lives?,” while the committee pores over endless piles of pallid folders, the delicate housewife cries out, “We shouldn’t even have the power to make this decision!” However, she and her colleagues at least brave the clearly-understood ramifications of crafting countless letters featuring the dreaded words, “We regret to inform you...” Today, meanwhile, we largely avoid such formalities, by revering our high-minded legal dictates, and remaining casually inattentive to the tragic reality of thousands of end-stage kidneys.