Hopeful first eyeball allotransplantation

November 30, 2023

Authors: Juan Manuel Palomares Cantero y María Fernanda Martínez Palomo 

Introduction

In the field of medicine, there are times when breakthroughs challenge our understanding and raise bioethical questions of great relevance. One such medical achievement that has captured global attention is the complete eye allograft, an innovative procedure carried out at the NYU Langone Medical Center in New York on May 27, 2023. This unprecedented procedure had Aaron James, a 46-year-old man who suffered severe injuries, including the loss of his left eye, due to an electrical accident in 2021, as its recipient. It is crucial to emphasize that this transplant not only involved the recovery of the eye but also a portion of the donor's face.

Despite the impressive medical advancement represented by this procedure, there remains significant uncertainty regarding whether James will ever regain his vision. This uncertainty casts a shadow over what, in many ways, could be considered a hopeful medical achievement. In addition to the medical challenges, this case raises fundamental questions in the realms of ethics and bioethics that deserve careful examination. In a world where medicine and technology advance rapidly, it is essential to reflect on the fundamental principles guiding our decisions in health matters. This story is not merely an account of medical feats; it is a call for reflection on the intersection between science, ethics, bioethics, and morality.

Furthermore, it is relevant to mention that currently, there are over 43 million blind people worldwide. The first documented complete eye transplant dates back to 1885 when Dr. Bradford performed a xenotransplant, transplanting an eye from a rabbit to a human. Dr. Bradford's report describes how the optic nerves of both the host and the recipient were coaptated, documenting "ocular movements in all directions" after the operation. However, the lack of vascular anastomosis and immunosuppressive therapy inevitably led to the failure of the xenotransplant.

This medical breakthrough raises key bioethical questions that need to be addressed. These include the perceptions and desires of patients regarding complete eye transplants, whether they restore vision or not, as well as aesthetic and functional considerations. It is also crucial to evaluate the risks and benefits of complete eye transplantation compared to prosthetic alternatives, considering additional immunosuppressive risks when combined with facial transplantation. Managing potential allograft failures, psychosocial implications for recipients and their loved ones, and public perceptions of complete eye donation are also significant ethical aspects.

Establishing ethical mechanisms for the fair allocation and distribution of complete eye transplants is essential, as is the need to encourage dialogue within the medical community to ensure responsible and ethical research, keeping the values and well-being of potential eye transplant recipients at the forefront of the investigation.

Moreover, the principle of justice in bioethics raises questions about resource allocation and the use of an eye for transplant, knowing that visual recovery is uncertain. It could be questioned as an inappropriate use of medical resources that could benefit other patients with specific conditions offering a better prospect of visual recovery. Additionally, the principle of justice in bioethics raises questions about resource allocation. On one hand, to date, eye transplantation lacks a certain prognosis regarding visual capacity. On the other hand, the donation of certain parts of the eye, such as corneas, tear ducts, eyelids, or the pigmented epithelium of the retina, has highly beneficial outcomes for patients with specific conditions where visual recovery is possible. Given this, the appropriate use of medical resources in such a complex procedure as the total allograft of the eye could be questioned.

DIGNITY OF THE HUMAN BEING

Within the field of bioethics, one of the fundamental pillars guiding medical and ethical decisions is the recognition of the intrinsic value of every human being. Each individual, regardless of their origin, social status, or health condition, possesses an inalienable value that deserves to be respected and protected. The dignity of the human person, a central principle in bioethics, underscores that every human being deserves to be treated with respect and consideration, irrespective of circumstances. In the context of eye transplantation, this means that both the recipient, as in the case of Aaron James, and the donor, along with their families, should be treated with the utmost regard for their dignity.

This fundamental notion manifests in various ways in the case of eye transplantation. Firstly, the decision to undertake such a complex and risky operation must consider not only the technical and medical aspects but also the intrinsic value of life and the dignity of Aaron James as a human being. This involves a thorough analysis of potential benefits and risks, ensuring that any procedure is consistent with his well-being and respects his physical and psychological integrity. Additionally, the dignity of the human person extends to donors and their families. The donation and transplantation process must be carried out ethically and respectfully, ensuring informed consent from the donor and protecting the privacy and rights of both parties involved.

In a world where medicine and technology are advancing rapidly, these fundamental ethical principles, such as the value of the human being and the dignity of the human person, must continue to guide decision-making in the field of transplants, especially in advanced procedures like eye transplantation. These principles not only ensure ethical and fair treatment for those involved but also contribute to strengthening trust in medicine and society at large, reaffirming the importance of respecting and protecting the dignity of every human being in all circumstances.

ETHICAL DISCERNMENT

How is the respect for human dignity balanced, considering both the recipient and the donor, with the performance of an eye transplant that potentially places the recipient in a lifelong vulnerability due to dependence on immunosuppressive drugs? This central question highlights the complexity of ethical discernment in the context of eye transplantation. Ethical discernment involves deep reflection and moral consideration that should guide medical professionals, patients, and society in general in decision-making related to this innovative medical intervention.

To begin with, the application of the principle of human dignity in this context involves carefully considering how each step of the procedure affects the integrity and well-being of the recipient, in this case, Aaron James, and future recipients of such transplants. It means ensuring that any action taken is consistent with respect for their dignity as individuals, including evaluating the potential risks and benefits of transplantation, as well as the quality of life that James and future recipients might experience, considering the potential vulnerability arising from dependence on immunosuppressive drugs.

Ethical discernment around eye transplantation raises fundamental questions that require deep reflection and discussion. In addition to the issue of vulnerability, how do we ensure genuine and comprehensive informed consent, ensuring that both the donor or their representative and the recipient fully understand the risks and benefits, including those related to the vulnerability arising from immunosuppressive drug dependence and the purpose of the transplantation procedure?

