The University of Southampton

Engineering Replacement Body Parts 2023

UOSM2031

Philosophy and medical consent

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Before I begin this blog on philosophical arguments and medical consents, it should be noted that there usually is no “real” definitive ethical answer to an argument as I follow JS Mill’s view that knowledge is not infallible, and that All sides contain plausible explanations. Truth, lies, or partially true, should be brought together in discussion (JS Mill, On Liberty).

Case analysis

In the paper by Murray (1990), the author stated many legal cases through out the history, providing evidence in how the medical consent was progressed. From the legal cases provided, in general, it can be observed that utilitarianism and deontology were combined. Although mainly, in the cases where informed consent was present, patient-centred deontological view is followed, and that the surgeons will respect patients’ individual liberty, and one’s right to one’s body. Some examples containing the theoretical traits are:

  • Luka v Lowrie, 136 N. W. 1106, Michigan 1912: A child, who experienced a crash injury to his foot, was deemed by the surgeons that amputation was necessary. Normally, a child would not be considered to have competence for consent, therefore the parents should grant consent to the surgery. However, the parents were unavailable for discussion during the duration of the surgery. Without consent, the surgeon, after consulting with several physicians, performed the amputation. From this case, it can be justified based on act utilitarianism, where the goal of an action should be to achieve the maximum amount of happiness. Had the surgeon acted in a strong deontological view, and that the surgeon absolutely respects individual liberty and consent, the child’s situation may have turned another way.
  • In re Melideo, 390 N. Y. S. 2d 523, New York, 1976: Mrs. Melideo received a dilatation and curettage of the uterus for diagnostic purposes. The patient developed significant bleeding soon after. The patient however, refused blood transfusions based on her religious belief. The court ultimately ruled that blood transfusion should and was not ordered to the patient, since the patient has consent competency. This follows the patient centred deontological view, where certain rules are unethical to be broken no matter the circumstances, and the patient has the ultimate right. Interestingly, in this case, there are two layers of deontological reasoning present. The first layer exists in the surgeons who acts as the “agents”. The surgeons respected the rule for a patients’ liberty based on the patient centred deontology, and the patient followed the basic deontology view where the decisions should never break certain rules laid upon oneself.

The two cases above represented how the two views can be at play at the same time instead of counter arguing. The deontological approach respects one’s autonomy and liberty, while the utilitarianism view fulfils certain situations where emergency consents are needed. Murray confirmed this in one of the conditions for emergency consent: the proposed treatment is for the ultimate benefit of the patient.

One possible reasoning for this might be the importance of liberty from both viewpoints. In an action-based context, such as the world-famous trolly cart problem, where 5 people will die if you don’t push the lever, and 1 person will if you do, the deontologist will not push the lever, only if the person has a doctrine to never kill in their mind. The utilitarian will push the lever for the maximum amount of happiness. This may make the utilitarianism seem like a violation of some individual liberties in some cases.

However, in the context for information, Mill argues that even though some truth may result in harms, they should still not be suppressed. The reason for this is that Mill follows the empiricism of knowledge, that knowledge can only be gained by experience, and that future knowledge (or truth) cannot be known. Therefore, suppressing the truth will assume its infallibility, which contradicts to Mill’s empiricism. This also supports the importance of information transparency to the patients so construct patients’ well-rounded judgement toward the procedure.

Free will and Determinism

Cobbs v. Grant, 502 P2d 1 California, 1972. In this legal case, it was mentioned by the author about the disclosure of risks:

“Had the patient, judged as a reasonable and prudent person, been provided adequate information about the procedure and its risks prior to consenting to the procedure, or if some material risk had been presented, would the patient have refused to proceed with surgery?”

This leads to another philosophical debate on free will and determinism. From the determinism point of view, Paul Ree is an example, that he holds a hard deterministic view. Ree believes that every decision was made from past events, and that an association of causation is present. Ree also argues that free will is an illusion since the causes are internal. For example, when a rock was thrown, the causation was observable, and it is external. Those events can be replicated and proven, given the exact force applied and other factors such as wind speed. To say that the rock has free will would not be plausible. From this logic, internal factors such as body chemistries or past experiences leads to determined behaviours of a person or an organism. Ree gave the example of a donkey between two of the same haystacks. If the donkey was observed to turn left and eats the left haystack, externally, it would seem like the donkey has free will, but what about hidden factors? The wind may be blowing towards the donkey from the left side, or a hidden body behaviour gathered from past experiences. Therefore, since some factors were internal and unobservable, and created the illusion. Ree believes that if the exact past causation, both internal and external were recreated to the exact same extent, the donkey would still choose to turn left. Same as when a person makes certain decisions.

