She lay anesthetized upon an operating table in the City of Hope National Medical Center in Duarte, Calif. A surgeon inserted a 1-in.-long needle into the baby's hip and slowly began to withdraw bone marrow. In 20 minutes they removed about a cup of the viscous red liquid -- the stuff of resurrection.
The medical team then rushed the marrow to a hospital room where Marissa's 19-year-old sister Anissa lay waiting. Through a Hickman catheter inserted in the chest, the doctor began feeding the baby's marrow into Anissa's veins. The marrow needed only to be dripped into the girl's bloodstream. There, like salmon heading home to spawn, the healthy marrow cells began to find their way to the bones.
Done. If all goes well, if rejection does not occur or a major infection set in, the marrow will do the grail's work. It will give life to the older sister, who otherwise would have died of chronic myelogenous leukemia. Doctors rate the chance of success at 70%.
The Ayala family had launched itself upon a sequence of nervy, life-or-death adventures to arrive at that denouement last week. Anissa's leukemia was diagnosed three years ago. In such cases, the patient usually dies within five years unless she receives a marrow transplant. Abe and Mary Ayala, who own a speedometer-repair business, began a nationwide search for a donor whose marrow would be a close match for Anissa's. The search, surrounded by much poignant publicity, failed.
The Ayalas did not passively accept their daughter's fate. They knew from their doctors that the best hope for Anissa lay in a marrow transplant from a sibling, but the marrow of her only brother, Airon, was incompatible. Her life, it seemed, could depend on a sibling who did not yet exist.
A brave, surreal gamble. First, Abe had to have his vasectomy surgically reversed, a procedure with a success rate of just 40%. That done, Mary Ayala ventured to become pregnant at the age of 43. The odds were 1 in 4 that the baby's bone marrow would match her sister's. The Ayalas won that gamble too. In April 1990 Mary bore a daughter, Marissa. Fetal stem cells were extracted from the umbilical cord and frozen for use along with the marrow in last week's transplant. Then everyone waited for the optimum moment -- the baby had to grow old enough and strong enough to donate safely even while her older sister's time was waning.
Twelve days before the operation, Anissa began receiving intensive doses of radiation and chemotherapy to kill her diseased bone marrow. As a result, she is losing her hair. Her blood count is plummeting. Her immune system has gone out of business. But in two to four weeks, the new cells should take over and start their work of giving Anissa a new life.
The drama of the Ayalas -- making the baby, against such long odds, to save the older daughter -- seemed to many to be a miracle. To others it was profoundly, if sometimes obscurely, troubling. It called up brutal images -- baby farming, cannibalizing for spare parts. Many saw in the story the near edge of a dangerous slippery slope at the bottom of which they glimpsed an abyss, and maybe the shadow of Dr. Mengele at work.
A marrow transplant represents little risk to the donor: Marissa's health was never in danger, and she came out of last week's procedure with only an ache in the hip. In the words of Dr. Mark Siegler, a medical ethicist at the University of Chicago, "The morbidity rate for this operation is much less than for roller-skating."
What disturbed was the spectacle of a baby being brought into the world not, it seemed, as an end in herself, attended by all the sentiment and sanctity that people supposedly accord a new life. Rather the baby was ordered up to serve as a means, as a biological resupply vehicle.
The baby did not consent to be used. The parents created the new life, then used that life for their own purposes, however noble. Would the baby have agreed to the transplant if she had been able to make the choice? Metaphysics: Would the baby have endorsed her own conception for such a purpose?
People wanting a baby have many reasons -- reasons frivolous, sentimental, practical, emotional, biological. Farm families need children to work the fields. In much of the world, children are social security for old age. They are vanity items for many people, an extension of ego. Or a sometimes desperate measure to try to save a marriage that is failing. Says Dr. Rudolf Brutoco, Marissa Ayala's pediatrician: "Does it make sense to conceive a child so that little Johnny can have a sister, while it is not acceptable to conceive the same child so that Johnny can live?" In American society, procreation is a personal matter. Crack addicts or convicted child abusers are free to have children.
The Ayalas were surely procreating on the side of the angels. Considered on the family's own terms, their behavior is hard to fault. They acted from desperate first principles. Life wants to live. The first duty of parents is to protect their children. The Ayalas say they never considered aborting the fetus if its marrow did not match Anissa's. They will cherish both daughters in the context of a miracle that allowed the older to live on and the younger to be born. It was possible to see the drama as a visitation of grace.
