Health Matters

GUEST: Dr. Isadore Rosenfeld
VTR: 3/29/1983

I’m Richard Heffner your host on THE OPEN MIND. In a strange way today’s program would have been harder to do had not a brave and resourceful man died just the week before we do this program, a man whose strength and determination made possible a literal medical miracle. We used to say about such a man, “He’s all heart”. Well, I don’t know what we can say now. I couldn’t even pretend to guess at what the subtle shift in metaphor that we’ll have to experience now will do to our sense of ourselves. For Barney Clark lived 112 days with an artificial heart. Indeed, at the end the headline said, “Dr. Clark’s death linked to failure of all organs but the artificial heart”. Perhaps the philosophical, ethical, and psychological aspects of this extraordinary event will take the course of our lives and perhaps longer to decipher. I am reminded of those lines from Pascal: “The heart has its reasons which reason does not know”. But the medical implication of Barney Clark’s 112-day life with an artificial heart can be more clearly identified. And so I’ve invited as my guest today a most distinguished cardiologist, Dr, Isadore Rosenfeld, Clinical Professor of Medicine at the New York Hospital Cornell Medical Center. Dr. Rosenfeld’s discussions here on THE OPEN MIND of his widely popular volume, Second Opinion: Your Medical Alternatives, have always elicited an audience cry for “More, more”.

Dr. Rosenfeld, thanks for joining me again today. I know this is a kind of difficult subject to deal with. Indeed, when we arranged the program Barney Clark was very much alive.

ROSENFELD: Well, he was alive.

HEFFNER: Okay. Tell me what you mean. Even as I said that, Dr. Rosenfeld…

ROSENFELD: You regretted it.

HEFFNER: No, not regretted it; wondered if you’d pick that up. What do you mean?

ROSENFELD: Yeah. Well, I think we’re going to talk about some of the philosophy of the artificial heart. Who should get it, should anybody get it at this point? The only regret I have in this particular case, and I fully concur with you about the man’s courage and the ordeal through which he went in the 112 days. But I think he was so desperately sick to begin with, not only with respect to his heart, that this is almost a distorted experience with respect to the premise or the use of an artificial heart. What I’m saying is there are so many people, young people who are otherwise intact except for the heart. Their brains are working, their lungs are working normally, their kidneys are functioning well, except that the heart has been destroyed by some process or other. There’s isolated involvement of the heart. I wish that the recipient of an artificial heart, the first recipient perhaps, would have been somebody like that. Because I don’t really think that one can judge the efficacy of this particular primitive prototype unit in this particular case, because as you yourself said, everything had gone except the artificial heart.

HEFFNER: Now, Jarvik and the others certainly would have preferred, wouldn’t they, to have used this first artificial heart on someone who was otherwise, as you suggest, all systems go with their other organs? They would have preferred that too, wouldn’t they?

ROSENFELD: I suppose they would have. But my understanding of it was that there were other people who had requested an opportunity to be the recipients of this artificial heart. This was not the sole recipient.

HEFFNER: Yes, but the question I’m getting at is – I understand what you’re saying – but the point that I’m trying to get at, feebly I’ll admit, was that there were other considerations that the medical profession had, and that the whole concern with…Well, for instance, The New York Times, when shortly after the original operation, there was an editorial “Prolonging death is no triumph. But can all that pain and exertion be worthwhile? The purpose of medicine is to improve life’s quality, not to make Methuselahs of us all”. And there was so much opposition in the first place to this, perhaps this act of arrogance, putting an artificial organ into a creature of God, that didn’t they have to worry about picking someone who was in extremis before they could operate?