While not many philosophers support purely on free will, many of them believes that free will and determinism can exist at the same time (Compatibilism). Compatibilists argue that if only causal determinism exists, there won’t be any needs for moral responsibilities. Since determinism argue that only one path was available to the person, and that person must act in that way. Therefore, there isn’t a responsibility for that person’s action. To apply moral responsibilities then, free will will be required. For compatibilism, theories vary. But Fischer’s (1994) theory can provide a supporting ground for information transparency in medical consent. Fischer provides an element called regulative control which is a control agent that can bring and refrain one from doing certain behaviours. As a result, different paths open for one to choose at that exact moment. For medical consent, the importance for surgeons to provide patients a clear view of the procedure surfaces. Therefore, the compatibilist view justifies the need for risk disclosure that it provides the patients a clear, rational judgement when they are competent for consent.

From the example and arguments above, medical consent is constructed on the foundation of individual liberty. While it can be fitted into many different philosophical debates. For novel medical research, personally I would argue for the respect of liberty and autonomy, and transparent communications for patients to create rational and justified decision. Yet, certain context may prove otherwise and incite debates.

Restoring My Old Self- Is tissue Engineering Really the Key?

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From beginning this module, I was exposed to various different topics all under the field of engineering replacement body parts ranging from ethics in research to orthopaedics. However I was surprised to find myself knowing nothing about tissue engineering until the lecture we had on it had taken place. Which was what had inspired me to do some research on the topic.

WHAT IS TISSUE ENGINEERING

Falling under the field of regenerative medicine, tissue engineering bares the goal: to assemble functional constructs that restore, maintain, or improve damaged tissues or whole organs.

It could potentially be used in surgeries in which necrosis (premature cell death in tissues) occurs. It has very considerable potential, for which scaffolds from human tissue are thrown away because of necrosis, and in combination with a patients own cells, could make synthesized organs that won’t be rejected by the immune system.

Because tissues are groups of cells grouped together, its obvious there would be certain cells needed so that tissue engineering can be brought about, the types are:

  • Adult/fetal cells
  • Adult/fetal stem cells
  • Pluripotent stem cells

And these cell sources can be divided based on their origin:

  • Allogenic cells- from a human donor
  • Autogenic cells- the donor and recipient are the same
  • Syngenic cells- from an identical twin
  • Xenogenic cells- from an animal
Allogenic cells
– Adult cells- currently have greatest clinical use
– Using fibroblasts which come from banks (of human donors)
– Available commercially Have a high growth potential		Autogenic cells
– Involved biopsy of cartilage (examination of sample cells from a patient to determine presence/extent of disease)
– From which chondrocytes are isolated and cultured, then implanted (with a biomaterial) back into a damaged joint to form a functional cartilage
– But its controversial and has mixed results
Syngenic cells
Aren’t used commercially		Xenogenic cells
– Aren’t used commercially at all
– Hybrid embryos are allowed to be created
Table summarizing the 4 origins of cell sources

TISSUE ENGINEERING IN PRACTICE

 A science paper published on the National Institute of health mentions: “currently, tissue engineering plays a relatively small role in patient treatment. Supplement bladders, small arteries, skin grafts, cartilage, and even a small trachea have been implanted into patients, but the procedures are still experimental and very costly. “

This means, they have been successful in implanting small tissues into patients, however it comes at a price. On the other hand, more larger organ replacements like the heart and lungs, although have been successfully synthesized in the lab, have yet to be successful in replacing the organ in a patient. But steady progress has been made.  

From another point of view:

A different means in which tissue engineering can provide a useful solution in is plastic surgery:

  • another paper published by the National Institute of Health mentions:

“As a group, reconstructive surgeons are facing more challenging composite defects than ever before coupled with internet and media savvy patients with increasing expectation.”

 And goes on to say:

“Among these approaches, the most attractive concept is tissue engineering.”

 Indicating in order to overcome the increasing expectations of patient’s expectations, and the number of potential patients in the future, by using the concept of tissue engineering. They can meet these demands, and “restore both form and function” to the area in which surgery takes place.

CONCLUSION

To conclude, tissue engineering has brought about potential solutions to various issues in both the medical and cosmetic field. Ranging from lack of potential donors in both of these fields (which means they won’t have to standby and wait for donors in transplant surgeries), to overcoming the severely high demand to of potential patients in the future expecting full restorations in reconstructive surgeries. Meaning, tissue engineering could become a key in which modern medicine can be revolutionized.

Prosthetics in developing countries

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Following our lecture on prosthetics and orthotics, I became interested in the affordability of the new prosthetic technology in the UK and in developing countries. From the age of nine to sixteen I was a competitive swimmer, this lecture reminded me of a girl I swam with who had a below the knee amputation, she always struggled with her prosthetic limbs and swimming. This was mainly due to one factor; she could not afford the newest technology and the NHS would only cover certain costs. 

What is a prosthetic limb?

