Hostname: page-component-745bb68f8f-s22k5 Total loading time: 0 Render date: 2025-02-06T17:00:56.038Z Has data issue: false hasContentIssue false
  • English
  • Français

Self-Inflicted Gunshot Wound as a Consideration in the Patient Selection Process for Facial Transplantation

Published online by Cambridge University Press:  12 July 2019

MICHELLE W. MCQUINN ,
LAURA L. KIMBERLY ,
BRENDAN PARENT ,
J. RODRIGO DIAZ-SISO ,
ARTHUR L. CAPLAN ,
AILEEN G. BLITZ  and
EDUARDO D. RODRIGUEZ
Rights & Permissions [Opens in a new window]

Abstract:

Facial transplantation is emerging as a therapeutic option for self-inflicted gunshot wounds. The self-inflicted nature of this injury raises questions about the appropriate role of self-harm in determining patient eligibility. Potential candidates for facial transplantation undergo extensive psychosocial screening. The presence of a self-inflicted gunshot wound warrants special attention to ensure that a patient is prepared to undergo a demanding procedure that poses significant risk, as well as stringent lifelong management. Herein, we explore the ethics of considering mechanism of injury in the patient selection process, referring to the precedent set forth in solid organ transplantation. We also consider the available evidence regarding outcomes of individuals transplanted for self-inflicted mechanisms of injury in both solid organ and facial transplantation. We conclude that while the presence of a self-inflicted gunshot wound is significant in the overall evaluation of the candidate, it does not on its own warrant exclusion from consideration for a facial transplantation.

Keywords

facial transplantationself-inflicted gunshot woundpatient selectiontransplant outcomes
Type
Articles
Information
Cambridge Quarterly of Healthcare Ethics , Volume 28 , Issue 3 , July 2019 , pp. 450 - 462
Copyright
Copyright © Cambridge University Press 2019 

Introduction

Of the 40 facial transplantations (FTs) that have been performed to date, 18 have been the result of ballistic trauma,Footnote 1,Footnote 2,Footnote 3 and at least five of these cases have been explicitly identified as intentionally self-inflicted gunshot wounds (SIGWs).Footnote 4,Footnote 5,Footnote 6,Footnote 7 Five additional cases of SIGWs have been reported; however, it is less clear whether or not these incidents were intentional.Footnote 8,Footnote 9,Footnote 10 The events resulting in SIGWs vary widely, and details surrounding the incident of injury may make it difficult to identify a suicide attempt.

In the general population, attempted suicide carries an increased risk of subsequent attempts compared to those without a previous suicide attempt.Footnote 11 Of the ten SIGW patients who underwent FT, one recipient has committed suicide post-transplant.Footnote 12 Little is known about the risk of reinjury in FT recipients, and data on short- and long-term outcomes of SIGW FT recipients have not been consistently reported. As SIGWs are prevalent in a number of candidates evaluated for FT,Footnote 13,Footnote 14,Footnote 15 it is important to address how or if mechanism of injury (MOI) should be considered in the patient selection process.

The decision about eligibility could have a broad impact on organ donation. Some might be less willing to donate facial allografts for transplantation if they knew their donations could go to individuals with self-inflicted wounds.

As the issue of MOI has not been explored extensively in the FT literature, experiences in solid organ transplantation addressing the ethics of patient selection for those who self-harm may offer guidance. In addition, a better understanding of the association between mental health and suicide risk before and after transplant can help to ensure ethically sound approaches to patient selection for FT.

Background

Suicide and Risk of Reinjury

A history of attempted suicide presents as a strong risk factor for future suicide attempts and completed suicide.Footnote 16,Footnote 17,Footnote 18 The use of a firearm as the method of self-harm is similarly associated with higher risk of future suicide.Footnote 19,Footnote 20,Footnote 21 Although the number of individuals who commit suicide after an initial attempt is relatively low (1.3-5% at 5-year follow-upFootnote 22,Footnote 23 ; 6.7-12% at 14 or more years of follow-upFootnote 24,Footnote 25 ), these data suggest that concerns about reinjury risk after FT in SIGW patients are warranted. However, it is possible that the FT itself, or other factors, might actually diminish the likelihood of repeat attempt.

Mortality from SIGWs can be as high as 80%.Footnote 26 For those who survive, numerous long-term morbidities are often present as a consequence of the injury, frequently including: visual defects and/or motor, swallowing, speech, or hearing difficulties.Footnote 27 These morbidities leave patients with life-long disabilities.

The association between mental illness and suicide, as well as repeat attempts,Footnote 28,Footnote 29,Footnote 30,Footnote 31,Footnote 32,Footnote 33 has led to concern that recipients with self-inflicted injuries may have difficulty withstanding the rigors of the FT procedure and subsequent long-term treatment, particularly with regard to adherence. Inability to adhere to the post-transplant regimen can lead to adverse outcomes, including rejection and graft failure.Footnote 34 Patients in the general population who are struggling with significant mental health issues tend to require additional support when receiving medical care, including reminders to take medication, assistance in getting to and from appointments, or coping with treatment side effects.Footnote 35 Some data suggest that solid organ transplantation recipients with mental health issues who receive adequate psychosocial support do not fare worse than other recipients post-transplant.Footnote 36,Footnote 37,Footnote 38 Furthermore, patients who have attempted suicide are likely at lower risk of reattempt when given additional psychosocial support.Footnote 39,Footnote 40,Footnote 41 This evidence, combined with the possibility that FT may reduce depression and other psychological sequelae of severe facial injury, suggests that perhaps suicide attempts such as intentional SIGW should not serve as absolute contraindications to FT.

In some cases, an intentional SIGW may even be considered an indication that FT ought to be provided, along with adequate psychosocial support and treatment prior to the procedure and throughout post-transplant follow-up, as deemed appropriate by the transplant team’s mental health practitioners. Practitioners should encourage a holistic approach to meeting patients’ mental health needs by establishing ongoing contact with local mental health providers in the recipients’ communities, as well as with members of their social support systems to better facilitate continuity of psychosocial support throughout the transplant process and long-term follow up. Transparency among centers in disclosing required mental health treatment before, during, and after FT is strongly encouraged to ensure optimal outcomes for these patients. Moreover, if the FT team determines that a patient has recurrent or ongoing mental health needs, expectations for mental health treatment should be communicated clearly to patients and their families, and reinforced throughout the transplant process, to facilitate adherence as well as to optimize patients’ psychosocial functioning.

