Is it perfectly permissible to use the kidneys of Negroes for one's welfare, but then deny them the rights of employment, the opportunity to better their minds through education, and to reject their right to the pursuit of happiness? Science may have brought to the fore a divine subtlety, but it is for us in the wake of transplanting a new heart to also acquire a new spirit of authentic religious equality in dealing with all of God's children.

Senator HARRIS. Very good.

Let me just say once again, that I know there are those who would fear that a Commission of this kind which you advocate, and which I join you in advocating, would get involved in questions which are not rightly within their province. It is our intention to explore those kinds of questions in these hearings. You and I, among others in this country, have to set public policy and we are effectively doing it even when doing nothing. And if we continue that, at least it ought to be as a result of a conscious choice. I think, rather, that we ought to decide if what we are doing in the right thing and decide it rationally on the basis of the facts. It is far better to put a spotlight on these questions and discuss them than to obscure them because they're difficult. These matters go about as deep as anything in the consideration of man and they ought to be talked about in the open by people from various backgrounds with various viewpoints-theological as well ts medical, legal as well as sociological and psychological. These problems must be discussed and faced up to.

Well, I would like to invite you, Senator Mondale, during the rest of these hearings, to join us here at the committee table, to the extent that you can. I know you are involved in other matters on the floor and that you won't be able to be here throughout the hearings, but you are welcome.

Senator MONDALE. One final comment, if I may.

Shortly after I came to the Senate, a bill was introduced which, in my opinion, would have sharply restricted animal research. At the University of Minnesota I think it is fair to say that we have gone very far in this field, and there has been a remarkable dividend, to human health and to animal health, from the experimentation that has occurred there. That is one of the reasons for our advance in transplantation technology.

Doctors from the university came to me and said, "Senator, this is a very, very serious thing. The public does not understand this problem. They think it is a case of mutilating doges. They do not understand it. And if we are not careful, we are going to destroy one of the basic sources of medical knowledge, and new medical knowledge."

I listened to them and I said, "You are right." And I introduced legislation to protect against the inhumane treatment of dogs, and to provide funds to assist in the proper care, treatment, and feeding of animals, including dogs, but at the same time to leave the medical profession free to do the experimentation that it needs-humane research.

But I think there is somethink instructive there. I think what it tells us is that those who really believe in advancing medical knowledge have far more to gain from public understanding than public ignorance. That was an emergency situation. We could have taken steps that would have blocked the advance of human knowledge in this field. Fortunately, I think we came up with a measure that was workable.

But I would hope the medical profession would approach these hearings not as a risk or a danger, but as an opportunity to put their work in proper perspective; to promote public knowledge of what they are doing; and to foster what I am sure will be broadened and more sophisticated public support.

Senator HARRIS. Thank you very much. We will be happy to have you join us here at the table.

We are very pleased now to hear from Dr. John S. Najarian, Professor and Chairman of the Department of Surgery, College of Medical Sciences, University of Minnesota.

Without objection we will place in the record at this point a brief biographical sketch concerning him which has been prepared by our staff.

Biographical Sketch: John S. Najarian, M.D.

Professor and Chairman, Department of Surgery, College of Medical Sciences, University of Minnesota, Minneapolis, Minnesota.

A.B. with honors, University of California; M.D., University of California Medical School.

Internship straight surgical, University of California Medical School, 195253; Residency-surgical, University of California Medical School, 1955-60.

Research training-Surgical Physiology, University of California Medical School, 1955-56; Immunopathology, University of Pittsburgh Medical School, Special Research Fellow, NIH, 1960-61; Tissue Transplantation Immunology, Scripps Clinic and Research Foundation, La Jolla, California, Senior Fellow and Associate NIH, 1961-63.

Honors Alpha Omega Alpha; Markle Scholar in Academic Medicine 1964–69; California Trudeau Society Award, 1962; University of California Football Alumnus of the year-1967.

Member many professional organizations.

Assistant Professor of Surgery, Department of Surgery, University of California, San Francisco, 1963–66; Professor and Vice Chairman, 1966-67; Professor and Chairman, Department of Survey, College of Medical Sciences, University of Minnesota, Minneapolis, 1967-.

NIH, Special Consultant, Clinical Research Training Committee, Institute of General Medical Sciences, 1965-69; Consultant, United States Bureau of the Budget, 1966-68; Member, Advisory Committee on Hemodialysis and Renal Transplantation, Department of Public Welfare, Minnesota State Medical Association; Consultant, Midwest Chapter of National Kidney Foundation; Council Member, Midwinter Conference of Immunologists.

