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Operational Ethics

TIMES MEDICAL WRITER

Surgeons and ethicists are pondering a host of questions in the aftermath of an unprecedented hand transplant conducted in France three weeks ago.

An international team of surgeons at Edouard Herriot Hospital in Lyon took the hand and lower arm from a man who died in an accident and grafted them onto the arm of a man who had lost his hand 10 years ago.

Such a transplant has been attempted only once before--20 years ago in Ecuador--and that graft failed in less than two weeks when the recipient’s body rejected the arm.

But drugs for suppressing such rejections have improved dramatically since then, and the recipient, a New Zealand-born Australian named Clint Hallam, was scheduled to be released from the hospital Friday.

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Surgeons caution that it may be as much as 18 months before they will know how much function the transplanted hand will have. Nonetheless, the Lyon team is planning another hand transplant later this year, and a team headquartered at Jewish Hospital in Louisville, Ky., has announced that it will also perform such a graft.

“If we are successful, it opens up avenues for reconstructing any part of the body,” said Dr. John H. Barker of the University of Louisville.

“It [could] bring an enormous improvement to quality of life,” added Louisville’s Dr. Gordon R. Tobin.

Critics, however, charge that even if the graft is not rejected--and that is a very big if--the arm is unlikely to regain much more function than is available with a good prosthetic arm. For what amounts to only a cosmetic benefit, they say, potential patients are exposing themselves to an increased risk of cancer and infectious disease resulting from suppression of the immune system.

“I can almost guarantee that you will have a shorter life, on average, in order to have this transplant done,” said Dr. Vincent R. Hentz of the Stanford University School of Medicine, president of the American Society for Surgery of the Hand. “That is the real ethical issue here.”

The Louisville group triggered the ethics debate two months ago when it held a news conference to announce the world’s “first successful hand transplant,” even though it had not yet attempted the procedure in anything other than pigs.

That represented a distinct reversal from the normal route of performing a new surgery, then announcing it. But Barker said, “We hope this new way of doing things--getting public and professional feedback before doing the procedure--will be as important as the transplant.”

The team also hoped that the publicity would attract potential recipients, and it has. From 10 prospective recipients before the announcement, the pool of candidates has climbed to more than 100.

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But before the Louisville team could follow through on its announcement, another team beat it to the punch, setting off some international sniping. Louisville surgeons said they had never heard of the team headed by Dr. Jean-Michel Dubernard of Lyon and Dr. Earl Owen of the Centre for Microsurgery in Sydney, Australia, and that members of the French team had not spoken up at meetings where potential hand transplants were discussed.

“Louisville is not the center of the universe,” Dubernard riposted.

But the French team suffered some embarrassment of its own earlier this month. It had initially announced that its patient, Clint Hallam, was a 48-year-old Australian businessman who lost his hand in a logging accident.

But Australian newspapers reported that Hallam had actually lost his arm in an accident in New Zealand’s Rolleston Prison while serving a two-year sentence for fraud. Additionally, he is wanted by police in Australia and New Zealand on seven counts of fraud stemming from allegations of a pyramid-type scheme involving credit cards.

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Owen said the surgical team had been “completely duped” by Hallam and was not aware of his background. Dubernard said Hallam’s background is irrelevant and that even imprisoned criminals have a right to the same medical care as the innocent.

Hallam’s background aside, the ethics of the transplant have created a minor firestorm. The American Society for Surgery of the Hand released an official position paper arguing that the risk-to-benefit ratio for such transplants “has yet to be convincingly established.”

The society urged other surgeons to abstain from similar procedures pending an evaluation of the success of Hallam’s transplant and further results in animals.

British physicians appear to be particularly concerned about the risk. Newspapers there reported that the surgery had originally been planned for St. Mary’s Hospital in London, but that the hospital’s ethics committee had rejected the proposal.

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Dubernard said the operation was performed in France because of the greater availability of donors. Under French law, everyone who dies is a potential organ donor unless he or she has specifically left instructions to the contrary.

Other critics said that Hallam was not a good candidate for the procedure, even beyond his criminal background. Dr. Guy Foucher, president of the International Federation of Hand Surgeons, argued that too much time had elapsed between Hallam’s loss and the transplant.

Foucher said the 10-year period would have allowed muscles in Hallam’s arm to wither from disuse and his brain to lose memory of the limb, impairing future recovery.

Questioning Impact on Patients

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Other potential ethical issues include such factors as the psychological impact of a graft failure on the patient. The Louisville team members say they will choose only a patient who has used a mechanical prosthesis and thus will know what to expect if the graft fails.

Members might even choose a patient who has lost both hands, on the presumption that the benefits of a partially functioning hand would be higher for such an individual.

The fact that a hand is not critical to survival does not automatically mean that hand transplants should not be attempted, however, said Dr. Linda Emmanuel, the American Medical Assn. vice president for ethics. “Medicine is not just life and death,” she said. “It’s also about being whole. Transplantation of this kind is within our normal range of healing.”

Despite all the admonishments for caution, surgeons will probably continue performing the procedure. Said Dr. Nadey Hakim of St. Mary’s Hospital, a member of the French team: “You have to dare in medicine, or it does not advance. And what we have done here is to dare.”

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(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Making Connections

Surgeons at a hospital in Lyon, France, recently transplanted a hand and lower arm from a cadaver onto the arm of a man who had lost his own hand in an accident.

1. In the 13.5-hour operation, surgeons began by cutting off the end of the patient’s stump to expose fresh tissue, carefully labeling each part.

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2. The next step was to join the bones together with metal plates and screws to hold the graft in the proper position.

3. Then circulation was restored to the arm by joining the two major arteries and the veins.

4. Next, surgeons joined the tendons and muscles.

5. In the most time-consuming portion of the surgery, they joined the nerves.

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6. Finally, they loosely joined the skin.

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Source: University of Louisville


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