Patient Selection Process for Facial Transplantation: Psychosocial Assessment

A standardized approach to the psychosocial assessment of FT candidates has yet to be adopted.Footnote 42 Possible psychosocial contraindications may include: active psychoses;Footnote 43,Footnote 44,Footnote 45,Footnote 46 untreated and/or inappropriately managed psychiatric disorders resulting in psychological instability;Footnote 47,Footnote 48,Footnote 49 inadequate social support systems;Footnote 50,Footnote 51 and inability to commit to immunosuppressive therapy and consistent follow-up care.Footnote 52,Footnote 53

The presence of an SIGW has not precluded patients from consideration for FT at most institutions. However, suicidal tendencies (including attempt history) have been cited as exclusionary criteria at some institutions.Footnote 54,Footnote 55,Footnote 56 Intentionally self-inflicted MOI is considered grounds for exclusion at one transplant center.Footnote 57 Currently, most institutions considering individuals for FT agree that patients should be evaluated on a case-by-case basis in terms of psychological stability.Footnote 58,Footnote 59,Footnote 60,Footnote 61

Facial Transplantation Outcomes for Self-Inflicted Gunshot Wounds—Limited Data

One of the primary challenges in exploring whether or how SIGWs might be considered during the patient selection process is that, currently, little is known about long-term outcomes of FT recipients, including those of the five clearly intentional SIGW patients. Of these, one patient committed suicide three and a half years post-FT.Footnote 62 Three are alive and report somewhat mixed psychosocial outcomesFootnote 63,Footnote 64 in regards to post-transplant quality of life, self-esteem, and social approval. At their most recent follow-up, one patient reported improved mental health and self-esteem compared to baseline, while another reported a decrease in mental health and self-esteem; the third patient reported an increased quality of life from baseline.Footnote 65,Footnote 66 No long-term data have yet been reported on the fifth patient. Caution is required in interpreting data from such a small sample size, and evidence from these three patients cannot be generalized to all patients with SIGWs, nor can meaningful comparisons be drawn to the overall FT recipient population.

Though outcomes data have been reported for some FT recipients (with self-inflicted injuries or otherwise), it is difficult to directly compare outcomes among individuals due to the fact that each transplant center utilizes different scales for measuring psychosocial changes following FT. Across the FT population, reported outcomes appear generally positive in terms of improved quality of life, satisfaction with the procedure, and overall well-being.Footnote 67,Footnote 68,Footnote 69,Footnote 70,Footnote 71

Ethical Considerations

Recipient Considerations

Personal Responsibility.

Whether suicide is an irrational act committed under the duress or coercion of an internal or external influence such as mental illness or extreme social pressure, or whether it may be viewed as an acceptable reasoned autonomous act remains the subject of considerable debate.Footnote 72,Footnote 73 Because suicide resulting from ballistic trauma often involves the interplay of mental illness and, frequently, substance abuse, the complexity of these factors can impede attempts to assess individual agency, further complicating perceptions of personal responsibility and the role that it plays in decision making.

Current Western research indicates a strong association between mental illness and suicide,Footnote 74 and the focus has shifted toward addressing suicide through a neurobiological lens.Footnote 75 Within this framework, uncertainty remains as to how best to characterize the pathway from mental illness to fatal suicide attempts. In fact, recent inquiry suggests that while mental illness is a good predictor of suicidal ideation, its predictive power does not extend to suicide attempts or to fatal suicide attempts.Footnote 76 It is also important to recognize that Western medicine’s increasingly neurobiological approach to suicide reflects a specific medicalized and pathology-oriented paradigm that leaves less room for the socially, politically, and historically mediated nature of the phenomenon.Footnote 77,Footnote 78,Footnote 79 For example, in China suicide tends to be regarded as a reasoned, if desperate, response to unbearable social stress, thus locating suicide as a rational, contextually-driven sociocultural phenomenon, rather than an irrational act stemming from an internalized pathology at the individual level.Footnote 80 Acknowledging alternative paradigmatic interpretations of the act of attempting suicide can help frame ethical debate about the nature of personal responsibility, and its appropriate role in patient selection for FT.

In solid organ transplantation, an intentionally self-inflicted MOI is generally not sufficient to deny an individual a liver transplant,Footnote 81,Footnote 82,Footnote 83,Footnote 84,Footnote 85,Footnote 86,Footnote 87,Footnote 88,Footnote 89,Footnote 90,Footnote 91,Footnote 92,Footnote 93 nor does it serve as a criterion in liver allocation priority.Footnote 94,Footnote 95,Footnote 96,Footnote 97,Footnote 98 These conclusions are derived from data suggesting that long-term outcomes for those with intentional self-inflicted injury are comparable to those with non-self-inflicted injury, which supports ethical arguments that the circumstances creating the need for liver transplantation should not influence whether transplant will be offered as a treatment option. Furthermore, the ethical consensus in solid organ transplantation suggests that personal responsibility should be irrelevant in considerations of transplant eligibility because it is intrinsically subjective,Footnote 99,Footnote 100 and the complex interplay of psychosocial, emotional, and economic factors contributing to a particular situation renders the concept of personal responsibility difficult to ascertain, much less endorse as an eligibility criterion.Footnote 101,Footnote 102

Moreover, personal responsibility as a construct may be used to mask personal bias toward stigmatized behavior,Footnote 103 and is not invoked in the distribution of healthcare resources across other medical fields—for example, in the decision to treat injuries resulting from contact sports.Footnote 104 The Council on Ethical and Judicial Affairs of the American Medical Association deemed it unethical to factor a patient’s contribution to his or her disease into allocation criteria if the treatment involves a scarce resource, such as organs.Footnote 105 Therefore, it is unethical to utilize MOI in the patient selection process for liver transplantation.Footnote 106,Footnote 107,Footnote 108,Footnote 109,Footnote 110 Extending this line of argument to FT, it would thus be unethical to deny a face transplant to a patient on the grounds of an SIGW, especially if FT were determined the optimal treatment for functional, aesthetic, and quality of life improvement.

