Commentary: Why This May Change Health Care As We Know It

On July 2, the first fully implanted artificial heart was stitched into the chest of Robert L. Tools, a 59-year-old technical librarian, at Jewish Hospital in Louisville. His failing heart had so debilitated him that doctors had given him less than 30 days to live; surgeons said at best, the high-tech device might double that number.

Well, 60 days have come and gone, and Tools has survived. His AbioCor heart, developed by Abiomed Inc. in Danvers, Mass., is a far cry from the technology of the 1980s, when volunteers died grim deaths tethered to pumps the size of washing machines. In contrast, the AbioCor is completely enclosed in the chest cavity, its pumping rate controlled by microprocessors, and its battery unit charged through the skin by a belt worn around the waist. With no wires or tubes connecting the heart to outside power sources, there are few openings for infection. Where the technology comes up short---the heart is heavy and too large to be inserted in children or in many women--advances in new materials and microelectronics should quickly kick in.

But now, society must grapple with a fresh conundrum: Where will the money to pay for these miracle devices come from? And how will society determine when it is the right time for the old and the terminally ill to actually die? In the words of Jonathan D. Moreno, director of the University of Virginia's Center for Biomedical Ethics in Charlottesville, "these patients can no longer die a traditional cardiac death."

LONG WAITING LIST? There isn't a lot of time to come up with answers. The Food & Drug Administration has authorized four other major medical centers to implant AbioCor hearts. And even before these experiments get under way, Tools's lease on life could inspire thousands of aging baby boomers to add their names to the waiting list. Many of the 100,000 people in the U.S. who are candidates for heart transplants might accept an artificial device, and "there is a vastly larger number of patients who could benefit," says surgeon Robert D. Dowling of the University of Louisville, who with Laman A. Gray Jr. performed the seven-hour surgery on Tools at Jewish Hospital.

From one perspective, this huge customer base represents a hair-raising social liability. Surgical and hospital costs for regular heart transplants run as high as $500,000. These procedures haven't burdened the medical system so far--but only because the supply of transplantable hearts has been limited to about 2,000 a year. Abiomed plans to price its heart between $75,000 and $100,000 initially, and with volume production, the price could fall as low as $10,000. However, even at the lower price, artificial hearts are an issue that will lead into moral quicksands, says medical ethicist David Steinberg of the Lahey Clinic in Burlington, Mass. What happens, Steinberg muses, "if heart replacement--an intervention directly and visibly linked to who will live and who will die--becomes available only to those who can afford it?"

HIT THE SWITCH? On the bright side, devices like the AbioCor could offer a ray of hope to thousands. Tools recently said he was looking forward to going bass fishing with his surgeon, Gray. Multiply such hopes by millions, and heart replacements are a boon, whether the promise is measured in years or just months of enjoyable, productive life.

Still, disturbing questions linger. What will doctors do when the patient's other biological systems signal that it's time to die and the mechanical heart just keeps whirring? Someone will eventually have to hit the switch--be it patient, family, or physician. True, patients on dialysis machines and respirators face such issues daily. But if the AbioCor device becomes common, "physicians and families would be dealing with far more of these cases," predicts Nancy Tuana, director of the Rock Ethics Institute at Pennsylvania State University.

Ethicist Rebecca Dresser at Washington University in St. Louis is counting on laws such as the Patient Self-Determination Act to help people establish "living wills" before undergoing surgery. " Meanwhile, as the pains of perpetuity become more obvious, patients, health-care providers, and legislators will all struggle with the same enigma: It's not just how society will pay for the plethora of artificial organs. It's how we define the new parameters of a human life.

By Alan Hall

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