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Abstract
Artificial organs are used in medical practice to replace an organ or a failing function, and many prostheses have been developed for this purpose. Based on technical developments, the prostheses are increasingly efficient and not only can recover a lost function but sometimes do better than the organ or joint replaced which raises the question of enhancement. One of ethical questions is the boundary between the two. How far should the failing function be replaced? Increasing the individual’s abilities, is it acceptable?
Biotechnology and miniaturization of devices has enabled the development of genuine artificial organs such as the artificial heart which aims to replace the natural organ that is definitively and irreversibly altered. In such circumstances, the replacement of vital organs raises the issue of the duration and quality of survival. Since these situations are still experimental, ethical questioning concerns the conditions of the experiment, the choice of subjects, and the information given to them. The subject will have the choice between the artificial heart and ventricular assist devices that are used for several years. Ethical reflection on artificial prolongation of life and the decisions to switch off the assistance device will be presented.
Finally artificial organs pave the way to new technologies and to choices of research that might generate excessive belief by the public in machine reliability and provide excessive hopes.
Introduction
Since ancient times, the replacement of a limb or defective organ has been an ongoing concern for physicians. The constant improvement of techniques and substitutes led to the first successful prostheses and grafts. However, the use of organic products from the human body for transplantation has limits of tolerance and survival, which explains why mechanical artificial organs or the use of biomaterials become a promising alternative.
The main challenges of the development of artificial organs are first technological, with the development of reliable medical devices, then tests on living organisms, and then implementation in humans. The second phase is the development and commercialization of technological innovations. Finally, regarding distributive justice, the availability for the greatest number is a crucial issue. However, as soon as an artificial organ is available with proven technical quality and durability, the implementation is carried out on humans according to precise criteria. Any subject who does not fulfill the criteria will be ineligible and might feel discriminated. Accessibility for all is not technically or medically possible.
In this entry, the author presents in the first part the ethical issues encountered in medical practice. The question of finality is the justification for the use of artificial organs; the therapeutic purpose is to restore a function, but there are limits because generally the subject does not completely recover his previous function. When the purpose is to replace or to assist a vital organ, the major ethical question is about the length of survival and the quality of life and moreover how to stop the device. Will life be artificially prolonged beyond natural norms? What will be the end of life? Artificial organs, however, may have other purposes, such as improving the sensory performances or to regenerate tissues through cell culture in which part of the organ is artificially created, so regenerative medicine could even go beyond the performance of natural organs (enhancement). After these general ethical concerns, the subject’s consent and decision-making processes in order to receive an artificial organ will be addressed. Several surveys illustrate the difficulties encountered by professionals whose choices reflect in particular the influence of culture, whether that of the professionals or patients.
The second part will deal with issues related to research. Research on artificial organs opens a wide field according to the technical possibilities. Should any research program be initiated when the techniques are potentially achievable? As with drugs, the significant potential market in some areas of innovation justifies substantial funding and deposition of patents. Due to advances in electronics, an important part of biomedical research on these artificial organs has recently developed.
Finally, in the third part, the public hopes that these new technologies will quickly restore the body and even extend life or increase capacities will be examined. There is an excessive belief in the possibilities of science and ignorance of the limits. The early extension of certain technological success gives a misleading picture, and the distinction is not always possible in the mind between the possible future and reality. The influence of science fiction remains very present!
