Intended for healthcare professionals

Education And Debate

A tale of two novel transplants not done: the ethics of limb allografts

BMJ 2002; 324 doi: (Published 20 April 2002) Cite this as: BMJ 2002;324:971
  1. David Benatar, associate professor (,
  2. Don A Hudson, associate professorb
  1. a Department of Philosophy, University of Cape Town, Private Bag, Rondebosch 7700, South Africa
  2. b Department of Plastic and Reconstructive Surgery, University of Cape Town, Observatory 7925, South Africa
  1. Correspondence to: D Benatar
  • Accepted 13 September 2001

When it becomes technically possible to perform a “ground breaking” surgical procedure, an important moral problem arises. In view of the strong incentive for surgeons to be the first to perform a novel operation, their judgments about whether such an intervention is justified may well be clouded. We describe two cases in which surgeons decided not to perform a novel transplant. In the second case transplantation continued to be considered until the ethical analysis performed in writing this paper was completed.

Summary points

At the Red Cross Children's Hospital in Cape Town it was decided, on ethical grounds, against novel limb allografts for two patients—one with no hands and one with no hands or feet

The costs to health and cumulative lifetime risks of immunosuppression for child recipients of a limb allograft are substantial and do not outweigh the functional benefits

There are good reasons for not using “informed consent” to bypass the difficulties of weighing the benefits of limb allografts against the costs

The ideal candidate for limb transplantation is somebody who could gain the most and for whom the associated costs and risks are lowest

A potential recipient should be very close to this ideal if transplantation is to be morally justified

Two amputees

In July 1994, a 3 year old boy was admitted to the intensive care unit at the Red Cross Children's Hospital in Cape Town with meningococcal septicaemia. He developed infarction of all his fingers and these were amputated at the level of the carpus bilaterally with skin grafting of the stumps.

In January 2000, a 4 year old girl was admitted to the same hospital, also with meningococcal septicaemia. She developed distal necrosis of all four limbs. Both hands were amputated just distal to the carpus, leaving three metacarpal stumps on the right hand and a vestige of …

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