An artificial substitute for a missing part, such as an eye, limb, or tooth, used for functional or cosmetic reasons

medical dictionary

This prosthetic toe has been dated between 950 – 710 BC. It was composed of wood and leather

Prosthesis technology has been around since 950 BC, prosthetic limbs are used after a limb or body part can no longer be used due to incidents such as disease, trauma, or a medical condition present at birth. 

In recent years prosthetics are made from advanced plastic and carbon fibre. The leaps in our technology astounded me, but it left me thinking with increasing technology there must be an increase in price. After investigation I found that the NHS is improving significantly when it comes to accessibility and in November 2022 the new bionic arm became available through free healthcare this came as a shock as I previously had other ideas regarding the accessibility in the UK.

As I read around the subject further, I found that I was more interested in prosthetic limbs in developing countries especially after learning that the professor delivering our lectures on prosthetics is running an accessibility campaign. 

Approximately 40 million people have a need for a prosthetic leg in the developing world yet a mere 5% have prosthetic options. The newest technologies are expensive; I was astounded when I realised many people don’t have access to the most basic prosthetics! The citizens that have access may not even be able to afford the prosthetic limb available. I have come across an organisation called LIMBS they aim to develop new designs to allow people in developing countries to have access to prosthetics. They focus on rehabilitation processes amputees can go through which supports amputees mentally and physically. They call for social change to allow these countries to work through their emotional trauma whilst also providing high-quality, low-cost prosthetic limbs.

The LIMBS project is under the borgen project, which is a non-profit organisation. This provides a good source of information when researching prosthetics in developing countries and the real-life effects of their work.

Click on the picture to find out more.

What is Southampton university doing to help? 

Dr Alex Dickinson is currently leading a multidisciplinary team of health scientists and engineers to discover how we can use technology to help improve accessibility to prosthetic limbs in Cambodia. They are looking at the growing number of amputees and the countries inability to keep up with the high demand.  They have been researching into portable 3D Scanners and most importantly Dr Maggie Donavan-hall has been looking at what technologies will realistically meet their needs, culturally and socially. The key aspects I took away from reading about this research is the need to tailor prosthetics and orthotics to the country and the people, the prosthetics need to work well with what is already in place in that country. As well as this it made me think about how else portable and personalised prosthetics having would help communities. For example, it was explained that it would also help due to decreasing waiting times to see a clinician, the clinicians would be mobile meaning they can take these devices to the patients. This allows the patients to take less time off work. I think this is a big step as it means more members of the community can come forward to receive help as they won’t be scared about it affecting their jobs.

https://www.southampton.ac.uk/news/2019/01/a-step-change-in-prosthetics.page: Prosthetics in developing countries

Getting back on your feet- I Mean Literally

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As comparison to now and a few decades ago, the field of bioengineering has come a long way, especially in the field of prostheses. Throughout our engineering lectures thus far, what particularly struck me was the week in which we had covered prostheses and limbs in our lectures. This was because they have such a huge number of applications in which can be used to help people return to living a normal life (at least as best as they can).

As someone who is passionate about the field of sports medicine, what triggered me to do further research into what prostheses were like in earlier ages- like the 90s in comparison to the ones now, specifically ones specialised for athletes.

  • The picture on the left is what prosthetics had looked like during the mid-90s. Earlier prosthetics were often made of wood, leather and metal that limited movement.
  • The image in the middle displays what prosthetics look like now. It shows that advances in material and design have enabled prosthetic limbs we use now to be more functional and comfortable. Making use of lightweight yet very durable materials like carbon fibre and thermoplastics.
  • The image on the right is what a specialized prosthetic for athletes looks like now, they make use of a device with a curved blade, which provides a good balance between flexibility and strength to withstand high- impact activities like sprinting and jumping.

From these design and material advances, more endeavors have been made to aid people in somewhat returning to a normal life (as well as attempts to make less expensive alternatives for those who can’t afford certain prosthetic’s), and furthermore provide less fortunate people an opportunity to at least recover from trauma.

A research study, taken by the University of Southampton, published in the journal of Global health. Talks about how they’re helping countries like Cambodia plan future prosthetics and orthotics.

It mentions: “thanks to a grant from Global challenges Research Fund, the University’s People Powered Prosthetic group and Exceed Worldwide, a Non-governmental Organisation (NGO) which trains specialist staff and provides P&O services- like supplying prosthetic limbs, braces, wheelchairs and community support- were able to access and, for the first time, analyse routinely collected data from existing electric patient records in an aggregated and anonymous way”

This indicates that by determining patterns in the cause of injury and disease from which amputations are required. Together with cross referencing data from the data from current patients, applications of prosthetics can be made specifically for these people, which can provide opportunities to return to work and sustain both themselves and their family.

