Transplant Melodrama

Lawrence Cohen

Maylis de Kerangal’s Réparer les vivants, beautifully translated into English by Sam Taylor and published as The Heart, has been something of a publishing sensation in France, and beyond. I am reading it at a café by a small lake in a South Indian town, where I have just been talking to a transplant surgeon about his practice.

It is a book centering on a heart and the events set in motion when this heart becomes marked for a possible transplant. I am an anthropologist who writes about organ transplantation. The surgeon I met was a urologist; he did not work with hearts but with kidneys.

Our conversation kept returning to how transplants become public affairs and organs gain celebrity. The surgeon chairs his hospital’s Ethics Committee, and I asked him about what kinds of transplant situations get marked as ethical problems. He answered by mentioning transplants that make it into the newspapers, onto television and the Internet. There was a story just today, he said, from Bangalore, about whether HIV-positive persons should receive transplanted organs. Then there was a story not too long ago, he added, about a kidney donor who was mentally disabled: the hospital would not allow him to give a kidney to his brother because the offer could not be considered a matter of consent. He described some of the hopes and challenges of heart and liver transplants, mentioning accounts of surgeries conducted elsewhere in India that he knew of from professional meetings and from the popular press. In considering when an organ becomes an ethical problem, he did not speak of his own practice as a surgeon as much as he elaborated on his participation in a range of mass and expert publics and the ways these animated his concern.

<i>Heart</i> in <i>Gray's Anatomy</i> (1858). Wikimedia Commons

Our sense of what is good and what is troubling is often linked to the incitements of public affect: we might speak of an ethical publicity. The concept is a way to capture how our moral sense may come to be bound up with participation in the lives of others through mass media. Television, newspaper, film, and online media regularly feature troubling or heartwarming accounts that position us in intimate relation to the suffering of another. If the philosopher Emmanuel Levinas wrote of the face-to-face encounter as the intersubjective ground of an ethical condition, we may be living in the age of something like a televisual or Internet-based hyper-Levinas, face-to-face with another’s publicity.

In such moments of immediacy—and my point is not to demean them—the quickening of our sense of concern may be carried not by the face of the other but by some other thing that stands in for it: the image of a bomb crater, say, or the sense of a word like trafficking, or the story of a brother’s kidney on offer. These things become part of the world we face, and in the age of the transplant operation they include human organs. I asked the surgeon about differences, at his hospital, between the conduct of kidney, heart, and liver transplantation. He told me that there were not very many heart or liver transplants here; the town is too small. “We have,” he said, “a lot of kidneys.” But then he reflected, “There do seem to be livers and hearts moving about. We talk about them.” These organs attract publicity.

In The Heart, in a different and larger town, call it Paris, a car—“a thermally regulated vehicle designed specifically for this type of mission”—moves through traffic. It contains two surgeons, a driver, and a carefully packaged human heart that is many things but principally “nothing less than life itself, the possibility of life.”

There is tension, exacerbated when the car and its well-packaged vitality encounter delays due to a major France–Italy football match just concluded at the Stade de France. But the feel of the situation that de Kerangal conveys is set against the formulaic publicity of television news:

 

Inside the car, all is calm: while the tension is palpable, there is no trace here of the kind of urgency shown in televised reports on the glory of transplant surgeons, on human-chain heroics, no hysterical pantomime, no bright-red countdown in the corner of the screen, no flashing lights or sirens, no squad of motorcyclists in white helmets and black boots opening the road in a blaze of tensed thumbs and impassive faces, jaws contracted.

 

How to write of what is at stake in the movement of an organ from one body to another? For de Kerangal, one writes against “hysterical pantomime.” And yet the language of her book, rendered powerfully in its translation, has an extraordinary, accelerating quality. To write against hysteria is not to evade the intensities of the world the transplant brings into focus. De Kerangal frequently uses language like the physician may use adrenergic drugs, to accelerate the heart rate, and quite explicitly.