History
There are many artificial organs with a long history. Prostheses were intended to repair the bodies of the war wounded (e.g., wooden legs or hooks for hands) that allowed them to compensate for deficits in mobility. At the beginning, the first hip prostheses were implanted in subjects aged over 65 for the treatment of femoral neck fractures because there was not enough information on the tolerance of, and the life of, the prosthesis. Since then, artificial joints are now used routinely in orthopedics. The technical and performance skills have improved steadily and allow their use on younger and younger patients. Besides the prosthesis, the best-known artificial organ is the artificial kidney, an external device for renal dialysis, developed in the 1950s. The volume of the device has now been reduced, allowing dialysis at home. Mechanical heart valves have been placed in subjects aged over 70 since the 1960s; organic valves were then crafted from pig, ox, or horse valves. The pacemakers, implantable devices designed to compensate abnormal heart rhythm disorders, has been used since 1958. Now, these devices are perfectly well known by the public and easily accepted because they are reliable and provide better quality of life with limited constraints. Finally, for cardiac support, the first artificial heart was implanted in 1969 and requires an external compressor. Since then, transitional cardiac assistance devices are regularly used to wait for heart transplantation. The first recipient of the cochlear implant has worn it since 1982. With an experience of over 30 years, implantation is now a validated technology and accessible for adults and children. Each device category has continued to develop and to gain new technologies that make them more reliable and efficient.
Definitions
“Artificial organs” are elements or parts of the body that perform a necessary function in the activity of the body or in the maintenance of life. They can be external or internal medical devices that will allow a stabilization of a function or the return to the previous condition. Included in this scope are, for example, joint prostheses, assistance machines, pacemakers, insulin pumps, and cochlear implants.
Some artificial organs operate outside the body to replace a function during surgery, such as a cardiopulmonary bypass machine; others have a temporary application for a shorter or longer period, usually when waiting for a transplant, as is the case of the dialyzer (artificial kidney) or the left ventricular assist device (LVAD) that helps the heart to maximize the volume of blood it pumps around the body. Various devices are implanted in the body to compensate for a functional failure, e.g., prosthetic joints, pacemakers, or insulin pumps. Finally there are devices aimed at improving sensory perceptions such as cochlear implants or retinal prostheses or at increasing motor performance such as exoskeletons or specific artificial joints for athletes.
This entry does not intend to provide an exhaustive overview of all devices or artificial organs; examples that raise ethical questions are chosen.
Ethical Dimension
Purposes Of The Use Of Artificial Organs In Medical Practice
The main goal is a therapeutic one, with the aim to provide benefit to a sufficient number of subjects for an affordable cost. The benefit is provided by replacement of a lost function, improvement of functionality, or extension of life.
The Substitution Of An Injured Or Lost Limb Or Organ
In the framework of restorative surgery, joint replacements are put in place in case of traumatic or degenerative damage to render a functionality of movements and autonomy.
With electronic components, the “bionic” prosthesis becomes an organ, such as an artificial arm. Approved by the FDA for marketing authorization, the DEKA Arm System allows for complex movements with the new hand. The prosthesis is capable of multiple, simultaneous movements created through the electrical activity produced by muscle contractions located near to the attachment of the artificial arm. These electrodes transmit electrical signals to an electronic chip that translates them into specific movements.
Having in mind the principle of beneficence, which benefit is expected from the introduction of prostheses regarding the constraints of the adaptation and rehabilitation that might be difficult? What are the limits for new bionic prostheses? How will the replacement of an organ improve life? Which quality of life and for how long?
Exoskeletons: On June 26, 2014, the FDA approved a device enabling paraplegics to walk. This device could be used by 200,000 people in the USA. It consists of a combination covering the legs and the upper part of the body, a backpack, and crutches. This ReWalk exoskeleton has engines at the hips, knees, and ankles that perform the movements. Inclination and orientation sensors monitor the body’s center of gravity. The information is processed and sent to the backpack. The subject controls its movements with a button at the wrist to sit, stand, and walk. After rehabilitation the subject would not need his wheelchair any more.
The Improvement Of Sensory Performance
Cochlear implants: The hearing implant is designed to give a better hearing performance in case of severe or profound deficiency of hearing. The technology is different from mobile acoustic prosthetics, since it requires implantation in the inner ear. Any risks of failure of cochlear implants arise from infections related to implantation or an inability to adapt to the device. It should be noted that the implant is not an artificial ear and does not render perfect hearing. Processor microphones pick up the sound and convert them into digital information that is sent to an implant located under the skin. The implant sends electrical signals along the electrode in the cochlea. The fibers of the auditory nerve pick up the signals and send them to the brain to create the sensation of sound.
