Shoofly Pie & Chop Shop (64 page)

“People underestimate pathologists. We have to know something about every realm of medicine and surgery. We have to be familiar with every kind of procedure and its risks, and we have to be able to diagnose diseases by both tissue and fluid. Besides, in my residency I did a subspecialty in renal pathology.”

“A national waiting list,” Nick said thoughtfully. “All that information in one place. Who has access to that list?”

“Nobody.”

“Nobody?”

“Not if you’re talking about calling up the list and just looking it over. Nobody gets to do that. It’s very private, and it’s extremely secure.”

“Then how is it used?”

“Suppose you have a motorcycle accident, and at the hospital you’re pronounced brain-dead; that’s when the local organ procurement organization goes to work. In western Pennsylvania, it’s called COPE—the Center for Organ Procurement and Education. The hospital keeps you on a ventilator—they keep your
body
working—while COPE talks to the next of kin to request your organs for transplant.”

“Do they always have to ask the family?”

“Not if you’re over eighteen and you’re carrying a donor card. But if you’re underage or your wishes were never made clear, then somebody has to grant permission. So let’s say they do—that’s when COPE sends your medical information to UNOS, and UNOS sends back a matching donor list.”

“And who’s on that list?”

“Everybody in your local area that’s a potential match, in order of priority. COPE calls the transplant surgeon in charge of the first person on the list and offers the organ; if he wants it, it’s his; if not, it’s offered to the second person on the list, and so on until the organ is placed. If no one wants the organ locally, it’s offered regionally; if no one wants it regionally, it’s offered nationally. That’s how the system works.”

“How is your place on the list determined?”

“The placement protocol is different for every organ. For kidneys, it’s done by body size, tissue compatibility, medical urgency, and time spent on the waiting list.”

“How long can you stay on the waiting list?”

“Forever,” she said. “Some people are harder to match than others.”

“So how do you beat the system?”

“You can’t.”

“Come on, Riley. What about our own governor a few years ago—what was his name?”

“Robert Casey,” she said. “I was an undergraduate at Pitt at the time. Casey had a heart-liver transplant here at UPMC. He was on the waiting list less than a day, when the average wait for a liver was two months—six months for a heart.”

“So it doesn’t hurt to be first citizen of the state.”

“It doesn’t help either. They reviewed that case, Nick. Six people were ahead of Casey for a heart, and two for a liver. Casey jumped to the top of the list because he needed a multi-organ transplant—that’s the only reason.”

“You’re telling me there’s
nothing
the rich and powerful can do to manipulate the system in their favor?”

“Oh, there might be a couple of things. They could move to the transplant hospital with the shortest waiting list—the wealthy can afford to do that. Their surgeon could put them on the waiting list earlier than necessary, just to increase their seniority. And their surgeon could hospitalize them early, too, in order to make their need appear more urgent. But those are small things, Nick; none of them really tip the scales your way. For the most part, the rich and powerful have to just sit tight and wait—just like the rest of us.”

Nick said nothing for a few minutes, busying himself with his dinner. Halfway to his mouth with a forkful of pasta and mushroom sauce, he stopped and set the fork down again.

“You said COPE sends the donor’s information to UNOS.”

“That’s right.”

“And COPE gets the matching donor list back.”

“Right—all the potential matches in your local area.”

“The size of that list would change from area to area. What about this area? They must do a lot of transplants in Pittsburgh.”

“UPMC Presbyterian does. It’s a huge transplant center.”

“So when COPE gets a matching donor list, it could show most of the people at UPMC Presbyterian waiting for that organ.”

“It could, yes.”

“Think about it,” Nick said. “Nobody gets to browse the waiting list, but every time COPE submits a donor’s name, they get to see a
piece
of that list.”

“In a way, yes.”

“So if COPE wanted to, they could compile a list of all the people awaiting a kidney transplant in this area. And by comparing those lists over time, they could know how long each person has been waiting for their kidney.”

“I suppose so—but why would they want to?”

“Listen to this,” he said, turning to his open book. “ ‘The French law on organ procurement adopted in 1976 is one that presumes the consent of persons who do not, during their lifetime, expressly refuse to have their organs taken on their death. The law states that “an organ to be used for therapeutic or scientific purposes may be removed from the cadaver of a person who has not during his lifetime made known his refusal of such a procedure.” ‘ According to this book, laws like this exist in Austria, Belgium, Finland, Italy, Norway, Spain, and Switzerland.”

“It’s called ‘presumed consent,’ ” Riley said. “They
presume the consent
of the donor unless he says otherwise.”

Nick frowned. “I thought I was going to impress you. OK, smart girl, try this one: ‘Within the United States, at least two states have considered laws that would, if enacted, have properly been called presumed consent laws.’ Maryland is one of those states; for one hundred dollars, name the other one.”

“Pennsylvania,” Riley said without looking up. “It didn’t pass.” She pushed her plate away and looked at him. “Where are you going with all this? Why the sudden interest in organ transplantation?”

“Julian Zohar,” Nick said. “Executive Director of COPE. He’s the guy who pushed for this law in Pennsylvania.”

“Why wouldn’t he? That kind of law would make COPE’s job a whole lot easier.”

“He’s also a member of PharmaGen’s ethics advisory board.”

“So? What’s the connection?”

“Ian Paulos told me that the ethics advisory board exists mostly to instill public confidence—to convince people that PharmaGen can be trusted to do the right thing. Paulos was brought on because he has the perfect image—he’s an Episcopal priest. But Paulos gave me the feeling that his ethical input is not really valued. Paulos wants to talk about ethical concerns, and Truett wants to build a company.