CASE STUDY- AN ATHLETES POV

From another perspective- of someone with congenital (birth) defects- more specifically an athlete would be Richard Whitehead (a Paralympic gold medalist in London 2012, and silver medalist in Tokyo 2020). He was born with a congenital condition with which had left him with a ‘double through knee amputation’ meaning he was born without the bottom half of his legs.

Even with this condition, he went on to set a world record for athletes with double amputation (which took place at the 2010 Chicago marathon). Unfortunately, he was unable to compete in the marathon at London 2012 as there was no category for leg amputees, and was refused permission by the IPC to compete against upper limb amputees.

Because of this he turned to sprinting to compete at the 2012 Paralympics. Here was where he obtained gold in the 200m T42 Athletics event, setting a world record time of 24.38 seconds. And later on in 2013 was appointed the first ever patron of Sacroma UK, a bone and soft tissue cancer charity.

CONCLUSION

From just the past few decades (as mentioned before) technological advances, aiding both design and material advances have allowed us to consistently come up with new and innovative ways to get people back on their feet both figuratively and literally. And its yet to show and slowing down in its rate of improvement.

Overall, from cases such as Richard Whitehead, who had taken his condition as something that will not stop him from reaching his dream. As well as other cases like the people from the research study who were provided with a means to recover from traumatic events like natural disasters. It’s clear to see that prosthetics have become an integral part in the lives of these people. And taking these examples, as starting points for more research, more persistent endeavours can be made from which, more ingenious solutions can be introduced and applied to treatment for potential patients in the future.

Treating the Invisible Pain: Prosthetics and Phantom Limb Pain

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I was initially intrigued by the concept of Phantom Limb Pain (PLP) because I was fascinated by how someone could experience pain in a body part they no longer possessed. The depiction of PLP in the sci-fi movies I watched when I was younger seemed to be a figment of the imagination; it appeared to be a mysterious occurrence, somewhat fantastical and an element of creative licence adding dramatic effect.

After further research, I discovered that this perplexing phenomenon is real, not make-believe! The basis of PLP although unclear, is suggested to be due to changes in an amputee’s brain organisation; more specifically, alterations in the somatosensory cortex responsible for processing sensory information such as sight and touch, thus affecting the perception of pain sensitivity.

For those who are unaware, PLP can occur within the first few days after amputation; and can persist without intervention. The symptoms vary from the perceived ability to voluntarily move the phantom limbs to intense pain and tingling sensations. PLP treatment is usually with pharmacotherapy, and prosthetic use is considered an adjuvant therapy.

So where do prosthetics come in?

A prosthesis is an artificial device that substitutes for part of the body that is absent due to amputation as a result of a disease or traumatic injury.

Weiss et al. (1999) investigated how increased use of the residual limb by a prosthetic could alleviate PLP by comparing the amount of PLP experienced by upper extremity amputees who wore either the Sauerbruch prosthesis or a cosmetic prosthesis. The Sauerbruch prosthesis allows for the performance of several activities by being connected to one of the muscles of the arm through a surgically created tunnel with cables that operate a rod inserted into the arm, allowing for the contraction and relaxation of the muscle connected to the prosthesis and therefore promotes substantial use of the residual limb. Contrastingly, a cosmetic prosthesis has little functional value and usually leads to the non-use of the affected limb in most individuals who use one. The study concluded that individuals using the Sauerbruch prosthesis have substantially less PLP due to direct motor control of and somatosensory feedback from the prosthetic hand originating in the muscle of the residual limb than those using a cosmetic prosthesis.

The original Sauerbruch arm
Cosmetic Prosthesis
Depiction of the functionality of the Sauerbruch Prosthesis

Modern myoelectric prostheses function like the Sauerbruch prosthesis, however, they utilise electrodes in the prosthesis to detect nerve and muscle activity along the residual limb musculature, which triggers motors in the prosthetic to control and produce the movement intended.

Basic Diagram of a myoelectric limb

Final Thoughts:

The understanding of PLP and prosthetics as an adjuvant treatment allowed me to consider further; whether cosmesis of prosthetics(making artificial limbs look lifelike, similar to the original missing limb) aids the alleviation of PLP, as the somatosensory cortex also processes visual information.

My learning extended to another study suggesting that the correction of body perception may modulate PLP. This hypothesis stems from the prosthetic ownership concept, whereby prosthetic use is experienced as part of the body rather than an attached device foreign to it. This added to my insight into the prosthetic treatment of PLP as the brain combines visual input and direct cortical-somatosensory electrical stimulation by the prosthetic, creating a multisensory illusion that an artificial limb actually belongs to the body, thereby reverting the somatosensory cortex to a healthy state.

Overall, PLP accounts for a significant reduction in the quality of life of amputees; thus, the development of prostheses with somatosensory feedback and a cosmesis effect is a promising therapeutic tool to reduce PLP.

