|Dr Robert White|
[The Sunday Telegraph Magazine, 2000]
THE operation, when it finally succeeded, was choreographed and rehearsed in meticulous detail. It had been mapped out like an old fashioned dance pattern, where footprints and arrows instruct the unwieldy in the intricacies of the rhumba. Chalk marks on the floor fixed the positions of more than thirty highly drilled professionals: two surgical teams, a squad of anaesthesiologists, assorted nurses, phalanxes of technicians, a bevy of scientists equipped to analyse blood and urine samples on the spot. Mindful of a dozen or more failed attempts - due to loss of blood, surgical errors or simply the fragile condition of their subjects - the experts proceeded in their exacting task by a combination of vigilance and rote. It was a matter of 18 hours later that, exhausted, they could rest and once again wait to see if the patient would regain consciousness.
The patient did; and promptly tried to bite a finger off one of the assistants. The result was pandemonium. The patient's mood, as described by the presiding surgeon, was “dangerous, pugnacious, and very unhappy.” This is understandable, the patient being a rhesus monkey, never the sweetest-tempered creature at the best of times. And this was not - for the monkey, at least - the best of times. It had just woken up with its head firmly attached, at the neck, to another rhesus monkey's decapitated body.
But for Dr Robert White and his team, it was a triumph, the first effective mammalian head transplant ever performed. It took place on March 14, 1970 at the Metrohealth Medical Centre in Cleveland, Ohio. In the intervening three decades, the transplanting of internal organs has become accepted, life-saving medical practice, and work has begun in earnest on replacing external body parts. Within the last twenty months, two operations have been performed to graft replacement human arms onto amputees. But Dr White, despite his stated willingness and preparedness to undertake the surgery, has not even come close to seeing his procedure applied in human medicine. The idea has been met with horrified opposition from the public, from scientists, from bio ethicists, even from fellow neurosurgeons.
This opposition may be far from universal, but it has been loud and emphatic. Inevitably, White has been perceived as a Frankenstein figure, seeking, from some demented impulse, to transgress the laws of nature and foist his ghastly patchwork creations upon a world recoiling from them in disgust. Never mind that medicine began to transgress the laws of nature from the moment it became effective. Never mind, too, that the purpose of the operation is not what it may at first appear to be. We instinctively know that head transplants are a step too far, and that anyone who would propose such a thing patently has a few loose screws rattling around in his own noggin. It stands to reason, doesn't it?
DR ROBERT J White is 75, and now retired from full-time medicine. Walking with him around Cleveland, where he spent the longest part of his practising career, it's easy to forget that he is infamous among his various opponents for slicing up and reassembling dogs and monkeys. In the West 25th Street Market area, a district as old-fangled in its style as White himself, people greet him at every turn and call him “Doc'. He is the physician who has advised, treated or operated on them and theirs for the last four decades. He chats with them in the down-home manner of a horse-and-buggy doctor from a Jimmy Stewart movie. It seems more than a little incongruous that this white-haired gent, a churchgoer and family man, should have developed what is arguably the most radical idea in modern surgery. If White is some kind of deranged fantasist, he seems to have done a good job of concealing it from both Cleveland's medical establishment and its citizens.
White is still hopeful that he will the first to conduct a human head transplant - or, as he would rather put it, full body transplant (The distinction is more than euphemistic; as we shall see, the philosophical implications of his preferred term are profound.) Should he achieve this, it will be the culmination of a life devoted to the brain, both as a physician and in the course of research backed by the city's Case Western Reserve University, where he is Professor of Neurological Surgery.
We meet at White's old stamping ground, the Metrohealth centre, a vast agglomeration of redbrick cuboids stacked together at right angles, a few miles south of where Lake Erie laps at downtown Cleveland. As we settle down to a latte in a quiet cafeteria, White explains how he embarked on his singular program of research
“My PhD at Harvard,” he says, “had to do with hemispherectomy, which is - well, I guess you'll always think of me as a violent person now - taking half the brain out of an animal while keeping it alive.”
Which begs a reasonable question, as does all of White's work: why would anybody want to do something like that?