Furthermore, what is society's responsibility in the fair allocation of medical resources, and what is the need to provide adequate emotional support to those involved, considering long-term vulnerability? It is also crucial to apply ethical principles such as solidarity, calling us to care for and support the most vulnerable in our society, and subsidiarity, seeking to make decisions at a level closer to the individual whenever possible.

In this context, the use of an eye for transplant, knowing that visual recovery is uncertain, could be questioned from a bioethical justice perspective. Is it appropriate to use a valuable medical resource in this way when other patients could benefit more from it? These questions urge us to carefully consider resource allocation and equity in access to medical procedures, especially those with an aesthetic and functional component.

Finally, how do we apply these ethical principles along with responsibility, prudence, the precautionary principle, autonomy, and justice to make ethical and equitable decisions in the context of eye transplants, considering the vulnerability that recipients may experience due to dependence on immunosuppressive drugs? These issues challenge us to carefully consider not only the technical aspects but also the ethical values that should guide our actions in the medical field and society at large, protecting the dignity and physical life of every individual involved.

WHAT COMES NEXT?

While this procedure has not restored vision to the left eye of its recipient, Aaron James, it has proven to be effective in aesthetic terms, setting an important precedent. Additionally, it opens the possibility for individuals who have lost an eye in the past to regain not only their appearance but also the hope of regaining sight. However, it is essential to highlight that projections for this transplant indicate that, in the future, vision could be significantly restored, although there is considerable uncertainty in this regard. This uncertainty reminds us that, much like in head transplantation, until a technique allowing successful reconnection of the vascular and nervous components of the eye to the brain is developed, and sufficient medical and scientific advancements are achieved, a successful total eye transplant with vision recovery will remain a challenge.

In this regard, in the coming years, a step-by-step approach will be required, prioritizing the research and development of nerve reconnection techniques that have faced significant challenges due to the complexity of the multiple nerve fibers of the optic nerve. A successful total eye transplant with vision recovery will depend on sufficient medical and scientific advances allowing the successful reconnection of the vascular and nervous components of the eye to the brain. This goal remains a significant challenge in the field of medicine.

The possibility of restoring vision through eye transplants poses ethical challenges and significant opportunities. Challenges include issues related to the fair distribution of these procedures, informed consent in a context where vision recovery is a real possibility, and the need to consider the implications of these advances for the identity and self-perception of patients. On the other hand, opportunities lie in the potential to improve the quality of life for those who have faced vision loss and in the prospect of advancing towards more effective treatments in the future.

As we progress in this field, it is crucial for medical ethics to evolve to address these new scenarios. Solidarity, which calls us to care for and support the most vulnerable in our society, plays a crucial role in determining who should have access to these procedures, ensuring that those who could benefit are not excluded. Subsidiarity, seeking to make decisions at a level closer to the individual whenever possible, must also be considered in decision-making about eye transplants to respect autonomy and individual needs. Moreover, respect for the physical life of each individual involved is fundamental, ensuring that any procedure is consistent with their well-being and protects their physical and psychological integrity.

These ethical principles, along with responsibility, prudence, the precautionary principle, autonomy, and justice, are essential for making ethical and equitable decisions in the context of eye transplants, considering the vulnerability that recipients may experience due to dependence on immunosuppressive drugs. These issues challenge us to carefully consider not only the technical aspects but also the ethical values that should guide our actions in the medical field and in society at large, protecting the dignity and physical life of each individual involved and ensuring an equitable approach in the distribution of these procedures.

CONCLUSIONS

The possibility of restoring vision through eye transplants presents bioethical challenges and significant opportunities. These challenges include issues related to the fair distribution of these procedures, informed consent in a context where vision recovery is a real possibility, and the need to consider the implications of these advances for the identity and self-perception of patients.

As we progress in this field, it is crucial for medical ethics to evolve to address these new scenarios. Solidarity, which calls us to care for and support the most vulnerable in our society, plays a crucial role in determining who should have access to these procedures, ensuring that those who could benefit are not excluded. Subsidiarity, seeking to make decisions at a level closer to the individual whenever possible, must also be considered in decision-making about eye transplants to respect autonomy and individual needs. Moreover, respect for the physical life of each individual involved is fundamental, ensuring that any procedure is consistent with their well-being and protects their physical and psychological integrity.

These bioethical principles, along with responsibility, prudence, the precautionary principle, autonomy, and justice, are essential for making ethical and equitable decisions in the context of eye transplants, considering the vulnerability that recipients may experience due to dependence on immunosuppressive drugs. These issues challenge us to carefully consider not only the technical aspects but also the ethical values that should guide our actions in the medical field and in society at large, protecting the dignity and physical life of each individual involved.

Ultimately, Aaron James's case of a complete eye transplant reminds us that bioethics and medicine must advance together to ensure that medical advancements are carried out responsibly and with profound respect for human dignity in a world where science and bioethics are more intertwined than ever.

Juan Manuel Palomares Cantero is a lawyer, teacher, and Ph.D. in Bioethics from the Anáhuac University, Mexico. He served as the director of Human Capital, director, and general coordinator at the Faculty of Bioethics. Currently, he works as a researcher in the Academic Directorate of Integral Training at the same University. He is a member of the National Mexican Academy of Bioethics and the Latin American and Caribbean Federation of Bioethics Institutions.

María Fernanda Martínez Palomo is a medical surgeon and a master's degree holder in bioethics from the Anáhuac University, Mexico. She is currently undertaking clinical and surgical practices at the Association of Ophthalmology and Visual Health, an institution specialized in ophthalmological services.

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