In the beginning of the use of implants (in the 1990s), ethical questions arose regarding the use of such implants in children. The problems are much more complex in young profoundly deaf children (congenital deafness and deafness occurring before language acquisition) rather than becoming deaf after learning to talk (post-lingual deaf) that are of an age capable alone to make the decision to be implanted. In fact, of parents of deaf children who are hearing, 90 % of them were invited to consent to the implantation of their child. By this time, uncertainty persisted about the capacity of implanted children to acquire – after years of rehabilitation – satisfactory oral communication. This is why learning sign language was recommended before implantation to allow children to start communicating with those around them from the age of one year to ensure their cognitive and psycho-emotional development. The deaf community had taken a position because deafness is seen as an identity. Deaf people saw, in the use of implants for congenitally deaf children, a new threat to the “deaf identity” when implantation prevented them from learning sign language.
This example is interesting because it highlights the importance of the concept of uncertainty when a new device is placed on the market. Today, with 25 years of use, the implants are well known, accessible, and responsive.
Retinal prostheses: A retinal prosthesis, or bionic eye, is an implant grafted on the patient’s retina whose electrodes receive signals from a camera placed on glasses. The images are processed by a box carried by the patient and sent to the implant by a wireless connection. Transmitted by the optic nerve, the information creates the perception of luminous forms that the patient must then learn to reinterpret.
This prosthesis does not restore vision but helps patients to distinguish the shapes of people in a room and the objects, and it improves their daily lives. They can follow white lines on the floor, avoid falling over objects, and read some large letters (9 in.) (University of Michigan Kellogg Eye Center, January 29, 2014). Therefore, the number of patients who can benefit is very limited; they must have retinitis pigmentosa, a hereditary disease characterized by the degeneration of retinal cells and progression to blindness. The device got the agreement of the FDA in 2013.
The Extension Of Life
The final replacement of a vital organ by a graft or an artificial body raises the question of the extension of life. If a candidate accepts a heart transplant or an artificial heart, he wants to avoid death and wants to extend the duration of his/her life. But for how long? The duration of survival of a transplanted heart has a physiological limit depending on the organ, but will the artificial heart be programmed for a certain period or without limit? When will artificial organs be stopped?
Some consider the extension of life, even with a small improvement in the short term, as a benefit. Doctors have a duty to do everything to maintain life and consider ventricular assist implementation conforms to the standards of resuscitation of cardiac failure, unless the patient himself can express its opposition.
The patients have the right to refuse any intervention they do not want. Some consider that God decides when life ends and they refuse all artificial support to prolong life by resuscitation or transplantation.
If the subject is not able to speak for himself, one must rely on the accounts of others (family members, relatives) to assess whether his fundamental values would support consent or refusal. If advanced directives have been expressed, they will be very useful.
The Assistance Of A LVAD For Heart Failure
End-stage heart failure (ESHF) is a major public health problem with at least 10 million patients in Europe and more than 5 million in the USA. The standard treatment for ESHF, heart transplantation, is only available for a minority of patients either due to organ shortage or patient contraindication. For patients awaiting transplantation, mechanical support such as left ventricular assist devices (LVADs) or an artificial heart is an option as a bridge to transplantation and has significantly reduced mortality (Neragi-Miandoabb 2014). Unfortunately, mechanical support systems also have disadvantages, such as increased risks for infection, thromboembolic complications, and bleeding.
So the choice available for the subject is firstly transplantation, which may take several years, secondly implantation of a LAVD, or finally palliative care. In choosing transplantation, the relevant issues are the success of the transplant and the quality of life afterward. Since 1967, more than 110,000 transplantations have been performed worldwide. However, some serious complications are associated with transplantation, such as acute or chronic rejection, cardiac allograft vasculopathy, infection, and malignity.