But their case resonated with meanings and dilemmas larger than itself. The case opened out upon a prospect of medical-technological possibility and danger that was like a medieval navigator's map -- inscribed in blank mid- ocean, "Here there be monsters."
The monster possibility is this: in the past, it was mostly cadavers from which transplant organs were "harvested." Today, as with the Ayalas, life is being tapped to save life. This suggests in some cases the sort of moral trade-offs that were worked out in the blizzards of the Donner Pass in the winter of 1846-47. Is there a principle of cannibalism involved? Sometimes.
Beyond the Ayala case, the ethics can become trickier. What if a couple conceives a baby in order to obtain matching marrow for another child; and what if amniocentesis shows that the tissue of the fetus is not compatible for transplant? Does the couple abort the fetus and then try again? Says Dr. Norman Fost, a pediatrician and ethicist at the University of Wisconsin: "If you believe that a woman is entitled to terminate a pregnancy for any reason at all, then it doesn't seem to me to make it any worse to terminate a pregnancy for this reason." But abortions are normally performed to end accidental pregnancies. What is the morality of ending a pregnancy that was very deliberately undertaken in the first place? The slippery slope becomes abruptly steeper.
In the world of advanced medical technology, the uses of living tissue have become very suddenly more complex and problematic. A newly born infant suffering from the fatal congenital malformation known as anencephaly will surely die within a few days of birth. Anencephaly means a partial or complete absence of the cerebrum, cerebellum and flat bones of the skull. Such babies could be an invaluable source for organs and tissues for other needy infants. Is that sort of "harvesting" all right?
Aborted fetal tissue has shown promise as a treatment for Parkinson's disease and Alzheimer's disease. But such experiments have mostly been blocked in the U.S. by a ban on federal funding for research using fetal tissue. Some antiabortion activists think that if the technique proves successful, it would encourage women to conceive just to provide material for relatives in need. A mother of a diabetic girl in Maryland gives credence to such fears: "If the technique were perfected today, I'd hop in bed right now. It's not an easy issue. But I'd kill an unborn sibling to improve my daughter's life."
Transplant technology is developing so rapidly that new practices are outpacing society's ability to explore their moral implications. The first kidney transplants were performed over 35 years ago and were greeted as the brave new world: an amazing novelty. Today the transplant is part of the culture -- conceptually dazzling, familiar in a weird way, but morally unassimilated. The number of organ transplants exceeds 15,000 a year and is growing at an annual clip of 15%. The variety of procedures is also expanding as surgeons experiment with transplanting parts of the pancreas, the lung and other organs. As of last week, 23,276 people were on the waiting list of the United Network for Organ Sharing, a national registry and tracking service.
A dire shortage of organs for these patients helps make the world of transplants an inherently bizarre one. Seat-belt and motorcycle-helmet laws are bad news for those waiting for a donor. The laws reduce fatalities and therefore reduce available cadavers, thus inviting the mordant thought that the speed limit should be raised when the donor-organ supply is low.
A doctor's new dilemma: two weeks ago, Ronald Busuttil, director of UCLA's liver-transplant program, heard that a liver, just the right size and blood type, was suddenly available for a man who had been waiting for a transplant. The patient, severely ill but not on the verge of death, was being readied for the procedure when Busuttil's phone rang. A five-year-old girl who had previously been given a transplant had suffered a catastrophe. Her liver had stopped functioning. Busuttil had to make a decision. "I had two desperately ill patients," he says, but the choice was clear. Without an immediate transplant, "the little girl certainly would have died."
Most organs come from cadavers, but the number of living donors is rising. There were 1,788 last year, up 15% from 1989. Of these, 1,773 provided kidneys, nine provided portions of livers. Six of the living donors gave their hearts away. How? They were patients who needed heart-lung transplant packages. To make way for the new heart, they gave up the old one; doctors call it the "domino practice."
Ethical thought about the living-to-living transplants divides into two general perspectives, two systems of thought that are in many ways as incompatible as Apple and IBM. On one side are the non-alarmist accommodationists. On the other side are the biotechnical Luddites.
