The World's First Pediatric Bilateral Hand Transplant: Ethical Considerations and Implications
Benjamin Chang, M.D.1, Michael G. Tecce, D.O.2, Vijay S. Gorantla, M.D., P.H.D.3, Joseph E. Losee, M.D.4, WP Andrew Lee, M.D.5, Abraham Shaked, M.D., P.H.D.2, Arthur L. Caplan, P.H.D.6, L. Scott Levin, M.D.1.
1University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA, USA, 2University of Pennsylvania, Philadelphia, PA, USA, 3University of Pittsburgh, Pittsburgh, PA, USA, 4University of Pittsburgh, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA, 5The Johns Hopkins Hospital, Baltimore, MD, USA, 6New York University, New York, NY, USA.
PURPOSE: Since 1998, 110 upper limb vascularized composite allotransplantations (VCA) have been performed in adult patients worldwide. This year, an 8year old became the world’s first pediatric hand transplant recipient. The child was a quadrimembrenal amputee secondary to sepsis and had received a renal transplant. We present the unique social and ethical considerations in pediatric hand transplantation.
METHODS: Social and ethical issues in adult VCA recipients were reviewed and issues unique to children were identified. Issues related to patient autonomy (parental consent, patient assent, cognitive preparedness, noncompliance), personal identity (body integrity/image perception), risks (immunosuppression, graft loss), benefits (improved quality of life, sensibility, growth) and parental/family support were examined to mitigate harm to the patient.
RESULTS: A major disadvantage of hand transplantation compared to prosthetic options is the need for lifelong immunosuppression. Factors favoring this patient’s selection (preexisting immunosuppression, bilateral hand absence, and potential for improved function compared to prostheses) had to be balanced against possible technical failure, rejection of the transplanted hands and harm to the transplanted kidney. Critical emphasis was placed on psychosocial, compliance, family support, and emotional issues.
CONCLUSION: Pediatric VCA warrants significant social and ethical safeguards. Ensuring the optimal environment for compliance and an exit strategy in the event of failure are of paramount importance. In this case, careful consideration of ethical and social issues was undertaken during the patient selection process and can serve as a model for thinking through the broad range of social and ethical issues in future pediatric VCA candidates.
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