Transplant Headaches: Head transplant on the horizon

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series

By Marleen Eijkholt, PhD, LL.B/LL.M

Introduction
On May 1, 2017, the Daily Mail reported on a successful head-transplant involving rats, as a “practice run for [a] controversial human experiment.” Indeed, this run would seem timely and perhaps minimal pertaining only to rats, given the proposed timeline toward the first-ever human head-transplant (HHT). Some reports suggest December 2017 as the date for the HHT, while others report that December is unlikely, and that the procedure would have to be delayed.

With the first HHT on the horizon, guttural yuck-reactions, and references to the ethical questionability of this procedure abound. A famous ethicist suggested that the surgeon is “out of his mind.” But I am unsure if this rejection is fair. If we have allowed the development of kidney, heart, hand, face, uterus, and penis transplants, why would this new area of transplant medicine raise prohibitive concerns?

Several areas of ethical concerns have been identified, and I want to address three reflections briefly here. Although many more could be identified, including the concern that a ‘body transplant’ also means that its other organs cannot be used for other purposes, I will not go into these issues due to word limitations. I offer thoughts for further discussion, drawing on parallels from other controversial (surgical) interventions, i.e. stem cell interventions for spinal cord injury (SCI) and deep brain stimulation (DBS). Often ethics is seen as a prohibitive ‘science’ but I do not want to endorse this idea. Instead, I hope to ask how we can ensure that this development proceeds as reflectively as possible.

Background

operating room photo
Image description: two surgeons are shown in an operating room while performing a transplant procedure on a patient who is out of frame. Image source: Scott & White Healthcare/Flickr Creative Commons

The history of HHT up to this point is described in many places. In 2013, an Italian surgeon, Canavero, first suggested his willingness to do a HHT, causing outrage and interest. Canavero has given a TED talk in the meantime, published several manuscripts [3, 19] and protocols [1, 2] on the procedure. Initially, one Russian individual, Valery Spiridonov, came forward to undergo the HHT and is now considered as potentially the first patient, while others have started to line up. Spiridonov has a degenerative and incurable muscle disease (Werdnig-Hoffmann) and is confined to a wheelchair. Cost-estimates of the procedure include a 7.5-20 million dollar, 36-hour operation, with a team of 150 people. The community has expressed serious reservations about the scientific feasibility. Still, we read that the first head-transplant in monkeys occurred in 1970 and that several dogs and mice have undergone the procedure. These were mostly as proof of principle, and not focused on long-term survival. Currently, there is no substantial proof that the recipient can be ‘kept alive’ long-term.

Informed Consent (IC)
A primary concern is whether Spiridonov can offer informed consent. Given his vulnerability, suffering Werdnig-Hoffmann disease, and based on reports about what Spiridonov said, these concerns are real. Spiridonov’s desire is to be like the “first man on the moon,” generate knowledge for future generations, and that the HHT will help him. Hence, he seems vulnerable to therapeutic misconceptions and risk-mitigation biases, especially in the light of a surgical learning curve that will challenge the first HHT [10]. Spiridonov’s narrative refers to the first man on the moon—who successfully made it—failing to mention the others who did not make it. Another part of this concern relates to identity problems that transplant individuals might experience with an alien body (part), where HHT concerns a whole body and an irreversible transplant [17].

These areas of concern have been dealt with at length, in reference to transplants and other emerging (surgical) interventions. I do think these concerns can be addressed, provided a thorough shared decision-making process, like in DBS [7]. Why would it be different in the HHT context?

Necessary Evidence
It seems an incredible leap to move from rat experiments to human interventions, without bigger animal models. However, such leap is not unprecedented, and might not automatically be condemned. Geron, a company that injected stem cell derived products in the spinal cord of SCI patients, moved from rat trials to humans. They skipped large animal models in assessing feasibility. Their decision was met two ways. One set of arguments stated the unacceptability of this practice as humans would now be exposed to unacceptable risks, based on insufficient knowledge. Another set of arguments was perhaps less outraged, suggesting that animal rights arguments might favor such direct application. Sacrificing large animals could not always be justified, especially if evidence in large animals may still not apply to humans [9]. Would it be in the HHT case?

