Inside the Finnish Mind: How Psychologists Screen Face and Hand Transplant Candidates

When a person loses a face or a hand, medicine can rebuild what was taken. But deciding who deserves that second chance is one of the most ethically fraught questions in modern surgery. Now, clinicians at Helsinki University Hospital have opened a rare window into how they answer it, publishing the first detailed account of the psychosocial machinery behind Finland’s national face and hand transplant program.

Vascularized composite allotransplantation, or VCA, sits in a category of its own among transplant procedures. Unlike a heart or kidney, a transplanted face or pair of hands will not save a life. Instead, it restores function, appearance, and the ability to participate in society, benefits that are real but purchased with a lifetime of immunosuppressive drugs and their attendant risks of infection, cancer, and organ damage. That trade-off, exchanging survival for quality of life, makes the psychological profile of each candidate as consequential as their surgical anatomy.

In a perspective article published in Frontiers in Transplantation, clinical psychologist Benita Antas and psychiatrist Jan Nyberg of Helsinki University Hospital describe their longitudinal observations of five candidates evaluated within the Finnish VCA program since 2013. Three of those candidates went on to receive either a face or hand transplant, and the combined assessment and follow-up period for some individuals has now exceeded six years. The article is not a formal research study but a synthesis of routine clinical care, published with the written informed consent of all patients involved and with identifying details anonymized.

The Finnish approach begins with the surgical team, which conducts an initial appraisal before referring promising candidates for deeper psychological and psychiatric evaluation. Surgeons look for stable premorbid functioning: a history of work, preserved relationships, and the capacity to maintain social networks despite disfigurement or limb loss. Adaptive traits such as perseverance, psychological flexibility, and a sustained sense of humor weigh in a candidate’s favor. The authors even invoke sisu, a culturally embedded Finnish concept of persistent determination in the face of adversity, as something that manifests clinically in the patients they assess.

Just as telling are the red flags. Chronic bitterness, externalization of blame, fixation on minor grievances, and rigid, problem-saturated thinking are considered unfavorable. Severe depressive symptoms, hopelessness, or the belief that transplantation will solve every problem in a person’s life raise additional concerns, and significant substance misuse is treated as a contraindication. Because VCA is life-enhancing rather than life-saving, candidates must show substantial quality-of-life impairment while still retaining enough functioning and adaptive capacity to endure surgery, rehabilitation, and decades of medical follow-up.

The formal psychological assessment combines a semi-structured interview with a battery of standardized instruments, including the Structured Clinical Interview for DSM Disorders, the Impact of Event Scale, the Resilience Scale, the Body Appreciation Scale, the Coping Orientation to Problems Experienced Inventory, and the Difficulties in Emotion Regulation Scale. Some candidates also completed the Personality Assessment Inventory and the Wartegg Drawing Completion Test. But the most intriguing lens the authors propose is mentalization, the capacity to understand one’s own and others’ behavior in terms of underlying mental states. They argue that a candidate’s ability to reflect on their illness, expectations, relationships, and the changes transplantation may bring could predict how well they cope with the prolonged and demanding process ahead.

Cognitive capacity receives its own careful evaluation, typically through anamnestic information such as educational and occupational history alongside clinical observations of comprehension, retention, and consistency across interviews. Only one candidate underwent formal neuropsychological testing, and no structured capacity assessment tool was employed. The psychiatric assessment, conducted by a consultation-liaison specialist, examines past and current mental disorders, symptom severity, substance use, social support, and adherence history, since poor pre-transplant adherence is a known predictor of difficulties afterward. The teach-back method, in which candidates describe the procedure, risks, and follow-up requirements in their own words, helps gauge understanding and decision-making capacity.

The clinical picture that emerges from the Finnish cohort is notably encouraging. Psychiatric symptoms observed during assessment were limited to mild depressive and adjustment-related symptoms, with no trauma-related disorders identified. Although a history of suicidality was present in the candidate group, no active suicidality was observed at evaluation or during follow-up. Candidates’ expectations proved generally realistic, with primary goals emphasizing function over appearance, such as breathing through the nose after facial transplantation or gaining independence in daily activities after hand transplantation. Recipients demonstrated high resilience and sustained motivation, with humor emerging as an important emotional resource. During rehabilitation plateaus, recipients described transient frustration, captured by the Finnish colloquial term vitutus, a situational emotional response rather than sustained psychopathology.

Yet the Finnish experience also exposes practical tensions inherent in a centralized national model. None of the recipients live in the capital, and for some, travel distances are substantial. Limited familiarity with VCA among regional providers can result in referrals back to the transplant center even for minor issues, adding logistical strain. Recipient feedback emphasizes the value of accessible, low-threshold communication with the transplant team, and one recipient specifically noted the importance of clear written guidance on early signs of rejection, medication side effects, and self-care strategies. Long waiting periods shaped by donor availability were described as psychologically demanding, with some individuals experiencing a sense of life being on hold.

Perhaps most striking is what recipients said about identity. Two explicitly expressed a wish not to be perceived solely through the transplant, as a face or a hand, but as whole individuals with relationships and life contexts extending beyond the graft. As functional recovery progresses, emerging sensory and motor experiences appear to support the development of a sense of ownership over the graft, but recipients emphasized that transplantation does not define them entirely. Based on these observations, the authors propose three interrelated domains for psychosocial assessment in VCA: psychosocial functioning, cognitive capacity, and social context. They acknowledge the limitations of a small, highly selected national program and note that formal psychometric evaluations were not conducted systematically during follow-up. Still, their central message is clear: psychosocial suitability in VCA is not a snapshot but a process, one that must be reassessed and supported from the first referral through decades of life with a visible graft.

Subject of Research: Psychosocial assessment and follow-up of vascularized composite allotransplantation candidates in the Finnish national VCA program

Article Title: Psychosocial assessment and follow-up in vascularized composite allotransplantation candidates: clinical observations from the Finnish experience

Article References: Antas, B., & Nyberg, J. (2026). Psychosocial assessment and follow-up in vascularized composite allotransplantation candidates: clinical observations from the Finnish experience. Frontiers in Transplantation, 5, Article 1845139. https://doi.org/10.3389/frtra.2026.1845139

Image Credits: AI Generated

DOI: 10.3389/frtra.2026.1845139

Keywords: vascularized composite allotransplantation, face transplantation, hand transplantation, psychosocial assessment, mentalization, Helsinki University Hospital, transplant psychiatry, Psychosocial, assessment, follow-up, vascularized, composite