“For two reasons. Some malignant tumours, you could do everything to them, and they just came back. So the idea was, what if you took the whole hemisphere off? And the other idea was that a lot of children have uncontrollable epilepsy soon after they are born, and no matter what they medicate them with it doesn't work. It turns out that one of the hemispheres in these children is very defective as far as its growth and its appearance and its activity. Then, and even now, surgeons were removing most of it. My experiments just carried it a little further in that I removed the entire hemisphere, in monkeys again, to see what the effect might be, if it were necessary - if the animal would regain consciousness and function.”
By the time White received his doctorate in 1962, his attention had turned to animal experiments with the isolated brain. This is exactly what it sounds like; removing the brain from the skull, while maintaining its blood supply. White and his colleagues successfully kept the brain alive externally with blood diverted from another subject, and also managed to transplant it into the neck of a separate animal. Again, these seemingly bizarre ventures had a purpose and delivered results. White believes that, “to some degree, we wrote the book on neurochemistry. A good deal of basic brain chemistry and brain physiology was born of these isolated brain experiments. If you're going to treat anything as far out as Alzheimers, you need these basic chemical facts.”
These early Sixties experiments also pioneered the use of deep hypothermia; White and co. showed that, when cooled to between ten and fifteen degrees centigrade, the brain could be cut off from its blood supply for over an hour without suffering damage - a discovery which has obvious applications in the operating theatre: “A lot of neurosurgery now, particularly what they call vascular neurosurgery, brain surgery, is conducted at very low temperatures. We didn't know until our studies how much oxygen and how much glucose the brain consumes at 10 degrees centigrade. So with those pieces of the ladder put together we could then go back and offer this as a technique, first in animals, then in man.
“The other thing that's very important, we demonstrated for the first time that the brain is an immunologically privileged organ.” In other words, unlike a heart or liver, a transplanted brain was in no danger of being rejected by the host body - even if, White believes, the animal it came from belonged to a different blood group. White now knew pretty much everything he needed to in order to undertake an animal head transplant.
“Once again you could ask,” says White, “what were you doing all this for?” He plucks abstractedly at the white roll-neck of his jumper, something he will do again and again when discussing any procedure that involves head removal. “Well, I didn't know whether these animals were really awake. When I was transplanting a brain into the neck of an animal, I didn't have the proof that maybe a psychologist would demand. When the first monkey head/brain transplant woke up here, it would eat, and it would look at you. . .”
And although carefully anaesthetised against pain, it would bite lumps out of you, given half a chance. The thing was conscious and alert, no doubt about it. Apart from the stitches around its neck, it resembled a perfectly ordinary monkey. What it could not do, of course, was control or move its new body. While White was able to sew the blood vessels together, there was, and is, no way of connecting the brain to the spinal cord.
By the early 1980s, White's experiment had progressed to the extent that the preparation, as researchers call it, could breathe without mechanical assistance. And there the matter might have rested, had it not been for a question posed by a British doctor when White gave a presentation on his work at Hammersmith Hospital in London in 1985.
“He said, ‘Dr. White, if you can actually accomplish this in monkeys, why can't you accomplish it in humans?’ And I replied that it was something I had certainly thought about over time, but I didn't want to make an issue out of it. I had to make a living as a neuro surgeon. He pointed out that quadriplegics, people who are paralysed from the neck down, become very ill and die much earlier than they would if they weren't paralyzed; and the reason for that is their various organs, like kidneys, liver and above all lungs, give up. What if those people came to me or my clinic, having already been pronounced in a state of terminal health, and requested a new body with all its new organs?
“As a result of that, the monkey experiments were in a sense reborn at a human level. People were now calling me and coming to talk to me - scientists, journalists, patients - to ask me about the possibilities of doing a total body or head transplant onto humans. I had no financing, no directors, so I just sat down and thought about it. What would I have to do in preparation for undertaking such an operation or series of operations at a human level?”
What White did was return to the dissection room, a way-station in the training of all doctors, and work out the steps for the operation on cadavers. Meanwhile, when operating around the neck on patients, he would make theoretical notes on what would need to be done. “It wasn't really difficult because in a man you're looking at a much bigger structure than the monkey. So it could be argued that if we did a human body transplant, it might be easier - technically, surgically - to do it, than it was on monkeys.”
