Exchanging Hearts: A Medievalist Looks at Transplant Surgery
A new heart I will give you, and a new spirit I will put within you; and I will take out of your flesh the heart of stone and give you a heart of flesh.
—Ezekiel 36:26We are members one of another.
—Ephesians 4:25
The exchange of hearts, a familiar motif in hagiography and romance, may seem one of the stranger marks of medieval alterity. Lyric poets routinely send their hearts questing after resistant ladies, who take the organ hostage with a kiss. When forced to separate, couples pledge their loyalty by exchanging hearts, which may come back to them with alarming literalism. Mystics—always female—offer their hearts to Jesus and receive his in return, sometimes entering his body through the bloody wound in his side. Jealous husbands kill and excoriate their wives’ paramours, feeding their hearts to the ladies in a secret cannibal feast. On autopsy, a lover’s heart reveals the name or image of the beloved or, mutatis mutandis, the tokens of Christ’s Passion.
Lovers no longer use these metaphors, nor do the devout. Yet, from one perspective, such narratives should be more intelligible today than ever before. Imagine what a medieval reader would have made of the following tale. In 2004 a man named Sonny Graham, sixty-five, of Hilton Head, South Carolina, married Cheryl Cottle, a widow thirty years his junior. Such unions, though rare, seldom make national headlines. This one did because in 1995 Sonny Graham had received the transplanted heart of Cheryl’s late husband, Terry Cottle. After four years of wedded bliss, Graham shot himself in the head and died—just as Terry Cottle had done thirteen years before.
In the three decades since modern transplants literalized the poetic metaphor of exchanging hearts, more and more such tales have emerged, to the consternation of surgeons. A 1999 study by Paul Pearsall and colleagues, published in the journal Integrative Medicine, describes ten cases of remarkable personality change among heart transplant recipients, as ascertained from interviews with patients, their families and friends, and donors’ families. A middle-aged white factory worker, described by his wife as an Archie Bunker type, makes friends with his black colleagues and develops a passion for classical music. His donor, it turns out, was a young black man killed in a drive-by shooting en route to a violin lesson. A five-year-old boy, given a new heart in infancy, picks out his donor’s father in a crowd and runs up to him, calling, “Daddy!” Another young boy with the heart of a drowned girl develops a sudden fear of water, which he always used to enjoy. A man with a woman’s heart becomes a better lover and experiences a newfound joy in shopping, while another develops a taste for perfumes and the color pink. A lesbian activist becomes heterosexual and gives up her favorite restaurant, McDonald’s, because the smell of meat now disgusts her. Her donor, a vegetarian and heterosexual, had run a health food restaurant. One of the case studies might have come straight from a medieval romance. An eighteen-year-old girl receives the heart of a boy her own age, a songwriter, killed in an auto accident. More than a year later, the boy’s parents discover that he had predicted his own death in a song titled “Danny, My Heart Is Yours.” When the girl sees the boy’s picture, she recognizes in him the longtime lover who died to save her life: “I know he is in me and he is in love with me. He was always my lover, maybe in another time somewhere. How could he know years before he died that he would die and give his heart to me? How would he know my name is Danielle?”
Scientific responses to such anecdotes differ, to say the least. In the study just cited, the authors remark that all seventy-four patients in their sample “showed various degrees of changes that paralleled the personalities of their donors,” though not always as dramatically as those described. They posit a theory of cellular memory to explain how “information and energy are transmitted electromagnetically between the brain and heart, [so] that through electromagnetic resonance, the brain may process information derived from the donor’s heart.” Other studies cite organ recipients who claim to have internalized such donor traits as generosity, artistic talent, piety, aggression, and even the ability to speak a foreign language. Claire Sylvia’s 1997 memoir, A Change of Heart, narrates her own developing relationship with her donor and presents a range of theories, both scientific and metaphysical, that purport to explain such phenomena. Meanwhile, popular culture has begun to embrace the idea of heart transplants as not only saving but also transforming lives. In the early 1990s, a segment of the Phil Donahue Show featured a group of New York–area heart transplant patients who claimed not only to have taken on characteristics of their donors, but to know intimate details of their lives without being told. The 2000 romantic film Return to Me, directed by Bonnie Hunt, anticipates the real-life story of Sonny Graham and Cheryl Cottle. In his short story “Whither Thou Goest,” Richard Selzer imagines a distraught widow who finds comfort only when she tracks down her husband’s heart and listens to it beating in the breast of its new owner.
