Swedish Womb Transplant Update

One of the nine women who received uterus transplants in Sweden earlier this year has now had a fertilized embryo transferred into her body. The embryo is from the woman's own egg, so if it implants and if she can carry to term, the resultant baby would be her genetic child. The woman suffered from MRKH syndrome, which prevents proper uterine development but does not affect ovaries or eggs. The donated uterus came from the woman's own mother, so if the procedure works, she would not only be the first woman to bear a live child with a donor uterus, but also the first woman to bear a child with the uterus from which she, herself, earlier emerged.

Pass Me That Kidney! Indian Edition

The Hindu is reporting the successful completion of India's largest ever "domino" kidney transplant: a chain of transplants in which A's relative donates a kidney to B, B's relative donates one to C, C's to D, and so on, until (in this case) F's relative completes the chain by donating a kidney to A. 12 patients (6 donor-recipient pairs) were operated on. Doctors at Johns Hopkins did a similar set of procedures in 2009. Physicians in Mumbai completed a 5-family domino donation last year; an earlier attempt at a 5-family donation failed when one of the 5 prospective recipients died. In 2012, doctors in 11 different American states completed the largest domino donation chain ever, involving 30 donor-recipient pairs.

Womb Transplants in Sweden

A team of surgeons in Sweden have transplanted donated uteruses into 9 women who were born without them, or who had lost them to cervical cancer. The aim is to permit the women to bear their own children. From the story:

"The transplant operations did not connect the women's uteruses to their fallopian tubes, so they are unable to get pregnant naturally. But all who received a womb have their own ovaries and can make eggs. Before the operation, they had some removed to create embryos through in-vitro fertilization. The embryos were then frozen and doctors plan to transfer them into the new wombs, allowing the women to carry their own biological children."

There are several ethics issues here, clearly. First, there's the danger to the donors of the uteruses. Doctors said they preferred live uterus donors to dead donors because they could be certain, with live donors, that the uteruses were functioning properly and didn't have any problems like HPV infection. But the uterine donation is a major surgery--more dangerous than a hysterectomy, since it involves removal not only of the uterus but also of surrounding blood-vessel needed to keep the uterus alive in the donee. The procedure thus subjects donors to serious risk for the sake of a donation that isn't lifesaving.

Perhaps more troubling is the question of how the pregnancies will proceed. Will the developing fetuses be affected by the anti-rejection drugs the women are taking? What happens if rejection occurs part-way through a pregnancy? Will the uteruses be strong enough to carry the fetuses to term safely? Will placental formation and blood flow be sufficient to ensure the fetuses are healthy? At what stage and for what reasons will pregnancies be terminated?

If pregnancy is achieved, doctors plan to remove the uteruses to prevent the women's having to take anti-rejection drugs for life. (The drugs can have serious side-effects.) Two earlier attempts at human uterine transplantation (using uteruses from dead donors) failed: one in 2000 in Saudi Arabia, which had to be abandoned when a blod clot formed; and another in Turkey last year, in which the pregnancy failed at 2 months. Uterine transplants have been done in mice, sheep and baboons, but the baboon transplants did not result in pregnancy.

An American team announced its intention to perform a uterine transplant some years ago, raising some ethical issues, but no such procedure has yet been performed in the US.  

Regulation, War, and Face Transplants

These proposed regulations from the US Department of Health and Human Services would subject vascularized composite allographs (VCA) to the rules currently governing solid organ procurement and transplantation. VCA involves transplanting multiple tissue-types as a single functional unit. The highest-profile VCA procedures are face and hand transplants, but VCA procedures around the world have included limb transplants, abdominal wall transplants, finger transplants, and transplants of penises and uteruses. What the procedures have in common is the need for re-vascularization via surgical connection of blood vessels to the transplanted tissue. Bringing these procedures under the existing organ procurement and transplantation rules will rationalize the supply and distribution of transplantable tissue, and permit medical teams to find better matches for their patients.