ROSENFELD: Well, I think you’ve made several good points there, and I’d like to…

HEFFNER: Undo them? (Laughter)

ROSENFELD: …address myself to them. There are many people who are candidates for an artificial heart, who have no alternative without the artificial heart, or a heart transplant. As a matter of fact, in order to get a heart transplant, you have to be under 55 years of age and in very good condition. So that, and that’s also a massive operation and a very drastic decision for a patient to make. The point is that there are people who have very little life expectancy, who are intact. I don’t think this was an act of arrogance. I think that the whole question about an artificial heart is viewed from an emotional point of view because it’s the heart. There are thousands, hundreds of thousands of people the world over who live by virtue of an artificial organ other than the heart, and who would be dead without it. And I refer to kidney transplants, and I refer to kidney dialysis. Now, there are people who go three or four hours a day three or four times a week to have the impurities washed out of their blood through the artificial kidney. For me as a doctor there is very little difference technically to choose between the artificial heart, the artificial kidney, the artificial liver that you’re beginning to read about. I mean any organ without whose normal function of life is not possible is to a scientist and a technologist and to a physician equally important and drastic. So the fact that this is a heart and not a liver and not a kidney doesn’t change things. And I think the process of selection is what counts. I’ve heard doctors say, “Well, now we ought to spend the money on prevention and not fiddle around with an artificial heart”. The fact is you can’t stop it. You can’t stop people going to the moon. You can’t stop these interplanetary expenditures. You can’t stop the challenge. And the challenge is a surmountable one. You can be sure that within our lifetime people will be getting artificial hearts routinely. Almost as routinely as kidney transplants. The unfortunate aspect of this particular case is that it was implanted, in my judgment – and I am not privy to all of the medical, or to any of the medical data other than what you and I have read in the newspapers and what I have read in the medical literature – but I know that just prior to the operation itself, the weeks during which the team was being set up, they were looking for somebody under 55 years of age, they were looking for somebody without serious disease of other organs, somebody who was not a diabetic for example with other vascular involvement. They were looking for these people. I understood that there were two or three such subjects in the wings waiting. And why they selected Barney Clark, I’m sure they had a, you know, perfectly valid reason, I don’t know. I think it’s unfortunate though.

HEFFNER: Would you have chosen him if there were no one else in the wings?

ROSENFELD: NO, I would not have chosen him, because it seemed clear to me that this man would not survive regardless of how the artificial heart functioned. And I think it’s in a sense too bad to have subjected him to the pain and suffering. That’s the thing that I regret. To have subjected him to the pain and suffering without a real chance for a meaningful life. And I’m not talking about the hose that connect them to the wall.

HEFFNER: What are you talking about?

ROSENFELD: I’m talking about a life in which he would not have recurrent lung problems, kidney problems, all things that he was already suffering from, and that could not be cured by the artificial heart alone.

HEFFNER: But you know, it is that meaningful life or meaningful quality of life that I think does disturb so many people. How do you define that?

ROSENFELD: Well, I think each one of us has to define “meaningful life” in our own terms. I think there is no question that the issue was put to Barney Clark and that he chose this for him was a meaningful life, to be aware of his environment. His mind after all, at least before the operation, was intact, to be aware of his environment. To have his loved ones around him even though he was tethered by a six-foot wire or rope or…That to him was the important thing. Now, whether it would be important for you and me is beside the point. He was a free agent. He was an educated man. As a matter of fact, he was a dentist, a professional man with a medical background. He made that decision. Now, we can’t fault him for making that decision. But I think if I had been the physician or surgeon in charge I might not have gone that route for precisely the reasons, you know, what’s happened.

HEFFNER: You said something before that was distinctly reminiscent of the Kennedy’s. Talk about sending a man into space. That old notion: Because it’s there. Because we can work at this, we’re going to; there’s no stopping it. You really mean that?

ROSENFELD: Well, the reason…I know, I know. But let me elaborate. I’m not talking about prolonging life so that people can live forever with an artificial heart. I think we’re programmed so that life for us is finite. I’m talking really – and it may sound odd – about quality of life. There are countless thousands of young people, people in their 20s, 30s, 40s, 50s, and even 60s who are young, who have no quality of life because of severe cardiac impairment, whether the heart has been damaged by a valve that’s diseased by rheumatic fever, by some virus that’s destroyed the heart muscle. There are thousands and thousands of such young people who are not well enough to live comfortably and who are not sick enough to die immediately. And I think that the promise of an artificial heart for them, not this model with the big console, but the battery-implanted one will be fulfilled one day. And the only way it will be fulfilled is if we start now working on prototypes. It’s like the Wright Brothers’ airplane as compared to the 747 or the Concorde.

