A surgical frontier
By the mid-1960s, surgeons had learned to stop the heart temporarily, repair it, and restart it, thanks to the heart-lung machine. Replacing a failing heart altogether was the next logical step, and laboratory work on animals had been under way for some years. Researchers in the United States, notably Norman Shumway and Richard Lower, had refined the surgical technique in dogs. The main obstacles were not the stitching, but rejection, in which the body’s immune system attacks the new organ, and the question of when a donor could properly be considered dead.
Cape Town, 3 December 1967
The operation took place at Groote Schuur Hospital in Cape Town, South Africa, and was led by Christiaan Barnard, who was then 45. His team included his younger brother, Marius Barnard, and several other surgeons and specialists.
The recipient was Louis Washkansky, a 53-year-old grocer who was suffering from severe heart failure, reportedly with other health problems such as diabetes. He was close to death and had no other realistic treatment. The donor was Denise Darvall, a young woman of 25 who was fatally injured in a road accident on 2 December. Her father agreed to the donation. The operation took several hours, and the new heart was restarted with an electrical shock.
Washkansky was kept on drugs to suppress his immune system, a treatment that was crude by later standards. It reduced rejection but also left him vulnerable to infection. For a short period he seemed to do well, and Barnard’s team was reported to be encouraged. Then he developed pneumonia, and he died on 21 December, 18 days after the operation. The heart itself, according to the surgeons, was still working at the time. The cause of death was infection, linked to the suppressed immune system, rather than failure of the transplanted organ.
World attention
News of the operation spread rapidly. Barnard became an international celebrity almost overnight, appearing on magazine covers and television. The speed of the publicity itself became a subject of comment, since Barnard was not previously the most prominent name in the field. Some of the surgeons who had done much of the groundwork, such as Shumway at Stanford, were reportedly ready to attempt a human transplant and were overtaken.
Only a few days later, on 6 December 1967, a team led by Adrian Kantrowitz in New York carried out a heart transplant on an infant, who survived only a matter of hours. In January 1968, Barnard’s second patient, Philip Blaiberg, received a heart and lived for well over a year, which showed that longer survival was possible. Shumway’s team performed the first adult transplant in the United States in January 1968.
A rush, and then a retreat
In 1968, transplant teams around the world rushed to perform the operation. Many patients died within weeks or months, and by the early 1970s the number of operations had fallen sharply, with many programmes closing. A small number of centres, notably Shumway’s at Stanford, continued the work. Survival improved after the early 1980s, with the introduction of the immunosuppressant cyclosporine, which allowed the body to accept a donated organ with fewer of the infections that had plagued earlier patients. Over the following decades, heart transplantation became an established treatment for selected patients with end-stage heart failure, although the supply of donor hearts has always been limited.
The ethical debate
The operation raised questions that went beyond surgery, and several of them remain relevant.
- When is a donor dead? Traditionally, death was defined by the stopping of the heart and breathing. A donor heart, however, needs to be taken from a body whose heart is still beating, which meant that doctors had to rely on a different concept of death. In 1968 a committee at Harvard Medical School proposed criteria for irreversible coma, often described as brain death. The proposal was influential and is often linked to the transplant debate, although the definition has been refined and argued over many times since.
- Consent and the donor’s family. The decision rested with relatives during a moment of grief, and the way requests were made, and by whom, became a topic of discussion.
- Risk to the recipient. Critics asked whether it was justified to attempt an operation with such uncertain prospects, and whether patients could give meaningfully informed consent when they were close to death. Supporters argued that the patients had no alternative.
- Fairness. With donor organs scarce, who should receive them became a question that societies had to answer through selection rules and waiting lists.
There was also a political backdrop. South Africa was governed under apartheid, and some commentators at the time pointed to the contrast between its pioneering surgery and its racial laws.
Reading the milestone carefully
It is worth separating several claims. The Cape Town operation was the first transplant of a human heart from one person to another in which the recipient woke up and lived for a period of days, and it is widely and rightly counted as the first successful one, even though the patient lived only 18 days. Earlier attempts in the same field, including James Hardy’s 1964 transplant of a chimpanzee heart into a human in Mississippi, had failed within hours. The achievement of 1967 was to show that the operation could be done and that the patient could recover from the surgery itself. Making it a durable treatment took years more of work.
The operation came only weeks after the Apollo 1 fire had shown the human cost of pushing technology forward, and the transplant raised the same underlying question in medicine: how much risk is acceptable while a new technique is still being proved.