When transplantation is rejected by the patient for personal reasons, sometimes religious, or when the patient does not fulfill heart transplantation criteria, only two choices are left: ventricular assistance or end-of-life palliative care.
Ethical Dilemmas In Decision Making: Example Of The LVAD
Implantation
The subject with full capacity makes the decision of implantation of a LVAD under the same conditions as any other medical act. The information given must clearly state that the support device has no therapeutic action and that there is no alternative treatment for heart failure. It is a means of survival for a subject in need of transplant. The subject who does not agree with resuscitation should certainly refuse the device. When the patient agrees, he or she may also request that the conditions of turning off the LVAD are clearly defined in advance so that their views are known by the medical team.
If the subject does not have the capacity to make the decision or to give a valid consent, then the decision will be made by third parties. Usually consensus is sought with the family members or the relatives who might know the wishes, the lifestyle, and behavior of the subject. The medical team takes part in the decision in the best interest of the subject, and professional guidelines should also be followed in any decision.
However, disagreements may occur among family members, and in some complicated family situations, the positions are not as clear-cut. The same issue may occur among the professionals in charge of the patient. If so, the medical team can ask for a specialist opinion (an ethics committee, a psychiatrist, a palliative care specialist) to help in decision making.
Switching Off
How long should one keep the artificial organ? An LVAD offers a particular respite period while awaiting transplantation. Approximately 30 % of patients die after two years of implantation, but an LVAD can function beyond this. What is an acceptable survival time or, in other words, the maximum possible until transplantation? The FDA has given approval for humanitarian relief for the LVAD because it addresses a limited number of patients.
Who decides to turn off: the patient, the family, the doctor? Patients at the end of life or their representatives may perceive that supplementation in the treatment generates more harm than benefit and they request to stop the device, even if they know that death will soon follow. Switching off the device is ethically and legally possible in many countries.
The conscience clause allows the professionals to make personal choices, as some do not agree with turning off. The attitudes are quite different between countries and alternatives may be used. Do they personally turn off the LVAD? Do they consider the LVAD as life sustainment or as something else (substitute of organ)? Any “do not resuscitate order” should be respected?
A study has been conducted on the attitudes of clinicians about the cessation of ventricular assistance devices on end-of-life patients. In 2011, 7168 questionnaires were sent to members of the European Society of Cardiology, the Heart Failure Association of the ESC (HFA-ESC), the International Society for Heart and Lung Transplantation (ISHLT), and the Heart Failure Society of America (HFSA). The authors obtained 303 responses on the opinions of clinicians (Swetz et al. 2013).
Among professional answers, 46 % had personally turned off LVAD in two or more patients approaching death and 92 % regarded LVAD as life-sustaining treatment.
There is a difference between the behavior of Europeans and non-Europeans. There is a greater acceptance of switching off of the device in end-of-life patients for non-Europeans (non-EU) who are also faced with this situation more frequently: 58 against 21 % of Europeans (EU). Eighty-two percent of non-EU had switched off an LVAD versus 50 % of the EU. Moreover, giving the order to stop the device is easier, 40 % of non-EU feel comfortable or very comfortable with ordering to stop versus 12 % of the EU.
Regarding the conditions and consequences of the switching off, the physician should be present for 87 % EU versus 64 % non-EU. The physician is the person who should actually switch the device off: EU 83 % versus 56 %. Death after switch off is considered as euthanasia or assisted suicide in 27 % of Europeans versus 4 % non-EU. When the patient is not approaching death, the request to switch off should never be honored by 61 % of EU versus 30 % non-EU. A high risk of litigation for wrongful death is perceived by 63 % of EU versus 21 % non-EU.
Ethical Aspects Of Research And Experiment Dealing With Artificial Organs
Research, Strategic Choices, And Funding
The realization of complex artificial organs is a technological and financial challenge. For processes in development, the cost of the device or artificial organ raises the question of accessibility for all (distributive justice). Initially, the device produced in small quantities is very expensive because of the expenses related to research. Its price may be reduced if it is possible to produce an adequate quantity; that is to say, the target population is large enough and able to support a high price, such as for bionic arm and artificial heart, for instance.
