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[33]
allografts, funding, and general support for or against future procedures . To date, media reports have
largely focused on the benefits of VCA for the recipient, which may increase the availability of allografts but
[61]
lack an accurate portrayal of the difficult course to recovery . Transplant centers have an ethical obligation
to develop public trust by reporting on both positive and negative outcomes, and data-sharing is essential
for continued improvement in the field . However, these duties come at the cost of donors and recipients
[62]
who may be subjected to unwanted media scrutiny. In order to achieve sufficient informed consent, both
recipients and donor families should be cautioned that their identities will likely be revealed . With the rise
[63]
in social media, patient privacy and confidentiality are at increased risk of compromise, and institutions
should continue to aid potential candidates in understanding these possibilities.

PATIENT SELECTION
The fairness of candidate selection for extremity transplantation has been questioned due to its strict
criteria. Maximum clinical success requires selection based on anatomic, medical, and psychosocial factors.
Contraindications have been outlined and include age > 65 years, serious coexisting medical or
psychological conditions (i.e., coronary artery disease, diabetes, alcoholism), history of malignancy within
five years of remission, human immunodeficiency virus infection, positive crossmatch with the donor, and
positive pregnancy test in female candidates - although these are becoming less stringent with evolution of
[64]
the field . Surgical indications remain undefined, and standardized criteria for inclusion and exclusion of
recipients are lacking .
[65]
Given the experimental nature of the procedure, institutions and providers may choose the “easier” patient
to avoid negative outcomes and bypass those with the greatest need. Patients with better social support and
less significant psychological complications are considered more suitable, as adaptive coping styles,
supportive family and friends, stable finances, and logistical factors have been shown to be predictors of
successful outcomes . However, substantial differences exist in the already subjective mental health
[66]
[49]
evaluation of candidates , thereby leaving room for biases to act. In optimizing outcomes, decisions may
be indirectly colored by discrimination based on disability, criminal history, suicidal behavior, or
socioeconomic status. Issues regarding access to and disparities in VCA are further complicated by some
institutions considering certain causes of limb loss as contraindications to VCA, as a history of risky
behavior can reflect a non-psychologically ideal candidate [67,68] . As a result, less psychosocially ideal patients
are often passed over as candidates. While these selection methods are not equitable, their restrictions may
be non-negotiable given the necessity of long-term medical appointments, a complex immunosuppressive
regimen, and physical rehabilitation for successful outcomes. It must be noted that currently, the field of
VCA remains experimental and most reported patients are enrolled in review board-approved clinical trials
with institution-dependent inclusion criteria. Therefore, the concept of “need” is still under study. Equitable
allocation of care and fair patient selection will become more central to the ethical conversation if extremity
transplantation utilization increases.

ETHICAL CHALLENGES OF PEDIATRIC VCA
As discussed previously, the first case of lower extremity transplantation occurred between three-month-old
ischiopagus twins. In 2000, a 28-day-old infant with congenital absence of the hand was the first pediatric
[69]
recipient of an upper extremity allograft from her monozygotic twin . The first attempt at pediatric
extremity VCA with a non-biologically identical donor was performed in 2010 outside the United States.
The recipient was a 17-year-old female with bilateral proximal-third arm amputations who underwent
[70]
bilateral transplantation and expired in the immediate postoperative period . The first successful bilateral
hand transplantation in a pediatric patient was performed in 2015 at the University of Pennsylvania . The
[71]
8-year-old recipient was already immunosuppressed because he had previously received a kidney transplant