“Then PharmaGen brought on a second ethicist: Julian Zohar. Zohar is philosophically much more to PharmaGen’s liking—he likes to get things done. So the ethics advisory board stops with just two members, Paulos and Zohar. Publicly, they serve their function as symbols of moral uprightness. But privately, they butt heads. Zohar says ‘go,’ Paulos says ‘slow.’ I wonder who really has Truett’s ear?”

“Where is all this taking us, Nick? We start with Lassiter, then we drop in on Truett, then you go to see Paulos, and now it’s this Zohar guy. Aren’t we getting off track here? What’s the tie-in with all this?”

“Remember the blowfly,” Nick said.

“The clueless one or the female?”

“The female. She finds a body by tracking molecules of blood in the air. First a single molecule, then a small cluster, then an even larger one, back to the source of it all. The blowfly follows the path of increasing concentration—that’s what we’re doing here. Follow your nose, Riley. We started with the anomalies in Lassiter’s autopsies. Then we found that he’s investing enormous amounts of money in a single company—PharmaGen. That’s more than a wild investment. What gives Lassiter his confidence in PharmaGen? And why is PharmaGen willing to take on such a small-time private investor?

“Next we visited Truett. PharmaGen is about to make a ton of money—
if
they can keep public confidence long enough to produce a marketable product. But when we asked about things that could get in the way, pesky little things like ethical concerns over genetic privacy, who did he direct us to? Not Zohar, but Paulos—he never even mentioned Zohar. But Paulos tells me that he’s mostly a figurehead, and that Zohar may be the real conscience behind the company.”

“My head is spinning,” Riley said, rising from the table. “I need to lie down for a minute—it’s been a long day.” She moved to the sofa and stretched out facedown. Nick turned in his chair and watched her. She seemed especially weary tonight, and she moved more slowly than usual. There was a sort of heaviness about her. She straightened slightly and grimaced, rolling her shoulders from side to side.

“Want me to rub your back?”

“What?”

“Your back seems to give you a lot of trouble. Want me to rub it for you?”

“It won’t help.”

Nick picked up his chair and carried it to the sofa, setting it down beside Riley. “Want to hear a wild idea? What if Zohar and Truett and Lassiter have found a way to create a black market in human organs?”

Nick watched Riley closely. She blinked once but said nothing.

“You’re still not impressed. Now I’m really disappointed.”

“The idea occurred to me,” Riley said, “but it’s crazy.”

“Is it? There have been attempts before—in the Philippines, in India, even in England. We know that Julian Zohar is a big fan of ‘routine salvaging’ or ‘presumed consent,’ or whatever you want to call it. What if he found a way to pull it off? What if Lassiter refused to release that first kidney for transplant because he had some other use for it? What if you’re being shut out of autopsies because Lassiter doesn’t want you to see what’s happening behind closed doors? What if Lassiter is ‘salvaging’ organs from cadavers for Zohar, and PharmaGen is acting as some sort of go-between?”

“C’mon, Nick,” Riley said, sitting up slowly. “That’s an old urban legend. It’s just not possible.”

“Why not?”

“There are a dozen reasons. How many people would it take to pull off something like that? Where would the organs be removed? At the coroner’s office? We don’t get bodies until hours after they’re dead, and the organs would no longer be viable. And what does Dr. Lassiter do, just drop a kidney in a cooler and walk out like it’s his lunch? Where would these organs get transplanted? What doctor would do that? What hospital would allow it?”

“What if—”

“Nick—there are a
dozen
reasons, and I’m just too tired to go into them all tonight.” Riley stood up and stretched painfully.

Nick looked at her again. He saw the droop in her shoulders, and he heard the dullness in her voice. Riley McKay was strong and she was stubborn, but her exhaustion was showing through like the bones behind her lucent skin.

“I’m worried about you,” Nick said.

Riley stopped and looked at Nick. “I like you too,” she said. “You can be a very sweet bug man. You don’t know what your help means to me.”

“No, I don’t. I wish you’d tell me.”

She put one hand on his chest and spoke slowly and deliberately. “Nick, I think it would be better … if we
both
tried … to keep this on a professional level.”

Nick paused. “Want to know what
I
think?”

“No,” she said. “I’m sorry, Nick. I’m just telling you the way it has to be. Now if you’ll excuse me, I really need to get some rest. Can you let yourself out? Just lock the door behind you when you leave.”

Nick watched her turn and shuffle slowly down the hallway toward the bedroom.

“I’ve got a long drive home,” he called after her. “Mind if I use the bathroom?”

She reached in an open doorway and flipped on a light switch, then continued silently down the hallway, closing the bedroom door quietly behind her.

Nick shut the bathroom door and turned on the water in the sink. He quietly opened the white porcelain medicine cabinet and looked inside. There were three shelves containing cosmetics, deodorants, lotions, and a predictable array of items for personal hygiene and first aid. On the lowest shelf, front and center, were three prescription medicine bottles. Nick took out a pen and copied down the information from the label of each.

He flushed the toilet, turned off the light, and quietly let himself out.

Let me get this straight,” Leo said. “Somebody dies, the coroner’s office gets the body, and somebody strips it for parts before they release it for burial. Right?”

“Wrong—somebody strips it
before
it gets to the coroner’s office.”

Nick raised his head to get the waitress’s attention. It wasn’t difficult; she had been periodically glancing over at the man with the funny glasses for the last half-hour. Nick pointed to his coffee cup.

“Remember I told you about the guy in the cooler and the wound on his back, just below the ribs? It was tack-sutured shut. That’s not a wound, Leo, it’s an
incision
—and I found two maggots in that incision. That means it was made out of doors, and it was made sometime before dark—because blowfly activity tends to stop at night. The time of death was around dusk the night before the body was discovered; that means the incision was actually made at the time of death.”

“Made by whom?”