The population that can potentially benefit from bionic prosthesis match the 50 000 yearly amputations in the US (2/3 vascular origin and 1/3 traumatic). The DEKA program for amputees started in 2006 and received $40 million from the government to support research. A clinical trial conducted by scientists of the Pentagon on 36 veterans shown that 90 % of the participants were able to perform complex tasks with the bionic arm. After eight years of development and testing, the device has been approved by the FDA. Next challenge will be transforming that technology into a commercially viable product (Guizzo 2014).
The artificial heart is designed for subjects in a state of terminal heart failure. The market is important, it would be in the USA and Europe 100,000 patients with terminal heart failure for which there are only 4000 potential heart grafts. For the bioprosthetic autonomous artificial heart (Carmat www.carmatsa.com), research began in 1978, with a first patent deposit in 1980. A public private financing group was established in 1993. Then the Carmat company was listed on the stock exchange in 2010. The CE label for the bioprosthesis is expected for 2016, and it will allow the use of the device outside the experimental context. In order to receive this label, an experiment with 20–25 patients will be conducted on subjects with less-severe heart failure profiles.
Testing On Humans
Ethics and research in phase 1 – the first human trial: In phase 1 trials, the risk/benefit ratio leans very clearly toward the side of risk, which seems contradictory to the Declaration of Helsinki. The patients selected for the tests are beyond any potential treatment, but most are willing to participate, very hopeful to get some benefit. The doctor is facing a conflicting situation: while the interests of the patient would command him to provide the best available treatment in the present state of knowledge, the patient is offered an experimental treatment that benefits more to public health than his own. The well-being of the individual and his interests must prevail over the interests of science. Article 8 of the Helsinki declaration says: “If the primary purpose of medical research is to generate new knowledge, this goal should not prevail over the rights of the interests of those involved in the research.”
Feasibility of experimentation with an artificial heart: When replacing a vital organ like the heart by an artificial organ for the first time, the proposed experiment raises the question of the irreversibility: since implantation begins with removal of the heart, the subject is virtually dead. In the heart transplantation, the patient’s heart ablation is followed by the transplantation of another heart, with significant chances of success and a comfortable survival. This is not, for the moment, the case for the artificial heart because the safety is unknown. Thus the chosen subject should be off therapeutic alternatives such as cardiac assistance and will have a very short life expectancy.
Is it acceptable for a subject to participate in such experiment? He still has a few days to live and is asked to undergo a major surgery and resuscitation constraints when all hope for transplantation is excluded and there is no alternative treatment. His last moments will be for the welfare of other patients. There is no possible treatment, and participation in the experiment is intended to advance the science. The patient will also be deprived of palliative care that could improve the quality of end of life.
In research, the quality of life of the patient must always be taken into account and in no case should be compromised by the lack of supportive care due to him. A palliative approach suitable for the patient’s condition remains a priority. However, the implantation of an artificial heart leads to significant constraints linked to the surgical procedure and deprives the subject of comfort care.
The artificial heart is different from the LVAD, since the latter is implemented on a patient waiting for a transplant. Even if the subject is not eligible for transplantation, he/she can benefit the LVAD device. With this assistance device, the heart of the subject is not removed. In contrast, the bioprosthetic heart is an autonomous artificial heart placed after removal of the heart, and whether fails, the subject has no means of survival.
A feasibility clinical trial has been authorized by the ANSM (National Agency for Medicinal Products Security) to over four patients in France. On 18 December 2013, a first artificial heart was implanted in a 75-year-old man who survived 73 days. This death led to the suspension of the inclusions during the technical analysis of the device and evaluation of the patient’s biological data. The agency has authorized renewed inclusions in July 2014. A new implantation was conducted August 5, 2014; the patient is still alive at the time of writing of this entry, with above four months survival. He regained his independence and some activity.
