6. NONESSENTIAL TRANSPLANTS

Surgeons have not focussed on developing techniques for transplanting hands, feet, and other appendages in the same ways that they have for internal organs, because appendages, unlike hearts and lungs and kidneys and livers, are not essential for life. But many people have lost hands and feet in industrial accidents, many have had their hands and feet blown off and destroyed by land mines and bombs, and some people are born with deformed or missing appendages.

So, in 1998 and 1999, teams of doctors in France and the United States transplanted new hands to two men who had lost their hands more than a decade early. Clint Hallam, an Australian, received his new hand in France; Matthew Scott, an American, received his in the United States. Each operation took about 13 hours.

The surgeries were complicated because the hand is complex. It includes 27 bones, 28 muscles, three main nerves, two main blood supplies, and many tiny blood vessels, nerves, muscles, tendons, and skin. All of these had to be connected to their counterparts in the recipient's arm to give the new hands a chance of functioning fully.

As of June 1999, both hands seemed to be doing well. Each man is taking strong immunosuppressive drugs and will do so for the rest of his life to prevent his body from rejecting the new hand. (The only other recorded attempt at a hand transplant took place in Ecuador in 1964, but the hand was rejected in two weeks.) Both recipients have also taken antibiotics to prevent infections. If all the link-ups were successful so that blood can circulate properly in the new hands and muscles can operate and nerves can fire, then there is a chance that the men can eventually use their new hands just as they are able to use their other hand. Only time will tell.

Although hand transplantation is in its infancy, surgeons have had a reasonable amount of experience reattaching hands (and fingers, toes, and feet) that were severed in accidents. In those situations, immunologic rejection is not a problem, because the donor and recipient are the same person. But, sometimes bones were crushed or other tissues were damaged in the accident, creating additional technical challenges.

Most of these reattachments are done rapidly, as soon as the injured person can get to a hospital. But one odd situation arose in 1994, when a mentally ill man, Thomas Passmore, sawed off his own hand, convinced by hallucinations that his hand bore signs of the devil. Although he was rushed to the hospital and at first agreed to have his hand reattached, he later refused the operation when he started hallucinating again. The doctors acceded to his wishes. His hand was not reattached, but some time later he sued the doctors for not doing it.

References

New York Times, 1999, 26 January, A10-11.
Lancet, 1999, 353(9161):1315-1320.
Right Hand and Autonomy, Arthur Caplan, in Due Consideration, John Wiley and Sons, Inc, NY 1998, 197-198.

Additional Resources

http://www.handtransplant.com (This site contains information on Matthew Scott's transplant operation, including regular updates on his condition.)
http://www.fpa.ysu.edu/course/art758/
finalprojects/evans/animatedhand.html
Aldous Huxley, Brave New World, 1998, Perennial Classics, NY.
Chet Fleming, If We Can Keep a Severed Head Alive, Polinym Press, St.Louis, 1987.
Robin Cook Coma, 1977, Little, Brown, and Co., Boston.
Oliver Sacks, A Leg to Stand On, 1994, HarperPerennial, NY.

Aims

Students should understand the following:

Technical aspects of hand transplantation
The difference between essential and nonessential transplants
Risks involved in transplantation surgeries
The meaning of individual rights or autonomy
Some medical procedures that are experimental are not covered by insurance
How immunosuppressive drugs work
How appendages are preserved

Topics for discussion/written assessment

Some people who lose appendages continue to feel the lost or "phantom" limb. What accounts for this phenomenon?
How are various organs and appendages preserved? How long can different organs be preserved? How quickly must each organ or appendage be transplanted?
What are the medical procedures involved in different types of transplant operations?
How do immunosuppressive drugs work? What risks are associated with taking them? What are the most effective immunosuppressive drugs?
What problems arise from treating organ recipients with immunosuppressive drugs and antibiotics for long periods (and, in some cases, for the rest of their lives)?
Assess the doctors? responses to Mr. Passmore when they decided to listen to him and not reattach his hand.
The U.S. patent office awarded a patent in 1987#4,666,425for a procedure to keep a severed head alive. The inventor?s motivation was to get the patent so that no one would ever actually be able to carry out that procedure. The inventor claims to have no intention of using the procedure himself. Is keeping a head alive a ridiculous or rational pursuit? What would it mean if a head could be transplanted? Should it be attempted? Where would you draw the line on acceptable types of transplants?
In 1932, Aldous Huxley wrote his futuristic book Brave New World, in which various categories of people were designed and cloned to fulfill needed functions in society. How far has technology come since Huxley wrote his book? Could his ideas now be considered science rather than science fiction? Could factories, labs, or organ farms produce hands for transplantation?

Topics for teacher preparation