But such tales also elicit widespread skepticism. A 2004 Israeli study finds that of thirty-five male heart transplant patients, only a third thought they might have experienced personality change caused by their donors’ hearts. The researchers ascribe these patients’ “fantasies” and “magical thinking” to the physical and emotional stress of surgery. In a study by F.M. Mai, eighteen of twenty transplant patients engaged in denial: seven claimed to have no special thoughts about their new hearts; five said they never wondered about their donors; and six showed denial on both fronts. In an Austrian study of forty-seven patients, 79 percent categorically denied any personality change. As if to prove that Freud’s Vienna has not changed very much, the authors of this study see the patients as presenting “massive defense and denial reactions.” Even in this group, however, three patients reported personality change in conformity with their donors. The philosopher Jean-Luc Nancy, who received a heart transplant around 1990, described his experience in a trenchant essay titled “The Intruder” (L’Intrus). Though known for his philosophy of “being-with” (Mitsein), Nancy expresses surprisingly little interest in his donor, remarking that “the whole dubious symbolism of the gift . . . wears out very quickly.” Instead, the “intruder” of his title “is nothing but myself and man himself.” His graft, which extended his life without restoring his health, inspires a meditation on the fragmented identity, the long process of self-alienation, induced by the medically altered body.
Whether dramatic or subtle, common or rare, the experiences of those who have undergone a literal change of heart suggest that, even in medical terms, the organ is far more than a muscle that pumps the blood. Understood in cultures around the world as the seat of life, soul, personality, and emotion, the heart remains the most frequent and symbolically charged metonymy for the whole person. The ancient idea of giving one’s heart to another takes on new potency now that it has become physically possible. In this article, I mean to explore the ethics of transplants—in particular, the relationships they establish between the living and the dead—from my perspective as a historical theologian. Seeing through the lens of such Catholic doctrines as the coinherence of the Trinity, the mystical body of Christ, and the communion of saints, I pay special attention to medieval practices based on those doctrines. With Wendy Doniger I believe that “though it has become physically possible to do such operations only in recent decades, people have imagined, for a very long time indeed, the sorts of problems that might arise if one could do such things.” This kind of imagining shapes medieval legends about lovers exchanging hearts, as well as the practice of saints offering their own pain to relieve that of others, living and dead. For Christians wrestling with the ethical problems posed by this life-saving, yet disquieting surgery, such legends and practices, in dialogue with contemporary studies, can help us gain a fresh moral and ontological purchase on the problematics of transplants.
Let me return to Pearsall’s case histories. What makes his work so important is that for the first time he established an experimental protocol to test claims that had been surfacing within the transplant community for years. In each case, the recipients of new hearts, with their families and friends, were first interviewed about personality changes observed since their transplants. Only later were potential links between these traits and the donors confirmed by interviews with people who had known those donors well. The recipients themselves had no prior contact with their donors’ families or friends, nor had they received any information about the donors beyond age and gender. In these patients, therefore, unexpected changes bearing a demonstrable relationship to the donors’ qualities could not be dismissed as mere “incorporation fantasies.” That is actually one of the kinder terms that physicians have used for such patient reports, when they have deigned to notice them at all. Although patients often express such beliefs, their statements are typically characterized as “animistic,” “regressive,” and “magic-infused thinking.” One physician’s assistant defended the hospital’s policy of keeping donors anonymous with the remark,
When you give somebody a gift, you don’t ask them, “How’s my chess set that I gave you? How’s the basketball I gave you?” The same is true with organs. We don’t want people saying, “How’s Johnny’s heart? Are you taking good care of it?” Some people feel that just because you have their brother’s heart in you, they have some influence over your life. And we don’t like to foster that feeling at all.
Accordingly, many surgeons, lawyers, and economists, and even some bioethicists, have adopted what Renée Fox and Judith Swazey call a “spare parts” approach, wishing to distance themselves as far as possible from the “superstitious” idea that the dead person lives on in donated organs.