Equity.

Justice considerations, including equitable access and fair distribution of resources, become more prominent as a procedure shifts from experimental to standard of care. If FT were to be considered the standard of care and the volume of procedures performed were to increase substantially, allocation decisions would take greater priority, likely leading to additional pressure to standardize the assessment and allocation processes. As it is, donor scarcity in FT has far more to do with matching the appropriate donor face with a given recipient rather than an absolute shortage of available donor faces. Limited demand for the procedure means that it is highly unlikely that two potential recipients who are comparable in every way, with the exception of MOI, will compete for a single available donor face. Although fair distribution of resources with regard to allocation of facial allografts may not present a pressing concern at this point in time, programs should strive to generate consensus across the field about psychosocial eligibility criteria for FT (or absolute contraindications, at the least), and encourage transparency of the patient selection process to support equitable access to FT.

Unique Nature of FT.

Transplant recipients must be able to incorporate a new organ or tissue into their sense of identity and bodily integrity.Footnote 111 Inability to do so can lead to serious psychological and emotional distress, resulting in adverse clinical outcomes such as graft removal and even attempted suicide.Footnote 112,Footnote 113,Footnote 114 Psychological concerns related to transplantation (e.g., fear of allograft rejection and immunosuppression side effects) might be compounded in FT because of the relationship between the face and self-identity, communication, and social relationships.Footnote 115 Facial allografts tend to be more closely associated with one’s sense of identity, in part owing to the visible nature of the tissues and to the status of the face as the locus of identity.Footnote 116 Thus, FT teams must be carefully attuned to recipients’ post-operative psychosocial functioning and provide ample psychosocial support to facilitate this period of adaptation to the new graft. While the particular nature of FT may require unique post-operative psychosocial adaptation processes, currently, there is no evidence to suggest that an FT recipient with an SIGW would be less able to adapt to a new face post-transplant than other FT recipients.

Public Scrutiny.

Finally, the novelty of FT may predispose the recipient to media scrutiny and intense public attention. For these reasons, FT necessitates a candidate who is both psychologically and socially prepared for the “limelight,” and prepared for this attention to wane when the next high-profile procedure is performed. While navigating public scrutiny may present a challenge for recipients, individuals with SIGWs cannot at this point be deemed more or less capable of coping with these psychological pressures than other FT candidates solely on the basis of their MOI. Thus, it would be unethical to deny them an FT on these grounds alone.

Public Perception and Donor Considerations

While a majority of the general public in the United States supports solid organ donation, some individuals may be less willing to donate tissue for vascularized composite allotransplantationFootnote 117,Footnote 118 due to lack of awarenessFootnote 119,Footnote 120 or understanding of these procedures, and of the possibility of donating tissues for this type of transplantation. Additionally, the close association of these grafts with one’s personal sense of identity and bodily integrity may lower willingness to donate for vascularized composite allotransplantation.Footnote 121,Footnote 122,Footnote 123

Depending on the general public’s perception of self-inflicted injuries, it is possible that potential FT donors and their family members may object to the idea of donating tissues for transplantation in recipients with an SIGW, even if they are willing to donate for vascularized composite allotransplantation procedures overall. In solid organ transplantation, self-inflicted MOI draws mixed reactions from the public, with support dwindling in some, while in others it does not influence willingness to donate.Footnote 124,Footnote 125 Studies that assess how the public’s willingness to donate facial allografts may change if it were known that the recipient had intentionally injured him or herself have not yet been performed. Thus, donation requests would need to be undertaken with great caution and sensitivity until potential donors’ attitudes and beliefs are better understood.

Our donation system in the United States prioritizes donor autonomy, allowing each individual to decide whether to participate in organ donation, which organs to donate, and for what purposes (research, education, transplant). However, there are limits on the donor’s choice; aside from direct donation to a specified individual, registered donors are not allowed to restrict their transplant donation to particular “types” of people, according to race, age, gender, MOI, or any other category.Footnote 126,Footnote 127 This reflects the moral belief that it is not the public’s responsibility to determine who is worthy, but instead that participation in the system is a commitment to every person in need. To respect the autonomy of donor families, they should be informed about the potential causes that lead to the need for FT, including SIGW, as well as the benefits and risks of receiving an FT, which should inform their decision whether to participate in FT, solid organ transplantation, or both. To prevent the insertion of personal judgment regarding recipient worthiness, the donor family should not automatically be informed regarding a specific recipient’s MOI when deciding whether to approve the donation, which is consistent with the policy of the Organ Procurement and Transplantation Network.Footnote 128 However, in the event that family members inquire about MOI, withholding information might betray the trust relationship with the donation team and dissuade the family from agreeing to donation. Furthermore, the current media attention around FT means that donor families will inevitably obtain information about the recipient and MOI through news reports, which behooves the team to provide this information prior to donation. The authors are familiar with at least two cases in which donor families requested to know MOI, were informed of the recipient’s SIGW, and chose to donate.

With regard to public perception and media scrutiny, knowledge of a given FT recipient’s MOI, publicized by the media, might influence how a recipient is regarded post-transplant in his or her community. If the general public is wary of performing FT on recipients with an SIGW, current challenges in safeguarding FT recipients’ anonymity could result in undesired and harmful attention for this particular recipient population following FT, especially given the social stigma surrounding suicide.Footnote 129,Footnote 130

Cost and Self-harm

FT is a resource-intensive procedure combining expenditure on the surgery itself and long-term costs associated with lifelong immunosuppression.Footnote 131 In the general population, suicide attempters have an increased likelihood of repeat attempt,Footnote 132 which raises the question of whether it is ethical to perform such an expensive procedure on individuals who may be at greater risk of reinjury than other FT recipients. In solid organ transplantation, the observed rate of fatal suicide following liver transplantation in acetaminophen overdose patients appears comparable to that of the general nontransplant population following a failed suicide attempt;Footnote 133,Footnote 134,Footnote 135,Footnote 136,Footnote 137,Footnote 138 however, owing to limited data on long-term FT outcomes, the same cannot yet be said conclusively for FT recipients. In solid organ transplantation, rates of retransplantation resulting from reinjury in alcoholic liver disease have been compared among acute liver disease recipients and nonacute liver disease recipients, with the former population being retransplanted at comparable or lower rates than those observed in the latter population.Footnote 139,Footnote 140 This leads to the consensus that retransplantation in patients with acute liver disease is justified,Footnote 141 though recidivism does complicate the clinical and ethical picture.

