Transplant Ethics: Quality of Life & Functional Restoration

Art Caplan discusses the ethics of transplanting for quality of life, not for functional restoration.
https://www.staging.medscape.com/view...

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Hi. I'm Art Caplan. I'm at the Division of Medical Ethics at New York University Grossman School of Medicine.

One of the opportunities I have being here at NYU's medical school is that I get to interact frequently with my colleagues and clinicians in various departments. One place that I've had a close relationship over the years is with our Department of Plastic Surgery, a world-leading unit that helped pioneer many of the procedures that are used to repair things like cleft palate.

Some of you know that NYU is among the few institutions that have attempted face transplantation. There are other institutions that have also attempted hand transplants, arm transplants, and penile transplants.
This whole category is known as vascularized composite allografting. This involves moving different varieties of tissue, almost always external — although uterine transplant falls into this, which is sort of an internal transplant — but generally speaking, you're trying to change organs or tissue systems where you can see that there's been a transplant, such as a hand or face, as opposed to liver, heart, or kidney, which are the traditional forms of transplantation.

One issue that comes up for these vascularized composite transplants is how to think about the ethics. Recently, we announced at NYU that we had done a face transplant, but also transplanted a whole eye from the donor. There was much amazement at the technical achievement of being able to make that happen, and it was an amazing thing.

One of the reasons it was done was that the person needed it, and they were going to be on immunosuppression because they were going to get the whole face transplant. The drugs that can be harmful for kidney function take a toll on the recipient of a heart, liver, kidney, face, or hand. They're going to be administered anyway.

It does raise the question about someone who just wants to have an eye transplanted for cosmetic reasons, maybe even hoping for a functional restoration of vision. That certainly comes up in thinking about eye transplantation.

I've discussed this often with experts here, and I've taken a look into the literature. This is how you would think through the ethics of a brand-new, novel possibility of eye transplant. First, if someone wasn't going to be on the immunosuppressive drugs, would you put them on those drugs, which could shorten their life or damage their organs, just to transplant an eye cosmetically? There are prostheses, and although people have varying views about whether they like them or not, they are out there as an option.

If you hope that you could restore vision by the transplant, I think we've got much more animal work to do because we don't know, really, that the optic nerve would regenerate as part of this transplant and permit signals to go to the brain. We're not even sure whether a new eye from a different person would send signals to the brain, even if there were signals, that could be interpreted by the recipient's brain properly as vision. In other words, you've got different kinds of signals from what that brain was trained to receive in the person who is going to receive the eye. Maybe that would confound vision.

I think it's hard to make the case just on the basis of cosmetics. It might be possible to make the case for eye transplants based on quality, appearance, and vision restoration.

Let's presume somebody has some vision in the other eye. Well, there you get into the difficulty, as my ophthalmology friends remind me, that sometimes operating on one eye can damage the other eye unintentionally; it can have a negative impact on the seeing eye.

Again, a risk that has to be taken into account is if you operate on an eye that doesn't see in a person who has vision in one eye or you do a transplant, are you risking blindness because of this interaction between both eyes, where different chemicals and substances can go from the eye that was operated on over to the healthier eye and wreak havoc?

There's much to think about in this area. Despite the technical achievement that was done in moving the eye along with the face, I'm not sure yet we're ready for prime time with respect to eye transplantation.

Do we need more study in animals? Yes. Can we hope for better improvement in nerve regeneration, trying to use chemicals to facilitate that so that the optic nerve can reattach to the brain in the transplanted eye and get signals going? That's absolutely something we should be doing work on, too.

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