As Don Keyes has noted, the prevailing method of defining death in the transplant community implies a brain-body dualism, with the brain uneasily taking the place of the soul: “There seems to be an implicit assumption that as long as the brain is intact, the self remains intact. Other body parts are interchangeable and transplantable.” I argue that this model is seriously flawed. Not only does it fly in the face of our everyday assumptions about psychosomatic wholeness, which are supported as much by biblical theology as by nearly unlimited evidence for the unity of body and mind in the living person. In a more disconcerting way, this primitive dualistic model is undercut by Pearsall’s study and a great deal of related evidence, which suggests that some elements of what we call “soul” or “personality” cling to transplanted body parts—especially the heart—even after the death of their owner. Medical research now confirms an insight memorably expressed by the critic Dennis Slattery in The Wounded Body: “Perhaps something of our own souls is permanently in our body, in each of its parts. To lose something of ourselves is to lose something of psyche, even of a memory that is embedded deep in every organ.” After transplant surgery, patients of all ages and both sexes, most with no history of psychological illness, have unexpectedly found themselves in a personal relationship with their donors, living or dead. Instead of pathologizing their experiences or dismissing them as “fantasies,” we might have the courage to admit that a new medical procedure has given us new evidence about our humanity, challenging the limitations of brain-body dualism and, more broadly, of scientific materialism. How might we think more creatively if we acknowledged that patients, as well as surgeons, are now pushing the frontiers of discovery?
Traditional funeral customs have always assumed a continuing link between the body and the personal presence of the deceased. Why else do we go to mourn our loved ones at their graves if any other site might serve as well? Remarkably, the Catholic cult of relics assumes that even saints in heaven work most powerfully through their remains on earth, often centuries after their deaths. The experience of Pearsall’s patients suggests that such traditional beliefs should not be taken lightly. If organ transplants can lead, as one psychiatrist puts it, to a “fusion of the ego boundaries of donor and recipient,” this may suggest not that the patient is psychotic but that the boundaries of the ego are not easily separable from those of the body, which the surgery itself has breached. I do not, however, wish to argue on the grounds of this psychosomatic unity that transplants should not occur. Rather, I suggest that prospective donors, families, recipients, and—if it is not too much to ask—medical teams should acknowledge this jarring evidence and make a psychological and spiritual effort to come to terms with it. As a first step, we might reconsider the way we conceptualize personhood.
Nowadays we assume, without much reflection, that a “person” is roughly the same as an “individual.” As a theologian, however, I would propose a different starting point: the doctrine of the Trinity, which asserts both the inseparable oneness and the eternal distinction of the three persons. In patristic theology, the Latin persona, or mask, was used to translate the Greek hypostasis, a subsistent being. A “person” thus came to denote a center of consciousness, or what we might call a “self,” over against a “nature,” an abstract set of properties characterizing a particular type of being. Theologians formulated the central paradoxes of Christian doctrine through the interplay of these terms, defining the Trinity as three persons sharing one nature and Christ as one person possessing two natures, divine and human. Once these dogmas were in place, both could be extended to define human selfhood. Christian anthropology is founded on the idea of imago Dei, the human person created in the image of God. Yet the divine Self is conceived as supremely permeable, for the three persons of the Trinity not only share the same nature. They are also said to “indwell” one another reciprocally—a doctrine known as coinherence, or being-within-one-another. As Jesus in the Gospel of John declares, “I am in the Father and the Father in me” (John 14:11). This divine coinherence extends to the redeemed: “You will know that I am in my Father, and you in me, and I in you” (John 14:20). As a theory of selfhood, coinherence asserts the porousness of human persons on the model of the divine. “The glory which you have given me I have given to them,” Christ tells the Father, “that they may be one even as we are one, I in them and you in me” (John 17:22–23). On this model, the essence of personhood is the capacity to be permeated by other selves, other persons, without being fractured by them. A “person” in this sense has little to do with either the self-sufficient Enlightenment self or the decentered, fragmented postmodern self. Rather, the personal is, by definition, the interpersonal. One cannot be a person by oneself but only with, through, and in other persons. Or in St. Paul’s words, “We, though many, are one body in Christ, and individually members one of another” (Rom. 12:5).
The great twentieth-century Anglican writer Charles Williams—poet, novelist, and theologian—explored the profound implications of coinherence as a spiritual practice, even founding a lay religious order called the Companions of the Co-inherence. In his view, this overarching reality involves bodies no less than souls. Hence he ends his book The Descent of the Dove, subtitled A Short History of the Holy Spirit in the Church, with an observation about pregnancy—a subject on which church historians usually have little to say. “At the beginning of life in the natural order,” Williams wrote,
Is an act of substitution and co-inherence. . . . The child for nine months literally co-inheres in its mother; there is no human creature that has not sprung from such a period of such an interior growth . . . It has been the habit of the Church to baptize it, as soon as it has emerged, by the formula of the Trinity-in-Unity. As it passes from the most material co-inherence it is received into the supernatural.
