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The first successful human hand allograft, performed in Lyon in September 1998 by an international surgical team including one of the authors (NH), was greeted with general admiration in the British press, some scepticism in the French media, and surprising disinterest by medical ethicists. It might be thought, at least by English-speaking readers, that the case is therefore closed. On this basis, hand transplants cross technological frontiers but not ethical ones. They raise no ethical questions that have not been answered long since, in favour of transplantation. There can be no objections except from die-hard opponents of progress in science, according to one of the very few articles in medical ethics to have appeared on the issue of limb transplants, which concludes in favour of cadaveric hand transplantation provided professional, procedural standards of competence have been met (including field strength of the clinical team, scientific background of the innovation, and open public evaluation). 1
None the less, it is broadly agreed that doctors are not obliged to do everything which is technologically possible. We can stave off the moment of death over and over again in terminally ill patients, but there is a widespread dread of pointless 'high-tech' intervention. Modern medicine tends to generalise the application of technologically innovative procedures beyond their original target group, as epitomised by the widespread overuse of cardiopulmonary resuscitation. 2 3 Specifically in transplant surgery, "in every instance, the extension... to organs beyond the original kidney, such as the heart, liver, lungs and pancreas, has raised questions and controversies in the mind of physicians and the general public". 4 Similarly, a leading professor of transplant surgery has expressed his concerns that "the definition of a suitable cadaver donor has undergone relentless expansion". 5 All these are problems of what philosophers would call the 'slippery slope' nature. 6
It might be argued that where a path runs across a slippery slope, it is best avoided in the first place. We do not necessarily advocate that course in this editorial, but we will scout the terrain thoroughly, rather than simply assume that the ethical footing is secure. In transplant surgery, the territory is particularly unfamiliar to many of the settlers. At least one study has identified an 'ethics gap' between the medical...