This language tenses up and relaxes in quick succession through the novel’s unfolding of Simon Limbres’s destruction after the van in which he and his friends are riding crashes into a pole. Precisely calibrated shifts in affect and tempo track the efforts of a complex collection of efficient, effective, and all-too-human medical-bureaucratic personnel to move Marianne and Sean, the young man’s parents, toward donating his life-saving organs to others. The shifts in velocity, which achieve moment to moment what the anthropologist Kathleen Stewart has termed “atmospheric attunement,” convey the simultaneously highly structured and deeply contingent emergence of a situation. The pulse of the text propels a range of actors out into the world and follows their circulation: a transplant coordinator, a bureaucratic form, a turn in the road, a dream of California, explosive rage, a mother, a heart; a sort-of girlfriend, a surgeon born to his discipline’s great promise, a surgeon in the throes of achieving such greatness, a kiss, the ways one’s children can and cannot offer their love; the writings of anthropologists who study transplantation; a liver, two kidneys.

This language is—how to put it—quickening. At times it also dilates. Or it surprises, becomes heart-stopping. To describe it I have resorted here, clumsily, to what de Kerangal might call “figurative” language. This was perhaps inevitable. Attending to the heart, she notes, underscores how language is something both in and of the world and separated from it, trying to get back to it.

De Kerangal gives Virgilio, the surgeon not born to greatness, a sentence that only an anthropology professor would love. It comes as Virgilio reflects on why he chose the heart for his career, as opposed to some other body part. He envisions the heart as

 

both a cutting-edge mechanism and the operator of mankind’s supercharged imagination … as the keystone to representations ordering man’s relationship with his body, with other humans, with Creation, with gods, and the young surgeon was awestruck by the idea that he would be a part of this, a recurrent presence at this magical point in language, permanently situated at the exact intersection of the literal and the figurative, of muscle and emotion.

 

It may at times be difficult to separate the hysterical pantomime that attends the organ’s ethical publicity on television from the quickening that for de Kerangal defines the transplant situation. Transplant melodrama and transplant realism fold into one another, and distinguishing between the two may not always be easy.

<i>Reconstruction of Dr. Barnard's first human heart transplantation in December, 1967 (Cape Town).</i> Photograph by Tiiu Sild, 2011. Wikimedia Commons

The difference between the quickening world and the crude pantomimes by which we struggle to grasp it may be observed, suggests de Kerangal, by attending to how each of us differently encounters the world in its fullness. Her characters rise or fumble into an attentiveness to life. Virgilio contemplates the encased heart. He is awestruck by what it joins together. Simon, the young man whose heart it had been, loves to surf and, in forming his body to take the wave, to discover that “moment when he is able to seize the explosion of his existence” and “to become part of the life around him.” Révol, the doctor who diagnoses Simon as brain-dead, likes night duty, enjoying “the intensity, the specific temporality, the fatigue that acts like a surreptitious stimulant, gradually rising through the body, accelerating and sharpening it, in a way that is almost erotic.” Thomas, the transplant coordinator who works with Simon’s parents, is brought into a state of wonder and grace by the discovery of his own singing voice. “By discovering song, he discovered his body. Like a sports enthusiast the day after an intense run or bike ride or gym session, he felt tensions he had never felt before, knots and currents, points and zones, as if his body were revealing to him unexplored possibilities within himself. He undertook to identify everything of which he consisted.” Cordélia, the nurse who attends to the brain-dead Simon, devours life but struggles with fatigue and doubt. Leaving her new lover after an unexpected alleyway tryst, she “walked slowly to begin with … but once she had rounded the corner, she began to spin like a top, face to the sky, mouth open to the wind, arms held wide like a whirling dervish, then, once she was facing the right way, started to run.” Each gets pulled into the quickening world in a distinct idiom.

In a world coming aparT—in the wake of an early morning crash of a van containing three happy and exhausted surfers—what is left is to repair those who survive.

Perhaps most attention is given to Thomas’s exploration, through sound, of the knots and currents of his body and then of the world. He discovers the unique sound of the goldfinch and travels with a friend to Algiers and to a merchant who has brought a collection of the near extinct birds to show him. De Kerangal devotes several leisurely pages to Thomas’s encounter with Hocine, the merchant of goldfinches. Perhaps the birds, precious and rare, encaged and fragile in transit, their collection bordering on the edge of legality, are like organs. Does one enter the market? The text slows further until Thomas, “suddenly filled with wonder, stroked the bird’s back through the bars of the cage”; then “he thought for a long time.” In his work with people like Sean and Marianne, asked to consider giving over their son’s organs, Thomas avoids the hard sell. “You have to think about the living, he often says, chewing the end of a matchstick, you have to think about those who are left.” The reference is to a play by Chekhov. In Algiers, what is to be done? Thomas hands over the money and claims his caged bird.