Pregnancy is the only circumstance in which one human being actually dwells in the body of another—or at least it was until the advent of transplant surgery. Today, therefore, coinherence may provide the most ontologically useful way to understand the new relationship between persons that is established through transplants. I would propose that the gift offered by an organ donor is far more than a functional “spare part” to replace a broken one, like a new hard drive in an old computer. Rather, it is a gift of self in a much deeper sense, a literal enactment of the dictum that “we are members one of another” (Eph. 4:25). Like a child in its mother’s womb, the transplanted heart represents the sojourn of one person within another. But, while the first instance of coinherence ends with a birth, the other begins with a death.
For medieval writers, the exchange of hearts likewise originates as a corporeal metaphor of love. More specifically, it denotes the lover’s mysterious and transforming presence within the beloved. At first the motif is used playfully by troubadours and romance poets. Over the course of time, however, it reveals a surprising pull toward literalizing the gift. From the twelfth century on, poets imagine the heart under amorous provocation taking leave of the lover’s body. Ablaze with delicious pain or bitter joy, it goes to dwell with the lady, who takes it captive with a kiss. Forced to part at dawn, illicit lovers pledge fidelity by exchanging hearts along with their rings. In Chrétien de Troyes’s Yvain, a newlywed knight departs on a quest but leaves his heart behind with his wife. As Chrétien says comically:
We know the body can’t survive
without a heart, yet he’s alive!
His body has no heart inside!
So it can never be denied
that such a wonder came about,
because he’s still alive without
his heart, which, though enclosed before,
will not go with him any more.
In Chaucer’s Troilus and Criseyde, as the heroine debates whether to take Troilus as her lover, she falls asleep and dreams that an eagle, “feathered white as bone,” sets his claws beneath her breast, extracts her heart, and replaces it with his own, amazingly causing no fear or pain—“and forth he flew, with heart there left for heart.” The dream foreshadows and facilitates their actual affair. Another exchange of hearts occurs in the thirteenth-century romance, Flamenca. Meeting again after a separation, the hero, Guillem, asks his beloved, “How is my heart doing?,” and she replies:
This is a strange new thing indeed
and comes of love and subtlety—
I keep your heart in place of mine
and you keep mine, in such a way
that I suffer mine to live in you,
and in the same way you suffer yours
to live in me through pure desire.
The exchange of hearts does not only symbolize mutual love but can also convey darker meanings of pain, betrayal, and sacrifice. Abelard tells Heloise that she is “immortally entombed” in his heart, from which she will never emerge while he lives. When a lover is faithless—as Criseyde is to Troilus—the survivor can only perish miserably, having lost not one heart but two. In a gruesome cluster of romances, the so-called eaten heart tales, a poetic exchange of hearts ends with a material gift. The dying lover in Jakemes’s Romance of the Castellan of Couci and the Lady of Fayel asks his valet to remove his heart, embalm it, and send it to his beloved in a silver casket. But the gift is intercepted by her jealous husband, with fateful consequences. He secretly gives the heart to his chef, who prepares an exquisite dish for his wife to eat. On learning what she has just devoured, the lady resolves to turn her unwitting cannibal act into a Last Supper by starving herself to death:
Alas! What a sorrowful gift
is his heart, which he has sent me!
He showed me truly it was mine,
so mine should just as well be his!
So it is! I will prove it well,
for I will die for love of him.