Sustainability in Replacement Body parts

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Replacement body parts are a central part of the medical world with anything from an organ to a finger able to be replaced in a human body. With the world population growing and the expectation for a certain quality of life rising, demand for replacements are at an all time high but the issue coupled with this demand is the environmental impact of designing, producing and implanting replacement body parts into patients. One of the biggest issues in the world today is the battle against climate change and not only how individuals can combat this issue but how bigger corporations like the NHS can contribute to the fight, and as a knock on effect, this alters the way in which replacement body parts can be manufactured.

Waste in the NHS

Biodegradable materials in medicine

I’ve always been a keen enthusiast of lowering carbon footprint and doing my part to contribute towards sustainability in the world and I’m also very keep on advancing medicine but the true inspiration for this literature came from my work experience at Bournemouth Hospital in the orthopaedics unit. Shadowing an anaesthesiologist allowed me to encounter many different angles of a working hospital but the most interesting area was the orthopaedics unit. I watched several knee replacement surgeries and the hundreds of pieces of sterile machinery and equipment used in the replacements but also the amount of waste produced. It made me question all the waste produced on the bigger scale and the negative environmental impact the manufacturing of the tools and prosthesis used in everyday surgeries and procedures.

Impact of sustainability on replacement body parts

A visit from MatOrtho in a module workshop highlighted how the pressure for the NHS to have net zero emissions by 2045 put immense pressure on them as manufacturers of replacement body parts to find more eco-friendly ways of producing what they already produce. With there already being so many limitations and restrictions to the way prosthesis can be produced, finding sustainable ways to carry on with their work is proving challenging but what I question is, at what point can you justify the production of carbon emissions in order to improve the quality of someones life through the creation of replacement body parts?

I was surprised to find the arguments of some claiming that the state of global health is a greater issue than the quality of life of those with a debilitating injury or loss of a limb but with the rise of sustainability activists like Greta Thunberg, the whole world needs to be thinking of ways to be more sustainable, not just the bigger corporations.

What does this mean for the future of replacement body parts?

3D printed heart using organoids and stem cells

Medicine is constantly advancing and nearly everyday there are discoveries or advances in the scientific world that lead to the improvement or saving of someones life so at what point do you limit that? As of 2022, there were 7000 patients on a waiting list for an organ transplant in the UK but this number is expected to decrease as organoids have opened up a whole new pathway in the world of organ transplants.

However this research could be restricted with the increasing regulations placed upon industries in order to preserve global health. But, if you were to break it right down to the foundations of transplants and prosthesis to the patients and family, if you were given the option to change your mothers, fathers, partners life by giving them the opportunity to undergo replacement surgery but the outcome may result in damaging the planet, would you go through with it? I know I would.

An Extra Brain Just in Case?

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I was reading about how stem cells are used so much in research in recent years to grow and develop organs in the lab. In particular, the advancements being made in growing mini brains. How amazing would it be if we were one day able to develop a fully functioning brain from our own brain cells that could be transplanted into brain dead patients!

So how close have scientists got to creating a fully developed and functioning brain?

Many ongoing experiments have been able to take human tissue and develop it into cerebral organoids, better known as mini brains. But what is the science behind this? I read an article written by Tiare Dunlap from University of California, Los Angeles. The article explains that scientists take the human tissue and engineer it to become induced pluripotent cells. Induced pluripotent cells are cells that can differentiate into any cell type in the body. They can then take these cells and by changing the environment the cells are in they can make them become neural stem cells. These neural stem cells are capable of developing into most of the types of cells found within the brain. The article also explained how there is no set protocol that is used across labs resulting in huge differences between ongoing experiments. I suppose the differences obtained in the results of the experiments can be a good thing in such a new and developing area of science. However, it did make me question if discoveries could ever be backed up with more evidence if each experiment carried out is slightly different. Is it limiting the discoveries that could be made within this highly important research? (https://newsroom.ucla.edu/releases/making-mini-brain-organoids-brainier#:~:text=To%20produce%20mini%E2%80%93brain%20organoids,cell%20type%20in%20the%20body.)

I found this video which gives a good summary of the the ongoing research and some of the science behind it.

What can we do with mini brains?

This is an image of cerebral organoids that were grown in a lab. At the minute, the mini brains are being used to research neural development, creating models to research neurodevelopmental disorders and for testing drug administration and responses.

But the big question is how far can we go with these mini brains?

A large amount of ongoing research is aimed at developing mini brains that can be conscious. There has been a few experiments that have shown that it is possible for the organoids to develop properties of a conscious brain. This includes, in 2019, Muotri’s group published a paper showing the creation of human brain organoids that produced coordinated waves of activity, resembling those seen in premature babies.