Editorial Board-Journal of Surgical Research, 1968—; Minnesota Medicine, 1968-.

Author of numerous publications.

Senator HARRIS. Dr. Najarian, you have a prepared statement. You may either read that, or if you like, file it, and excerpt from it, or however you may want to proceed.

STATEMENT OF DR. JOHN S. NAJARIAN, PROFESSOR AND CHAIRMAN, DEPARTMENT OF SURGERY, UNIVERSITY OF MINNESOTA, SCHOOL OF MEDICINE, MINNEAPOLIS, MINN.

Dr. NAJARIAN. I will choose the latter, Senator Harris.

First off, I would like to express my appreciation to Senator Harris and Senator Mondale for giving me this opportunity, as Senator Mondale pointed out, to really point up what is going on in this area of medical science, and to try to put this hopefully in some sort of perspective so it is meaningful to us.

I think that all of us became rather enthralled by the recent advances that have been made, "breakthroughs" in heart transplantation, in

DNA replication, and this sort of thing. There is no question that these were remarkable achievements in themselves.

However, I think it is important to realize that these really represent to us a beacon, if you will, pointing toward the biological revolution that is currently going on in biomedical sciences. And it is important to put these in their proper perspective.

I think one of the things that has come out of the heart transplants is public information-the reason why this committee is here, the reason why we have been asked to speak, the reason and stimulus, I hope, for Senator Mondale to propose the Commission that he has proposed-being aware of the social and public needs under these circumstances of medical advances and for this reason, I think that we should continue in this public education process, public information, and this is why I would like to speak to this committee.

I think that at the present time good health is something that our public deserves, it is something that is a right of the public. If it is a right, and not a privilege of a few, then we have to examine very carefully whether we, in the Federal Government, are providing proper delivery system of translating those advances that are made in the laboratories, these advances that have been recently publicized, so that they will have social translation as soon as possible.

The important feature of this entire hearing is to put some sort of emphasis on whether or not a Commission should be created, and I would like to say at the outset that I am very very firmly for this resolution, the Senate Joint Resolution that Senator Mondale has proposed for the creation of such a Presidential Commission.

Before I begin to answer some of the questions, Senator Harris, that you asked me specifically, if I may, I would like to state that I will confine most of my remarks to transplantation. There are two areas we are really interested in here. One is transplantation, and the other is the possibility of changing the DNA, the essential nucleic acid molecules of the cell, and what implications this is going to have on the genetic makeup of the future and of humans today.

I think that the important consideration is that the DNA replication, or the changes in DNA, or DNA engineering, as Senator Mondale pointed out, is something that is in the future. But I think we have a more immediate problem-and I want to address myself to this problem-and it has to do with transplantation in particular.

First of all, if I may for a moment, I would like to regale you with some of the past history in transplantation briefly, and to state that in the fact these things have been around for a while-the first heart transplants that were described in medical literature were described in 1905 by Alexis Carel and Charles Guthrie. These were heart transplant performed on dogs, and they were transplanted to the neck of dogs, the hearts did work for a while. They were eventually rejected.

At this particular point in time, at the turn of the century, many other transplants were attempted. These same doctors who were working at the Rockefeller Institute at the time, established a technique of putting blood vessels together, and once this technique was established, the same technique we use today in surgery, they began transplanting a variety of organs. They transplanted kidneys, livers, spleens, hearts. They even transplanted a second head to a dog-which was all published in approximately 1906 through 1908, in the AMA Journal.

However, these investigators assumed that the answer to transplantation of organs primarily was a technical feat-the ability to put these organs in the craftsmanship of surgery. But this was not the case. In each instance the transplants were repudiated by their hosts in a predictable period of time, and the reason for this rejection or repudiation was not found for many years thereafter. It was about in the middle 1940's when we became aware of the fact that this represented an immunological phenomenon, that these transplants were rejected because of the recipients own immunological defense mechanism. This is a defense mechanism that all of us have, which really allows us to exist in a very hostile environment we live in, constantly at the attack of bacteria, protozoa, various viruses and the like. And the reason we survive, and long before antibiotics, is that we have the ability to discern between our own proteins and foreign proteins. This is our uniqueness. And as a result of our individuality, we are able to throw off these foreign proteins.

