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INFORMED CONSENT
Given the complexity and high-risk profile of VCA, issues surrounding patient autonomy are central to the
ethical conversation. Candidates must understand the implications of their decision and receive sufficient
education to provide informed consent. The discussion should thoroughly address the burdens,
commitments, and demands of VCA - including but not limited to adherence with and complications of
long-term immunosuppression, potential initial decreases in quality of life, and psychosocial challenges.
Benefits are likely easily imaginable for candidates, whereas the extent of risks assumed is less transparent.
This discrepancy in knowledge is further worsened by the publicity surrounding extremity transplantation.
Media coverage unsurprisingly tends to focus on the positives of the procedure and on patients with the
best outcomes, thereby creating misunderstanding regarding the true risk-benefit profile amongst potential
candidates and compromising informed consent .
[53]

It is pertinent to note that VCA candidates, especially bilateral amputees, may be particularly vulnerable to
accepting the substantial risk involved with the experimental nature of limb transplantation [54,55] . This may
further contribute to the agreement without appropriate consideration of the risks involved. Thus, while
patient autonomy must be prioritized and recipients have a right to choose, the decision for VCA must also
be approached with a caution that requires scrutiny from providers.

DONOR AUTONOMY
In contrast with solid organs, VCAs are not currently a routine part of first-person or family authorization
[56]
for organ donation . The Uniform Anatomical Gift Act creates the option to register as an organ donor
when applying for a driver’s license and is thereby the most appropriate means for ensuring donor consent.
[57]
However, the existing law does not currently cover VCAs . In 2018, Pennsylvania became the first state to
modify its adaptation of the law to include VCAs . As such, the question of autonomy largely remains
[58]
unaddressed for donors in the extremity transplantation process. VCA donation currently requires separate
and explicit authorization by the donor prior to death or, more commonly, by family as surrogate decision-
makers after death. Surrogate consent, while better than no consent, is not equivalent to first-person
consent. The current practice of asking for VCA separately also carries the concern about negatively
influencing the willingness to donate solid organs, which can further decrease an already insufficient
[59]
supply .
Furthermore, limb transplantation is tied to a social significance that can make donation especially difficult
for donor families. The potential for post-transplantation rejection and discarding of the allograft(s) may be
difficult for donor families to accept but a realistic consequence about which they must be informed . If
[60]
explantation were to occur, they may learn of the event through the media. An additional psychological
deterrent would be knowing another person has the attributes of a loved one, especially if there are
markings that are unique or recognizable on the allograft. In these cases, limbs may not be eligible for
donation. If the allograft is deemed to be an otherwise excellent match, the recipient must also agree to
accept the potential identifiability of the markings. Therefore, discussion of the potential consequences and
possibility of failure should be considered when obtaining informed consent from donor families.

PATIENT PRIVACY & PUBLIC DISCLOSURE
Loss of patient privacy is a risk that should be assumed with modern-day VCA, as the procedure is
commonly reported on through print, social, and visual media . The novelty of VCA creates a conflict
[61]
between physician and institution excitement for publicity and recipient/donor right to privacy and
confidentiality. Outside of medicine, the success of VCA is largely judged by the general public on aesthetic
outcomes and media depictions of transformation. Such perceptions can influence willingness to donate