At the present time, there is no evidence that cerebral oranoids can become fully conscious, but the theory behind it has sparked many ideas on how we can further develop and use cerebral organoids. The downloadable PDF written by Sara Reardon gives a great insight to some further research ideas that are starting to become a reality.

can_lab_grown_brains_become_conciousDownload

Further reading and research into my initial question; whether a fully functioning brain could be developed from our own cells, has shown that there is still a lot of research to be done if it is to become a reality. And although the reality of this happening is still far down the line it was extremely interesting to see how far science has come.

Henrietta Lacks: The Immortal Woman

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If you’ve taken any lecture within the realm of cell biology – be it about cell division, transport, signalling, and so on – you’ve most likely encountered an experiment involving the use of HeLa cells. I certainly did, and after repeatedly seeing images of those strange, purple cells on my lecture slides, it made me wonder “What exactly is so special about HeLa cells that they are used in virtually every experiment to do with human cells?” This blog post is about these cells: what exactly makes them so remarkable, their polarising legacy, and the important bioethical discussions they raise about medical consent and racism.

An image of stained HeLa cells under a microscope.

What are HeLa Cells?

HeLa cells are an immortal cell line derived from the cervical cancer cells of Henrietta Lacks, a 31-year-old black woman and mother of five. They are the oldest and most used human cell line in scientific research and have contributed to countless scientific studies since their discovery in 1951.

Lacks was a patient at Johns Hopkins Hospital, Baltimore, Maryland in 1951, being treated for a very aggressive form of cervical cancer. Several months before her death, a sample of her tumour was given to George Gey, the head of tissue culture research at Hopkins at the time. Gey had been searching for an immortal human cell line to study cancer with for two decades and he had finally struck gold: Lacks’ cells multiplied faster than any cells he had ever seen, reproducing an entire generation every 24 hours. Unfortunately, it was this rapid and unlimited division that caused Lacks’ cancer to metastasise to virtually every organ in her body within months. She passed away on October 4, 1951.

The dicey bioethics of HeLa cells

It is quite difficult to put into words just how impactful Henrietta’s cells have been on medical research. They were used to develop the polio vaccine, study leukaemia, AIDS, and cancer, and more recently, help develop COVID-19 vaccines. Since their isolation, HeLa cells have been used in more than 70,000 scientific studies around the world as of 2022. There is a darker side to this story, however.

After her passing, Henrietta Lacks was buried in an unmarked across from her family’s tobacco farm in Virginia. For the next twenty-odd years, her family had no clue her cells had been shipped worldwide and were being used pioneering medical research. It wasn’t until 1975 that the Lacks family even were made aware about the widespread use of her cells in said research.

Henrietta’s cells were taken without her consent, which was legal at the time. Since then, policy changes have been made, and ethical guidelines for medical research have been put in place like the Declaration of Helsinki, which places emphasis on the informed consent of patients. In the USA, changes are being attempted to be made to the Common Rule, the set of ethical policies for research with human subjects, to make its consent rules more far-reaching.

Racism in science and Henrietta’s legacy

In my opinion, what Lacks’ story really highlights is the racism that has historically plagued science, particularly medical research and services in the United States. Hopkins, where she was treated, was one of the few American hospitals at the time that would admit black people. None of the multiple biotechnology companies whose research benefitted from her cells have financially compensated her family. In the 1840s, James Marion Sims, known as the “father of modern gynaecology”, infamously conducted experimental gynaecological surgery on enslaved black women without anaesthesia. There was also the Tuskegee Syphilis Study, when hundreds of black men in the 1930s were denied treatment for syphilis by researchers so the progression of their symptoms could be studied. I have linked further reading on both cases and more general scientific racism at the end of this blog.

While it is important to reflect on these past injustices, what the Lacks family would like to shift the focus is to is the legacy of Henrietta herself. In 2010, the Henrietta Lacks Foundation was established by Rebecca Skloot, the author of a book about Lacks, which awards grants to her descendants and other family members of people whose bodies were used without consent in research. In 2020, on her centennial year, the Lacks family started the #HELA100 initiative to celebrate her life and legacy.

Henrietta loved to dance and cook. She dressed stylishly and wore red nail polish. And most importantly, in the words of her grandson: “[Her cells] were taken in a bad way but they are doing good for the world.”

Henrietta Lacks (HeLa): The Mother of Modern Medicine by Kadir Nelson is a portrait of Lacks which has been on view in the Smithsonian Institute’s National Portrait Gallery in Washington D.C. since 2018.

My thoughts

I wanted to write about Henrietta Lacks for my blog post because as someone who wishes to work in biomedical research in the future, I will probably end up working with these cells myself and I think it is important to highlight the legacy of these cells: both the unjust way in which they were acquired, and what we and the scientific community at large can learn from these past injustices so we do not repeat them.