Respect Of Dignity And Confidentiality
Media are very eager to announce technological successes and some professionals might also be. Is it acceptable to expose the private life of a person experiencing a new technique? In France, the CCNE (National Consultative Ethics Committee) has ruled on this issue (CCNE 2004), in the case of face transplant stating that the dissemination of information by professionals was to be made from a certain distance. However, nothing prevents the subject himself/herself or relatives to reveal the innovative technique that has been tried on him/her. An Australian patient with a graft on both hands was first proud to be exposed in the media, and then finally asked for removal of both transplanted hands.
Privacy is not protected in the same way across countries, and the links with the media are different. Some subjects involved in experimentations wish their identity not to be revealed by the press. The name of the first artificial heart recipient in France is known, but the second patient refused his identity to be revealed and wanted absolute secrecy.
Perception And Representation Of Artificial Organs By The Public
Appropriating Organ
The prosthesis replaces a part of the body which has been mutilated, destroyed. Repair and reconstruction integrate prostheses in the body. They become part of the individual who appropriates and even can forget it. Emma Palese says, “the advanced scientific progress combined with the artificial reality, the human and the natural one, as the technology is embodied in each of us and thus becomes an extension of the body. The body incorporates and adopts a continuous and constant metamorphosis and man becomes a union between artificial and biological creation” (Palese 2012).
The external device remains always a visible accessory; there is no integration as for the implanted prostheses. However, a person for whom a specific prosthesis was manufactured assimilates the prosthesis as a part of their body and does not hide it. The injured prosthesis wearers proudly display their prosthesis. This is the case of Hugh Herr, mountaineer who lost his legs and became head of a group dedicated to prosthetics. Haslet Adrianne Davis, injured in the attack in Boston, could dance in public with an artificial leg, specially designed for her; the film of this achievement is circulating on the Internet.
Similarly, the amputated model Aimee Mullins uses for her professional photos artificial legs decorated in different colors. She gives conferences to facilitate raising funds for research on prosthesis. All three of them are famous, which makes them valuable examples for other amputees. Paralympic games also participate in this valorization.
The Representation Of The Artificial Organ: Hopes And Dreams
The public nurtures major hopes in artificial material and believes that everything might be possible. There are implants for many bodily functions: active implants with electronic operation for sensory nerve stimulation (the infusion pumps, pacemakers, ventricular assist devices), implants for the hollow organs that replace diseased tissues (trachea, esophagus, vascular grafts, coronary stents), and finally series of passive prostheses (dental, mammal, and joints).
The public believes in the promise of a better future. It prefers artificial over natural repair with overconfidence, while immunological reactions require long-term treatment. The duration of substituting devices is limited in time and can lead to chronic diseases. For example, the implantation of artificial joint ligaments in young subjects could lead to osteoarthritis after the age of 50.
The restoration of the human body can go beyond the simple replacement for therapeutic reasons and be conducted at the request of the subject according to his desires for cosmetic purposes or to limit its aging. Skin generated and developed for the treatment of burn victims could be used for younger appearance. Testing materials and devices in patients may be viewed as potential abuses where augmentation and repair are carried out for cosmetic as opposed to clinical reasons (Nicholson 2013).
Extended Capacities With Artificial Organs: Enhancement
Enhancement, “going beyond therapy,” enables a person to exceed the normal or healthy state. This is already possible with certain prosthesis, since athletes can sometimes achieve superior performance with prostheses than athletes without any. Can supplementation be infinite? Research is conducted with this goal, especially with braincomputer interfaces (BCIs). One can imagine that there is no limit to the pursuit of happiness, as soon as it becomes technically possible (Frankel and Kapustij 2008).
The Future
Research programs in tissue engineering use cell cultures and try to regenerate part of an organ. Multifunctional stem cells can be replicated in labs and differentiated through a matrix to create the myocardial tissue. However, the volume needed and the quality of reprogrammed stem cells remain the main constraints in obtaining cells able to regenerate organ function.
