Table Of ContentInternational Library of Ethics, Law, and the New Medicine 73
James L. Benedict
A Revised Consent
Model for the
Transplantation of
Face and Upper Limbs:
Covenant Consent
International Library of Ethics, Law,
and the New Medicine
Volume 73
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James L. Benedict
A Revised Consent Model
for the Transplantation
of Face and Upper Limbs:
Covenant Consent
123
James L. Benedict
Centerfor Healthcare Ethics
Duquesne University
Pittsburgh, PA
USA
ISSN 1567-8008 ISSN 2351-955X (electronic)
International Libraryof Ethics, Law,and theNewMedicine
ISBN978-3-319-56399-2 ISBN978-3-319-56400-5 (eBook)
DOI 10.1007/978-3-319-56400-5
LibraryofCongressControlNumber:2017937723
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The original version of the book was revised:
Incorrect volume number of the book has been
updated. The erratum to the book is available
at 10.1007/978-3-319-56400-5_7
v
Contents
1 Introduction.... .... .... ..... .... .... .... .... .... ..... .... 1
1.1 The Challenge of Medical Advancement for Healthcare
Ethics. .... .... .... ..... .... .... .... .... .... ..... .... 2
1.2 Vascularized Composite Allotransplantation. .... .... ..... .... 2
1.2.1 Emergence of the Field and Special Demands
on Patients ... ..... .... .... .... .... .... ..... .... 2
1.2.2 Implications of VCA for Consent... .... .... ..... .... 5
1.3 Covenant Consent.... ..... .... .... .... .... .... ..... .... 6
1.4 Structure of the Book. ..... .... .... .... .... .... ..... .... 7
1.5 Conclusion. .... .... ..... .... .... .... .... .... ..... .... 7
2 Vascularized Composite Allotransplantation... .... .... ..... .... 9
2.1 Introduction .... .... ..... .... .... .... .... .... ..... .... 9
2.2 History and Development of Solid Organ Transplantation
and Limb Replantation..... .... .... .... .... .... ..... .... 10
2.2.1 Ancient Evidence ... .... .... .... .... .... ..... .... 10
2.2.2 Developments in Transplantation Prior to 1954 ..... .... 11
2.2.3 Early Developments in Replantation. .... .... ..... .... 13
2.2.4 Sixty Years of Successful Solid Organ
Transplantation ..... .... .... .... .... .... ..... .... 14
2.2.5 Developments in Replantation.. .... .... .... ..... .... 15
2.3 History and Development of Vascularized Composite
Allotransplantation ... ..... .... .... .... .... .... ..... .... 15
2.3.1 Upper Extremity Transplantation.... .... .... ..... .... 17
2.3.2 Face Transplantation. .... .... .... .... .... ..... .... 20
2.3.3 Other VCA... ..... .... .... .... .... .... ..... .... 23
2.4 Similarities and Differences in VCA and SOT... .... ..... .... 25
2.4.1 Similarities ... ..... .... .... .... .... .... ..... .... 25
2.4.2 Unique Features of Solid Organ Transplants... ..... .... 26
2.4.3 Unique Features of Vascularized Composite
Allotransplantation .. .... .... .... .... .... ..... .... 28
vii
viii Contents
2.5 Practical and Ethical Concerns in the Field of Vascularized
Composite Transplantation.. .... .... .... .... .... ..... .... 34
2.5.1 Immunological Concerns.. .... .... .... .... ..... .... 34
2.5.2 Psycho-Social Issues. .... .... .... .... .... ..... .... 40
2.5.3 Procurement and Allocation Concerns.... .... ..... .... 47
2.5.4 Financial Costs ..... .... .... .... .... .... ..... .... 48
2.5.5 Ethical Issues . ..... .... .... .... .... .... ..... .... 50
2.6 Conclusion. .... .... ..... .... .... .... .... .... ..... .... 71
3 The Ethics of Consent.... ..... .... .... .... .... .... ..... .... 73
3.1 History and Development of the Role of Consent
in Health Care .. .... ..... .... .... .... .... .... ..... .... 73
3.1.1 Pre-enlightenment Developments ... .... .... ..... .... 75
3.1.2 The Influence of Post-medieval Philosophy.... ..... .... 79
3.1.3 Building on the Philosophical Foundation. .... ..... .... 81
3.2 The Current Understanding of Consent .... .... .... ..... .... 93
3.2.1 The Dominant Formulation.... .... .... .... ..... .... 93
3.2.2 Critiques and Alternatives. .... .... .... .... ..... .... 94
3.3 A More Fundamental Critique ... .... .... .... .... ..... .... 102
3.3.1 Historical Origins ... .... .... .... .... .... ..... .... 103
3.3.2 Philosophical Origins .... .... .... .... .... ..... .... 105
3.3.3 Atypical Contexts ... .... .... .... .... .... ..... .... 109