It is no coincidence that in tales like this one, what begins as a metaphysical gift of love ends in a physical act of cannibalism. Stuart Youngner has proposed that “in an entirely concrete sense, organ transplantation is a form of nonoral cannibalism, that is, the taking of the flesh and blood from one person into another.” Living persons can make a symbolic gift of the heart, but (unlike a kidney) the actual gift requires a sacrificial death—which in the Christian tradition has always been the supreme proof of love. In 1972, when members of the Uruguayan rugby team found themselves stranded in the Andes after a plane crash, the survivors justified their practice of cannibalism by linking it to the Eucharist. “It’s like Holy Communion,” one explained. “When Christ died he gave his body to us so that we could have spiritual life. My friend has given us his body so that we can have physical life.” Disturbing as the analogy might be, the Eucharist is indeed a rite of symbolic cannibalism; without sacrifice there could be no communion. Transplant patients—“survivors” of another fearsome but life-giving rite—might suffer less guilt if they could acknowledge their donors as honestly as this Catholic athlete acknowledged his dead teammate. But, whatever the context, the choice to benefit knowingly from another’s death should not be an easy one. For this reason medieval saints often became hyperscrupulous about receiving communion. In response, churchmen defended both partaking with gratitude and abstaining from a sense of unworthiness. Much like communicants in the Middle Ages, transplant patients today sometimes feel guilt and gratitude so intense they can be paralyzing. Such feelings are not “morbid,” though they are often presented as such in the literature. On the contrary, they demonstrate spiritual maturity and moral sensitivity. Yet Christians, at least in principle, have already accepted the knowledge that “another died so that I might live.” Honoring that context, with the principle of coinherence and exchange that governs the mystical body, could make it easier for patients to manage such troubling emotions.
Medieval tradition followed the exchange of hearts into a similar realm, linking it with both the Eucharist and personal sacrifice. From the mid-thirteenth century, hagiographers began to imitate secular poets, noting that holy women exchanged hearts with Jesus just as romance heroines did with their lovers. This grace is first reported of Lutgard of Aywières, a Cistercian nun who died in 1246. Whether her life established a model or simply marked a trend, the exchange of hearts soon became a regular feature of women’s vitae. More than thirty saints were ultimately said to have received this grace, among them, Gertrude of Helfta, Catherine of Siena, Dorothy of Montau, Teresa of Avila, and Margaret Mary Alacoque. An exchange of hearts served to confirm the coinherence of a saint with Christ. Often the exchange would occur as the mystic received communion. In one miracle story, when St. Juliana Falconieri lay dying in 1341 she was too ill to swallow the host, so she asked the priest to place it on a corporal above her heart. No sooner had he done so than it vanished—and at the same instant the saint died, smiling, in the kiss of her Beloved. Such a death can be viewed as a variant on the exchange of hearts: the saint receives the eucharistic Christ into her heart even as, dying, she enters his.
The most famous and complex of these tales concerns St. Catherine of Siena (d. 1380). Ten years before she died, as her biographer Raymond of Capua reports, Catherine was praying the words of Psalm 50—Create in me a clean heart, O God”—when Christ appeared to her, opened her side, and extracted her heart. This was no mere vision, Raymond insists, but an experience so physically compelling that when she next went to confession Catherine said “she no longer had a heart within her breast.” Her confessor laughed, but she persisted: “It is a fact, Father. As far as I can judge from what I feel in my body, I seem no longer to have any heart in it.” For the next few days she repeated this claim—until Christ returned with his own heart, “ruby in color and ablaze with light,” and placed it within her breast. For Raymond, the material reality of this miracle was all-important. Hence, he notes that Catherine’s “companions informed myself and many others that they had often seen the scar” from her incision, while she herself claimed that she could no longer commend her heart to Christ because he already possessed it.
For Catherine, this divine transplant was the first stage of a lifelong process. After an active ministry caring for the poor and sick, making peace between feuding city-states, and trying to persuade the pope to return from Avignon to Rome, Catherine was heartbroken when Gregory XI did return in 1377 only to die soon afterward, provoking the election of two rival popes and inaugurating a schism that would last for forty years. When all else she could do had failed, Catherine finally gave her heart, pulsing with Christ’s blood, as a remedy to heal his ailing bride. In a farewell letter written with her own hand, she tells Raymond how, at God’s urging, she had offered her life for the church. “Oh eternal God,” she prayed, “accept the sacrifice of my life within this mystic body, holy Church! I have nothing to give except what you have given me. Take my heart and squeeze it out over the face of this bride!” In response, “God eternal, turning the eye of his mercy [on me], tore my heart out by the roots and squeezed it out over holy Church. He had drawn it to himself with such force that if he hadn’t encircled the vessel of my body with his strength (not wanting it to be broken), the life would have gone out of it.” As she prayed thus, Catherine suffered what seems to have been an actual heart attack. She describes feeling “as if my memory and understanding and will had nothing to do with my body” while simultaneously enduring demonic attacks and perceiving divine mysteries. In a second and final letter, composed later the same day, she adds that at the time
The pain in my heart was such that my tunic was torn apart wherever I could get hold of it, while I reeled about the chapel as if I were in convulsions . . . The terror and physical pain were such that I wanted to run . . . But all of a sudden I was thrown down, and, once down, it seemed to me as if my soul had left my body . . . I remained that way for such a very long time that the family was mourning me as dead.