This immunological defense that we have, however, also presents the hurdle which is necessary for those of us working in transplantation to overcome, to gain successful transplantation of organs from one individual to another.

In approximately the late 1950's, we found there were ways that we could abrogate, or blunt this immunological response. This could be done with radiation. However, radiation had many lethal factors associated with it, and subsequently we turned our attention to certain chemotherapeutic drugs-these are drugs used in cancer therapy-and these drugs were found to be very effective in reducing our immunological responsiveness, so we could accept foreign organs.

When this came about, we began looking at transplantation again, first in the laboratory, and then subsequently in clinical material.

We chose as our primary model the kidney transplant, for a variety of reasons. I will enumerate three.

In the first place, the people that die in this country or abroad, who die of renal disease, for the most part are young individuals ages 15-35. The tragic situation of a young person dying, only because his kidneys do not work, the rest of his organs are perfectly normal, presented a real challenge to the medical community. But in addition to this, we had the advantage of the kidneys being a vital and a paired organ, and we could survive very well with a single kidney. Thus the donor could survive if you were to remove this from a living donor, and the recipient survive as well if receiving a transplant of a single kidney.

We began, then, with kidney transplants.

The first kidney transplants were performed in identical twins in 1954, where there is no immunological barrier, since identical twins represent basically two individuals from one-their tissues can readily be exchanged. And it was found that kidney transplantation in man was a technically feasible procedure.

When the new drugs came along in the early 1960's, we began transplanting from individuals who were no longer identical twins, and from primarily individuals who were blood relatives-brothers, sisters, mothers, fathers, and the like.

We found that we could transplant with a reasonable degree of success, kidneys, and at the present time we have a registry in which all the kidney transplants that have been done throughout the world are

recorded-there have been approximately 1,700 kidney transplants performed between nonidentical twins. It is amazing to note that of these, some 60 percent are still alive and well today. The unfortunate feature is that we still have not answered all the immunological questions. At the present time-Senator Mondale asked about what our success is the answer to his question is we have approximately 80percent success in survival of those 100 patients that you spoke about. But we can achieve something in the magnitude of 75- to 80-percent survival for 3, 4, and now it appears to be 5 years with a kidney transplant taken from a blood relative.

Now, the situation in heart transplants cannot be analyzed, or at least equated with kidney transplants in this regard. We cannot take organs, obviously a single vital organ, from a living blood relative and, therefore, we must by necessity look at cadavers, individuals who have recently died, as a source for these organs.

So as a result, immediately we are posed with a question in which we have a wider genetic disparity between the donor and the recipient. Under these circumstances in kidneys we have found that rather than our 75-percent survival we can achieve, our survival rates at best are around 30 percent, with our current methods of immunological sophistication.

As a result, we are still studying this problem-finding better ways to transplant between nonrelated individuals, and this involves many problems.

One the problem of tissue typing. This is something that has just come on the scene really in the past 4 or 5 years, where we now find that as we have red blood cell types, we also have tissue types, and that we can find what these tissue types are, and that all of us in this room, if there are 360 here, at least one pair would be almost identical if we could tissue-type these individuals. So we are beginning in this area-we are typing and trying to get better matches between donor and recipients, and with this technique we have found we can improve our results from the unrelated individual.

Moreover, we are looking for better methods of suppressing the immunological response. The drugs we currently use, if in blood relatives achieves a 75-percent survival, we are still losing 25 percent of our patients. How can we possibly overcome this?

We are now testing many drugs and many sera. We are working with something we call antilymphocytic sera. This is sera raised in a horse usually, someone of another species, against the lymphocytes, which are the small important white cells in our body, that are responsible for this immunological rejection. And we find if we use an antisera against these lymphocytes, that we are able to achieve increased success of our kidney transplantation.

Where does this put us in heart transplants?

Well, in the kidney we have a very unique situation. Fortunately in the mid-1940's Dr. Koff developed the artificial kidney which has had many modifications since. Now we know, and I think this committee heard testimony from Dr. Scribner and others with regard to the use of the artificial kidney at Oklahoma City, and you know we can keep patients alive on an artificial kidney for a period up to as long as 6 years, without any kidneys at all. This is a remarkable feat. This gives us the opportunity to transfer a kidney, to maintain a patient if the transplant fails, to transplant again. As a matter of fact,