Exorbitant costs of other medical procedures such as heart valve replacements in intravenous drug users with high rates of recidivismFootnote 142,Footnote 143,Footnote 144 have raised similar debates.Footnote 145,Footnote 146,Footnote 147 These patients are often uninsured or receive health insurance through the government-funded Medicaid program, where costs are ultimately passed along to taxpayers.Footnote 148 Arguments made in support of repeating valve replacements suggest that individuals, regardless of personal responsibility for the illness, have a right to medical treatment because (1) it is not the responsibility of medical providers to decide who is worthy of care, and (2) there are often circumstantial events beyond the individual’s control that led to the drug use, which ultimately contributed to the need for treatment; thus, refusal of surgical treatment would be unethical.Footnote 149,Footnote 150,Footnote 151 By contrast, those not in favor of repeat valve replacements for intravenous drug users maintain that the procedure is too costly, and the financial burden that typically must be absorbed by the healthcare system renders it untenable as routine treatment for those at risk of relapse, perhaps multiple times.Footnote 152,Footnote 153 Some surgeons have ultimately exercised their right to refuse to perform a repeat valve replacement in these patients.Footnote 154,Footnote 155 While the cases of valve replacement for intravenous drug users and FT for those with SIGW have many salient differences, it is possible that echoes of a similar debate may resurface for FT recipients.

Conclusion

An ethical argument justifying the use of MOI as a criterion in listing decisions should be grounded in clear evidence that MOI has a significant impact on recipient outcomes. To determine this impact, evaluation should not strictly compare FT outcomes of those with SIGW to those undergoing FT for other reasons, but should also consider outcomes in SIGW patients who do not undergo FT. If data suggest that SIGW patients fare better with FT than without, this may support FT as optimal treatment for this population. In the absence of these data, it would be unethical at present to deny a patient access to FT solely on the basis of MOI.

Careful tracking and dissemination of long-term outcomes data will ultimately help inform the relevance and potential use of MOI in the patient selection process. Moreover, transparency of the patient selection process, including reasons for both acceptances and declines, will help to promote equitable access across the field. Until robust outcomes data are available, FT programs should make every effort to ensure fair and equitable patient selection based on the best available information, and should continue to focus on optimizing recipients’ clinical and psychosocial functioning both pre- and post-transplant.

References

Notes

1. Sosin, M, Rodriguez, ED. The face transplantation update: 2016. Plastic and Reconstructive Surgery 2016;137(6):1841–50.CrossRefGoogle ScholarPubMed

2. Chicago Tribune. After twin tragedies, man gets face transplant at Mayo Clinic [Internet]. S, Cohen, author. [cited 23 Aug 2017]; available at http://www.chicagotribune.com/lifestyles/health/ct-mayo-clinic-face-transplant-20170217-story.html (last accessed 16 Dec 2018).Google Scholar

3. Chicago, Tribune. Woman receives face transplant after being disfigured by gunshot wound [Internet]. CR, Wootson Jr., author. [cited 23 Aug 2017]; available at http://www.chicagotribune.com/lifestyles/health/ct-gun-shot-face-transplant-20170720-story.html (last accessed 16 Dec 2018).Google Scholar

4. See note 2, Cohen.

5. Lantieri, L, Grimbert, P, Ortonne, N, Suberbielle, C, Bories, D, Gil-Vernet, S, et al. Face transplant: Long-term follow-up and results of a prospective open study. The Lancet 2016;388(10052):1398–407.CrossRefGoogle ScholarPubMed

6. Kiwanuka, H, Aycart, MA, Gitlin, DF, Devine, E, Perry, BJ, Win, TS, et al. The role of face transplantation in the self-inflicted gunshot wound. Journal of Plastic, Reconstructive & Aesthetic Surgery 2016;69(12):1636–47.CrossRefGoogle ScholarPubMed

7. Lassus, P, Lindford, A, Vuola, J, Bäck, L, Suominen, S, Mesimäki, K, et al. The Helsinki Face Transplantation: Surgical aspects and 1-year outcome. Journal of Plastic, Reconstructive & Aesthetic Surgery 2018;71(2):132–9.CrossRefGoogle ScholarPubMed

8. See note 3, Wootson Jr.

9. See note 5, Lantieri et al. 2016:1398–407.

10. GQ. The New Face of Richard Norris [Internet]. Laskas JM, author. [cited 23 Aug 2017]; available at https://www.gq.com/story/richard-norris (last accessed 16 Dec 2018).

11. Harris, EC, Barraclough, B. Suicide as an outcome for mental disorders. A meta-analysis. British Journal of Psychiatry 1997;170:205–28.CrossRefGoogle ScholarPubMed

12. See note 5, Lantieri et al. 2016.

13. See note 5, Lantieri et al. 2016.

14. See note 6, Kiwanuka et al. 2016.

15. Coffman, KL. Psychiatric evaluation of the face transplant candidate. Current Opinion in Organ Transplantation 2015;20(2):222–8.CrossRefGoogle ScholarPubMed

16. Mann, JJ. A current perspective of suicide and attempted suicide. Annals of Internal Medicine 2002;136(4):302–11.CrossRefGoogle ScholarPubMed

17. Lewinsohn, PM, Rohde, P, Seeley, JR. Psychosocial risk factors for future adolescent suicide attempts. Journal of Consulting and Clinical Psychology 1994;62(2):297–305.CrossRefGoogle ScholarPubMed

