In 1954, a plastic surgeon named Joseph Murray made history with the first organ transplant — the transfer of a kidney from one identical twin to another. In retrospect, this then-groundbreaking procedure had plenty of training wheels: The organ was living, taken from a donor as compatible as compatible can be (who, conveniently, could be expected to live with his remaining kidney), which compensated for the fact that no one knew how to keep the recipient's body from rejecting a foreign organ.
And Murray knew the circumstances were niche. "We didn't think we made history," he told National Public Radio in 2004. "We didn't even think of history. We thought we were going to save a patient." He doubted the surgery could ever help more than a handful of very sick patients. "It seemed almost impossible that you would have twins, one dying of kidney disease and another healthy."
Today, an average of 79 people receive organ transplants — heart, lungs, livers, you name it — every day in the United States.
Most of these patients are seriously ill, facing death, or at least suffering dire health consequences because of their malfunctioning organ. But increasingly, a new kind of transplant patient is emerging. They're undergoing some of the newest, riskiest transplant procedures in the world — and their lives don't even depend on them.
Charla Nash got a new face. Thomas Manning got a new penis. Zion Harvey got new hands. None of these patients were dying, but they'd suffered profound loses that were affecting their quality of life. And surgeons decided to do something about it.
Last week, Manning became the first recipient of a penile transplant in the United States, replacing the organ he lost to cancer several years ago. Only three such surgeries have been performed worldwide, and one of those ended in failure when the recipient asked that the organ be removed because of psychological distress. The second, performed last year in South Africa, was wildly successful: The transplant restored enough of the young recipient's sexual function that he fathered a child soon after.
It will take months to know whether Manning's surgery will come anywhere close to those stunning results. Indeed, his surgical team at Massachusetts General has plenty to worry about. The most obvious risk, rejection, could occur after any organ transplant (despite the drugs Manning will take to suppress his immune system, which will make him vulnerable to infection for as long as he needs to take them). The doctors also have to keep close tabs on the numerous veins and arteries they connected in order to make the penis, which came from a compatible deceased donor, part of Manning's body. They'll have to monitor the urinary system they've reconnected for any complications. Manning may become unbearably distressed by his new body part, as the Chinese patient once did. Even if everything else goes perfectly, Manning may never regain full or even partial sexual function.
Similar challenges are faced by all recipients of vascularized composite allotransplantation (VCA) surgeries. These procedures — transplantation of the uterus, face, hand, penis, stomach wall and presumably other body parts in the future — involve the reconnection of more than one type of tissue. Transplanting a heart isn't a cake walk, but with a VCA, doctors must reconnect some combination of skin, subcutaneous fat, nerves, blood vessels, muscle and bone in one fell swoop.
"VCA is a different type of transplant from the kind happening every day, because it doesn't increase the quantity of life, but the quality of it," W.P. Andrew Lee, chairman of the department of plastic reconstructive surgery at Johns Hopkins, told The Washington Post. Lee and his team are working on a procedure like the one performed on Manning, although they'll focus on veterans with traumatic genital injuries rather than cancer survivors who've had amputations. These men aren't in danger of dying — and a catheter can allow them to urinate as needed — but Lee and his colleagues are treating more than just their immediate physical wellness.
"These patients ended up with catheters, they lost all sexual function, and ultimately they kind of lost a sense of who they were as individuals," Mass General urologist Dicken S.C. Ko, who co-led Manning's surgical team, told The Post. "Helping them be able to get up and go to the bathroom every morning by giving them a catheter is one thing, but it isn't necessarily the best we can do for them. If we can help them look in the mirror and say, 'Yeah, I'm doing all right,' that's what we want to do."
These decisions don't come without controversy: All of these procedures faced years of scrutiny from hospital review boards. When Johns Hopkins surgeons sought approval to attempt a penis transplant, hospital officials even weighed the possibility that misinformation about penis donation (it's strictly opt-in — no organ donor can be used for one of these new transplants without their family's express permission) would cause a drop in organ donation across the board.
Uterine transplants in particular have made some medical ethicists think twice (especially after the country's first uterus recipient suffered from an infection and had her new womb removed), with some arguing that carrying a child to term isn't a quality-of-life enhancement worth the risk, especially when there are so many alternative ways to reproduce that are cheaper and safer for the mother and fetus. But one could just as easily argue that prosthetic alternatives to penis transplants are perfectly fine, or that the use of donated hands over prosthetic ones isn't worth a life spent avoiding organ rejection with dangerous drug cocktails.
Once a patient's psychological needs are taken into account — as they already are in so many (admittedly much safer) plastic surgeries — it's impossible for anyone but the patient to know whether a procedure is worth it. But that does seem like opening a can of worms: As these experimental procedures ever so slowly become more common, the hospitals capable of performing them may see a flood of patients who consider the risky surgeries an answer to their prayers. And they'll have to figure out who actually "needs" the procedure.
One day these ethical quandaries could all but disappear. We could find drugs that do the trick without making patients prone to infection and cancer for the rest of their lives, but it's even more likely that one day the organs used in these kinds of donations will be grown in a lab somewhere — tailored to play nice with each recipient's immune system. Attaching a new hand or penis to the human body will always be a long, grueling, risky surgery — but when it doesn't carry a lifelong risk of medical complications, it's arguably no different than the hours of cosmetic surgery that many choose to undergo. The next big question will be whether and when insurance companies will cover the expensive procedures.
Ko thinks that the booming business of perfecting VCA surgical techniques shows an important shift in the way we think about medicine.
"I think we’re taking a lot more holistic view of health care now," he said. "I think for a long time it was, you know, you’re in, you’ve got a problem, you’re fixed, you're out," and under that paradigm, it might seem crazy to risk a patient's well-being by giving them a new penis – or hand, face, or uterus, for that matter. "But a lot of attention now is put in our psychological health and well-being and the ability to live not just a healthy life but a life with fulfillment," he said.
"We're getting back to treating the whole patient," Ko said.