“The mind lives on the heart”: A Death Deferred

March 30, 2016   •   By Rishi Goyal

CATASTROPHE AND MIRACLE are the two poles of our bipolar imagination, and both are enveloped in the folds of contemporary science. Apocalyptic fiction rehearses stories of the end of the world brought on by scientific malfeasance and tragic hubris, while science journalism touts the end of human suffering through cloning and stem-cell research. The Heart, Maylis de Kerangal’s recently translated French novel, flutters lightly in the midst of this frenzy, like a prayer whispered on a string. Through language infused with the muscularity of material bodies, Kerangal explores the limits, possibilities, and multiple meanings of death in a biomedicalized society.

Simon Limbres and his two friends wake at dawn. They pack into a van, drive to the beach, worry on their neoprene suits, and crash through cold waves on their newly waxed boards. For the briefest of moments, Simon is his body — his discrete parts all in harmony — but on the way home, the van swerves off the road and smashes into a post. Two boys escape with minor injuries; Simon does not. Propelled through the windshield, Simon experiences a traumatic brain injury. Thus as the seaside bucolic prologue ends, the novel kicks into gear. Simon’s body is transported to the hospital where it is greeted by a team of doctors and nurses, first in the emergency room and then in the ICU. They quickly establish that Simon’s injuries are irreversible and that while his heart is still beating, his brain is effectively dead. He is a living cadaver and the perfect organ donor.

The last (and only) time I went on an organ “harvest” (that’s what the surgeons call it, the botanic metaphor of fertility and fecundity barely audible over the rapaciousness of child-robbers and grave-robbers), we stood quietly over the body for a moment before making the first cut. It was impossibly long, from suprasternal notch to the pubis — this was not a surgeon’s cut or an anatomist’s cut or even the cut of an autopsy; it was not a window but a door. The aorta was cross-clamped, and cold infusion started. We removed the heart in minutes and left the other teams from the other hospitals to harvest the other organs (nothing would go to waste: liver, pancreas, intestines, kidneys) as we packed ours in a $10 red and white Rubbermaid cooler. We were casual but hurried as we returned with our prize and delivered the not-beating but fresh heart into the hands of the waiting surgeons, who stood over the gaping maw of another cavernous and empty cavity. The recipient was old, and his chest and heart were dilated. Our donor had been young, a boy of not 19, and his heart was small and strong. Like many organ donors, his death was tragic and unexpected. In her essay “Commodity Fetishism in Organs Trafficking,” the anthropologist Nancy Scheper-Hughes writes,

The global traffic in organs follows the modern routes of capital and labor flows, and conforms to the usual lines of social and economic cleavage. In general, the organs flow from South to North, from poor to rich, from black and brown to white, and from female to male bodies.

But Scheper-Hughes misses one line of flow, that of young to old. In this medical gerontocracy, the lives of the old are replenished through the tragedy of young deaths. The very same event, a car wreck and a death, is both a miracle and a catastrophe.

In the novel’s ICU, Simon’s care is overseen by Pierre Révol, a long, thin physician with a penchant for hallucinogens and Miles Davis. The books on Révol’s shelf, L’homme devant la mort, La sculpture du vivant, and most tellingly, Twice Dead: Organ Transplants and the Reinvention of Death by the medical anthropologist Margaret Lock, signal that this is not just any old kind of medical thriller, but one that is intimately invested in the meaning of modern death: What is it and when does it occur? How many times must we die? When Blaise Pascal wrote “Le cœur a ses raisons que la raison ne connaît point” (The heart has its reasons that reason cannot know), he couldn’t have known that the invention of organ transplantation in the 20th century would reverse the primacy of the heart over the head and occasion a new definition of death. The idea of brain death had to be invented to provide a fresh supply of transplantable organs, but this newly brain-dead body contradicts our experience of death: the pulse and heart are bounding, the skin is warm to touch, and the chest rises and falls exactly like that of someone asleep. In her study of brain death in Japan and North America, Lock argues that organ donors maintain a separate ontological status from the rest of humanity: they are the “twice dead.” They die a first time when they are declared brain-dead, and they die a second time, a biological death, after their hearts are stopped and their organs removed. Officially, there is but one death; but death is not one. Death is understood and experienced differently by different peoples at different times. Death can be gradual, incremental, and flexible.