18. Hawton, K, van Heeringen, K. Suicide. The Lancet 2009;373(9672):1372–81.CrossRefGoogle ScholarPubMed

19. Christiansen, E, Jensen, BF. Risk of repetition of suicide attempt, suicide or all deaths after an episode of attempted suicide: A register-based survival analysis. Australian and New Zealand Journal of Psychiatry 2007;41(3):257–65.CrossRefGoogle ScholarPubMed

20. Runeson, B, Tidemalm, D, Dahlin, M, Lichtenstein, P, Langstrom, N. Method of attempted suicide as predictor of subsequent successful suicide: National long term cohort study. The British Medical Journal 2010;341:c3222.CrossRefGoogle ScholarPubMed

21. Haukka, J, Suominen, K, Partonen, T, Lonnqvist, J. Determinants and outcomes of serious attempted suicide: a nationwide study in Finland, 1996–2003. American Journal of Epidemiology 2008;167(10):1155–63.CrossRefGoogle Scholar

22. Beautrais, AL. Subsequent mortality in medically serious suicide attempts: A 5 year follow-up. Australian and New Zealand Journal of Psychiatry 2003;37(5):595-9.CrossRefGoogle ScholarPubMed

23. Miller, M, Hempstead, K, Nguyen, T, Barber, C, Rosenberg-Wohl, S, Azrael, D. Method choice in nonfatal self-harm as a predictor of subsequent episodes of self-harm and suicide: Implications for clinical practice. American Journal of Public Health 2013;103(6):e61–8.CrossRefGoogle ScholarPubMed

24. See note 20, Runeson et al. 2010.

25. Suokas, J, Suominen, K, Isometsa, E, Ostamo, A, Lonnqvist, J. Long-term risk factors for suicide mortality after attempted suicide: Findings of a 14-year follow-up study. Acta Psychiatrica Scandinavica 2001;104(2):117–21.CrossRefGoogle ScholarPubMed

26. Bukur, M, Inaba, K, Barmparas, G, DuBose, JJ, Lam, L, Branco, BC, et al. Self-inflicted penetrating injuries at a Level I Trauma Center. Injury 2011;42(5):474–7.CrossRefGoogle Scholar

27. Tholpady, SS, DeMoss, P, Murage, KP, Havlik, RJ, Flores, RL. Epidemiology, demographics, and outcomes of craniomaxillofacial gunshot wounds in a level I trauma center. Journal of Cranio-Maxillo-Facial Surgery 2014;42(5):403–11.CrossRefGoogle Scholar

28. See note 18, Hawton, van Heeringen 2009.

29. See note 19, Christiansen, Jensen 2007.

30. See note 23, Miller et al. 2013.

31. Bertolote, JM, Fleischmann, A. Suicide and psychiatric diagnosis: A worldwide perspective. World Psychiatry 2002;1(3):181–5.Google ScholarPubMed

32. Martin, CA, Chapman, R, Rahman, A, Graudins, A. A retrospective descriptive study of the characteristics of deliberate self-poisoning patients with single or repeat presentations to an Australian emergency medicine network in a one year period. BMC Emergency Medicine 2014;14–21.Google ScholarPubMed

33. O’Connor, RC, Smyth, R, Ferguson, E, Ryan, C, Williams, JM. Psychological processes and repeat suicidal behavior: a four-year prospective study. Journal of Consulting and Clinical Psychology 2013;81(6):1137–43.CrossRefGoogle ScholarPubMed

34. Gaynor, JJ, Ciancio, G, Guerra, G, Sageshima, J, Hanson, L, Roth, D, et al. Graft failure due to noncompliance among 628 kidney transplant recipients with long-term follow-up: A single-center observational study. Transplantation 2014;97(9):925–33.CrossRefGoogle ScholarPubMed

35. De Hert, M, Cohen, D, Bobes, J, Cetkovich-Bakmas, M, Leucht, S, Ndetei, DM, et al. Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry 2011;10(2):138–51.CrossRefGoogle ScholarPubMed

36. Rosenberger, EM, Dew, MA, Crone, C, DiMartini, AF. Psychiatric disorders as risk factors for adverse medical outcomes after solid organ transplantation. Current Opinion in Organ Transplantation 2012;17(2):188–92.CrossRefGoogle ScholarPubMed

37. Rosenberger, EM, DiMartini, AF, DeVito Dabbs, AJ, Bermudez, CA, Pilewski, JM, Troyoda, Y, et al. Psychiatric predictors of long-term transplant-related outcomes in lung transplant recipients. Transplantation 2016;100(1):239–47.CrossRefGoogle ScholarPubMed

38. Evans, LD, Stock, EM, Zeber, JE, Morissette, SB, MacCarthy, AA, Sako, EY, et al. Posttransplantation outcomes in veterans with serious mental illness. Transplantation 2015;99(8):e57–65.CrossRefGoogle ScholarPubMed

39. Gysin-Maillart, A, Schwab, S, Soravia, L, Megert, M, Michel, K. A novel brief therapy for patients who attempt suicide: A 24-months follow-up randomized controlled study of the Attempted Suicide Short Intervention Program (ASSIP). PLOS Medicine 2016;13(3):e1001968.CrossRefGoogle Scholar

40. Fleischmann, A, Bertolote, JM, Wasserman, D, De Leo, D, Bolhari, J, Botega, NJ, et al. Effectiveness of brief intervention and contact for suicide attempters: A randomized controlled trial in five countries. Bulletin of the World Health Organization 2008;86(9):703–9.CrossRefGoogle ScholarPubMed

41. Welu, TC. A follow-up program for suicide attempters: Evaluation of effectiveness. Suicide and Life-Threatening Behavior 1977;7(1):17–20.Google ScholarPubMed

42. Smeets, R, Rendenbach, C, Birkelbach, M, Al-Dam, A, Grobe, A, Hanken, H, et al. Face transplantation: On the verge of becoming clinical routine? Biomed Research International 2014;2014:907272.CrossRefGoogle ScholarPubMed

43. See note 15, Coffman 2015:222–8.

44. Pomahac, B, Diaz-Siso, JR, Bueno, EM. Evolution of indications for facial transplantation. Journal of Plastic, Reconstructive & Aesthetic Surgery 2011;64(11):1410–6.CrossRefGoogle ScholarPubMed