HEFFNER: Dr. Rosenfeld, you talk about the business of artificial heart. You talk about the other organs which, in Dr. Clark’s instance, are themselves on their way out.

ROSENFELD: Predominantly the lungs in this case, is what I understand.

HEFFNER: Where, then, do we draw the line? When do we say, “This is a bionic man or a bionic woman, and that’s not for us?” Can we replace the lungs? Can we replace the liver? Can we replace the kidneys? Where do we stop?

ROSENFELD: Well, at this moment we’re limited in the organs that we can replace. But I don’t think that there should be any prescription or limit in our biological, in our attempts to improve the quality of life. Now, I want you to understand, I’m not talking about living forever. But I see nothing wrong if somebody has been plagued with a congenital or terrible disease of the lungs or of any other critical organ, if medical science can devise a away to replace that particular affected organ, whether it be the kidney or the, and you know, we’re replacing kidneys by the thousands with kidney transplants, either from relatives or cadaver kidneys. We’re keeping thousands of people alive with dialysis. I mean, we’re already doing it. And you ask any of these people, ask somebody who is living a normal life now by virtue of the fact that they have somebody else’s kidney in them, whether they think they are bionic. They’re not bionic; they’re just healthier.

HEFFNER: You’re begging the question, if you’ll forgive me.

ROSENFELD: You think so?

HEFFNER: Let’s take someone with someone else’s kidney. That person then, getting along very well, does he or she become a subject for an artificial heart too at some point?

ROSENFELD: Not necessarily, no.

HEFFNER: No, no. I mean, if indicated?

ROSENFELD: If indicated?

HEFFNER: What would you say? Fine, why not?

ROSENFELD: Absolutely. If that person is now living normally just like you and I with a transplanted kidney that’s been successfully grafted, that person is still young and develops a disease which precludes his or her continuing to live because of something in the heart, and if science has developed either a heart transplant, which we’re not able to do much more easily because of new drugs that prevent rejection and so on, or by virtue of some technical achievement, I find absolutely no moral, ethical, philosophical objection to that at all, provided that this is not a method of prolonging suffering.

HEFFNER: Right.

ROSENFELD: That’s the difference.

HEFFNER: Who makes that decision? I mean, you say, again, many of the, not many, some of the editorial comments had to do with prolonging suffering. But we make that choice ourselves. Certainly Dr. Clark made the choice. And as his daughter said, “Why don’t they leave us alone? We’re living with this”. You say not prolonging suffering. But if I decide to suffer in a certain way so that I can live longer that’s my business.

ROSENFELD: That’s your privilege.

HEFFNER: Okay.

ROSENFELD: That’s your privilege.

HEFFNER: Now, I don’t want to reduce this to an absurdity, but obviously I’ve got to take you down this path. Now, someone who has experienced a kidney transplant is now in fit enough condition, has a long enough life naturally ahead of himself or herself, and you say yes for an artificial heart.

ROSENFELD: Yes, once they receive the kidney and it’s functioning, they’re living normally, they should not be considered differently from anybody else.

HEFFNER: Okay. And then after the artificial heart? Is it possible that you would conceive of another transplant or another artificial organ? You see what I’m doing.

ROSENFELD: Yes, you’re giving one particular individual a lot of bad luck. (Laughter)

HEFFNER: Good luck.

ROSENFELD: Well, this is somebody who is falling apart. (Laughter)

HEFFNER: Well, but not according to what you say.

ROSENFELD: From a practical point of view I must say that I understand what you’re saying, and you know, you’re asking me where does it end.

HEFFNER: That’s right.

ROSENFELD: And it’s not right to talk about one given individual going through all these terrible operations. It just normally doesn’t happen that way. But the point is…

HEFFNER: Wait a minute, Dr. Rosenfeld. You said, “Normally it doesn’t happen that way”. Normally do we put in an artificial heart?

ROSENFELD: By “Normally it doesn’t happen that way” I mean that in any given individual things don’t, you know, in otherwise young people don’t have things going wrong in a series…

HEFFNER: I’ll be when you and I were young there were a lot of things that we would have said normally we don’t do them that way, and now you do them as a matter of course as a medical doctor.