Medical Need
A final question is: How to go about the risk/benefit assessment for someone whose medical need is not immediately life threatening? Spiridonov does not suffer an immediately life threatening illness, unlike liver failure, so some might argue that the risk/benefit profile of this experiment is disproportionate. Aside from concerns about the patient facing risks, executing novel risky experimental interventions may entail a loss of trust in the field if they go wrong. We have seen this in the tragic story of Jesse Gelsinger, gene therapy trial participant. So, some could argue that Spiridonov’s medical need does not warrant a loss of trust in science. But in response one could propose that for a proper risk/benefit assessment, weighing many factors is required. We see that for many composite allograft transplant areas as well as for DBS, the focus is on improving quality of life, not providing a cure. References to medical need and life-saving interventions are social constructs. If interventions like penis transplants were justified and marked as life-saving, referencing suicide concerns, life-limiting conditions like Spiridonov’s condition could put these concerns into perspective.

Conclusion
Although HHT are a new transplant territory, many of the headaches are familiar ethical concerns to the domain of novel transplant medicine and emerging surgical interventions. I am unsure that HHT is very different than the first heart transplant, which was met with huge skepticism, involving concerns about survival, IC, and identity. Heart transplants have offered huge progress in medicine, by generating new knowledge and applications for patient well-being. What makes us say that this body/human head-transplant is going to be less of a revolutionary intervention, and should be stopped before it even begins?

Marleen Eijkholt photoMarleen Eijkholt is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Obstetrics, Gynecology and Reproductive Biology in the Michigan State University College of Human Medicine. Dr. Eijkholt is also a clinical ethicist at Spectrum Health System.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, June 22, 2017. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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References

