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Authors Note to the Original

1977 Edition of Coma
Tis novel was conceived as an entertainment, but it is not science
ction. Its implications are scary because they are possible, perhaps
even probable. Consider a classied advertisement that appeared in
the San Gabriel (Calif.) Tribune, May 9, 1968, col. 4:
Need a Transplant?
Man will sell any portion of body for nancial remuneration
to person needing an operation. Write Box 1211-630, Covina.
Te advertiser did not specify what organ or organs, or even
whose body they were to come from.
And there have been other advertisements, many others, in var-
ious newspapers across the country. Even specic oers of the
hearts from living people!
As gruesome as these ads sound, they should come as no great
surprise. Tere are plenty of precedents for the market economy in
medicine. Blood which may be considered as an organ is rou-
tinely bought and sold. Tere is a commerce in semen, which,
while not an organ, is the product of an organ.
Other organs have been bought and sold. In the 1930s, a rich
Italian man bought a testis from a young Neapolitan and had it
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transplanted into himself. (He not only wanted the product but he
wanted to be a distributor as well.) In the last few years there have
been episodes where families have declined to give their own kid-
neys to dying relatives and have sought out and paid volunteer
donors. Such cases have not been common, but they have occurred.
Te larger problem, the danger, arises from the simple matter of
scarcity. Tere are thousands of people waiting for kidneys and
corneas today. Te reason that these two organs are particularly
coveted is that they have most frequently been transplanted suc-
cessfully. Tanks to dialysis machines, potential kidney recipients
(some of them . . . others are left to die because of shortages of dial-
ysis machines, personnel, and funds) can be kept alive, but their
lives are far from normal. In many situations they border on the
desperate, so much so that kidney dialysis centers have reported a
so-called Holiday Syndrome. What that means is that when a hol-
iday weekend approaches, the patients spirits rise as they antici-
pate the rush of auto accidents and the victims who may supply the
eagerly awaited and desperately needed organs.
Te tragedy in this situation is that the solution to the problem
is already within our grasp. Medical technology has advanced to
the point where approximately seven percent of all cadaver kidneys
are suitable for transplant (and the gure is much higher for cor-
neas), if they are taken from the donor body within an hour of
death. But instead of being put to this noble use, these organs are
regularly delivered to the worms or to the res of the crematorium
because of legal mumbo jumbo whose origins lie in the dark ages
of English law. For back in those times corpses came under the
jurisdiction of the ecclesiastical rather than civil law. It seems
inconceivable that such a legacy should limit our lives today. But it
does.
However, most, if not all, states have now passed the Uniform
Anatomical Gift Act. Tis law has helped to provide cadavers for
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medical schools (whose supply was already adequate), but it has
not helped in rectifying the sad need for useful live organs for
transplant purposes. An alternative approach, by which all cadaver
organs would be immediately available for salvage unless the
deceased or the next of kin had made prior refusal, has been pro-
posed. But alas, the wheels of change turn agonizingly slowly, and
potential recipients are allowed to die while organs are wasted in
the ground. Hard questions remain to be answered, such as an
acceptable denition of death, and the legal rights of an individual
after death. But such diculties should not preclude a solution to
the egregiously wasteful practice of discarding valuable human
resources.
Te problem of organ scarcity for transplantation represents
only one agrant example of the failure of society in general and
medicine in particular to anticipate the social, legal, and ethical
ramications of a technological innovation. For some inexplicable
reason, society waits to the very end before creating appropriate
policy to pick up the pieces and make sense out of chaos. And in
the instance of transplantation, failure to recognize mounting
problems and enact appropriate solutions will certainly open Pan-
doras box, with its countless unconscionable possibilities: the Stark
et al. of my ction suggest only possible, execrable aberrations.
For those readers who are interested in delving into the complex
problems of organs for transplantation, I recommend two excel-
lent articles which are delightfully illuminating, despite the fact
that they appeared in law journals. Tis is not to cast aspersions on
law journals, but rather to emphasize that the lay individual will
nd these articles very readable: J. Dukeminier, Supplying
Organs for Transplantation, Michigan Law Review, vol. 68 (April
1970), pp. 811866; D. Sanders and J. Dukeminier, Medical
Advance and Legal Lag: Hemodialysis and Kidney Transplanta-
tion, UCLA Law Review, vol. 15 (1968), pp. 357413.
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For those who are interested in medical policy and its phleg-
matic character, combined with some positive suggestions for
future change, I recommend: J. Katz and A. M. Capron, Cata-
strophic Diseases: Who Decides What? Russell Sage Foundation,
1975. Tis is an excellent, thought-provoking book, probably years
ahead of its time. Its only drawback is that not enough people in
positions of power in medicine will read it.
A nal word about women in medicine: I must admit that the
research I did on the subject (there is not much available) caused
me to alter my opinions. I now have a heightened regard for female
physicians and female medical students. I recognize that their
training experiences are much more dicult and stressful than
those of their male counterparts. Tings are getting better in
this respect, but at a snails pace. Te article I found the most illu-
minating is M. Notman and C. Nadelson, Medicine: A Career
Conict for Women, American Journal of Psychiatry, vol. 130
(October 1973), pp. 11231127.
R C, M.D.
August 1976
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