Transplants for non-lethal conditions: a case against hand transplantation in minors

Abstract

Human allografts for life-threatening organ failure have been demonstrated to be lifesaving and are now considered to be standard of care for many conditions. Transplantation of non-vital anatomic body parts has also been accomplished. Hand transplantation after limb loss in adults has been shown to offer some promising benefits in both functional and psychological measures in preliminary studies. It has been suggested to expand eligibility criteria to include minors, with one such operation having already been performed. With this in mind, we examine the current state of hand transplantation research in the context of available alternatives. We examine the ethics of carrying out these operations in minors, including under the protections of clinical research. We argue that children should not be considered for this surgery due to the substantial risks of immunosuppressive medication, the likelihood that the graft will need to be replaced during the patient's lifetime and the lack of significant compensatory advantages over modern prosthetics.

Advanced Amputation Techniques in Orthopedic Surgery: Hand Transplantation

“…Hand transplantation has been shown to increase QOL, 10 body image, 55 self-esteem, 55 and satisfaction. 10,15,54,56 However, not all reported psychosocial outcomes have been positive. 54 Poor posttransplant body image, which affects unilateral more than bilateral transplant patients, has been associated with lower QOL.…”

“…Furthermore, despite the first successful pediatric hand transplant in 2015, 14 VCA in pediatric patients not already on lifelong immunosuppression for solid organ transplants is not recommended due to concerns for complications of lifelong immunosuppression as well as a relative lack of data focusing on pediatric patients. 15,16 In summary, VCA continues to be an experimental treatment option but with the potential for a life-altering improvement in QOL for the appropriate patient. As VCA progresses to becoming a more widely available treatment modality, clinical indications and eligibility criteria may be able to be standardized across centers.…”

The Baltimore Criteria for an ethical approach to penile transplantation: a clinical guideline

“…Thus far, the ethical difficulties associated with the use of a life‐enhancing transplant in children and donor matching concerns have limited penile transplantation to adults. It seems appropriate that this restriction should currently remain in place until additional evidence regarding the safety, efficacy and feasibility of penile transplants is available to inform the ethics analysis for several reasons.…”

What's Missing in Our Thinking About Quality of Life in VCA?

“…The emergence of QoL as a goal of organ transplantation has been called "a quiet revolution in organ transplant ethics" by Arthur Caplan and Duncan Purves. 11 Although some medical and ethical professionals remain skeptical as to the permissibility of HTx and other types of VCA 12,13,14 and many ethicists and health care professionals voiced strong misgivings throughout the early years of human experiments in the field, 1516,17,18,19 reports on the outcomes of the first cases of VCA-2 unilateral hand transplants in Lyon, France, and Louisville, Kentuckycelebrated these interventions' surgical success and the idea that hand transplants with a normal level of immunosuppression could be effective for some patients. 20,21,22 In these initial case reports-published 6 to 24 months after surgery-success is presented in terms of technical proof of concept (ie, the idea that HTx that yields functional returns and extended graft survival is scientifically possible) but not in terms of HTx patients' own understanding of their postoperative wellness and satisfaction with results.…”