As a woman of colour myself, I have rather mixed feelings on HeLa cells. It is chilling thinking about the horrific treatment people of colour, and especially women of colour have faced in historical medical research. However, HeLa cells have done so much good for the world and do so for all ethnicities. As long as we acknowledge the story of Henrietta and continue to compensate her descendants, I think HeLa cells can continued to be used in research.

Much progress has been made on bioethics and informed consent in medical research and treatment since that extraction was made from Henrietta’s tumour all the way back in 1951. However, as biotechnology continues to advance and gene editing and the like becomes more commonplace, the door has opened to once again start having these important discussions on how to ethically apply these new technologies.

References

Johns Hopkins Medicine (2023) The Importance of HeLa Cells, Johns Hopkins Medicine. The Johns Hopkins University, The Johns Hopkins Hospital, and The Johns Hopkins Health System Corporation. Available at: https://www.hopkinsmedicine.org/henriettalacks/importance-of-hela-cells.html (Accessed: March 8, 2023).

Martinez, I. (2022) What are HeLa cells? A cancer biologist explains, The Conversation. The Conversation Trust. Available at: https://theconversation.com/what-are-hela-cells-a-cancer-biologist-explains-169913 (Accessed: March 8, 2023).

Nature (2020) Henrietta Lacks: Science must right a historical wrong, Nature. Springer Nature. Available at: https://www.nature.com/articles/d41586-020-02494-z (Accessed: March 8, 2023).

Skloot, R. (2000) Henrietta’s Dance, Johns Hopkins Magazine. Johns Hopkins University. Available at: https://pages.jh.edu/jhumag/0400web/01.html (Accessed: March 8, 2023).

More Reading

Racism in science

James Marion Sims’ experiments on enslaved women

The Tuskegee Syphilis Experiment

The Immortal Life of Henrietta Lacks by Rebecca Skloot is a great non-fiction book about Lacks and HeLa cells, and goes into great detail on the ethical issues of race and class in medical research. There is also a film adaptation of the same name that can be watched on HBO and HBO Max.

The future of prosthetics – mind control

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Prosthetics have come a long way, from wooden toes in the Egyptian era, to now, where mind controlled prosthetics are enabling people to feel again. Prosthetics are artifical limbs, which replace those lost either from birth or from complications later in life, and they come in 4 different types. These are transradial (below the elbow), transhumeral (above the elbow), transtibial (below the knee) and transfemoral (above the knee). Prosthetics that begin below the joint are able to have a greater range of movement easier, but developments in research are finding ways for above the knee/ elbow prosthetics to have a better range of movement and capabilites.

A recent development in prosthetics are mind controlled prosthetics. These are more technically known as neuromusculoskeletal prosthesis. By connecting to the individuals skeleton, muscles and nerves, the prosthesis can be controlled by the individual much easier, and research has found, can enable them to feel the sensation of touch. This is a major development, impacting the individual greatly.

The neuromusculoskeletal prosthesis, and how it interacts with the arm. (Irving, 2020)

A small study, which focused on people with osseointegrated prosthetics, changed their prosthesis so that electrical connectors were embedded within their nerves and muscles, to understand its functionality as well as the impact it had on their lives. The individuals mental health and social life was followed, providing great insight into how these devices can really help someone.

This study of 3 individuals, all of which had socket fittings prior to their osseo integrated prosthesis, looked at their experinece of the attachment, control, sensory feedback, practice and use, phantom limb, self image and social relations. All of which are massivly important to the individual and all impact quality of life. It was found that the osseo integrated limb was more comfortable and easy to use, and they had better control of their prosthesis, due to embedded electrodes instead of surface ones, which would often interact with signals from their environment. It was found that the limb enabled sensory feedback but wasn’t described as natural. Although the participants did not seem to overly mind this lack of natural feeling. The prosthesis was found to increase the amount of activities the individuals could participate in, and they found an increase in self-esteem.

Overall, this development in technology has greatly improved the quality of life of the individuals within the study. In the future, the industry hopes to improve the sensory feedback of these mind controlled prosthesis, allowing for better sensation of touch. Hopefully, these prosthetics will continue to improve the quality of life for these individuals and be introduced to more people.

References

IRVING, M. 2020. Mind-controlled prosthetic arms “feel” like the real thing [Online]. New Atlas. Available: https://newatlas.com/medical/mind-controlled-prosthetic-arm/ [Accessed 09/03/2023].

MIDDLETON, A. & ORTIZ-CATALAN, M. 2020. Neuromusculoskeletal Arm Prostheses: Personal and Social Implications of Living With an Intimately Integrated Bionic Arm. Frontiers in Neurorobotics, 14.

ORTIZ-CATALAN, M., MASTINU, E., SASSU, P., ASZMANN, O. & BRÅNEMARK, R. 2020. Self-Contained Neuromusculoskeletal Arm Prostheses. New England Journal of Medicine, 382, 1732-1738.