It is possible to imagine that full organs might be created from cell cultures. Therefore, a bioartificial pancreas will contain cells originating from genetic engineering or stem cells.
While the research is progressing, three options are possible: what is technically possible, what is only feasible in laboratories, and what will be available for treating patients. The possible is already achieved, but biotechnology skills still need to be federated for the feasible. It is estimated that another 5–10 years will be necessary before such new products are available for patient use. Moreover, in some countries, there is still a debate regarding the origin of stem cells, especially when they come from embryos. 3D printing technologies hold great promise not only for the manufacture of prosthetic elements (the fingers of bionic arms) or artificial elements to replace destroyed bone structures but also to deposit cells on a support which will create replacement tissues such as the liver.
Intelligent agents, systems that perceive and act with environment, might be associated to artificial organs. Artificial intelligence has the potential to bring benefits to humanity as far as AI remains robust and beneficial and aligned with human interests (Russell et al. 2015).
Conclusion
Artificial organs have a long history and have provided well-being. Recent advances in information technologies, new materials, and biotechnology now allow producing artificial organs with much more efficiency, but at a particularly high cost, raising the question of access for all. The poorest are usually excluded. Developments in information technologies might reduce the costs, possibly that will make them soon available to a larger number.
But equal access is still a concern, because even if the products become available and less expensive, other factors will come into play and some populations will still be excluded. For instance, in England, there were inequalities demonstrated in accessing hip joint replacement due to age, geography, and deprivation (Milner et al. 2004). In the USA, however, under some circumstances and on compassionate grounds, cardiac support devices are supported by Medicare. In the same spirit, humanitarian organizations such as Handicap International militate and raise funds to provide prostheses for war victims in developing countries.
However, some patients refuse completely the use of artificial devices, considering that only nature should decide of the fate of their bodies, while others do not want to oppose God’s purposes.
Instead of developing artificial organs to restore human beings, preventive actions may avoid the use of such devices: better detection and treatment of kidney-destroying chronic diseases or reduction of risks factors that would lead to heart failures or organization of campaigns against traumas and crashes to prevent disability.
Finally for more social justice, fighting against poverty remains the best way to raise the level of health of disadvantaged populations and enable them to access quality care and artificial organs.
Bibliography :
- CCNE Opinion 82, 6 February 2004 Composite tissue all transplantation (Full or partial facial transplant) available in English www.ccne-ethique.fr visited on 10 Oct 2015.
- Frankel, M. S., & Kapustij, C. J. (2008). Enhancing humans. In M. Crowley (Ed.), From birth to death and bench to clinic: The hastings center bioethics briefing book for journalists, policymakers, and campaigns (pp. 55–58). Garrison: The Hastings Center.
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- Palese, E. (2012). Robots and cyborgs: To be or to have a body? Poiesis & Praxis, 8(4), 191–196.
- Russell Stuart contributor What do you think about machines that think? Today’s learning thinkers on the Age of Machine Jonh Brockman Ed 2015 Edge Foundation http://edge.org/response-detail/26157 consulted on 2 December 2015 University of Michigan Kellogg Eye Center January 29, 2014: http://www.kellogg. umich.edu/news/14/first-retinal-prosthesis-implant.html visited on 10 October 2015.
- Swetz, K. M., Cook, K. E., Ottenberg, A. L., Chang, N., & Mueller, P. S. (2013). Clinician’s attitudes regarding withdrawal of left ventricular assist devices in patients approaching the end of life. European Journal of Heart Failure, 15(11), 1262–1266.
- Miller, G. E. (2006). Artificial organs (Synthesis lectures on biomedical engineering, Vol. 1, No. 1, pp. 1–72). Morgan Claypool publishers. http://www.morganclaypool.com/ doi/abs/10.2200/S00023ED1V01Y200604BME004
- Warwick, K. (2003). Cyborg morals, cyborg values, cyborg ethics. Ethics and Information Technology, 5, 131–137.
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