Proposed Hand Transplant Ignites Medical and Ethical Controversy
It sounds like something right out of a campy, late-night horror film: eager doctors working to attach the hand of a cadaver to the arm of a living person.
But a team of Louisville surgeons says the procedure could be performed by year’s end. Members of the team claimed that the experimental surgery would be a medical breakthrough equal to the world’s first heart and liver transplants.
If successful, they said, the operation could initiate a new era of transplantation with the potential to restore hope to thousands of people with congenital defects and disfiguring injuries.
A historic achievement? Possibly. But some hand surgeons and transplant experts were startled by the July announcement, concerned that science has yet to evolve to the point where the projected rewards from such a project exceed the inherent risks.
“I don’t think the level of scientific research in this area in small and large animals allows us to move into the realm of human application,” said Neil Jones, an orthopedic surgeon and director of the UCLA Hand Center.
“There are simply too many problems that haven’t been solved in the prevention of tissue rejection. I think the press conference was more publicity than anything else and that they’re jumping the gun on this.”
Clinically, doctors say, microsurgical techniques are available to transplant a human hand from a deceased donor to a living recipient.
Ethics Murky
Ethically, however, the issue is murkier.
“It’s very, very risky and the ethical concerns are enormous,” said Matthew Tomaino, chief of microsurgery for the University of Pittsburgh’s orthopedic surgery department. “To this point, the potential for death or serious complication have not warranted the transplant of a non-vital organ.”
After any transplant operation, the recipient must take drugs that suppress the immune system. The anti-rejection drugs are meant to keep the body from trying to destroy the foreign tissue, but they also increase the risk of infection, cancer and even death.
Unlike a patient needing a new heart or liver who would likely die without a transplant and the anti-rejection drugs to sustain it, an amputee does not lack a vital organ. However, the hand patient still would be forced to take the potentially fatal drugs.
“This situation certainly presents some interesting ethical questions,” said Linda Emanuel, head of the American Medical Assn.’s Institute on Ethics. “The big question appears to be quality of life versus quantity of life. Does the potential benefit of having the procedure done justify the chance of death or serious illness that comes with it?”
Progress Cited
Members of the transplant team say animal research has shown that giving a variety of different anti-rejection drugs at very low doses can keep rejection complications to a minimum.
“Any medical procedure--any drug--does carry risks, including the risk of life,” said Jon Jones, a University of Louisville transplant surgeon. “But people now do very well with transplantations because we’ve learned a lot about how to handle immunotherapy. . . .
“Based on the positive results of our animal research, we feel we are now ready to do the first clinical case.”
Not all in the medical community believe the rejection problems have been sufficiently addressed. For example, attempts to transplant skin in animals have met with little success--most have been rejected within a year, Jones said.
Anne Ouellette, a hand surgeon and professor of orthopedic surgery at the University of Miami, said skin rejection, along with nerve regeneration to allow sensation, would be the key problems facing the Louisville surgical team.
“We talked about this 10 years ago, but I’m still not ready to attempt this,” Ouellette said. “Until I hear we can keep the skin from rejecting, shriveling up and dying, I’m ignoring any kind of procedure of this nature. Once that happens, I’m back in the game.”
Ouellette did not condemn the Louisville surgeons for attempting an experimental procedure.
“Somebody’s got to make the leap, whether it’s now or 10 years from now,” Ouellette said. “The same kind of concerns were raised when the first heart was done 30 years ago. The guys in Louisville are superb and I don’t blame them for trying.
“But . . . the risks are there. Significant risks. All of those along with every detail of the procedure has to be discussed with the patient up front. As long as everyone is up-front and honest with each other from the very start, I don’t necessarily think this is a bad thing.”
Brandi Clark of San Andreas, Calif., is interested in the progress made by the Louisville doctors. Her 6-month-old daughter, Jara, was born without a hand.
“If they start a waiting list, I want her on it,” she said. “If there are risks, she could make that decision when she’s old enough.”
Warren Breidenbach, a University of Louisville assistant professor of surgery who will perform the actual hand transplant, said technical and ethical concerns have been debated for nearly two years as the group sought to have its research validated.
The University of Louisville School of Medicine Human Studies Committee and Louisville’s Jewish Hospital Institutional Review Board granted their approval this summer for the procedure after studying the team’s data, which included the results of an international symposium.
“We’ve presented our information to several national and international organizations, and I can tell you that the majority have been in favor of what we’re doing,” Breidenbach said. “We’re not rushing into anything.
“There is a new concept behind how we’re approaching this. In the old concept, you would think of something, do it and then report it--maybe.
“We’re making this a very transparent process for both the medical community and the public. We’ve done the research, we’ve done the animal studies and we’ve put the information up for review all in a very public way before ever attempting a clinical case.
“We also plan to identify a patient advocate who will . . . make sure that our enthusiasm doesn’t overwhelm the ability of the patient to raise pertinent, aggressive and poignant questions and concerns.”
Ouellette said no matter what the outcome, actually performing a hand transplant would ignite more technical and emotional debate.
“Personally, I believe they’re going to lose the first [hands] and it’s going to be the skin rejection that backs them up,” she said. “But they’re going to learn so much . . . and that’s part of the process of medical advancement.”
