Several people I talked to lamented that the discipline has no established protocol for following patients like Josh Maloney and Jessica Arrigo who have had their transplanted hands removed. There are now six people in the US who no longer have their hand transplants but who took immunosuppressive drugs for various periods. But because the DOD grants that funded much of this work didn’t require following patients after a graft was removed, their care and monitoring fell to the discretion of the institutions and research teams.

Francis Perry Wilson, the Yale nephrologist, says VCA teams should follow their patients for the full length of the trial to provide proper care and to track the experiments’ long-term effects. “The patients who are going to do worse in general are going to be more likely to have the graft removed,” he says. “So all the more reason to keep track of them.” Or, as Levin puts it, “If somebody says, ‘Three months after my hands were amputated, I got liver cancer and died,’ we’d want to know that.” Which is why Levin plans to follow any of his patients who lose their grafts.

The Hopkins team’s research protocol does not include a way to do this. The team says they always intended to follow up with patients who had their grafts removed. Shores says he tried to reach both Jessica and Maloney to do a follow-up study around 2016. He couldn’t get ahold of Maloney; he says he talked to Jessica on the phone but couldn’t get her to come in for a follow-up. As a result, the trial has very little data on either of those subjects’ health after the grafts were removed.

In some senses, the field is still struggling with two linked problems that have dogged it at least since that operation in Lyon in 1998: the cost-­benefit ratio of VCA transplants and the failure to develop gentler anti-rejection treatments that have been proven to resolve the issue by reducing the risks.

Back in 1999, Andrew Lee and a colleague, writing of this quandary in the wake of the Lyon surgery, concluded that the “deficiency of experimental evidence” then available, along with the known dangers of immuno­suppression, “renders precarious the risk-benefit balance of hand transplantation at present.” Still, they believed the VCA field represented “the next frontier” in reconstructive surgery. By 2010, having done three transplants and witnessed 37 worldwide, Lee and others in his team wrote that while much work remained to reduce immuno­suppression’s costs, they had faith that the experimental protocols being tested—including their own Pittsburgh protocol—“will surely undergo further evolution during the next decade.”

Yet the burden borne by today’s hand transplant patients seems to be essentially no lighter than that assumed in 1999. Levin believes that the operation’s proven capacity to “give people back their dignity” makes hand transplants justified even now. Of Levin’s three patients, all have functioning hands, although one has begun having renal issues and may need a kidney transplant in the future. “We have enough data that, in my heart of hearts, I can say that we can continue in this field ethically and forcefully … There will be people who have horrible complications, but that’s called medicine.”

Others are less sanguine. Herrington believes the field may need to hit the pause button to gather and weigh more carefully the progress so far. Some surgeons have chosen to wait. Vishal Thanik, a member of the hand transplant team at NYU Langone whose lab is among many trying to develop gentler ways to calm the immune system, does not plan to do any transplants until he has “something really new to bring in terms of immunosuppression.”