45. Losee, JE, Fletcher, DR, Gorantla, VS. Human facial allotransplantation: Patient selection and pertinent considerations. Journal of Craniofacial Surgery 2012;23(1):260-4.CrossRefGoogle ScholarPubMed

46. Siemionow, MZ, Gordon, CR. Institutional review board-based recommendations for medical institutions pursuing protocol approval for facial transplantation. Plastic and Reconstructive Surgery 2010;126(4):1232–9.CrossRefGoogle ScholarPubMed

47. See note 45, Losee et al. 2012.

48. See note 46, Siemionow, Gordon 2010.

49. Lantieri, L, Hivelin, M, Audard, V, Benjoar, MD, Meningaud, JP, Bellivier, F, et al. Feasibility, reproducibility, risks and benefits of face transplantation: A prospective study of outcomes. American Journal of Transplantation 2011;11(2):367–78.CrossRefGoogle ScholarPubMed

50. See note 15, Coffman 2015.

51. Siemionow, M, Gordon, CR. Overview of guidelines for establishing a face transplant program: A work in progress. American Journal of Transplantation 2010;10(5):1290-6.CrossRefGoogle ScholarPubMed

52. See note 44, Pomahac et al. 2011.

53. See note 46, Siemionow, Gordon 2010.

54. See note 15, Coffman 2015.

55. See note 45, Losee et al. 2012.

56. See note 46, Siemionow, Gordon 2010.

57. See note 46, Siemionow, Gordon 2010.

58. See note 44, Pomahac et al. 2011.

59. See note 45, Losee et al. 2012.

60. Jowsey-Gregoire, S, Kumnig, M. Standardizing psychosocial assessment for vascularized composite allotransplantation. Current Opinion in Organ Transplantation 2016;21(5):530–5.CrossRefGoogle ScholarPubMed

61. Bueno, EM, Diaz-Siso, JR, Pomahac, B. A multidisciplinary protocol for face transplantation at Brigham and Women’s Hospital. Journal of Plastic, Reconstructive & Aesthetic Surgery 2011;64(12):1572–9.CrossRefGoogle ScholarPubMed

62. See note 5, Lantieri et al. 2016.

63. See note 5, Lantieri et al. 2016.

64. See note 6, Kiwanuka et al. 2016.

65. See note 5, Lantieri et al. 2016.

66. See note 6, Kiwanuka et al. 2016.

67. See note 5, Lantieri et al. 2016.

68. Coffman, KL, Siemionow, MZ. Face transplantation: Psychological outcomes at three-year follow-up. Psychosomatics 2013;54(4):372–8.CrossRefGoogle ScholarPubMed

69. Barret, JP, Gavalda, J, Bueno, J, Nuvials, X, Pont, T, Masnou, N, et al. Full face transplant: The first case report. Annals of Surgery 2011;254(2):252–6.CrossRefGoogle ScholarPubMed

70. Roche, NA, Blondeel, PN, Vermeersch, HF, Peeters, PC, Lemmens, GM, De Cubber, J, et al. Long-term multifunctional outcome and risks of face vascularized composite allotransplantation. Journal of Craniofacial Surgery 2015;26(7):2038–46.CrossRefGoogle ScholarPubMed

71. Khalifian, S, Brazio, PS, Mohan, R, Shaffer, C, Brandacher, G, Barth, RN, et al. Facial transplantation: The first 9 years. The Lancet 2014;384(9960):2153–63.CrossRefGoogle ScholarPubMed

72. Battin, MP, ed. The Ethics of Suicide: Historical Sources . New York: Oxford University Press USA; 2015.Google Scholar

73. Marsh, I. The uses of history in the unmaking of modern suicide. Journal of Social History 2013;46(3):744–56.CrossRefGoogle Scholar

74. Jamison, K, Hawton, K. The burden of suicide and clinical suggestions for prevention. In: Hawton, K, editor. Prevention and Treatment of Suicidal Behaviour: From Science to Practice. New York: Oxford University Press; 2005.Google Scholar

75. Mann, JJ. Neurobiology of suicidal behavior. Nature Reviews Neuroscience 2003;4(10):819–28.CrossRefGoogle Scholar

76. Klonsky, ED, May AM, Saffer BY. Suicide, suicide attempts, and suicidal ideation. Annual Review of Clinical Psychology 2016;12:307–30.CrossRefGoogle ScholarPubMed

77. See note 72, Battin 2015.

78. See note 73, Marsh 2013.

79. Szasz, TS. The ethics of suicide. The Antioch Review 1971;31(1):7–17.CrossRefGoogle Scholar

80. Ji, J, Kleinman, A, Becker, AE. Suicide in contemporary China: A review of China’s distinctive suicide demographics in their sociocultural context. Harvard Review of Psychiatry 2001;9(1):1–12.CrossRefGoogle ScholarPubMed

81. Crone, C, DiMartini, A. Liver transplant for intentional acetaminophen overdose: A survey of transplant clinicians experiences with recommendations. Psychosomatics 2014;55(6):602–12.CrossRefGoogle ScholarPubMed

82. Cooper, SC, Aldridge, RC, Shah, T, Webb, K, Nightingale, P, Paris, S, et al. Outcomes of liver transplantation for paracetamol (acetaminophen)-induced hepatic failure. Liver Transplantation 2009;15(10):1351–7.CrossRefGoogle ScholarPubMed

83. Thornton, V. Who gets the liver transplant? The use of responsibility as the tie breaker. Journal of Medical Ethics 2009;35(12):739–42.CrossRefGoogle ScholarPubMed

84. Khan, LR, Oniscu, GC, Powell, JJ. Long-term outcome following liver transplantation for paracetamol overdose. Transplant International 2010;23(5):524–9.CrossRefGoogle ScholarPubMed

85. Rhodes, R, Aggarwal, S, Schiano, TD. Overdose with suicidal intent: Ethical considerations for liver transplant programs. Liver Transplantation 2011;17(9):1111–6.Google ScholarPubMed