The end was in fact very near. A few days later Catherine suffered a second attack, after which she lay paralyzed until her death.
There need be no contradiction in seeing this near-death experience as a mystical sacrifice and a massive heart attack, though interpreters have been reluctant to offer such interpretations. Nor does one need to be privileged as the cause of the other. Catherine’s asceticism, especially her prolonged failure to eat, undoubtedly weakened her heart, and the pain she suffered gave her the opportunities for sacrifice that her ardent soul craved. What seems strangest about her account is not just its quintessentially late medieval fusion of extreme pain with ecstatic prayer, but the idea that she could heal a desperately sick woman (albeit an allegorical one) by squeezing her heart’s blood into her face. Catherine’s thought seems akin to the folk belief that leprosy could be cured by the blood of an innocent virgin or a child. The idea of transferring such a remedy to the church could have occurred only to someone who was steeped in blood piety, inclined to both physical and metaphysical realism, and utterly devoted to the cause of reform. Having already exchanged hearts with Christ, Catherine offered her new heart for the good of his mystical body, in a willed and ultimately fatal sacrifice. For this act she might today be exalted as the patron saint of donors.
Surgeons, of course, do not extract hearts from the living—or at least that is not their intent, despite lingering controversy over the criterion of “brain death.” Nevertheless, the decision to donate organs is often fraught, whether it is made by a living donor or, more painfully, by relatives after the sudden death of a young person. About 70 percent of all families approached for organs consent, usually in the hope of bringing life out of death and honoring the spirit of the deceased. These are deeply religious motives, whether or not the families profess any faith. In Denys Arcand’s 1989 film, Jesus of Montreal, organ donation is used as an explicit analogue for the resurrection. When the actor performing Christ in a passion play is killed in a production accident, his heart resurrects a dying man, his corneas give sight to the blind, and so forth. Even so, removal of organs from the newly dead (or, some would say, the nearly dead) violates ancient and profound taboos. Almost every culture has strictures against mutilating corpses, and the shocked and grieving survivors may be unable to anticipate how they will feel about their decision after the fact. Their trauma can be heightened if multiple organs are taken, as is often the case.
In Richard Selzer’s story, cited earlier, the young widow expresses anger and horror when she hears a radio preacher holding forth on the resurrection of the flesh. “Tell me this,” she asks. “What about Samuel Owen on your resurrection day? Here he is scattered all over Texas, breathing in Forth Worth, urinating in Dallas and Galveston, digesting or whatever it is the liver does in Abilene. They going to put him back together again when the day comes, or is it to the recipients belong the spoils? Tell me that.” As Selzer doubtless knew, this was the same objection that pagans raised against the early Christian belief in bodily resurrection: how could the flesh be restored to its pristine wholeness after it had been devoured by wild beasts or eaten by cannibals? Transplant surgery raises the specter of a new kind of dismemberment, appalling even to some who believe intellectually that the procedure is benign. In an essay titled “Why Organ Transplant Programs Do Not Succeed,” Leslie Fiedler points out that the Frankenstein monster, that irrepressible myth of our popular culture, is a patchwork of what would now be called “cadaveric organs.”
In view of such fears, I want to consider an alternative way of viewing the link between one person’s harm and the health of others. The medieval doctrine of purgatory is best known today as a system of otherworldly bribes that justly earned Luther’s wrath. But, long before it evolved into a cash nexus, purgatory provided some comfort for survivors by giving them concrete actions they could take to help their beloved dead. The “Poor Souls” languishing there were thought to be among the saved but not yet sufficiently purified to stand in the presence of God. They needed first to be cleansed by a time of suffering—which could be considerably shortened if the living were kind enough to share their burden. Hence, priests sang extra Masses for them; survivors made gifts of prayers, alms, and fasting; and saints took it on themselves to suffer not only for their departed friends and kin, but for poor sinners at large. Pain came to be seen as a currency that could be used to buy relief for the pain of others, whether they were afflicted by physical illness, mental anguish, or purgatorial torments. In effect, the practice of suffrages for souls is a gift exchange that, like St. Catherine’s gift of her heart, literalizes the metaphor of the church as Christ’s body. The fact of coinherence is presupposed: since “we are members, one of another,” pain as well as guilt could be displaced from one limb of the mystical body onto another. But the practice also promised benefits for the living. In a world where medical care was neither highly effective nor widely available, the gift of suffering as suffrage could be a strategy for the endurance of chronic disease and disability. It was a way of turning extreme helplessness into help for others, need into gift, abjection into power—thus introducing an altruistic dimension into what might otherwise seem an unavoidably slow and horrible loss of self.
