Reassessing Ethical Considerations in Pediatric Facial Transplantation: Where Are We Now?

Background: Many strides have been made in the field of vascular composite allotransplantation, and some vascular composite allotransplantation procedures, including upper extremity and facial transplantation, are arguably nearing the standard of care for adult recipients. Although centers devoted to pediatric upper extremity transplantation have been established, very little recent scholarship has addressed the advisability of initiating pediatric facial transplantation (PFTx). Methods: This conceptual ethical analysis assesses the present risks and benefits associated with PFTx based on a review of the literature combined with our team's clinical experience. Results: Considerations for PFTx include anticipated improvements in quality of life and social integration during a critically important formative developmental phase, ongoing risks associated with immunosuppression and known challenges with nonadherence in adolescent and young adult populations, unknowns about facial growth and continued incorporation of the allograft, the likelihood of need for retransplantation, and issues around decisional capacity and the ability to provide informed consent. Conclusions: Weighing the risks and benefits of PFTx, particularly the risks associated with long-term immunosuppression and the likely need for retransplantation, we believe that the reservations are such that pediatric patients should not be considered candidates for PFTx at this time.