86. Willey, JZ, Tolchin, BD. Liver transplant for international acetaminophen overdose and hepatic encephalopathy: A conflict between beneficence and justice. Continuum: Lifelong Learning in Neurology 2014;20(3 Neurology of Systemic Disease):681–5.Google Scholar

87. Karvellas, CJ, Safinia, N, Auzinger, G, Heaton, N, Muiesan, P, O’Grady, J, et al. Medical and psychiatric outcomes for patients transplanted for acetaminophen-induced acute liver failure: A case-control study. Liver International 2010;30(6):826–33.CrossRefGoogle ScholarPubMed

88. Appel, J, Vaidya, S. Ethical dilemmas in psychiatric evaluations in patients with fulminant liver failure. Current Opinion in Organ Transplantation 2014;19(2):175–80.CrossRefGoogle ScholarPubMed

89. Forster, J, Bartholome, WG, Delcore, R. Should a patient who attempted suicide receive a liver transplant? Journal of Clinical Ethics 1996;7(3):257–67.Google ScholarPubMed

90. Aulisio, MP, Arnold, RN. Exclusionary criteria and suicidal behavior: Comment on “should a patient who attempted suicide receive a liver transplant”? Journal of Clinical Ethics 1996;7(3):277–83.Google ScholarPubMed

91. Atterbury, CE. Annubis and the feather of truth: Judging transplant candidates who engage in self-damaging behavior. Journal of Clinical Ethics 1996;7(3):268–76.Google Scholar

92. Faeder, S, Moschenross, D, Rosenberger, E, Dew, MA, DiMartini, A. Psychiatric aspects of organ transplantation and donation. Current Opinion in Psychiatry 2015;28(5):357–64.CrossRefGoogle ScholarPubMed

93. O’Grady, JG, Wendon, J, Tan, KC, Potter, D, Cottam, S, Cohen, AT, et al. Liver transplantation after paracetamol overdose. The British Medical Journal 1991;303(6796):221–3.CrossRefGoogle ScholarPubMed

94. See note 83, Thornton 2009.

95. See note 85, Rhodes et al. 2011.

96. See note 88, Appel, Vaidya 2014.

97. See note 90, Aulisio, Arnold 1996.

98. Ethical considerations in the allocation of organs and other scarce medical resources among patients. Council on Ethical and Judicial Affairs, American Medical Association. Archives of Internal Medicine 1995;155(1):29–40.

99. See note 85, Rhodes et al. 2011.

100. See note 90, Aulisio, Arnold 1996:277–83.

101. See note 98, 1995:29–40.

102. Sharkey, K, Gillam, L. Should patients with self-inflicted illness receive lower priority in access to healthcare resources? Mapping out the debate. Journal of Medical Ethics 2010;36(11):661–5.CrossRefGoogle ScholarPubMed

103. Friesen, P. Personal responsibility within health policy: Unethical and ineffective. Journal of Medical Ethics 2018;44(1):53–8.CrossRefGoogle ScholarPubMed

104. See note 98, 1995.

105. See note 98, 1995.

106. See note 85, Rhodes et al. 2011.

107. See note 88, Appel, Vaidya 2014.

108. See note 89, Forster et al. 1996.

109. See note 91, Atterbury 1996.

110. See note 92, Faeder et al. 2015.

111. Carosella, ED, Pradeu, T. Transplantation and identity: A dangerous split? The Lancet 2006;368(9531):183–4.CrossRefGoogle ScholarPubMed

112. Meyer, VE. Hand transplantation. The Journal of Hand Surgery: British & European Volume 2001;26(6):509–10.CrossRefGoogle ScholarPubMed

113. Zhang, LC, Zhao, YB, Hu, WL. Ethical issues in penile transplantation. Asian Journal of Andrology 2010;12(6):795–800.CrossRefGoogle ScholarPubMed

114. BBC News. UK’s first hand transplant operation [Internet]. Gallagher, J, author. [cited 2017 Sep 24]; available at http://www.bbc.com/news/health-20898940 (last accessed 16 Dec 2018).Google Scholar

115. Morris, P, Bradley, A, Doyal, L, Earley, M, Hagen, P, Milling, M, et al. Face transplantation: A review of the technical, immunological, psychological and clinical issues with recommendations for good practice. Transplantation 2007;83(2):109–28.CrossRefGoogle ScholarPubMed

116. Kumnig, M, Jowsey-Gregoire, SG. Key psychosocial challenges in vascularized composite allotransplantation. World Journal of Transplantation 2016;6(1):91–102.CrossRefGoogle ScholarPubMed

117. Sarwer, DB, Ritter, S, Reiser, K, Spitzer, JC, Baumann, BM, Patel, SN, et al. Attitudes towards vascularized composite allotransplantation of the hands and face in an urban population. Vascularized Composite Allotransplantation 2014;1(1-2):22–30.CrossRefGoogle Scholar

118. Plana, N, Kimberly, L, Parent, B, Khouri, K, Diaz-Siso, JR, Frymi, E, et al. The public face of transplantation: The potential of education to expand the face donor pool. Plastic and Reconstructive Surgery 2018;141(1):176–85.CrossRefGoogle ScholarPubMed

119. Parent, B. Informing donors about hand and face transplants: Time to update the uniform anatomical gift act. Journal of Health & Biomedical Law 2015;10(309).Google Scholar

120. Haustein, SV, Sellers, MT. Factors associated with (un)willingness to be an organ donor: Importance of public exposure and knowledge. Clinical Transplantation 2004;18(2):193–200.CrossRefGoogle ScholarPubMed

121. Furr, LA, Wiggins, O, Cunningham, M, Vasilic, D, Brown, CS, Banis, JC Jr., et al. Psychosocial implications of disfigurement and the future of human face transplantation. Plastic and Reconstructive Surgery 2007;120(2):559–65.CrossRefGoogle ScholarPubMed

122. Hartman, RG. Face value: Challenges of transplant technology. American Journal of Law & Medicine 2005;31(1):7–46.CrossRefGoogle ScholarPubMed

123. Rodrigue, JR, Tomich, D, Fleishman, A, Glazier, AK. Vascularized composite allograft donation and transplantation: A survey of public attitudes in the United States. American Journal of Transplantation 2017;17(10):2687–95.CrossRefGoogle ScholarPubMed