3.3.4 Adapting Informed Consent for Treatment
Contexts . .... ..... .... .... .... .... .... ..... .... 113
4 The Meaning of Covenant ..... .... .... .... .... .... ..... .... 115
4.1 Introduction .... .... ..... .... .... .... .... .... ..... .... 115
4.2 Covenant in the Ancient Near East.... .... .... .... ..... .... 116
4.2.1 Etymological Roots.. .... .... .... .... .... ..... .... 116
4.2.2 The Structure of Covenants.... .... .... .... ..... .... 121
4.2.3 Covenants and Fictive Kinship. .... .... .... ..... .... 122
4.2.4 The Role of Shame and Honor in Covenantal
Relations. .... ..... .... .... .... .... .... ..... .... 123
4.2.5 Durability and Flexibility . .... .... .... .... ..... .... 124
4.3 The Role of Covenant in Contemporary Religious Ethics.... .... 126
4.3.1 Jewish Ethics . ..... .... .... .... .... .... ..... .... 126
4.3.2 Christian Ethics..... .... .... .... .... .... ..... .... 128
4.4 The Role of Covenant in Health Care Ethics .... .... ..... .... 131
4.4.1 General Use of the Covenant Concept ... .... ..... .... 131
4.4.2 Paul Ramsey.. ..... .... .... .... .... .... ..... .... 135
4.4.3 William F. May..... .... .... .... .... .... ..... .... 137
Contents ix
4.5 Covenant and Care Provider—Patient Relationships... ..... .... 140
4.5.1 Reciprocity, Loyalty and Disparities in Power . ..... .... 142
4.5.2 Covenantal Relationships: Accompanying
Characteristics. ..... .... .... .... .... .... ..... .... 144
4.5.3 A Covenant Approach to Care Provider—Patient
Relations. .... ..... .... .... .... .... .... ..... .... 146
5 Covenant Consent... .... ..... .... .... .... .... .... ..... .... 149
5.1 Introduction .... .... ..... .... .... .... .... .... ..... .... 149
5.2 Informed Consent: Dynamic and Evolving.. .... .... ..... .... 153
5.3 Incongruity: VCA and Standard Antecedent Consent.. ..... .... 161
5.4 The Concept of Covenant as a Resource ... .... .... ..... .... 169
5.4.1 Covenant Consent and the Duration of Treatment
in VCA.. .... ..... .... .... .... .... .... ..... .... 174
5.4.2 Covenant Consent and the Burdens and Risks
of VCA.. .... ..... .... .... .... .... .... ..... .... 175
5.4.3 Covenant Consent and Long-Term Active Participation
by the Recipient in VCA . .... .... .... .... ..... .... 176
5.4.4 Covenant Consent and the Role of Dignity
and Vulnerability in VCA. .... .... .... .... ..... .... 179
5.5 Covenant Consent for VCA . .... .... .... .... .... ..... .... 182
5.5.1 Re-imagining Consent in Covenantal Terms... ..... .... 183
5.5.2 Creating a Structure and Process for Covenant
Consent.. .... ..... .... .... .... .... .... ..... .... 188
6 Conclusion. .... .... .... ..... .... .... .... .... .... ..... .... 195
6.1 Summary and Restatement.. .... .... .... .... .... ..... .... 195
Erratum to: A Revised Consent Model for the Transplantation
of Face and Upper Limbs: Covenant Consent .... .... .... ..... .... E1
Bibliography .. .... .... .... ..... .... .... .... .... .... ..... .... 205
Index .... .... .... .... .... ..... .... .... .... .... .... ..... .... 253
Chapter 1
Introduction
Abstract Vascularizedcompositeallotransplantation(VCA)hasemergedoverthe
last two decades as a promising therapeutic option for persons who have suffered
theloss oflimbs orwho havesufferedmajorfacialdisfigurement. Whilethis book
willdemonstratefamiliaritywiththetechnicalaspectsofVCA,andwitharangeof
ethical issues, its focus will be on the role and structure of consent for this new
therapeutic option. In particular, it will argue that the nature and duration of the
treatment involved in upper extremity and face transplants makes necessary some
modificationtothetheoryandpracticeofconsent.Theconceptofcovenantwillbe
put forward as a resource for this modification. Covenant consent is needed for
VCA because it more adequately describes what is being asked of recipients and
whatisnecessaryfortreatmenttosucceed.Itisalsoneededbecauseitappropriately
honors the recipients by understanding them as active partners rather than as pas-
sive patients, as people assuming major burdens and risks while contributing
meaningfully to the development of the field.
©SpringerInternationalPublishingAG2017 1
J.L.Benedict,ARevisedConsentModelfortheTransplantationofFace
andUpperLimbs:CovenantConsent,InternationalLibraryofEthics,
Law,andtheNewMedicine73,DOI10.1007/978-3-319-56400-5_1
