Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether a hospital should allow the first-ever attempt at a head transplant.
Should the hospital's ethics committee approve this first-ever attempt at a head transplant?
Yes: 50%
No: 50%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in:
Brain transplantation -- or whole-body transplantation -- has long been a staple of science fiction. Iconic depictions include the work of Martian surgeon Ras Thavas in Edgar Rice Burroughs's The Master Mind of Mars (1927) and the experience of patient Johann Sebastian Bach Smith in Robert Heinlein's I Will Fear No Evil (1970).
Barriers to such a procedure succeeding in real life are substantial. Soviet experiments conducted on puppies by Vladimir Demikhov during the 1950s proved largely unsuccessful. In 1970, American neurosurgeon Robert White (1926-2010) managed to transplant the head of one rhesus monkey onto the decapitated body of another, although the second animal's immune system ultimately rejected the new head after 9 days. In the interim, however, the transplanted head was able to see, hear, smell, taste -- and even tried to bite a staff member. (White had already gained prominence in the 1960s for creating a "dog with two brains" by attaching an isolated canine brain to the blood vessels of another dog.)
In 2018, Italian physician Sergio Canavero, MD, and his Chinese colleague, Xiaoping Ren, MD, predicted that human head transplantation is "imminent," although these claims were met with widespread skepticism in the mainstream medical community.
Ethicists have been largely unsympathetic to the efforts of giving additional life to a terminally ill patient, such as Don. Arthur Caplan, PhD, a prominent bioethicist, wrote in Forbes that "one would have to be out of one's mind" to attempt a brain transplant with existing technologies. Caplan noted that such an operation would require immunosuppressive drugs that have serious side effects and risks; life on such a medication regimen might prove miserable for the recipient. Rejection of transplanted organs would pose a particular challenge in this case -- likely leading to a slow and potentially painful demise. The prospect for significant psychological distress should also be considered.
Clint Hallam, recipient of the world's first hand transplant, eventually chose to have the limb amputated because he felt "mentally detached" from it. What if a head transplant recipient became similarly detached from his new body? Finally, the likelihood of reattaching spinal nerves without further technical advances seems highly unlikely. At best, Don would find himself a quadriplegic.
Balanced against these concerns stands the stark reality that, without the transplant, Don will soon die. The principle of autonomy argues for letting him make his own decisions. He is a neurosurgeon, after all -- so he is likely to understand the dangers. Of course, the consequences of the surgery could prove horrific. Don might awaken to discover himself conscious but "locked" inside his own brain, without any sensory perception or ability to communicate. Even if a patient could truly anticipate and appreciate the torment that such a fate entails without actually having experienced it -- which is questionable -- one might ask whether there are some forms of suffering so horrific that no person should be permitted to risk them.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
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