Recent successes in face-transplantation have captured a great deal of media attention. But another reason for this move is the medical aftermath of the US military presence in Iraq and Afghanistan. More than 1,000 military personnel have lost an arm or a leg in these conflicts; one fifth of those have lost two or more limbs. In the summer of 2010 there were an estimated 200 soldiers who might be eligible for partial or full face transplant, and an additional 50 who could use hand or forearm transplants. The US Departments of Defense and of Veterans Affairs have been leading funders of research on limb and face transplantation. The proposed regulation of VCA is in part aimed at permitting more veterans to get the procedures they need, with the best available material.

Friday Frivolity, Allocation of Scare Resources Edition

Black Market Kidney Conviction in US

A man pled guilty yesterday to multiple counts of illegal trafficking in human kidneys. This is the first conviction under federal law banning the sale of human organs. The defendant took payments of $120,000 or more for each of three kidneys which he purchased from donors in Israel for $10,000 each. He was caught in a government sting operation, attempting to sell an organ to a federal agent. His attorneys argued that the resultant transplants worked, relieving the American buyers from the burdens of kidney disease and dialysis; that the organ recipients had sought him out and not vice-versa; that the donors in each case were aware of what they were doing; and that the surgeries were conducted by reputable and skilled transplant surgeons in well-known (but unnamed) American hospitals. The money, they argued, was used for "expenses associated with the procedures"--though it's not clear from the coverage what that's supposed to mean. Federal prosecutors were rightly unimpressed, noting that black-market organ sales pose a public health danger, and are also unfair, since they result in preferential allocation of organs to the rich (and corrupt).

Bioethicsy Stuff at Yale

A couple of things for folks who might be in New Haven: The Bioethics Center's sister-institution, the Forum on Religion and Ecology at Yale, is screening "Green Fire," a film on the life of environmentalist Aldo Leopold (author of "A Sand County Almanac"), tonight at 6. There'll be a reception and what looks to be a very fine panel discussion. Details are here. The event is being hosted by the Yale School of Forestry & Environmental Studies (from which Leopold graduated in '09), with cosponsorship from the Yale Forum on Religion and Ecology, the Interdisciplinary Center for Bioethics, the Yale Divinity School, the Environmental Film Festival at Yale, and the Center for Humans and Nature. Another sister institution, the Program for Biomedical Ethics at Yale Medical School, is hosting an event on Transplant Ethics on Wednesday evening; details here. And finally, look at our front page to find out about Hal Herzog's Oct. 27 address to our Animal Ethics group on "Moral Inconsistency, Psychology, and Animal Ethics," and David Chalmers' November 4 talk to our Technology and Ethics group on "The Singularity: A Philosophical Analysis."

Upcoming Bioethicsy Stuff at Yale

Two things to put on the calendar: First, Hal Herzog (Psychology, Western Carolina University) will speak to our Animal Ethics Working Group at 1 p.m. on Thursday the 27th at the Bioethics Center; his topic will be "Moral Inconsistency, Psychology, and Animal Ethics." Second (though it's a day earlier, I'm just writing this backwards), our sister organization, Yale Medical Schoo'ls Program on Biomedical Ethics, will host a conference on Transplantation Ethics on Wednesday the 26th, 5 p.m., in the Beaumont Room of Yale Med's Sterling Hall, above the medical library. Speakers will be Robert Truog and Norm Fost. Should be wonderful!

Nuffield on Bodily Donation

The Nuffield Council on Bioethics has posted a new report on donation of human bodies and body parts for medicine and research. It covers a wide range of topics: live and cadaveric organ donation for transplant, gamete donation for reproduction, use of healthy volunteers in first-in-human trials, blood and cord blood, tissue donation, and more. It's a huge and far-reaching report, and I haven't had time to read it deeply, yet, but it appears that the most controversial of its recommendations is to create a pilot program under which women would be paid for donating eggs for research.