A Lifesaving View of Vascularized Composite Allotransplantation

Abstract

Introduction:Most solid organ transplantation is viewed as lifesaving, whereas vascularized composite allotransplantation (VCA) has been viewed as life enhancing. This article challenges the latter and argues that “social death” evident in severe face, hand, and larynx disfigurement can be potentially treated via VCA. Social death (from a social science perspective) consists of a combination of 7 components: social isolation, loneliness, ostracism, loss of personhood, change of role and identity, harm, and disfigurement.Methods:In February 2016, PubMed and Google were searched for case reports of human face, hand, and larynx transplantation. Patient and team narratives were then coded for components of social death using social science and medical model criteria.Results:Eleven narratives were identified among 9 articles. The social science model (but not the medical model) described pretransplant social death and the resolution of social death by receiving VCA. Notably, the medical model of social death was deemed unsuitable for application to VCA. This is because case narratives consistently contradict elements of the medical model.Conclusions:By including social death as a patient inclusion criterion for face, hand, and larynx VCA, these transplants can be considered lifesaving. Additionally, because VCA requires lifelong immunosuppressant medication, considering VCA as a lifesaving intervention improves the technology’s risk–benefit analysis. Guidance for assessing social death is provided.

Social death in patients: Concept analysis with an evolutionary approach

“…refraining from receiving treatment), high pain threshold (e.g. reluctance to express pain), reduced personal hygiene, emotional indifference with excessive feelings of guilt, biological symptoms such as estrogen abnormalities, secondary amenorrhea, and imbalance anomalies( Bramstedt, 2018 ; Kalish, 1968 ; H. Sweeting & Gilhooly, 1997 ; H. N. Sweeting, 1991 ). Therefore, the attributes of social death have a bigger extent and structure than the concepts anxiety and bodily identity, and they are not specific to social sciences and become manifested when people have no hope of participating and playing a social role, and are considered dead when still biologically alive.…”

“…Extensive studies clearly demonstrate that older adults are worried about losing their social contacts and the absence of their family( Steele et al, 2015 ; H. Sweeting & Gilhooly, 1997 ). Social neglect usually becomes apparent when a chronically-ill older adult is abandoned by the caregivers and medical personnel, such that the doctors and nurses make less effort to establish a social rapport with the patient and merely provide medical services to him as robots( Bramstedt, 2018 ; Dageid & Duckert, 2008 ). Moreover, in most cases, these people are given the lowest priority for receiving medical services and have no place in the society for the allocation of resources and support.…”

“…Social death is associated with a rise in mortality rates, including suicidal ideations and suicide attempts. In addition to the homeless, social death has also been reported in many other groups, such as disabled patients, people with dementia, patients with low levels of consciousness, patients with facial deformities, massacre victims, patients with severe burns, and people with HIV( Bramstedt, 2018 ; Brannelly, 2011 ; Dageid and Duckert, 2008 , Hale et al, 2013 ). There is also a relationship between social death in patients and requests for euthanasia, which requires separate studies.…”

“…Some groups are more susceptible to this kind of death. According to studies, in addition to homeless people, social death is also reported in groups of people with disability and limited mobility, dementia, low consciousness levels, and facial deformities as well as victims of massacres, those with severe burns, and people with AIDS( Bramstedt, 2018 ; Dageid and Duckert, 2008 , Hale et al, 2013 ; H. Sweeting & Gilhooly, 1997 ). Nevertheless, theorizing about this concept in different patients is still not adequately specific and clear, and specialists in different fields dealing with distinct groups have no knowledge of the application and definitions of this concept in other fields and specialties( Borgstrom, 2017 ; Králová, 2015 ).…”

Saving faces

“…By including social death in the evaluation of patient need, face transplants can certainly be considered life-saving. 2 One of the unsettling -and fundamentally important -things about face transplant surgery is that it insists on an expanded definition of what constitutes health and wellness, and what can be done to achieve it. At the same time, it exposes biases against people with facial disfigurement so substantial as to create risks and challenges akin to death.…”