ROSENFELD: The point I want to make is that we must not be frightened by progress. I think that if the motivation, the motivation is not simply to prolong old, infirm, feeble, suffering lives…If that is hot he objective…And I don’t believe in that objective. But if in fact the objective is to help an otherwise healthy person lead a normal life by virtue of some operation… You know, what you’re saying, the questions you’re asking could have been asked…

HEFFNER: They’re really questions.

ROSENFELD: …could have been asked about removing an appendix. You talk about the miracles of surgery. I can visualize a conversation like this 60 years ago where a physician might be asked, “But Doctor, can you take out his appendix? And then you take out his gallbladder, and then you may have to take out his stomach because he’s got an ulcer. Doctor, what’s left?”

HEFFNER: You’ve said it for me, which doesn’t make the question quite as ridiculous or ludicrous as it might seem.

ROSENFELD: No, it’s not ridiculous.

HEFFNER: …because I’m asking you, how far down the path do we go? I’m really asking you how far down that path do you think we’ll be able to go?

ROSENFELD: I don’t know. I think, A, that we will be able to do heart transplants more successfully that we have in the past by virtue of development of new drugs against rejection.

HEFFNER: Transplants from other human beings?

ROSENFELD: Yes, from people who have been killed in accidents and so on, or…That’s what we’re doing now.

HEFFNER: What about from animals?

ROSENFELD: They won’t get them from donors. You can be sure about that. From animals? A possibility too. I see that perhaps as a little further down the line, but that is a possibility. I see miniaturization of an artificial heart so that ultimately the patient will not be restricted as Barney Clark was. I think they got a lot of information from that particular “experiment”, I call it, and I’m sorry that that was really done with so much suffering on the part of Barney Clark. I do think, however, that his suffering was not in vain in the general sense; that a lot of useful information which will be applied to further developments in the heart. I think in our lifetime we will see artificial hearts. I think we will see liver transplants. I don’t think we’ll see an artificial liver. I don’t think we’ll see an artificial brain. I don’t think we’ll see an artificial lung. They’re so complicated that I, at this time, can’t see that. The other thing that I…

HEFFNER: At this time.

ROSENFELD: At this time. Yes, you know, I wouldn’t have, you know, 25 years ago visualized somebody on the moon. The other thing I believe in a more immediate sense is that many of the hearts that are – and this is very important – many of the hearts that are now not functioning well and where in today’s setting they might be considered candidates for a heart transplant should that become feasible, I think that new drugs would be developed, and are in fact being developed, and will be available very soon which will extract the maximal power from a badly damaged heart so that it will begin to function more closely, I mean almost normally despite its obvious damage. In other words, if only ten percent of the heart is contracting and doing the job, there will be drugs, there are as a matter of fact are already drugs and there will be more which enable, which maximize that ten percent so that the patient can lead a more normal life.

HEFFNER: Dr. Rosenfeld, as always, when we talk together you mention so many things that I want to pursue, and I don’t want to get off this point, but you mentioned drugs and the question of whether drugs that can accomplish what you just described are available to us to the extent that they could be, as they are in other parts of the world, because of our own restrictions, restrictions imposed by the Federal Drug Administration. Now, are you one of those people who feel that we’re living too restricted a life in terms of drugs?

ROSENFELD: I used to think that way. I think the current commissioner of the Food and Drug Administration is much more liberal and realistic. And I have the impression that there are some very useful and exciting drugs which are seeing the light of day much sooner because of a change of policy in the FDA.

HEFFNER: Would you say that there are people now who suffer because…needlessly in terms of the real availability in other countries of medications that are not effectively available here right now?

ROSENFELD: Perhaps. The mechanism though, is this: That if there is an exciting drug developed in France or England or Italy or somewhere, and the FDA is not really sufficiently satisfied with its safety or efficacy and will not release it for widespread use, there are enough investigators in this country who have access to the drug and are able to use it under controlled circumstances so that really somebody should not be deprived unnecessarily because of the formalities. That drug is generally available, but on a research basis.