  1. Canavero, Sergio. “The “Gemini” spinal cord fusion protocol: Reloaded.”Surgical neurology international 6 (2015). Available from: http://surgicalneurologyint.com/surgicalint-articles/the-gemini-spinal-cord-fusion-protocol-reloaded/
  2. Canavero, Sergio. “HEAVEN: The head anastomosis venture Project outline for the first human head transplantation with spinal linkage (GEMINI).”Surgical neurology international 4 (2013): 335. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3821155/
  3. Canavero, Sergio, et al. “Neurologic foundations of spinal cord fusion (GEMINI).”Surgery 1 (2016): 11-19. https://www.ncbi.nlm.nih.gov/pubmed/27180142
  4. Caplan, Arthur. “Doctor Seeking To Perform Head Transplant Is Out Of His Mind.” Forbes. February 26, 2015. Available from: https://www.forbes.com/sites/arthurcaplan/2015/02/26/doctor-seeking-to-perform-head-transplant-is-out-of-his-mind/#19fcd7205ed3
  5. Čartolovni, Anto, and Antonio G. Spagnolo. “Ethical considerations regarding head transplantation.” Surgical neurology international 6 (2015). http://surgicalneurologyint.com/surgicalint-articles/ethical-considerations-regarding-head-transplantation/
  6. Couzin, Jennifer. “Celebration and Concern Over U.S. Trial of Embryonic Stem Cells.” Science5914: 568. January 30, 2009. Available from: http://science.sciencemag.org/content/323/5914/568.full?rss=1
  7. Eijkholt, Marleen, et al. “Shaking Up the Debate: Ensuring the Ethical Use of DBS Intervention Criteria for Mid‐Stage Parkinson’s Patients.”Neuromodulation: Technology at the Neural Interface (2017) http://onlinelibrary.wiley.com/doi/10.1111/ner.12608/full
  8. Elliott, Josh K. “Canadian gets the nod to help with first-ever human head transplant.” CTV News. December 8, 2016. Available from: http://www.ctvnews.ca/health/canadian-gets-the-nod-to-help-with-first-ever-human-head-transplant-1.3195262
  9. Frey-Vasconcells, Joyce, et al. “Translation of stem cell research: points to consider in designing preclinical animal studies.” Stem cells translational medicine5 (2012): 353-358. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3659706/
  10. Hopper, A. N., M. H. Jamison, and W. G. Lewis. “Learning curves in surgical practice.”Postgraduate medical journal 986 (2007): 777-779. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2750931/
  11. Howard, Jacqueline. “Human Head Transplants Now Possible, Italian Neuroscientist Says (VIDEO).” Huffington Post. July 6, 2013. Available from: http://www.huffingtonpost.com/2013/07/06/head-transplant-italian-neuroscientist_n_3533391.html
  12. Kean, Sam. “The Audacious Plan to Save This Man’s Life by Transplanting His Head.” The Atlantic. September 2016. Available from: https://www.theatlantic.com/magazine/archive/2016/09/the-audacious-plan-to-save-this-mans-life-by-transplanting-his-head/492755/
  13. Lamont, Tom. “’I’ll do the first human head transplant’.” The Guardian. October 3, 2015. Available from: https://www.theguardian.com/science/2015/oct/03/will-first-human-head-transplant-happen-in-2017
  14. MacDonald, Cheyenne. “Scientists carry out head transplant on a RAT to create bizarre two-headed rodent in practise run for controversial human experiment.” Daily Mail. May 1, 2017. Available from: http://www.dailymail.co.uk/sciencetech/article-4464052/Scientists-complete-head-transplant-RAT.html
  15. Matharu, Hardeep. “The Troubled History of Clinical Drug Trials.” The Independent. January 15, 2016. Available from: http://www.independent.co.uk/life-style/health-and-families/health-news/the-drug-trials-that-went-wrong-a6814696.html
  16. Neilson, Susie. “Would A Human Head Transplant Be Ethical?” Popular Science. July 3, 2013. Available from: http://www.popsci.com/science/article/2013-07/would-human-head-transplant-be-ethical
  17. Pascalev, Assya, Pascalev, Mario, and Giordano, James. “Head transplants, personal identity and neuroethics.”Neuroethics 1 (2016): 15-22. https://link.springer.com/article/10.1007/s12152-015-9245-4
  18. Radcliffe, Shawn. “Are Head Transplants Possible… And Ethical?” Huffington Post. September 19, 2016. Available from: http://www.huffingtonpost.com/healthline-/are-head-transplants-poss_b_12090894.html
  19. Ren, Xiaoping, and Sergio Canavero. “Human head transplantation. Where do we stand and a call to arms.”Surgical neurology international 7 (2016) Available from: http://surgicalneurologyint.com/surgicalint-articles/human-head-transplantation-where-do-we-stand-and-a-call-to-arms/
  20. Stewart, Will and Fagge, Nick. “EXCLUSIVE: Revealed, the terminally ill man set to be first to undergo the world’s first full HEAD transplant pioneered by doctor branded ‘nuts’.” Daily Mail. April 8, 2015. Available from: http://www.dailymail.co.uk/news/article-3029376/Russian-volunteer-head-transplant-operation-Valery-Spiridonov-says-no-choice-undergo-7-5million-procedure-controversial-Italian-surgeon-Dr-Sergio-Canavero.html
  21. Urken, Ross Kenneth. “Doctor Ready To Perform First Human Head Transplant.” Newsweek. April 26, 2016. Available from: http://www.newsweek.com/2016/05/06/first-human-head-transplant-452240.html
  22. “World’s first head transplant patient schedules procedure for 2017.” Fox News. September 10, 2015. Available from: http://www.foxnews.com/health/2015/09/10/worlds-first-head-transplant-patient-schedules-procedure-for-2017.html
  23. “Head Transplantation: The Future Is Now | Dr.Sergio Canavero | TEDxLimassol.” September 18, 2015. Available from: https://youtu.be/_EHCHv5u3O4

2 thoughts on “Transplant Headaches: Head transplant on the horizon”

  1. The issues of informed consent, risk assessment, and treatment protocols seem like gentle breezes compared to the hurricane of tough questions raised by HHT. Postsurgically, would I still call him Comrade Spiridonov? How would he reply if I asked him about his hat size? Or, Whom do you love? What losses do you grieve? What do you aspire to? If I grilled him about his character defects, which ones would he own up to, skip over, dodge, be ignorant of? Say the donor came from Italy. Would Spiridonov still be a Russian citizen? Would he be morally absolved of Stalin’s crimes? If none of these questions make any sense to him, where did Valery go?