White also recognised that, with human patients, he would need “some sort of fail-safe technology.” This took the form of a blood perfusion machine, which White and his team had refined over the years - in effect, a mechanical heart. “This instrument could be attached to the blood vessels in the neck. It had originally been developed for emergency purposes, if somebody's heart stopped or something. So we now had an instrument which could not only oxygenate but propel the blood. It also had an online heat exchanger, so that the blood could be cool or warm.”
From monkeys to man; White was, once again, ready. And remains so.
IT'S EASY enough to understand the general public's objections to Dr White's idea. For a start, there is what has been usefully labelled the Yuck Factor. Head transplants: ugh. The notion lurks, as White acknowledges, “not just in the world of science fiction but in the world of horror. Unfortunately, it does have a macabre aspect. Whereas the public has not been treated to a lot of effort on liver or kidney transplants, this comes up visually. If you were to push people's faces into open chests I don't think they would like it very much; but when it comes to the brain and above all you get down to the head, you're talking about visual structures which are right out there.”
White hopes that the recent, much-publicized arm grafts, “where you now can see somebody's hand, and that guy is in the grave', will help to make his procedure “more feasible in a social, visual sense.” But what about reactions which are less intuitive, from people who presumably have long since eliminated the Yuck Factor? What have been the responses among his peers?
“In the beginning, when I was publishing my research in highly respected journals like Science and Nature, and when I was on various podiums, they'd have a senior researcher who'd provide a commentary. These were, in general, very glowing. But some would argue, and have argued, that even if this concept of a total body transplant were to work, we're just talking about a few, at the most maybe 10,000 people; we're not talking about a cure for cancer. And others have looked at it, quite rightly, as a selfish operation, because somebody would get a body filled with organs. And if these were individually given to other patients, you might save five or six people. That is the other side of the coin.
“But I often ask people to imagine sitting on a committee which has a responsibility of providing and approving organs for transplantation. And let's say a man comes before you, totally paralysed from the neck down, he's now in his fifties, and he has been told that in six months he will be dead because of multi-organ failure. Are you going to sit there and tell him he can't have a transplant? Say that it's at a point in the future when we have genetically engineered animals whose organs will be available to us. Say you had bodies coming out of your ears, and you could certainly grant him one. Well, some people still wouldnÕt. There is a moral issue here. They feel it's too dramatic: who is the person?”
The question of identity is a major one, but White has no qualms about it. He believes that the head and brain are the physical location of the mind - and not only the mind. “I have been thinking,” he says, “more down the pathway of transplanting the human soul.”
White, father of ten, is a devout Catholic. In 1994 he became a member of The Pontifical Academy of Sciences, an advisory body appointed by the Vatican, where he is a frequent visitor. “You know when you're in at the Vatican,” he remarks, “because if you ever meet the Pope alone, they take photographs; but when you're in, they don't charge you for them.” The Catholic Church, curiously enough, is one of the few institutions where White doesn't encounter opposition to his big idea. Where does Catholic theology stand on this?
“I don't think they stand anywhere,” says White. “To my knowledge, there have been no pronouncements on this issue - does the brain imbue the entire body, and so forth. I think it is long overdue that organised religions, forget the Catholics, begin to examine the fact that not only does the mind contain all those elements that make us human and individualistic, but it also represents a physical sense of human spirit or soul. I don't know how you can have it any other way.
“I did once mention to the Holy Father, and I was a little cocky, that the human soul resided in the mind. The Pope backed off, he didn't really smile or comment. I had a feeling that I may have stepped a little over the border.”
There is, after all, the matter of the resurrection to contend with. There is also the more down-to-earth question of how one would match a body to a subject. The respective races, for example, of donor and recipient, while generally not relevant in other transplant procedures, would become an inescapable and highly sensitive issue in a full body transplant - the kind of issue that provokes protest campaigns, court cases and typhoons of unwelcome publicity. And while sex can, medically, make a significant difference in transplants, it would be of paramount importance in this case.