In Chekhov’s early and sprawling Platonov the drunken and derelict doctor Triletsky gets something like the play’s final word, and this word provides de Kerangal’s novel with its original title. Weary of talk of “medical ethics” in his conversations with the libertine schoolteacher Platonov and the latter’s several anguished lovers, Triletsky counsels restraint when one of the lovers, Sofya, shoots Platonov and kills him. The others turn to the doctor for counsel, and Triletsky responds, “Bury the dead and repair the living!” In a world coming apart—in the wake of an early morning crash of a van containing three happy and exhausted surfers, say, one of whose head meets the windshield at the velocity of our times—what is left is to repair those who survive.

Anton Chekhov in 1889. Photograph by V. Chekovskii / Wikimedia Commons

Repair is humbler, even baser than other modes of redress, of development or of cure; in Chekhov it is offered by a quack. Anthropologists write of the contingent and fragile conditions under which, in the wake of devastating circumstances, one may or may not come to reinhabit the world. Sean and Marianne are broken by the windshield that collided with their son. A woman named Claire, a possible recipient of Simon’s heart, struggles with far more than her physical collapse and subsequent diagnosis of heart failure. For both, with considerable uncertainty but some practice, repair takes a hospital, or several.

What of the dead, or, in Simon’s case, the almost dead awaiting their redefinition? Midway through The Heart, as exhaustion breaks “like a tidal wave” over Marianne and Sean and the doctors assemble to disaggregate Simon, one encounters what initially appears a needfully cold reading of Triletsky’s advice: time to move on.

 

It is time, now, to turn our attention to those who are waiting, scattered throughout the country and sometimes even beyond its borders, people whose names are on lists, classified by organ, to be transplanted, and who, every morning, ask if their position has changed, if they have moved up the ladder, people with no conception of their future, whose lives are restricted, suspended by the condition of one particular organ in their body.

 

We anticipate, in this moment, given de Kerangal’s skill at tracking complex assemblages across lives and their intensely variegated milieus, that we will now be spun out across France (or beyond its borders) to wait with these others. But this move never quite happens. We do come to know Claire, and her family, and her doctors, including Virgilio, but the focus shifts back and forth and never fully leaves Marianne or Sean, or the clinicians that care for them and for the remains of their son.

Bury the dead and repair the living. The injunction could be used to support the utilitarian ethics of British philosopher Janet Radcliffe-Richards, who again and again counsels that our ability to think hard about organs is deeply clouded by emotion. And there is an elegant rationalism to de Kerangal’s novel.

Yet, however calibrated the patterned and frequent shifts in intensity, this is in the end anything but a coldhearted book. Repair is not just for those who can make claims on other people’s organs. I am reminded of a scene early in Pedro Almodóvar’s film All About My Mother, when transplant coordinator and grieving mother Manuela uses her position to track the destination of her son Esteban’s outbound body parts, particularly his heart. Manuela desperately seeks to hold on to Esteban’s heart, but as soon as she sees the older man who now lives with and through the heart, cared for by the women in his life, she appears to realize there is no future for her, or Esteban, there. She turns away—bury the dead—but the repair of her broken life that follows is no utilitarian refusal of melancholic attachment. Esteban lives: ghosts and doubles of all kinds reanimate him in Almodóvar’s telling. The man who got the heart—that is someone else’s story.

In The Heart, in the end, the story is less that of Marianne, Sean, Claire, or the other survivors than of the tissue of human gestures and institutional forms, of forms of care and modes of intensity, that bind and animate and propel a heart, this magical point, onward. For all the familiarity of the story—French boy dies, parents grieve, surgeons work quickly, French woman gains new heart—that tissue binds together bedfellows no less fabulous and entangled—passionately, brokenly, unexpectedly—than in the Almodóvar film. One might give the last word, or sound, to Thomas’s goldfinch, captured, caged, and carefully transported across borders, whose singular gift resonates with the immanence of life at stake along the path of a transplant. Listen.