HEFFNER: You’re satisfied with that arrangement at this point?

ROSENFELD: I think so. It’s a tough situation. On the one hand there are dangers in rushing to the marketplace, as you k now from the various drugs that have been…Oraflex was withdrawn, Zomax was withdrawn. Both otherwise useful drugs, but which after they were used for awhile were found to cause fatalities. So I think that it’s a tough decision. You’ve got to find a middle ground. I think the current FDA is probably approaching it.

HEFFNER: You’re being so sweetly reasonable on…

ROSENFELD: About the FDA?

HEFFNER: Yes.

ROSENFELD: That’s because the commissioner used to be at New York Hospital. (Laughter)

HEFFNER: Oh, okay. I just wanted to identify that, Dr. Rosenfeld.

ROSENFELD: I used to be a very severe critic of the FDA on that account. They held up, I thought, the beta blockers, Inderal, for a long time. Much longer than I thought was necessary. But I do think there has been a change in policy.

HEFFNER: Okay. Let’s go back for – we just have a few minutes left – let’s go back to this business of what I call the bionic man, the bionic woman. Do you think we’re going to reach a point in this century when there may be demands for prophylactic activities of this kind, give me a better heart now, and give me a better liver now, give me a better kidney now, whatever it is that’s possible? It’ll be out of your hands in a sense and in the hands of the consumer.

ROSENFELD: I think it’s conceivable. I think if the state of the art is such that it’s easier and safer to implant an artificial organ of some kind or other – and we’re not talking about experimental – after this has become widespread and so on, and if a patient is plagued with symptoms that interfere with the quality of his or her life, and the risk, the cost benefit has been worked out, I think it’s possible. There are people today who have prophylactic pacemakers. Now, I know that there’s a lot of talk a lot of these pacemakers are unnecessary. But still in all there are many instances where a pacemaker is put in prophylactically and for very good reason. Now, whether one can extrapolate and say whether this would be true for other organs is hard to say, but I can see it. I have great enthusiasm about our potential, our scientific potential, and I have a great confidence really in the scientific community and in the medical profession sot that I don’t believe that these things are going to be done capriciously. I think that the goals are really to improve the quality of life.

HEFFNER: And the aspect of playing God, this doesn’t bother you? Because you don’t look at it that way.

ROSENFELD: No, I don’t look at it as playing God if a patient has severe angina and has an arteriogram and is shown to have virtually no flow in his heart and a surgeon can bypass those arteries and give him useful life, I don’t think the surgeon is playing God; I think he’s doing a job he knows how to do, and he’s doing it effectively.

HEFFNER: Let me ask you – we’re almost at the end of the program – I commented at the beginning that what may be the psychological impact upon us of the artificial heart. Do you think about that, given the role the heart has played in our literature and our thinking about ourselves?

ROSENFELD: You know, the heart is involved in so much literature and so much folklore and so much mythology that that’s going to take a long time to do away with. But you put yourself in my position. I sit in the hospital or at my desk every day and see a parade of human beings who come in with, who are suffering. They are suffering because of some kind of heart disease. Much of it can be treated medically. Some of it can be treated surgically, things we weren’t able to do before. But there remains a nucleus of people for whom I can do very little. And for me it’s very exciting to think of the prospect that someday perhaps in my lifetime that number of people for whom I can do nothing, who come to me in pain and suffering, may be able to be helped. And that’s the bottom line. No matter how you do it, that’s the bottom line, and that’s the way to think of it, I think.

HEFFNER: And you think we’re going to be able to survive that psychological turnaround?

ROSENFELD: Oh, sure.

HEFFNER: It’ll be an artificial heart, perhaps.

ROSENFELD: We’re psychologically turned around every day by the media and by the newspapers. Our attitudes change as you live. That’s why they do Gallup polls.

HEFFNER: Yes, but now it’s going to be the medical profession that’s going to do it. That’s the point at which I’ll end the program. Thanks so much for joining me today, Dr. Rosenfeld.

And thanks, too, to you in the audience. I hope that you will join us again here on THE OPEN MIND. Meanwhile, as an old friend used to say, “Good night, and good luck”.