“I really haven't thought those out,” White admits, “but they could be very serious problems. Are you going to take a white man and put a black man's body on him?” White thinks not, and considers that it may be “absolutely necessary to go male to male and female to female.” But as the great majority of both quadriplegics and potential donor bodies are male, “it matches up there.”
Many would find it hard, in principle, to deny a new lease of life to the severely disabled. But there are implications to the full body transplant which go far beyond that. The idea that we might see old heads being briskly marched about atop brand new bodies, as a grotesque and somewhat drastic alternative to fitness regimes or plastic surgery, is unnerving. What's to stop the procedure becoming a sinister means for the rich and wrinkled to latch onto the bodies of the young and fit? Simply this: it is presently impossible to regenerate or reconnect the spinal cord. For now, a transplanted body can be nothing more than an immobile, organic life support machine.
Dr Harold Hillman, former director of the Unity Laboratory of Applied Neural Biology at the University of Surrey, and a keen observer of White's work, has spent years working on what he sums up, for lay purposes, as a “brain glue', to enable just such a reconnection. His research is at present only theoretical, due to lack of funding. But as White himself points out, “There are literally hundreds of laboratories working in that area at this very moment.” And many of them are very well funded indeed.
“My idea,” says Hillman, “and Dr White's idea, I believe, is that all over the world there are lots of brain dead people with healthy bodies, and brain alive people with virtually dead bodies; and there should come a time when one could match them up and make two into one.”
But if Hillman or any of his rivals should discover a “brain glue', Quadriplegics could simply regain use of their own bodies, rather than commandeering somebody else's. Wouldn't this render the full body transplant redundant? White believes the opposite, although he views the issue in strictly medical terms, rather than in its potentially broader significance.
“If something along the lines of, let's call it the Hillman Glue, becomes a reality,” he conjectures, “many people who are not paralysed develop certain forms of cancer, which destroy the body but never involve the brain. Under those circumstances they might want a body because now you can glue it back together again, and it will function. You may find the body transplant even more with us.”
This raises a further complication; wouldn't the full body transplant then become a selective form of life extension, with a potentially huge demand for a very limited number of bodies? Who would decide who was worthy? While White has no solution, he does offer this analogy: “Back in the early days of artificial kidney machines, many cities in the USA had to have committees that were composed of doctors, clergy, lawyers, perhaps people off the street. And they had to look at a bunch of dossiers and see who they recommended to be hooked up to one of these machines. These people had end-stage renal disease. If they didn't go on dialysis, they died. And these committees had to sit around and decide who was going to get an artificial kidney run.”
A few days after our interview, the British press will report that doctors at renal units in London are being forced, by want of resources, into making exactly this kind of life-and-death decision. Appalling as this is, no one has been insane enough to suggest that in the interests of fairness, dialysis should be forbidden altogether - which would surely be the logical conclusion for anyone who wishes to prevent White's operation on the equivalent grounds. And while this is merely one example, it does seem that few of the moral dilemmas raised by the full body transplant are genuinely new, either to medicine or to society.
DR WHITE'S research laboratory once occupied an entire floor in a wing of the Metrohealth Centre. Since his retirement in 1998, most of it has been closed off. Two adjoining rooms now function as storage space and an ad hoc, uncatalogued museum. We continue our interview amid a clutter of medical instruments, operating tables, anatomical diagrams and such intriguing miscellanies as the perfusion machine and a human brain floating in a glass jar. To some scientists, this place would deserve the status of a shrine. But to White's most vocal, consistent and longstanding enemies, it is an atrocity exhibition, one of the most evil places on earth.
White's conflict with “animal rights” activists dates back to an article published in the mid-1960s, in what was then one of America's most popular magazines, Look. The journalist Oriana Fallaci had arranged via White's university to witness one of his isolated brain experiments. When the piece appeared, he claims, “She had humanised this monkey, gave it a name. She would propose a question to me, something like, ‘Do you think these monkeys have souls, and do they go to heaven?’ Then she would answer the question herself. That article was a sensation. It may even have helped to put together all the various pieces that became PETA” - People for the Ethical Treatment of Animals, the large and influential American pressure group.
