How The God Committee gets Organ Allocation and Xenotransplantation Wrong and Why it Matters

This is a guest post by Kailyn Price and Jacob Zionts. It discusses their thinking on some of the ethical dilemmas faced by organ transplant committees through the lens of The God Committee.

(Note: this post contains spoilers)

It is 2021 and Dr. Jordan Taylor (played by Julia Stiles) sighs relievedly as she sees the genetically modified pig heart that she has just transplanted into the chest of a baboon beat and come back to life. The apparently successful operation serves as the climax to Austin Stark’s The God Committee, a fast-paced medical drama that grapples with the ethics of transplant committees, xenotransplantation (cross-species transplantation), and benefit calculations.

Despite the achievement, the scene is haunted by Dr. Taylor and her transplant committee’s decision a decade earlier to accept a bribe from a suspiciously wealthy man whose adult son desperately needed a heart. Prior to learning of the twenty- something’s condition and prospect of a bribe, the committee had been coalescing around a decision between two other candidates: 1) a middle-aged Black man who struggled with bipolar disorder but is also a loving father of three daughters, and 2) a curmudgeonly 70-year-old white woman who demeans her nurses, has little extant family, and seems ambivalent about receiving the heart. The bribe required the committee to ignore the son’s typically disqualifying drug use and deprioritize the other candidates but, ultimately, funded the research that culminated in the pig-to-baboon heart transplant and enabled the hospital to care for more patients.

The God Committee wants its audience to walk away thinking that the ends justified the means—that the hard-nosed consequentialism of the committee and their willingness to shoo aside the more deontological and virtue-oriented constraints of standard bioethics were necessary to secure the greater good. But we don’t think that’s the right message to take home. In this post, we will explicate and reject both of the committee’s reasons for accepting the bribe: (1) saving the hospital and (2) securing xenotransplantation funding. In the end, we argue that (1) accepting the bribe undermines the committee’s ability to act in the best interest of the hospital’s patients; and (2) the film’s narrow focus on xenotransplantation occludes the upstream causes of heart failure that are imminently targetable with status quo technologies and, critically, have the upshot of positively interacting with the demands of racial, environmental, and animal justice.

Responding to Reason (1): Saving the Hospital

First, the transplant committee argues (tacitly, at least) that accepting the bribe will enable the struggling hospital to save more lives over the long-term. But we aren’t sure if that’s true. Even on the committee’s act consequentialist approach, accepting the bribe could have unacceptably deleterious effects on the very organ donation and allocation system they are attempting to bolster. Organ allocation is determined by viability, urgency, and other medical factors to maximize utility of the available organ. If word got out about the committee’s choice to favor the rich, then it would likely further undermine public trust and, as a result, decrease organ donations. (Morgan, Harrison, Afifi, et al. found that mistrust of doctors, hospitals, and the larger allocation system is already the most commonly cited reason for non-donation.) Given the United States’ acute organ shortage, that matters and will translate directly into avoidable deaths.

A committee member might reply that this is just a one-time thing; there will not be more lying, and it is highly unlikely that the public will ever find out. We don’t like that gamble. Regardless, that response ignores the compromising situation that accepting the bribe puts the committee in. The rich twenty-something’s father will always be able to hold the committee’s misconduct over its head. In other words, the committee is making itself vulnerable to blackmail, which could undermine their ability to make future efficacious medical decisions in highly unpredictable ways.

Responding to Reason (2): Funding Xenotransplantation Research

Second, accepting the bribe will help fund xenotransplantation research that The God Committee suggests could eventually eliminate organ scarcity entirely. Here, the act consequentialist heuristic that drove the first reason remains but the stakes are much, much higher.

The movie’s depiction of xenotransplantation research being driven by Dr. Boxer’s (Kelsey Grammer)—Dr. Taylor’s predecessor—individual genius and labor does not comport with reality. In real life, xenotransplantation breakthroughs are made possible by highly collaborative, often publicly funded, and strictly regulated research over several decades. (We would be remiss, however, if we didn’t mention that the movie accurately captures the fact that medical funding is disproportionately allocated to white men).

As with the first reason, we reject The God Committee’s unbridled optimism regarding what accepting the bribe will enable. The movie justifies acceptance of the bribe through a framing mechanism that portrays Dr. Boxer’s research as necessary for achieving pig-to-human heart transplants. We think that’s the wrong interpretation. From our perspective, the most that can be said is that accepting the bribe simply advances the pig-to-human heart transplant timeline forward a few years. Surely, The God Committee is not claiming that without Dr. Boxer accepting the bribe, humanity will never successfully transplant a pig heart into a baboon. Moreover, the singular focus on xenotransplantation ignores the promise of artificial organs (including total artificial hearts), which avoids the risk of zoonotic infection. With that in mind, the stakes here are lower than they first appear.

The God Committee (and public discourse) also fails to meaningfully account for the grim fact that xenotransplantation’s viability as a solution to the problem of organ scarcity requires a consistent and massive supply of genetically modified pig organs—a supply secured through a program of mass breeding, testing, and, ultimately, slaughter. It would also require ongoing primate experimentation. In other words, alleviating the human suffering and death caused by organ scarcity would require us to inflict suffering and death onto other conscious and intelligent creatures. Such a program would conflict with important goals of decarbonizing biomedical research and health systems and ending their dependence on animal exploitation.

Once we accept that xenotransplantation is not the panacea The God Committee makes it out to be, will eventually happen without Dr. Boxer, and comes with massive externalities, then the unjustifiability of the transplant committee’s choice comes into full view.

Challenging the Status Quo

As the genetically modified pig heart reanimates the baboon, we are left feeling sour. In the world of The God Committee, a sickly person who is a poor candidate for a human heart transplant will soon be offered a genetically modified pig heart in an experimental setting. Given the disproportionately high rates of end stage heart failure in low income and Black communities, there is a good chance that that person—and those who will receive the experimental intervention later—will come from a marginalized background. Later, many more will benefit. But those benefits won’t necessarily be accrued by the communities who bore the burden of experimentation. Because of xenotransplantation’s exceptionally high cost, it will likely only be available to the well off once out of its experimental phase.

And so it goes: Dr. Taylor’s work will be lauded by her peers and broader professional community; the project’s already rich private backers will profit off their investment, accumulating more and more wealth; the patients—yes, even those in ostensibly free clinical trials—will continue to accumulate medical debt, worsening already profound health inequities; and though some humans will live slightly longer, an untold number of pigs will be bred to die, exacerbating carbon emissions and deepening humanity’s dependence on animal exploitation. Meanwhile, the ability to find and afford healthy food, live in safe housing, regularly access and afford medical care—the racially stratified social determinants of cardiovascular disease that give rise to need for heart transplants—will remain unchanged.

The transplant committee should have rejected the bribe. And we should reject the worldview that justified their choice. Our salvation does not hinge on any single breakthrough medical or technological innovation. Rather, it lies in our ability to alter the murderous material conditions that make those innovations seem like a necessity in the first place.

Author bios: Kailyn Price is a neuroscience PhD student at The George Washington University. Jacob Zionts is a predoctoral fellow in the Department of Bioethics at the National Institutes of Health.

Disclaimer: The views expressed are those of the authors. They do not represent the positions or policies of the National Institutes of Health, the Department of Health and Human Services or the US Government.