PROSTHETICS, H. S. O. A. 2019. Prosthetics: What are They and How Do They Work? [Online]. Horton’s Orthotics and Prosthetics Available: https://www.hortonsoandp.com/prosthetics-what-are-they-and-how-do-they-work/ [Accessed 06/03/2023].

SURGICAL, P. 2017. History of Prosthetics [Online]. Premier Surgical Available: https://www.premierprosthetic.com/02/history-of-prosthetics/#:~:text=Ancient%20Greece%20and%20Rome%20through,Ages%20saw%20only%20limited%20progress. [Accessed 09/03/2023].

Reduce, Re-use, Recycle – Environmentally Friendly Prosthetics?

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Following both prosthetic workshops and after hearing about the ZeroThirty initiative hoping to see the NHS carbon neutral by 2030, I began to wonder whether the conventional plastic used in prosthetic components could be sustainably sourced or even recycled. Being someone who is passionate about developing a greener future and currently conducting a research project in sustainable land management, this led me to wonder whether environmentally friendly prosthetic limbs already exist via the creation of new prosthetics re-using wasted materials or recycling those that no longer serve their owner purpose.

By prolonging the working lifespan of such a persistent material, could this reduce the unnecessary contribution of yet another source of plastic to the growing waste accumulation and help keep the NHS on track towards its target?

Recycled Plastic Prosthetics:

Prosthetic leg structure. https://www.physio-pedia.com/File:AKparts-of-a-prosthesis-268×300.jpg

While you wouldn’t expect false limbs to make up a large portion of landfills, the materials used to make prosthetic sockets and implant components, include high density molecular weight polyethylene (UHMWPE) and other thermoplastic polyethylene. UHMWPE has a very high strength to density ratio needed to withstand large amounts of stress while being relatively lightweight compared to titanium or ceramic materials that have also been used. One key feature of UHMWPE is its longer chain structure which is able to resist heavy loads more effectively resulting in being a high impact strength. However, thermoplastics do not biodegrade and will therefore persist in the environment.

UHMWPE components used in artificial joints. http://article.sapub.org/10.5923.j.ijbe.20110101.02.htm

This only becomes an issue when prosthetics are no longer required by a person, due to outgrowing replacements, gaining upgrades or eventual death. In 2019, researchers from De Montfort University (DMU), developed a recycled prosthetic limb by pulverizing plastic bottles and spinning them into polyester yarns that were moulded upon heating. Dr Kandan stated that, “Upcycling of recycled plastics and offering affordable prosthesis are two major global issues that we need to tackle.” Not only is this solution more cost-effective, but it is also more durable. The DMU team claimed that price per socket could be reduced from £5000 to only £10.

Evolution of recycled plastic prosthetic development. From discarded plastic bottle, to polyester yarns and finally moulded prosthetic limbs. https://www.weforum.org/agenda/2019/10/plastic-bottles-waste-prosthetic-limbs/

In 2015, the World Health Organisation estimated there were 40 million amputees in the developing world with only 5% having access to prosthetic care. Due to the staggering cost reduction, the largest beneficiaries of the recycled prosthetic limb are presumed to be amputees in developing counties, bringing a more financially accessible option to areas with limited resources and narrowing the inequality treatment gap. Although, there is little long-term evidence that this creation performs the same quality of function as modern prosthetics, so it is difficult to assess long-term benefits (or possible disadvantages) of using a prosthetic limb that is so different from all that came before it. Another issue is the weakened chemical structure of the plastics and questionable longevity once in use again. Are these unknown risks going to do more damage? Only time will tell …

Re-using prosthetics:

After further research into solutions to tackle the barriers of cost, supply and demand of prosthetics for amputees in developing countries, I discovered the Legs4Africa charity which does exactly that. Relying on public donations, recycled prosthetic legs are shipped worldwide to Africa. Since 2014, over 12,000 prosthetic legs have been collected, allowing amputees to return to work and regain a higher quality of life.

Pie chart showing the proportion of prosthetic leg donations from each country involved in Legs4Africa. UK has the highest number of donations of all participating countries. https://www.legs4africa.org/recycling/

The short video below demonstrates the incredible work Legs4Africa has achieved making a huge difference to the lives of so many.

Final thoughts:

Though both aspects explored in this blog are small contributions, they are headed in the right direction. Extending the life of prosthetics to fulfil pressures of demand and repurpose existing materials to limit consumption and waste generation could become revolutionary. There is a long way to go, and I believe that with a scrupulous trial of performance, recycled prosthetics could really take off. This topic is so important and I find it fascinating that large prosthetic manufacturers have not yet made the link between sustainable regeneration of plastics in prosthetics. What does this suggest about its reality?