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Francis herself. I weigh in. Together we perform our best assessment of her outcome. Dr. James makes the call. She will be recommended to go on the heart transplant list.
    Doctors want to make rational, measured decisions, but most cases are not as purely rational and measured as we’d like. Some conditions change over time, with circumstances, with developments in science. In 1985, patients with HIV never received organ transplants. At the time, there was no long-term treatment for HIV; the prevailing wisdom was that if you were going to die of that disease, that new heart would be of more use to someone else. Now that there are treatments that can keep HIV patients healthy, they’re more often considered for certain organ transplants. But the truth is, we’re making not just scientific, but moral and ethical judgments. Although there are guidelines, processes, and metrics that try to make these decisions as clear-cut as possible, the fact is that our profession grants us the power of life and death over fellow human beings.
    One night, after a long day on the rotation, I can’t sleep as I try to unwind this mental dilemma. Why are we allowed to make these calls over people’s fates? Who are we to decide? It’s fair. It’s not fair. Someone has to do it. No one should do it. As doctors, we are better qualified than most because we know the diseases and the risk factors involved. But what about the intangibles—the value of one person’s life over another’s? We have no way of knowing which person might do more for humanity or who might be a better father, mother, friend, or colleague. We aren’t philosophers or priests or gurus. Maybe we shouldn’t do transplants at all. But then more people would die. I look at the clock and realize that it’s 4:40 a.m. In two hours, I’ll go back to work, where these questions won’t be rhetorical, and where these decisions will still have to be made.
    The next day, Dr. James and I meet Malcolm. He’s not the kind of case you see often, which means that he has Dr. James’s full attention. Malcolm is six foot four, a muscular former college wrestler, now mechanic, who had just turned thirty-three. My initial impression was that Malcolm looked exactly the way you’d expect a former wrestler to look. Nothing about him denoted frailty…until he needed to string together more than a few words, and then he had to work to catch his breath. And while most athletes tend to have low resting heart rates, in the range of 60 to 75 beats per minute, Malcolm’s resting heart rate was around 135. Even though he was in bed, hooked up to IVs and monitors, his heart rate was closer to what it would have been during his wrestling matches in college. He hadn’t made bad lifestyle decisions, had no bad habits, or even apparently bad genes. Although he hadn’t started to feel “different” until recently, he had told himself that his shortness of breath and inexplicable weight gain were just part of getting older, middle age coming on. But one day, he noticed that his legs were swollen as well, and had decided to see a doctor.
    At first, he’d been prescribed antibiotics for pneumonia. When he didn’t get better, his doctors tried treatments for other illnesses. But Malcolm was still tired, still out of breath, and his legs were still swelling. And then he had a heart attack—and not the mild, cheeseburgers-and-fries kind, but one caused by a thrombus, a painful, life-threatening blood clot in one of his arteries. In the cath lab, they located and sucked out the thrombus, and put in a stent to keep the artery open. But despite the evidence of Malcolm’s chest pain, his EKG, and his enzyme levels, it wasn’t a typical heart attack: It was the result of underlying heart failure.
    A patient suffers a heart attack when a blood vessel or artery is blocked. Heart failure occurs when the heart itself is the issue—and Malcolm’s heart was huge. It was dilated and functioning at a barely