Révol is responsible for telling Simon’s parents that even though his heart is still beating, their boy is dead. Marianne and Sean have been separated for a few months, divided in part by Sean’s love of the sea and his Maori spirituality (both of which had been passed on to his son). But as they pass through the stages of loss, as they rage and cry, as they find solace in each other, as they are undone by this death, they are confronted by the liminality of the modern, technologized space between life and death and the restoration possible through organ transplantation. These distinctions of death are made painstakingly clear and serve as the narrative engine that creates most of the tension in the novel. If at times the discussion of these thresholds comes across as academic, such moments are saved by the dazzling and dancing prose. For death is finally neither brain death nor heart death, but a linguistic death, a turn of phrase, a speech act, a pronouncement. And the human catastrophe at the heart of the novel, the “whole tragedy of the world,” is summed up in a single untranslated but oft-repeated phrase, coma dépassé, which might mean something like “a state beyond coma,” but for which English has no exact equivalent.

Organ transplantation is part of a network, a process of organ transfer that involves donors and recipients as well as procurement specialists (“vampires”), nurses, doctors, surgeons, social workers, and family members. Anonymity is at the heart of this gift economy, but Kerangal names all of the characters in this choreographed schema. Once Révol begins the process of declaring Simon brain-dead, he initiates a chain of action that starts with Thomas Rémige — a man who, far from being a “vampire,” is an organ and tissue removal coordinator, a thoroughly realized and emotionally nuanced young man who not only has to guide Simon’s parents to an acceptance of organ donation, but also coordinates the entire sequence itself. Kerangal invests each of these beads on a string with a full fleshy story and unfolds them like rooms in a large mansion: from Cordélia Owl, the plucky nurse always falling for the wrong guy, to Virgilio Breva, the ambitious bear-like Italian surgeon. The least effective character, Claire Méjan, the lonely wraith waiting for a heart in a one-bedroom apartment near the Pitié-Salpêtrière, suffers from a loss of élan and vitality that underscores her sick heart.

Ultimately, time is the central protagonist in this novel. Time dilates and constricts. The novel’s action takes place in the span of one day, 24 hours, with each hour and minute accounted for. The time of the living and the time of the dead are bookended by the tick-tock of the beating heart. But Kerangal manipulates time, sometimes speeding it up, sometimes replaying it, and sometimes slowing it down so that gestures are anatomized; we can then see the deliberate movements of the muscles and ligaments beneath the skin and are closer to the hidden body, the inner organs and bones beneath those muscles and ligaments. The threshold between the living and the dead is as thin as the lamina papyracea. And as if to parallel the life becoming object, objects and technological discharges like electromagnetic pulsations and radio waves sweep through the atmosphere with a purpose and haughtiness that seems almost lifelike.

In lyrical and controlled prose, expertly rendered into English by Sam Taylor, Kerangal offers a modern meditation on mortality. Medical technology has sustained and lengthened life; it allows us to live longer and better lives some of the time, but at a cost. Some lives are preserved only through the loss of others. The artificial respirator and the modern ICU have created a space between life and death, where the body persists but awareness has taken flight. The miraculous developments in transplant medicine threaten bodily integrity and transform some people into a storehouse of parts. The historian Melvin Kranzberg captures this ambiguity in the first of his six laws of technology, “Technology is neither good nor bad; nor is it neutral.”

During the first half of the 20th century, physics was the science most likely to challenge philosophy with the destabilizing effects of Einsteinian relativity, Heisenberg’s uncertainty principle, and the atomic bomb; since then, advances in biology and medical technology have become the dominant scientific framework within which to confront our oldest binaries — self/other, life/death, and mind/body have all become increasingly troubled by developments in immunology, organ transplantation, genetic therapy, and neuroscience. The first breathlessly long sentence of the novel announces the multiparous meanings the heart embodies in an era when space and time have been conquered. The heart is a pump, contracting ceaselessly 100,000 times a day; it makes the machine jump and dance; it is the seat of love. It is nothing more than a muscle and nothing less than the locus of human identity and human experience. But the heart has been displaced and dispossessed: “The heart is dead, long live the brain.”

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Rishi Goyal is the director of the Major in Medicine, Literature, and Society at Columbia University and an assistant professor of Emergency Medicine.