Ethics of Living Limb Donation: Is Donor Competent?

This transcript has been edited for clarity.

Hi. I'm Art Caplan. I'm at the Division of Medical Ethics at the NYU Grossman School of Medicine in New York City.

A friend of mine, a very experienced and well-respected surgeon, shared with me a request that was received by email recently about organ donation. I'm just going to read you what the request was. It says, "Hello, I was wondering if you all needed my left hand for a patient in need of a limb transplant. I saw on [organdonor.gov] that you were looking for an upper limb donation."

This means a hand and arm. There are definitely lists that the surgeons keep when they're looking for cadaver donors for a patient, and for something like an arm that is not an emergency, they can list something and say they're on the lookout trying to match, size, ethnicity, race, skin color, age, and those sorts of things.

This inquiry basically said, I have done some research and I know that I would have to donate my whole left hand and a pretty big portion of my arm. I'm okay with this.

Maybe as bizarre as it seems, this question arises as transplant begins to move into new areas of transplantation, sometimes called vascularized composite allografts. We've seen these in the news; they include faces, hands, limbs, eyes, and even the uterus. What should our policy be in this country about accepting volunteers who want to do living donation for this new array of organ transplants?

In part, we don't have to worry too much about this because faces and hands are still considered experimental. There's not much demand for these procedures yet, as the surgeons and transplant teams try to figure out the immunosuppression and how to do the microsurgery, trying to get nerves to regrow, and determining whether things are going to become functional. We're still collecting evidence in that way.

The number of trials is small. I should add that the cost of doing these kinds of procedures is very high. A face or hand can cost millions of dollars to get a transplant done. On the other hand, for traditional transplants, such as kidneys, livers, and lungs, we have seen living donors.

Certainly, for a kidney, the majority of kidney transplants in the United States today come from people who are actually living donors, not cadaver sources. We have allowed people to donate a lobe of lung, particularly to their child. There are instances in which people have donated a piece of their liver, which does in fact regenerate after that donation as a living source.

Living donation has tremendous advantages. For one, you can line up the donor and the recipient in the same place. You're not doing an emergency operation. Everything can be planned out. The team can be rested. You can make sure that nobody is sick.

When cadaver organs become available, it's kind of a crisis operation. Everybody has to get into the hospital, you're hoping that they're not overly tired or that no one has an infectious disease that would make the procedure too dangerous on that day to attempt because someone has the flu, COVID-19, or something like that on the surgical team.

The blood bank can be ready. You could pre-donate blood if you thought you were going to need that. You're set up to do this in an organized way when the source is a living donor. Also, the living donor can pick the recipient. We permit that, but it is not possible with cadaver donation, where we have a system for distribution.

If you want to move your loved one up on the waitlist, you can identify who it is that you want to get it. In some ways, that's an incentive for people to make living donations. There's also the reality that, if you do a living donation within a family, you may get a better biological match. Outcomes are better than they are with cadaver donations for all the existing forms of transplant.

What would the issues be when someone sends in a request and says, hey, I'd like to donate my arm? Obviously, first and foremost comes competency. Is this a person who is mentally competent? Is it someone who is psychiatrically disturbed? Do they know what they're doing? How could we possibly accept a gift where someone would become dysfunctional, would lose their ability significantly to do many things in the world by going down to one arm?

I doubt that it would be easy for anyone, even in a world where limb transplants and hand transplants were well established as therapies and much more common, to pass the competency test. Probably the best chance would be someone's family member who wants to donate a limb to a brother or child. We may have more of an understanding of why they'd want to try and help that way.

Thinking harder, maybe we would accept a living donor of a limb if we were in a situation where they were going to be terminally ill, that they knew they were going to pass away, and they'd like to donate their arm. They may not want to wait if they know outcomes are better when they're living. Why not do that before they pass?

We have some states also with medical assistance in dying, so people know that they are going to plan their death. Would we ever allow someone to make a living donation of a hand or a limb, or for that matter, a uterus or an eye or anything else?

Again, I think we would find ourselves in a very difficult situation where someone might require, even at the end of life, functional capabilities, such as pushing themselves up, the ability to eat, or undergoing a massive operation before they try to battle their own life-threatening disease. Even if someone was elderly and said, "I don't care, I want to do this. I'd rather my child or my adult child took this limb," you're still making them far worse off.

I think the combination of competency would rule out most out-of-the-blue inquiries like the one I told you that my surgeon friend received. Within families, we might consider situations where it would be possible to permit something as far out as a limb or a hand donation. Even there, you're still going to have to assess competency, coercion, and what it would mean to render somebody dysfunctional and have them undergo a massive, maiming procedure, even if it would benefit someone else and the benefit was worth it to the person who says they want to donate.

I'm pretty skeptical that we're in a limb, hand, and eye situation that our society is going to tolerate.

I'm Art Caplan at the Division of Medical Ethics at NYU Grossman School of Medicine. Thanks for watching.