Alice of Schaerbeek, a Cistercian nun of Ter Cameren, died in 1250. Her biographer, perhaps Abbot Arnold II of Villers, wrote her vita about twenty years later, relying on her sister and her maid as sources. What intrigued him about Alice was that she spent the last years of her life, perhaps as much as a decade, in a leper’s hut. There, within earshot of the monastery bells, she offered the ravages of her illness for the living and the dead until it finally carried her off. Alice’s heavenly bridegroom, the author writes, wished to have her all to himself, so he sequestered her “as a sign of perfect love” by smiting her with leprosy. Rhetoric of this kind should arouse suspicion, for nothing is easier than to glamorize someone else’s suffering. Nevertheless, in between evocations of horror and rhapsodic consolations we can discern the pragmatic use that Alice found for her pain. The author prefaces the onset of leprosy, the first major turning point in Alice’s vita, with a dream in which she sees a golden cross descending from heaven. At the second turning point, before her last and most agonizing year, he hails the “violence of charity” with which she begs God to “relieve the purgatorial pain of all the dead, and likewise purge the living of all sins,” on condition that she alone might bear “the vengeance of all for the sake of each.” Poena and vindicta are judicial terms; as Alice explains to her sister, she endures these punishments for the sins of others, not her own. At precisely the point when she can no longer leave her hut to walk to church, her disintegrating body becomes a microcosm of the church, as she makes a transition from contemplative martyrdom to vicarious penance. When she loses her right eye to leprosy, she offers it as a suffrage for the newly elected king, asking God to enlighten the eye of his understanding—literally giving an eye for an eye. Soon afterward she gives her left eye as a “fruit of penance” for the success of Louis IX’s crusade. Though Alice had no control over the loss of her sight, the belief that she could trade her blindness for another’s enlightenment goes a step beyond resigned or even joyful acceptance. It transforms an appalling biological process into a gift.
Other saints behaved in comparable ways, transforming both self-inflicted pain and the torments of illness into suffrages. Arnulf of Villers, a lay brother, flogged himself bloody for his friends. As he rhythmically scourged himself he would chant a ditty:
“Got to be braver, got to be manly; . . . friends need it badly; this stroke for this one; that stroke for that one; take that in the name of God.” As the flogging went on and on, he kept remembering and naming now this particular brother, now those various friends, and now these devout women, . . . [f]logging hard and begging hard that the Lord transmit to each a gracious forgiving of some sin of theirs, or a lightening of some trouble.
Around the same time, Margaret the Lame, a recluse of Magdeburg, made a gift of the depression she endured on account of her disability and social ostracism. Lidwina of Schiedam (1380-1433), a Dutch saint born in the year Catherine of Siena died, was afflicted with horrible complications from a skating accident. An invalid from fifteen until her death at fifty-three, she was said not only to release souls from purgatory, but even to heal the sickness of others with effluvia from her putrefying body. Such practices may now seem grotesque and repulsive—witnesses at best to the medieval tendency Esther Cohen calls “philopassianism,” the love of pain as a moral good. Even if literal rather than symbolic organ transplants had been possible in the thirteenth century, a leper like Alice would have been an unlikely donor. Yet her tale is not merely tragic or bizarre, for the principle she practiced can reach beyond the conditions of her life. Today’s “purgatories” may be the dialysis wards and intensive care units where desperately ill patients languish, waiting for usable organs that may or may not come in time to save them.
Intriguingly, Catholic bioethicists opposed transplants in their early, experimental years. The effective principle was that a body could be surgically “mutilated” only for the good of the whole. For instance, a cancerous organ might be removed, but a healthy kidney could not be taken for transplant. In 1944, however, Bert Cunningham turned the tables with his controversial thesis, The Morality of Organic Transplantation, which argued that the “whole body” whose welfare must be considered is not the individual but the mystical body of Christ—another version of coinherence. Hence “a person may licitly mutilate him- or herself for the good of the neighbor.” For example, Cunningham argued, a mother might give up a cornea to help her blind child, though the result would be a significant loss of vision. Even a one-eyed donor might sacrifice the cornea from his good eye and, in consequence, plunge into total blindness. If Cunningham had known about Alice the Leper, he would surely have approved. Neither the medical profession nor the church ever adopted so extreme a view, but after prolonged debate Cunningham’s underlying position was accepted by most ethicists.