    The cranium is luggage for the brain. Is the brain, with its complex gravy of neurochemicals, the seat of consciousness and self-reflection, the portal of identity? Do those neurochemicals simmer and combust into a narrative called person? Is the brain ontologically upstream from the liver, penis, uterus, indeed the face? Or are these questions species-centric or culturally biased? If so, OK, why not swap out Spiridonov’s broken hat rack with that, say, of a healthy rat?

    Before you get to the comfortable ethical questions raised by HHT, tell me first: Can you completely sever HHT from a case of murder or suicide by surgery?

  2. Dear David,
    Your questions are fascinating and triggering our existential fantasies. Could we/ would we ever be someone else? Thank you for raising them. With you, I can only imagine and ponder what confusion transplantation would cause, and feel compassionate towards anyone who is in need of a transplant and who ‘needs’ pieces of ‘others’ to live a ‘new/ better/healthy’ life.
    Concerns about identity, regardless of their application in transplant medicine, are fascinating. I’m not sure if you’re familiar with work that examines how identity is established (by self of others); i.e. referring biological, psychological, narrative, or numerical identity, or any of the other perspectives ( https://plato.stanford.edu/entries/identity-ethics/). I can’t call myself an expert on these questions or theories, but I can certainly testify that head transplants might challenge many of those accounts, but I expect these theories could also offer some responses to your questions.
    Questions about identity and embodiment after transplant are so difficult and in some cases so tragic. We read about the hand transplant recipient that did no longer want to take his immunosuppressing drugs because he felt estranged from his arm. (1) Further, we read that identity questions can be experienced by any transplant candidate, and that, so far, especially in facial transplant they can raise existential concerns for recipients. (2) I can only imagine that in case of a body/head transplant these concerns would be exacerbated for the recipient, although not ‘guaranteed’. It seems that this paper suggests that not every recipient experiences identity questions. I agree with the author of this piece that concerns about identity of the recipient, particularly in the face of variability of experience, means that transplants are not prohibitive on ethical grounds.
    Your last question then. I think you’re asking whether it would be acceptable to use organs/material from a murderer’s body or from the body of someone who committed suicide. Before I answer this question, a couple of references: Did you ever see the movie Blink? (http://www.imdb.com/title/tt0109297/) This movie triggers one’s imagination for sure! Lock (3), in the anthropological literature, also refers to such concerns on the part of a surgeon, who wouldn’t want to have a ‘murderer’s heart’. Just to say that your concern is shared by more than you! Then, the discussion about donation after suicide has an interesting context: In The Netherlands, where physician assisted suicide and euthanasia can be legal, contemporary debate ponders the question about donation after PAS or Euthanasia. (4)
    Personally I don’t have a problem with anyone who wishes to donate. I am unsure on what grounds we would allow anyone to be excluded from the ability to ‘donate’, or where we would draw the line for a suitable organ, but coming from a ‘morally reprehensible source’, provided that the donor has offered voluntary and free consent. I like the medical and biological criteria that currently dominate the world of transplant. I’m not sure that (disconnected) organs have any ‘moral character’ left in their tissue, or that a recipient should worry about ‘the moral character of the donor/donated organ’ in the light of their need and overall scarcity of organs. I would say these are real but maybe irrational fears that should not determine the playing field.

    1. DeMartino C. Passing through the threshhold of limb transplantation. In Motion. 2001;11:1–4.
    2. Swindell, J. S. “Facial allograft transplantation, personal identity and subjectivity.” Journal of medical ethics 33.8 (2007): 449-453.
    3. Lock, M. (2002). Twice dead: Organ transplants and the reinvention of death. Berkeley: University of California Press & Lock, Margaret. “Human body parts as therapeutic tools: contradictory discourses and transformed subjectivities.” Qualitative Health Research 12.10 (2002): 1406-1418
    4. Bollen, Jan, et al. “Organ donation after euthanasia: a Dutch practical manual.” American Journal of Transplantation 16.7 (2016): 1967-1972

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