The accommodationists review the history of innovation. In the '50s, when artificial insemination with donor semen was introduced, many ethicists said it separated procreation from marriage in a destructive way. Pope Pius XII, who denounced artificial insemination even from husband to wife, declared, "To reduce the cohabitation of married persons and the conjugal act to a mere organic function for the transmission of the germ of life would be to convert the domestic hearth, sanctuary of the family, into nothing more than a biological laboratory." When Louise Brown, the first test-tube baby, was born in England in July 1978, alarmists warned of a brave new world in which government would control the production of children.
The accommodationists, in other words, argue that all new things are initially strange and disconcerting but eventually become familiar, unthreatening and more or less acceptable. It is an ethical point of view that reposes faith in the common sense of society to weed out the potential horrors.
In 1972 Dr. Thomas Starzl, the renowned Pittsburgh surgeon who pioneered liver transplants, stopped performing live-donor transplants of any kind. He explained why in a speech in 1987: "The death of a single well-motivated and completely healthy living donor almost stops the clock worldwide. The most compelling argument against living donation is that it is not completely safe for the donor." Starzl said he knew of 20 donors who had died, though other doctors regard this number as miraculously low, since there have been more than 100,000 live-donor transplants.
Ethicists worry sometimes about the psychological damage done to both donors and recipients. How will children react in later life to being conjured up and used in this way? Consider the case of Michelle Kline, a contestant in the 1989 Miss America contest, who received a kidney from her brother 19 months before the pageant. She would not speak to him afterward, although they later reconciled. "The sense of having part of her brother inside her created tremendous tensions," says Renee Fox, a medical-sociology professor at the University of Pennsylvania. The tyranny of the gift: "It was a feeling of overwhelming debt that she could not repay." Conversely, one kidney donor became so depressed after the recipient did not thrive that he killed himself in despair.
There will never be enough cadaver organs to fill the growing needs of people dying from organ or tissue failure. This places higher and higher importance, and risk, on living relatives who might serve as donors. Organs that are either redundant (one of a pair of kidneys) or regenerative (bone marrow) become more and more attractive. Transplants become a matter of high- stakes risk-calculation for the donor as well as the recipient, and the intense emotions involved sometimes have people playing long shots.
Family members become more and more pressed to provide organs to save relatives. It is a bizarre request, of course, difficult to refuse, and can lead to ugly family conflicts. As Alexander Capron, a bioethicist at the University of Southern California, says, "a good medical team knows how to help a potential donor to say no." Often, doctors simply lie and say that the relative who does not want to do it is "not a match."
The most famous controversy over a spurned request led to the courtroom last year. Tamas Bosze, a Chicago bar owner, was told that only a marrow transplant could rescue his son Jean-Pierre, 12, from leukemia. The boy's only potential donors were twin half-siblings born out of wedlock to the father's former girlfriend. Bosze sued the woman in an attempt to compel her to have the children tested for tissue compatibility. She refused, and a court upheld her decision. Last November, Jean-Pierre Bosze died.
Federal law now prohibits any compensation for organs in the U.S. In China and India, there is a brisk trade in such organs as kidneys. Will the day come when Americans have a similar marketplace for organs? Turning the body into a commodity might in fact make families less willing to donate organs, says Capron: "A family would be willing to say, 'We gave Joey's kidneys away.' But would they say, 'We sold Joey's kidneys?' I don't think so."
The new technology of transplants disturbs everyone's model of the natural order. The human being has not been in the habit of walking around with someone else's heart in his chest. Or of breaking into the temple of someone else's body and making off with its faucets and pipes. There is adventure in the possibilities, and hope for some who would otherwise be doomed. But the issues lead into strange, unprecedented territory. It will require time and experience to explore.
CHART: NOT AVAILABLE
CREDIT: From a telephone poll of 1,000 American adults taken for TIME/CNN on June 4-5 by Yankelovich Clancy Shulman. Sampling error is plus or minus 3%. "Not sures." omitted.
CAPTION: Is it morally acceptable for parents to conceive a child in order to obtain an organ or tissue to save the life of another one of their children?
Is it morally acceptable to remove a kidney or other nonessential organ from a living person for use in another person's body?
Would you donate a kidney for transplant to a close relative who needed it?
Is it morally acceptable to:
Is it ethical to ask a child under the age of 18 to give up a kidney for a transplant to a relative?
If you or a close relative had a fatal disease that could possibly be cured by a transplant, which of these would you be willing to do?