Limb Transplants -- Modern Miracle or Future Frankenstein?

Biology 103
2003 First Paper
On Serendip

Limb Transplants -- Modern Miracle or Future Frankenstein?

Adina Halpern

We all know that transplants save lives. Liver, heart, renal, and other organ transplants are hardly controversial. But what happens when transplants do not save lives? What happens when they actually endanger them? At least twenty-one hands and arms have been transplanted since 1998 (and one in 1964) (1). Sure, the cosmetic and functional value of having a new hand could seem like a miracle to those without hands or arms, but do these benefits outweigh the risks?

Limb attachments are not uncommon. Dr V Pathmanathan and his team, who transplanted a left arm onto baby Chong Lih Ying from her twin sister who had died at birth, had already performed over 300 such operations (2). The controversy occurs when the limb is not simply reattached, but is transplanted from one person to another. This is because limb transplant patients, like any other transplant patients, need to be given anti-rejection medication, immunosuppressive therapy (1), so that the body's immune system does not recognize the new limb's tissue as foreign and destroy it (3). In fact, Chong Lih Ying was the only limb transplant patient not to receive immunosuppressive drugs. Because her arm was transplanted from her twin, there was very little risk of rejection (2).

As the name suggests, immunosuppressant drugs given to limb transplant patients greatly lower the body's immune system (4). This puts limb transplant patients at a much greater risk of cancer, infections, and other disorders (5), as has been the case in renal and liver transplants (6). Even with these drugs, the patient still has a great risk of rejection. Six weeks after Jerry Fisher's hand transplant, he had already experienced three episodes of rejection, a common and expected occurrence in limb transplant patients (7).

To avoid rejection, and to regain functions of the limb, limb transplant patients must follow a strict regime of intense physical therapy. During the period immediately preceding his hand transplant, Jerry Fisher underwent a two-hour physical therapy session six days a week, as well as therapy exercises on his own every two hours (7). Even so, normal functions of the limb come slowly, and according to test results to date, a transplanted limb will never have the full function of a limb with which one was born (6).

Transplant recipients must also undergo intense psychological therapy in order to view the hand as part of the self and not to associate it with the deceased body from which it came. They must also be able to deal with the fact that the limb could be lost yet again in the case of rejection or if the immunosuppressant drugs were to put their lives in grave danger (1). This was the case for Clint Hallam, the world's first hand transplant patient (aside from the recipient of the unsuccessful 1964 operation in which primitive immunosuppressive drugs were used). In 2001, Hallam's new hand was amputated. The doctors involved claim that it was due to Hallam's lack of commitment to the taking of immunosuppressant drugs and undergoing physical therapy (4) but Hallam claims that it was due to rejection and "mental detachment" (7). No matter where the blame lays, the truth is that the operation was unsuccessful and that this is a real risk that transplant patients must face.

The next most recent limb transplant took place in January of 1999 (4) – just under five years ago. We therefore cannot know the long term effects of limb transplants. Of renal and liver transplants, which have a much longer history and broader base than do limb transplants, only 30-60% last at least fifteen years before a second transplant is needed. (6) Heart transplant patients, which require similar dosages of immunosuppressant drugs to those of limb transplant patients, have an annual risk of lymphoma of 0.3%. Assuming that this risk is the same for limb transplant patients, Matthew Scott, for example, who was 37 when he received his new hand, has a lymphoma risk alone at 12.9%, assuming his natural life expectancy is 80 (8), as well as risks of other diseases. It must also be taken into consideration, however, that renal, liver, and heart transplant recipients are typically already sick when they receive their transplants. Limb transplant patients, though missing limbs, are otherwise in good health. They could therefore have a lower risk of disease.

The picture thus far looks dismal, but it is important to remember that for many amputees, life itself can be dismal. People missing one or both hands are unable to perform, or perform with difficulty, many tasks that the rest of the population takes for granted, such as shaving, cooking, and carrying large objects. They are also greatly debilitated in their capacity for human touch, which is so dependant on the hand (9). There are also cosmetic benefits of having two hands. Although these, in comparison to the functional benefits, are small, they must still be taken into consideration. The constant stares and unusual treatment received by those without two hands can be traumatizing.

Although limb transplant patients may never regain the full function of their new limbs, limb transplants make possible much more than do prostheses. After just two months, Jerry Fisher could toss a ball, use a paddle, tie and untie his shoes, and lift and carry a 35-pound crate. He was also ecstatic about his newfound ability to "Pick up the baby every morning just to hold him." After two years, Matthew Scott could throw a baseball, swing a light bat, write his name, feel the sensations of hot and cold, tie his shoes, pick up checkers, and use his cellular phone (7).

After reviewing the near exhaustive list of disadvantages and the comparatively short list of advantages, one would be tempted to render limb transplants simply unethical and selfish on the parts of both surgeon and recipient. After all, lives are not at risk with the loss of a limb as they are when organ transplants are necessary (6). However, it is not the quantity of disadvantages versus advantages that is at issue. Rather, it is their quality. One can never know the feeling of being without one or more limbs until one or more limbs are lost. One cannot judge Jerry Fisher as being selfish for wanting to pick up his baby son. One should not accuse the doctors who perform these highly controversial operations of being simply ambitious when they are greatly contributing to the field of medicine. As long as they have informed the patients of both the advantages and the risks of this new surgery and have psychologically tested the patients before going through with the operation, they have fulfilled what I feel are their ethical obligations.

I must therefore conclude that although limb transplants are not for everyone who is without a limb, they are nonetheless ethical. For these people, death is a risk worth taking. Although they do somewhat resemble the works of Frankenstein, to their recipients, limb transplants are modern miracles.

References

1)Hand Transplant, A plethora of information about hand transplants put together by Brown University students.

2)Time will tell for baby given dead twin's arm, News Article on IOL, South African news, classifieds, and information site.

3)Man Gets First Double-Arm Transplant, Article originally on ABCNEWS.com, on Marylin's Transplant Page, which includes over 300 news articles about transplants.

4)Hand Transplant History, A history of hand transplants and hand transplant technologies on the official transplant website.

5) Surgeons perform another successful hand transplant, A site combining the history of hand transplants with an article about Jerry Fisher, America's second hand transplant recipient.

6) ASSH / Hand Transplantation, A discussion on the ethics of hand transplants on the American Society for Surgery of the Hand site.

7) Arm-Hand Tx 2001, A selection of new articles associated with www.handtransplant.org.

8) bmj.com Benatar and Hudson 324 (7343): 971, A case study of two situations where limb transplants were considered but not performed.

9) Longing for Human Touch, Article originally in the Los Angeles Times, on Marylin's Transplant Page.