Today, the most obvious debating ground is the gift of kidneys from live donors, especially volunteers who are and remain strangers to their recipients. Anyone can understand such a gift to save a relative, spouse, or dear friend. But gifts from strangers are unnerving because they test the viability of coinherence, or the common good, rather than personal love as the motive for so intimate a sacrifice. In a 2009 New Yorker essay, “The Kindest Cut,” Larissa MacFarquhar profiles a group of volunteer donors and explores the powerful clash of feelings elicited by their gifts. While most people admire this form of altruism, others find it freakishly masochistic. “Cold-blooded altruism,” MacFarquhar muses, “seems nearly as sinister as cold blooded malevolence.” It is a bit too close, perhaps, to the practice of medieval saints. When the philosopher Hans Jonas characterized organ donation as a “supererogatory” gift, one that goes “beyond duty and claim,” he used a term the church has traditionally applied to the saints’ “treasury of merits.” Being more than sufficient for their own salvation, these can be applied at will to the account of souls in purgatory. In this connection the last of MacFarquhar’s profiles is telling. Kimberly Brown-Whale, who called her local transplant center after hearing on television that someone needed a kidney, is a Methodist pastor who works with the poor and owns practically nothing. Having adopted two children from foster care, she suffered hair-raising hardships with her family in the African mission field. On the morning of her surgery, she left home alone, deciding not to wake her husband because he had had a long drive the day before. As for the man who received her kidney, he never called, and she knew nothing about him. After the operation, Brown-Whale refused all pain medicine and was back at work in a week. Rather than agree with most volunteer donors, who warn that “it’s not for everyone,” she asked MacFarquhar, “Well, why not? . . . Give it a try. We can do more than we think we can. If you’re sitting around with a good kidney you’re not using, why can’t someone else have it? . . . Gosh, I’ve had flus that made me feel worse.” Though organ donors come in all varieties, the reporter chose to highlight one who would meet nearly anyone’s criteria for sainthood.
I have tried in this article to present what might be called the imaginary of organ transplants—the myths, images, fears, and values that surround not just the surgery itself, which is fairly new, but the ancient pattern in which it partakes. That pattern is one of sacrifice and communion, coinherence and gift exchange. Unless it is acknowledged and honored, the promise of “medical miracles” could end up dehumanizing donors and patients alike. Transplants save lives, yes—but only at the cost of risk and discomfort to the living, mutilation and dismemberment of the dying, and potentially heightened anguish for the survivors. Even as this surgery becomes more common, it continues to challenge our sense of personhood by blurring the most fundamental boundaries we know—between self and other, between living and dead. Both of these boundaries are more porous in traditional cultures than they have seemed to the post-Enlightenment West, which is one reason a backward glance at medieval beliefs and practices can paradoxically show us a way forward. The alternative, as the sociologist Renée Fox wrote in her eloquent farewell to the field, is a utilitarian “spare parts” approach that massively cheapens the gift of life, turning it into a commodity and diminishing the sense of awe that hovered around transplants in the pioneer days. Where they are commercialized and routinized, they are also profaned—a word Fox does not hesitate to use. Although transplant surgery is a moral good, it is what Charles Williams called a “terrible good”—like the Eucharist and the cross, like the heartrending gift of St. Catherine and the generosity of Alice the Leper. No matter how many transplants are performed, each remains a sacred act both for those who give life and for those who receive it—with all the ambiguity of the Latin sacer, “marked for sacrifice.” For a body wounded by the surgeon’s knife is indeed a sacred body, one in which “the wound may be the violent presence of the numinous, or the sacred that enters us through the actions of others.” Remembering this context may help us hold off the coming of a new marketplace in human flesh.
EDITORIAL NOTE: This article is used by kind permission of Spiritus Journal of Johns Hopkins Press, where it first appeared in Volume 12, Number 1, Spring 2012, ©Johns Hopkins University Press. Our special thanks go out to Professor Glen G Scorgie (Editor of Spiritus).