Covenant Consent: A Revised Consent Model For Vascularized Composite Allotransplantation

Vascularized composite allotransplantation (VCA) has emerged over the last two decades as a promising therapeutic option for persons who have suffered the loss of limbs or who have suffered major facial disfigurement. Despite the clear advantages of facial and upper extremity VCA in terms of function and cosmesis, VCA has elicited a great deal of ethical concern. Much of that concern is centered around whether or not persons should be exposed to the toxic side effects and possible shortening of life associated with immunosuppression as part of treatment for conditions which are not life-threatening. Ethical concern has also been raised about the vulnerability, dignity and autonomy of VCA candidates and about the justice of allocating the necessary resources to research a treatment that seems unlikely to become widely available in the foreseeable future. While this dissertation will demonstrate familiarity with the technical aspects of VCA, and with the ethical issues just mentioned, its focus will be on the implications of this new therapeutic option for the manner in which consent is understood. In particular, it will argue that the nature and duration of the treatment involved in upper extremity and face transplants makes necessary some modification to the theory and practice of consent. The concept of covenant will be put forward as a resource for this modification. Covenants, as agreements which establish and maintain on-going personal relationships of mutual obligation, are both durable and flexible. Covenants, by engaging persons affectively, promote commitment and encourage the formation of strong therapeutic alliances. Such alliances are especially fitting in light of the lengthy and demanding course of VCA, from screening through surgery and years of physiotherapy, maintenance of immunosuppression and self-monitoring for signs of rejection. Covenant consent is needed for VCA because it more adequately describes what is being asked of recipients and what is necessary for the treatment to succeed. It is also needed because it appropriately honors the recipients by understanding them as active partners rather than as passive patients, and as people assuming major burdens and risks while contributing meaningfully to the development of the field. The employment of covenant consent significantly strengthens the ethical justification for vascularized composite allotransplantation of faces and upper extremities by acknowledging what is actually required of patients and by creating a structure through which they are supported in carrying out their commitment through the long, arduous period of rehabilitation and beyond