But it wasn't until White himself wrote about his work in Readers Digest in 1985 that the protests really took off. “People sent hundreds of duplicate letters to the dean to get rid of me. One of them came to the hospital to do me harm, but was stopped by the police. Somebody destroyed a lab over at the medical school they thought was mine. I had to make arrangements with the FBI, and for reasons I'm still not too clear about, the Secret Service. I think some US senator supported me, and he needed protection, so it flowed over to me. We also had the local police staking out my house and providing escorts on my way to work. But the worst part, I have four daughters, and these girls would pick up the phone and people would say things to them that were horrible. It was,” he understates, “a bad scene.”
As a swift trawl of animal rights websites reveals, White is still whatever the opposite of their poster boy may be. They spell out, in capital letters and typically sprightly fashion, such rubrics as “DR ROBERT WHITE'S VIVISECTION ADDICTION” and “DR WHITE JUSTIFIES HIS TREACHERY'. The protests aimed at White have at times taken on a farcical quality. Once, en route to a banquet held in his honour by Cleveland's Visiting Nurses Association, the road was lined for two blocks by protestors in monkey suits; “great costumes, really beautiful,” he marvels. “One of their members, when everyone was seated, attempted to present me with a latex rubber monkey head. That was the most outlandish and at some points the most entertaining thing that I was personally in on.” This is a man who has stood in the eerie Room 19 of Moscow's Institution of the Brain, amid the pickled lobes of Russia's greatest minds, and handled Lenin's cerebellum; presumably, he knows outlandish when he sees it.
White is prepared to take the issue seriously when the occasion demands it, but his opinions have never faltered. Two years ago, at the public forum of Cleveland's City Club, he agreed to debate PETA's co founder, Ingrid Newkirk, whom he describes as “a former New Jersey dog warden.” By now he was wise to publicity gambits himself: “I brought a patient of mine, a beautiful young woman who had a brain tumour, and we'd had to put a device in her head which had been developed on animals. So in the course of this argument I asked this woman to stand up. She said - and she's very good looking - ‘I'm delighted to be here. And I owe my life to animal experimentation.’
“Now that may have been unfair. I don't know who won the argument. But I have been an advocate for almost a quarter of a century now of the need for animal experiments. All of the surgical procedures that we have discussed are done under general anaesthesia. At no time would I or my staff permit any sort of painful operation to be conducted. I do think it is absolutely necessary for the success of mankind and for control of diseases that we have animal models.”
When I first tried to contact Dr White, he called me back from his hunting lodge in Germany. More often he is to be found fishing on Lake Erie, writing in the Caribbean, or at home in the Cleveland suburbs. Clearly, this is not the life of a man haunted by his conscience. What does trouble him is disapproval within the medical fraternity. “Generally,” he says, “the criticism I get is not from brethren in neurosurgery or brain surgery, it's more from the neuroscientists.” Although that's not always the case. One notable exception is Dr Peter Hamlyn, a neurosurgeon at Barts hospital in London, who has publicly described White's research as cruel and irrelevant, and those people willing to undergo a full body transplant as cranks.
“Those are pretty harsh words,” sighs White. “I can understand those feelings that he has. I don't so much mind a very distinguished, highly-trained specialist, as any neurosurgeon is, taking me on. I would be delighted to review this with the group at his hospital. In a way, I need their approval. But he is willing to direct that to this ‘crank’ who is presumably a quadriplegic? Would he say that if the quadriplegic were to say, ‘My body is failing me; I'd like to go on seeing and hearing and enjoying life as I can. It's limited, but I want to go on. . .’?
“In the end,” he says, “I have always come back to the same basic concept, that you are preserving the brain and the mind and the soul. In spite of the physical limitations, there seems to be no limit if you're functioning via the cranial nerves. Look at Professor Stephen Hawking. Here he is, able to influence the entire world of mathematics, physics, astronomy, everything; and he's just - I don't like the term, but many people have used it - a head on a computer. People say, ‘I don't know whether the person is the body, or the head.’ Well, call up Stephen Hawking. Read his books. He might not be very happy with things like souls or spirits, but to my mind, his soul is still intact there.
“That would be a riveting scenario for the world to consider. As a result of Professor Hawking's great brain and great study, would it be justified to give him a new body? And I think if you took a poll, most people would say yes.”
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