124. Neuberger, J, Adams, D, MacMaster, P, Maidment, A, Speed, M. Assessing priorities for allocation of donor liver grafts: Survey of public and clinicians. The British Medical Journal 1998;317(7152):172–5.CrossRefGoogle ScholarPubMed

125. Walter, M, Papachristou, C, Danzer, G, Klapp, BF, Frommer, J. Willingness to donate: An interview study before liver transplantation. Journal of Medical Ethics 2004;30(6):544–50.CrossRefGoogle ScholarPubMed

126. Donor Alliance: Organ Tissue & Donation [Internet]. Donor Alliance Inc.; c2018 [cited 24 Sept 2017]; available at https://www.donoralliance.org/understanding-donation/why-donate/donation-faq/ (last accessed 18 Dec 2018).Google Scholar

127. Donate Life Washington, DC [Internet]. Donate Life DC; c2018 [cited 24 Sept 2017]; available at https://www.donatelifedc.org/frequently-asked-questions/(last accessed 18 Dec 2018).

128. U.S. Department of Health & Human Services: Organ Procurement and Transplantation Network [Internet]. Organ Procurement & Transplantation Network; c2018 [cited 24 Sept 2017]; available at https://optn.transplant.hrsa.gov/resources/guidance/guidance-for-donor-and-recipient-information-sharing/ (last accessed 18 Dec 2018).

129. See note 72, Battin 2015.

130. See note 79, Szasz 1971.

131. Siemionow, M, Gatherwright, J, Djohan, R, Papay, F. Cost analysis of conventional facial reconstruction procedures followed by face transplantation. American Journal of Transplantation 2011;11(2):379–85.CrossRefGoogle ScholarPubMed

132. Hawton, K. Assessment of suicide risk. British Journal of Psychiatry 1987;150:145–53.CrossRefGoogle ScholarPubMed

133. See note 20, Runeson et al. 2010:c3222.

134. See note 22, Beautrais 2003.

135. See note 23, Miller et al. 2013.

136. See note 24, Suokas et al. 2001.

137. Owens, D, Horrocks, J, House, A. Fatal and non-fatal repetition of self-harm. Systematic review. British Journal of Psychiatry 2002;181:193–9.CrossRefGoogle ScholarPubMed

138. Cullberg, J, Wasserman, D, Stefansson, CG. Who commits suicide after a suicide attempt? An 8 to 10 year follow up in a suburban catchment area. Acta Psychiatrica Scandinavica 1988;77(5):598–603.CrossRefGoogle Scholar

139. Pageaux, GP, Michel, J, Coste, V, Perney, P, Possoz, P, Perrigault, PF, et al. Alcoholic cirrhosis is a good indication for liver transplantation, even for cases of recidivism. Gut 1999;45(3):421–6.CrossRefGoogle ScholarPubMed

140. Wiesner, RH, Lombardero, M, Lake, JR, Everhart, J, Detre, KM. Liver transplantation for end-stage alcoholic liver disease: An assessment of outcomes. Liver Transplantation and Surgery 1997;3(3):231–9.CrossRefGoogle ScholarPubMed

141. Varma, V, Webb, K, Mirza, DF. Liver transplantation for alcoholic liver disease. World Journal of Gastroenterology 2010;16(35):4377–93.CrossRefGoogle ScholarPubMed

142. Galai, N, Safaeian, M, Viahov, D, Bolotin, A, Celentano, DD, Study, A. Longitudinal patterns of drug injection behavior in the ALIVE study cohort, 1988–2000: Description and determinants. American Journal of Epidemiology 2003;158(7):695–704.CrossRefGoogle ScholarPubMed

143. Xia, Y, Seaman, S, Hickman, M, Macleod, J, Robertson, R, Copeland, L, et al. Factors affecting repeated cessations of injecting drug use and relapses during the entire injecting career among the Edinburgh addiction cohort. Drug and Alcohol Dependence 2015;151:76–83.CrossRefGoogle ScholarPubMed

144. Evans, JL, Hahn, JA, Lum, PJ, Stein, ES, Page, K. Predictors of injection drug use cessation and relapse in a prospective cohort of young injection drug users in San Francisco, CA (UFO study). Drug and Alcohol Dependence 2009;101(3):152–7.CrossRefGoogle Scholar

145. Hull, SC, Jadbabaie, F. When is enough enough? The dilemma of valve replacement in a recidivist intravenous drug user. The Annals of Thoracic Surgery 2014;97(5):1486–7.CrossRefGoogle Scholar

146. DiMaio, JM, Salerno, TA, Bernstein, R, Araujo, K, Ricci, M, Sade, RM. Ethical obligation of surgeons to noncompliant patients: Can a surgeon refuse to operate on an intravenous drug-abusing patient with recurrent aortic valve prosthesis infection? The Annals of Thoracic Surgery 2009;88(1):1–8.CrossRefGoogle ScholarPubMed

147. Miljeteig, I, Skrede, S, Langorgen, J, Haaverstad, R, Josendal, O, Sjursen, H, et al. Should patients who use illicit drugs be offered a second heart-valve replacement? Tidsskrift for Den Norske Laegeforening 2013;133(9):977–80.CrossRefGoogle ScholarPubMed

148. Tampa Bay Times. Heroin’s surge raises life-or-death medical ethics issue [Internet]. Morelli K, author. [cited 28 Sept 2017]; available at http://www.tbo.com/health/heroins-surge-raises-life-or-death-medical-ethics-issue-20160101/ (last accessed 16 Dec 2018).

149. See note 145, Hull, Jadbabaie 2014:1486–7.

150. See note 146, DiMaio et al. 2009.

151. See note 147, Miljieteig et al. 2013.

152. See note 146, DiMaio et al. 2009.

153. See note 148, Morelli 2016.

154. See note 148, Morelli 2016.

155. DrugRehab. Florida’s opioid crisis fueled by pill mills [Internet]. Johnson P, author. [cited 28 Sept 2017]; available at https://www.drugrehab.com/2017/03/01/florida-pill-mill-crisis/ (last accessed 18 Dec 2018).