A tale of two novel transplants not done: the ethics of limb allograftsBMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7343.971 (Published 20 April 2002) Cite this as: BMJ 2002;324:971
All rapid responses
Dr Mukamal offers three criticisms (1) of our recent paper(2). In
doing so, he misconstrues some of our arguments and thus commits the straw
First, he charges us with paternalism for not deferring to the
patient's mother, the decision about transplantation. In doing so, he
misunderstands our comments about informed consent. We were specifically
addressing the view he raised and we were certainly not suggesting that
the imperfections of the informed consent process imply that it should
(always) be abandoned entirely. Instead, we drew a distinction "between
the acceptability of a person choosing some risky or costly course, and
someone else facilitating that person's assumption of the risk or cost".
We were suggesting that there are some (but only some) surgical procedures
in which the risks or costs are so great that it would be inappropriate
for doctors to offer them. Nothing Dr Mukamal says addresses *that* claim.
Second, Dr Mukamal asserts that claims we make about the risks and
benefits are unsupported. To the contrary, we did support them. Consider,
for example, our claim, disputed by him, that amputation of a graft later
in life would pose a greater disadvantage than being limbless from
childhood. In support of this, we noted that adaptation to life without
limbs is easier at a younger age, and that amputation of a graft later in
life would lead to greater functional loss given "that the limb would have
to have been cut back for the original allograft". If Dr Mukamal thinks
that these considerations do not support our claim, then he should say
why. Dr Mukamal also asks how "certain are the authors that a child with
no hands or feet can expect normal longevity"? Certainty is not the issue
here. Nobody can be certain of how long anybody will live. The question,
instead, is the likelihood of living a normal life span. We saw no special
reason for thinking that *this* patient's life would be shortened by her
disability. Her life is much more likely to be substantially shortened by
transplantation than by having no hands and feet.
Finally, Dr Mukamal criticises our suggestion that the deprived
social circumstances are (contributory but not decisive) considerations
against transplantation. He is correct that poverty can exacerbate
disability. Our point, however, is that on balance the social
circumstances count against rather than in favour of transplantation. In
suggesting otherwise, Dr Mukamal ignores the obvious fact that
immunosuppressed people living in conditions of deprivation are more
susceptible to opportunistic infections. And he ignores the considerable
"transport expenses for travelling to regular medical appointments". These
problems are hardly offset by the additional burden of disability (over
those who are more affluent) that the child experiences in consequence of
her social circumstances.
(1) Mukamal KJ. The perfect is the enemy of the good. BMJ Rapid
Responses, 24 April 2002.
(2) Benatar D, Hudson DA. A tale of two novel transplants not done: the
ethics of limb allografts. BMJ 2002; 324: 971-973.
Competing interests: No competing interests
The term paternalism does not appear in the case descriptions by
Benatar and Hudson (1), but it factors heavily in their discussion. The
relative risks and merits of the proposed procedures are discussed from
their viewpoint; patient (or parent)-derived insight is totally lacking.
The fact that informed consent is not a perfect process is an unacceptable
excuse for their decision to ignore the process altogether. Such logic
would suggest that we abandon informed consent altogether until it is
somehow perfected. Every surgical procedure has associated risks and
benefits; we should quantify those to the greatest degree possible, and
then work with our patients to match their beliefs and preferences with
those quantitated risks and benefits.
The authors also assume they understand the risks and benefits of
such a procedure with far more certainty than is justified. For example,
the authors conclude that amputation among children poses less
disadvantage than amputation later in life and that loss of the graft
later in life would be more difficult than the original loss. Both of
these conclusions are unsupported and, at best, debatable. Exactly how
certain are the authors that a child with no hands or feet can expect
normal longevity, and how dramatic is the quality-of-life decrement
associated with such a loss? A certain loss in quality-of-life must
indeed be weighed against an uncertain risk of lost longevity, but such
trade-offs are best judged by informed patients and parents, hopefully
with our guidance and support.
Finally, the authors suggest that the second patient's difficult
social circumstances are a factor affecting her suitability. Regardless
of the potential for bias inherent in such a statement, a young girl with
only an outside toilet would seem to have an extraordinary need for limb
function, much greater than a child in advantaged circumstances with
access to assistive devices.
1. Benatar D, Hudson DA. A tale of two novel transplants not done:
the ethics of limb allografts. BMJ 2002;324: 971-973.
Competing interests: No competing interests