Abraham Verghese - Cutting for Stone

Deepak, who found it difficult to sit face-to-face with Shiva and not feel he was speaking to me, said, “We considered a transplant early on, Shiva. In fact, Dr. Stone and I talked about transferring Marion to Mecc—I mean to Boston General, Dr. Stone's hospital. Dr. Stone's team does more transplants than anyone on the East Coast. But we decided against it for two reasons. First of all, transplants are notoriously unsuccessful when the liver is being destroyed by fulminant hepatitis B. Even if we found a cadaver liver of the right blood group and size and we did the transplant successfully, we would have to use massive doses of steroids and other drugs that suppress the immune system to prevent rejection of the new liver. That would give the hepatitis B virus a field day and the new liver would be destroyed and we would be back to exactly where we are now.”

“Yes, I know,” Shiva said. “But what if the transplant is a perfect match? Not just the same blood group, but all six HLA antigens and other antigens you don't even measure—what if they all matched? Then no immune-suppressing drugs would be needed? Right? None. No steroids, no cyclosporine, nothing. Would you agree?”

“Theoretically, yes, but …,” Deepak said.

“A perfect match is what you would have if you took the liver from me,” Shiva said. “His body would see it as self, not as foreign in any way.”

The air had been sucked out of the room. No one spoke for a few seconds. Seeing Hema's expression, Shiva quickly explained, “I mean take a part of my liver, Ma. Leaving enough for me and taking out a lobe to give to Marion.”

“Shiva …” It was on Hema's lips to apologize for Shiva—this clearly was not his field, or hers for that matter. But then she changed her mind. She knew something about his tenacity when it came to medical situations that others thought impossible. “But, Shiva, has that ever been done—transplanting part of a liver?”

Shiva slid one of the articles over to her. “This is from last year. A review by Deepak Jesudass and Thomas Stone on the prospects for live donor liver transplant. It hasn't been done in humans, Ma, but before you say anything, read page three where I have underlined. They say, ‘Technically, the success in almost one hundred dogs, the ability to sustain life in the recipient and not jeopardize life in the donor, suggests that we are ready to perform this operation on humans. The risks to a healthy donor present a significant ethical obstacle, but we believe the critical shortage of cadaver organs obliges us to move forward. The time has come. Live donor transplant will overcome both the problem of organ shortage and the problem of cadaver livers that are damaged because it has taken too long to get consent and too long to remove the organ and get it to where it needs to be. Live donor liver transplant is the inevitable and necessary next step.’ “

Shiva wasn't reading, but reciting word for word from memory. It didn't surprise Hema, but it astonishmed the other physicians at the table. Hema felt proud of Shiva. She was reminded how often she took Shiva's eidetic gift for granted. She knew he could draw the page he was reciting from, reproduce it on a blank piece of paper, beginning and ending each line just as it was on the original, down to the punctuation, the page number, and the staple marks and photocopy smudges.

Shiva, sensing that he had quieted Hema for the moment, addressed Thomas Stone and Deepak, the two surgeons: “May I remind you that the first successful kidney transplant by Joseph Murray involved a dying twin who received a healthy kidney from his identical twin brother?”

Deepak spoke, because it appeared that Thomas Stone was in a state of shock, “Shiva, we also state in the paper,” Deepak said, “that there are ethical and legal implications—”

Shiva interrupted. “Yes, I know. But you also say ‘in all likelihood the first donors will be a parent or sibling, because such a donor has a pure motive and takes on the risk willingly’ “

Deepak and Thomas Stone looked like defendants whose alibi had just been shot down by a surprise witness. The prosecutor was moving in for the kill.

But the attack came from another quarter. Hema said, “Thomas, tell me the truth: in the last four days, given that this is your area of interest”—she tapped the paper, her fingers bunched together—”seeing Shiva lie next to his twin, did the thought of this live donor operation not cross your mind?”

If she expected him to squirm and swallow hard, she was in for a surprise: Stone looked steadily at Hema, and after a beat, he nodded almost imperceptibly. “I thought of the Murray twins, yes. I thought of it. But then thinking of all the hazards … I dismissed it. This is much, much harder than removing a kidney. It's never been done.”

“ I never thought of it!” Vinu Mehta said quietly. “Madam, I should have thought of it. Shiva, I thank you. In anyone else with acute hepatitis B, a liver transplant would simply feed the virus. But with a perfect match … Of course, Shiva, the issue is really the risk to you.”

My brother was ready, and he spoke without glancing at his notes, addressing his comments largely to Thomas Stone even though Vinu had asked the question. “Your estimate, Dr. Stone, based on cutting out one or more lobes from patients with liver trauma, is that the risk of death should be less than five percent for me, the donor. The risk of serious complications, such as bile leaks and hemorrhage, you said should be no more than twenty percent in an otherwise healthy donor.” Shiva pushed a single sheet to Deepak and Thomas Stone. “I had my blood drawn last night. All my liver functions came back normal. As you can see, I am not a carrier of hepatitis B or anything like that. I don't drink or take drugs that might damage the liver. I never have.” Shiva waited for Thomas Stone.

“You know that paper of ours better than I do, son,” Stone said. “Unfortunately, those were estimates, a pure guess.” He put his hands on the table. “We don't know how it might really work in humans.”

“And if we fail,” Deepak added gently, since Thomas Stone was finished, “we lose you who walked in here healthy and we lose Marion. Not to mention that we won't have a leg to stand on or that our careers could be over. Even if we succeed, we will be heavily criticized.”

If they thought Shiva was done, they didn't know my brother. Hema was seeing her son anew. “I understand your reluctance. I wouldn't think much of you as surgeons if you agreed at once. However, if you can do this operation and if it has a reasonable chance, even a ten percent chance of saving Marion's life, and a less than ten percent chance of ending my life, and if you choose not to do the operation, then in my opinion, you would have failed Marion, failed Hema and me, failed medical science, failed yourselves. You would have failed my brother not only as his physicians, but as his friend, and as his father. If you did the operation and succeeded, you would not only save my brother, but you would have advanced surgery by a decade. The time is now.” He looked his father and then Deepak in the eye. “You may never get a chance like this again. If your rivals at Pittsburgh were facing this situation, what would they do? Would they not be bold?”

The prosecution rested. It was time for the other side of the table to respond.

“Bold, yes,” Stone said, breaking the long silence, and speaking in an undertone as if only for himself, “but they wouldn't be operating on their own sons. I'm sorry, Shiva, I can't imagine this.” He pushed back from the table, put his hands on the arms of his chair as if he were thinking of leaving.