The ethics of face transplants

As reported by AP (courtesy of Yahoo!), a team of doctors from the University of Louisville and the Netherlands has joined similar teams from Cleveland, England and France, all waiting for the chance to perform a face transplant. The procedure involves removing a donor's skin and other tissue, putting it over the recipient's bone and cartilage and reconnecting it. The team plans to reserve the procedure for patients whose faces have been severely disfigured as the result of disease or accident. A series of articles not yet posted on the WWW but appearing in the current American Journal of Bioethics tease out the ethical pros and cons of performing the procedure.

An article in yesterday's Louisville Courier-Journal explores some of the ethical considerations:

Nichola Rumsey of the University of the West of England, an expert in psychosocial issues in medicine, expressed [reservations] in one of 14 essays written in reaction to the UofL/Utrecht article and published in the bioethics journal.

"Previous research and current understanding indicate that the psychological risks are more complex and extensive than the Louisville team suggest," she wrote. "I have no wish to minimize the distress experienced by many people with severe disfigurements, but to my mind, the current risk/benefit ratio ... is dubious at best."

But Osborne P. Wiggins, chairman of the UofL philosophy department and one of the authors of today's article, said researchers have gotten as far as they can without actually performing the procedure.

"Do we let the uncertainties and unknowns stop us and decide not to do it at all? Or do we go ahead and perform the procedure and learn the answers? We're willing to take the second option," Wiggins said.

Face transplants differ from other transplants because the face is an integral part of someone's identity, said the researchers, who helped write the article. "What is at stake," the researchers wrote, "is a person's self-image, social acceptability and a sense of normalcy as he or she subjectively experiences them." * * *

Researchers outlined some potential problems, such as misuse of the procedure. Aging rich people, for example, might seek a transplant for cosmetic improvements and criminals might want to conceal their identity, researchers said.

People getting such transplants would also face the same risks as other transplant recipients, such as the increased incidence of infection and cancer associated with immunosuppressive drugs. * * *

But the benefits are many, researchers said in the bioethics article. For example, transplants could restore facial expressions and sensory functions and improve people's psychological outlook. Besides Louisville, such transplants are being considered by teams in Cleveland, England and France.

"In a large number of cases facial disfigurement leads to depression, social isolation and even the risk of suicide," the UofL researchers wrote. "Restoring the abilities
to make facial expressions, enjoy an aesthetically acceptable appearance and
interact comfortably with others lends significant weight to the benefit side of the risk/benefit equation."

But the other side of the equation weighs heavy too, some experts said.

Rumsey, the English researcher, wrote that potential recipients might have to wait a long time for suitable donors and might be tempted to put their lives on hold in the interim. They might also have to endure lots of media coverage, she said. Socially, she wrote, such a procedure might convey the notion that people can't live well with disfiguring conditions. Carson Strong, of the University of Tennessee College of Medicine, wrote that two prominent professional committees — the Royal College of Surgeons of England and the French National Ethics Advisory Committee — have said that a face transplant should not be carried out now.

Strong said recipients would face the risk that their grafts could fail, making things worse. But other experts agreed with UofL researchers that the time for a transplant is now. "Our position is that face transplantation could now be performed," wrote three surgeons from Henri-Mondor Hospital in Paris. "The switch from `could' to `should' depends on the ethical conditions surrounding the procedure."

UofL researchers said they are considering all of the critiques as they move forward. They also have to take several additional steps, such as developing a program with Kentucky's organ procurement agency, developing a funding strategy and finding a full clinical team. The team also needs to find a hospital in which to perform the procedure.