Current Transplantation Reports

, Volume 5, Issue 4, pp 334–338 | Cite as

Ethics and the Future of Vascularized Composite Allotransplantation

  • James BenedictEmail author
  • Gerard Magill
Vascularized Composite Allografts (V Gorantla and R Barth, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Vascularized Composite Allografts


Purpose of Review

This paper seeks to identify and examine a number of ethical issues that persist 20 years after the field of vascularized composite allotransplantation was established. Reflection upon these issues will be essential if the field is to fulfill its promise.

Recent Findings

A number of scholars, including the authors, have been involved in efforts to identify ethical issues in VCA. Meetings held in the US and in Europe have focused on ethical concerns related to procurement, risk-benefit, consent, and program standards, among others.


Improving the burden and risk vs. benefit ratio, strengthening the consent process, employing a patient advocate, bringing greater clarity to donation policy, and improving data sharing are identified as major ethical concerns in vascularized composite allotransplantation.


Vascularized composite allotransplantation Bioethics Consent Organ donation 


Compliance with Ethical Standards

Conflict of Interest

James Benedict and Gerard Magill declare no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Dubernard JM, Owen E, Herzberg G, Lanzetta M, Martin X, Kapila H, et al. Human hand allograft: report on first 6 months. Lancet. 1999;353(9161):1315–20.CrossRefGoogle Scholar
  2. 2.
    Petruzzo P, Dubernard J. World experience after more than a decade of clinical hand transplantation: update on the French program. Hand Clin. 2011;27(4):411–6.CrossRefGoogle Scholar
  3. 3.
    Bramstedt KA. A lifesaving view of vascularized composite Allotransplantation: patient experience of social death before and after face, hand, and larynx transplant. J Patient Exp. 2018;5(2):92–100 Bramstedt has advanced an argument that VCA may be regarded as “lifesaving” because the conditions treated may be seen as a form of “social death”.CrossRefGoogle Scholar
  4. 4.
    Androutsos G, Diamantis A, Vladimiros L. The first leg transplant for the treatment of a cancer by Saints Cosmas and Damian. J BUON. 2008;13920:97–304.Google Scholar
  5. 5.
    Hall R. Whole upper extremity transplant for human beings. Ann Surg. 1944;120(1):12–23.CrossRefGoogle Scholar
  6. 6.
    Fernandez JJG, Febres-Cordero RG, Simpson RL. The untold story of the first hand transplant: dedicated to the memory of one of the great minds of the Ecuadorian medical community and the world. J Reconstr Microsurg. 2018.
  7. 7.
    Diaz-Siso JR, Bueno EM, Sisk GC, Marty FM, Pomahac B, Tullius SG. Clin Transpl. 2013;27(3):330–7.CrossRefGoogle Scholar
  8. 8.
    Foroohar A, Elliott RM, Kim TWB, Breidenbach W, Shaked A, Levin LS. The history and evolution of hand transplantation. Hand Clin. 2011;27(4):405–9.CrossRefGoogle Scholar
  9. 9.
    Kaufmann C, Bredienbach W. World experience after more than a decade of clinical hand transplantation: update from the Louisville hand transplant program. Hand Clin. 2011;27(4):417–21.CrossRefGoogle Scholar
  10. 10.
    Zuo K, Olson J. The evolution of functional hand replacement: from iron prostheses to hand transplantation. Plast Surg. 2014;22(1):44–51.CrossRefGoogle Scholar
  11. 11.
    • Shores JT, Malek V, Lee WPA, Brandacher G. Outcomes after hand and upper extremity transplantation. J Mater Sci Mater Med. 2017;28(5):72 This report of outcomes, as well as continuing and emerging challenges, provides an excellent introduction to the primary clinical and ethical concerns in the field of upper extremity transplantation. See also Molitor, note 16, for a similar account of the state of the field for VCA more generally. CrossRefGoogle Scholar
  12. 12.
    Petruzzo P, Kanitakis J, Testelin S, Pialat J, Buron F, Badet L, et al. Clinicopathological findings of chronic rejection in a face grafted patient. Transplantation. 2015;99(12):2644–50.CrossRefGoogle Scholar
  13. 13.
    Siemionow M. The decade of face transplant outcomes. J Mater Sci Mater Med. 2017;28(5):64. Scholar
  14. 14.
    Testa G, McKenna G, Gunby R, Anthony T, Koon E, Warren A, et al. First live birth after uterus transplantation in the United States. Am J Transplant. 2018;18(5):1270–4.CrossRefGoogle Scholar
  15. 15.
    Benedict J. A revised consent model for the transplantation of face and upper limbs. Cham: Springer Nature; 2017.CrossRefGoogle Scholar
