Year: 2022
Type: letter
Abstract: We read with interest the viewpoint of Gilardino and colleagues on the ethics of facial transplantation.1 There can be no doubt that facial transplantation warrants nuanced ethical consideration to ensure the highest standards of care for patients, and the avoidance of moral injury. The four principles are the core tenets of the “principlist” approach to medical ethics. However, principlism is not without critique, and may not adequately encompass the subtlety of ethical decision-making necessary in facial transplantation.2 Autonomy, beneficence, nonmaleficence, and justice were described by Beauchamp and Childress as four principles of equal value, intended not as a general moral theory but as a framework for reflecting on moral problems.3 This process of reflection, with the aim of interrogating and revising our beliefs on a moral or ethical matter, is often termed reflective equilibrium, but it can be more simply stated as considering the matter at hand from all angles, and requires recognition of our intrinsic biases and social context. As the authors note, the principle of autonomy has taken on a position of “first among equals” in modern, Western society.4 Accordingly, a paternalist approach to health care is no longer acceptable. As such, we would contend that it is not the role of the clinician to weigh the risks and benefits of facial transplantation on behalf of the patient before deciding whether to offer such treatment. Rather, faced with a competent patient enquiring about transplantation, the clinician should present the potential benefits and risks, as currently understood, together with clear explanation of the limits of this knowledge. Further, a clinician facing this dilemma might best respect the patient’s autonomy by referring to an established reconstructive transplantation program. Such programs have instituted measures to support patient decision-making, through consistent dialogue and information sharing, cooling off periods, serial psychological assessment and support, and access to peer support from other patients.5 We would suggest that such services provide the safety measures advocated by the authors. Given the extensive regulatory oversight of modern health care, beneficence, nonmaleficence, and justice cease to be independent compass points but rather interact with autonomy and are swayed by prevailing health care models, fiscal priorities, politics, philosophy, and beliefs. We assume beneficence and nonmaleficence for the purpose of this discussion. With regard to justice, the egalitarian and utilitarian models tend to oversimplify a complex issue. Clinicians undoubtedly have a role to play in health care justice by contributing to societal debate and politics. However, if we are to uphold our patients’ autonomy, we must act first and foremost as their advocate, contributing to such discussions on their behalf. This may require that we seek to provide the effective treatment of their choice, regardless of cost, while wider societal factors determine acceptable limits on health care expenditure. The ethics of complex issues such as facial transplantation are not intuitive and cannot adequately be resolved by the four principles alone. While they present a convenient framework, a nuanced reflective equilibrium requires consideration of many factors both within and separate from canonical principlism. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Colin G. Leonard, M.B., B.Chir., L.L.M.(Medical Ethics & Law)Department of Head and Neck SurgeryRoyal Victoria HospitalBelfast, Northern Ireland, United Kingdom David A. Leonard, M.B.Ch.B., Ph.D.Canniesburn Plastic Surgery UnitGlasgow Royal Infirmary and Institute of Molecular, Cell, and Systems BiologyUniversity of GlasgowGlasgow, Scotland, United Kingdom
Source: Plastic & Reconstructive Surgery
Authors: Colin G. Leonard, David A. Leonard
Language: English
Subfield: Transplantation
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W4225680926