  16. 16.
    Molitor M. Transplantation of vascularized composite allografts review of current knowledge. Acta Chir Plast. 2018;58(1):19.Google Scholar
  17. 17.
    Krezdorn N, Tasigiorgos S, Wo L, Lopdrup R, Turk M, Kiwanuka H, et al. Kidney dysfunction after vascularized composite allotransplantation. Transplantation. 2018;4(7):e362. Scholar
  18. 18.
    Rinkinen J, Molway D, Carty M, Dyer GSM, Pomahac B, Chandraker A, et al. Avascular necrosis of the humeral head following bilateral upper extremity vascular composite allotransplantation: a case report. Case Reports Plast Surg Hand Surg. 2017;4(1):60–4.CrossRefGoogle Scholar
  19. 19.
    Shockcor N, Buckingham B, Hassanein W, Haririan A, Roberts SM, Nam AJ, et al. End stage renal disease as a complication of face transplant. Transplantation. 2018;102(7s):S434.CrossRefGoogle Scholar
  20. 20.
    Kanitakis J, Petruzzo P, Gazarian A, Testelin S, Devauchelle B, Badet L, et al. Premalignant and malignant skin lesions in two recipients of vascularized composite tissue allografts (face, hands). Case Rep Transplant. 2015;2015:356459. Scholar
  21. 21.
    • Kumnig M, Jowsey-Gregoire S. Key psychosocial challenges in vascularized composite allotransplantation. World J Transplant. 2016;6(1):91 Martin Kumnig and Sheila G Jowsey-Gregoire offer critical insight into the psychosocial challenges and potential benefits in VCA. Because the ethical justification of VCA is predicated on its ability to improve the patient’s quality of life, psychosocial issues are of extreme importance. This article, after giving a brief history of VCA, addresses the challenges and potential benefits while summarizing the psychosocial research that has taken place in the field. CrossRefGoogle Scholar
  22. 22.
    Jin J, Sklar GE, Min Sen Oh V, Chuen Li S. Factors affecting therapeutic compliance: a review from the patient’s perspective. Ther Clin Risk Manag. 2008;4:269–86.CrossRefGoogle Scholar
  23. 23.
    Beauchamp T. Autonomy and consent. In: Miller F, Wertheimer A, editors. The ethics of consent. Oxford: Oxford University Press; 2010. p. 55–78.Google Scholar
  24. 24.
    Franck G. The wage of fame: how non-epistemic motives have enabled the phenomenal success of modern science. Gerontology. 2015;61(1):89–94.CrossRefGoogle Scholar
  25. 25.
    Breidenbach, W. Conversation with Warren Breidenbach. Salzburg, Austria; 2017.Google Scholar
  26. 26.
    Plana N, Kimberly L, Parent B, Khouri K, Diaz-Siso J, Fryml E, et al. The public face of transplantation. Plast Reconstr Surg. 2018;141(1):178–9.CrossRefGoogle Scholar
  27. 27.
    OPO guidance on VCA deceased donor authorization - OPTN [Internet]. 2018 [cited 31 March 2018]. Available from:
  28. 28.
    • Parent B. Informing donors about hand and face transplants: time to update the uniform anatomical gift act. J Health Biomed L. 2015;X:309–26 The paper provides an exploration of the issues raised by VCA for the organ procurement process and for potential donors. If any type of VCA is to become a routine practice, these donor and procurement concerns will have to be addressed. Google Scholar
  29. 29.
    Shaw D. The consequences of vagueness in consent to organ donation. Bioethics. 2017;31(6):424–31.CrossRefGoogle Scholar
  30. 30.
    Hays R, Matas A. Ethical review of the responsibilities of the patient advocate in living donor liver transplant. Clin Liver Dis. 2016;7(3):57–9.CrossRefGoogle Scholar
  31. 31.
    Wall A, Testa G. Living donation, listing, and prioritization in uterus transplantation. Am J Bioeth. 2018;18(7):20–2.CrossRefGoogle Scholar
  32. 32.
    HRSA (US). Meeting Minutes of the OPTN/UNOS Vascularized Composite Allograft (VCA) Transplantation Committee, UNOS; Apr. 7, 2017 [cited 30 Mar 2018]. Available at
  33. 33.
    Reconstructive Transplant Research Program, Congressionally Directed Medical Research Programs [Internet]. 2018 [cited 31 March 2018]. Available from:
  34. 34.
    Howell M, Wong G, Turner R, Tan H, Tong A, Craig J, et al. The consistency and reporting of quality-of-life outcomes in trials of immunosuppressive agents in kidney transplantation: a systematic review and meta-analysis. Am J Kidney Dis. 2016;67(5):762–74.CrossRefGoogle Scholar
  35. 35.
    Petruzzo P, Lanzetta M, Dubernard J. International Registry on Hand and Composite Tissue Transplantation. Transplantation. 2014;98:44.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Center for Healthcare EthicsDuquesne UniversityPittsburghUSA

Personalised recommendations