Face Transplants: Medicine's New Ethical Dilemma

With a full U.S. transplant looming, some experts question when, if ever, the surgery is warranted

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By Amanda Gardner
HealthDay Reporter

WEDNESDAY, Dec. 7, 2005 (HealthDay News) -- French doctors who recently performed the world's first partial face transplant pushed not only scientific frontiers, but ethical ones as well.

The feat, which has struck a chord among professionals and lay people alike, has spurred heated debates on everything from the meaning of identity to doctor-patient relationships and the future of medicine.

The issues take on even more urgency as surgeons at the Cleveland Clinic in the United States screen candidates in preparation for the world's first full face transplant.

"With a partial transplant of the sort they've done in France, the stakes are less high," said Kenneth Goodman, director of the Bioethics Program at the University of Miami. "The procedure contemplated in Cleveland raises very interesting questions about personal identity, and how people think of themselves. That raises questions about the psychological and psychiatric risks, and we don't know what those are. We don't know how to communicate to people what it would be like to completely have a new face."

A large degree of uncertainty and mystery already surrounds the French case, which is acquiring all the elements of a Gothic novel.

The patient, a 38-year-old French woman, became severely disfigured after her dog attacked her in May. Doctors grafted a nose, lips and chin onto her face in December.

Beyond these bare facts, however, little else is clear. There have been allegations that the woman had attempted suicide by overdosing on pills and that the donor, a brain-dead patient, had hanged herself.

These allegations, in turn, have raised questions about the psychological state of the patient and the ethics of doing this surgery on this patient, with this donor, in the first place.

"The most important part of the relationship between doctor and patient is informed or valid consent. The patient needs to know what the risks are and what the alternatives are, and that requires that they be able to process information and make reasoned decisions," Goodman said. "Desperate people are poor models for the consent process. They're vulnerable by virtue of desperation."

People with suicidal thoughts or tendencies also "raise especially crimson-colored red flags," Goodman added. "In this context, the questions having to do with identity and the risks of surgery are substantially unknown. What you want for a really risky situation are patients who have their bolts in as tight as possible."

Many critics contend that the French team cut a few ethical and other corners in order to win the distinction of having performed the first partial face transplant. At the same time, they may have pushed hard on the publicity pedal.

"They didn't publish it in the scientific literature, but went to the lay press. It puts their credibility at issue," said Dr. David Arnold, an assistant professor of otolaryngology and head and neck surgery at the University of Miami Miller School of Medicine. "This smacks of showboating."

The surgeons, however, defended themselves at a news conference reported in The New York Times. "We are doctors," said Jean-Michel Dubernard, one of the doctors who led the transplant team. "We had a patient with a very severe disfigurement that would have been extremely difficult, if not impossible, to repair with classic surgery."

According to a profile in the Times, Dubernard leads a double life as a politician, a former deputy mayor of Lyon, and one of the most powerful members of the French National Assembly. A chain smoker who is no stranger to controversy, Dubernard gained notoriety after he transplanted a new hand to patient Clint Hallam in 1998. It was later revealed that Hallam had lost his hand while in prison, the Times reported.

Neither hand nor face transplants are technically lifesaving procedures, like receiving a kidney or heart would be. Yet all the procedures require recipients to take immunosuppressant drugs for the rest of their lives.

"You have to knock down the recipient's immune system, and that's one of the reasons why I can't ever see this working," Arnold said. Hallam refused to take his drugs, and eventually had his donated hand amputated.

Face transplants occupy such murky territory that the French National Ethics Advisory Committee and the Royal College of Surgeons of England rejected doing them, although the French body left open the possibility of doing partial transplants, the Cleveland Plain Dealer reported. The Cleveland Clinic team worked for more than a year to get approval for their procedure. They are currently evaluating 12 people who have been disfigured, and have fielded dozens of other inquiries from interested patients, according to the Dealer.

And then there's the issue of the face which, unlike a kidney or lung, is a major component in identity, providing the visual platform from which we interact with the world.

"It's important to recognize that patients who have very severe facial disfigurement have a suicide rate four times that of the general population and a very poor quality of life," said Dr. Malcolm Z. Roth, director of plastic surgery at Maimonides Medical Center in New York City.

"If somebody is not a candidate for standard reconstructive techniques, there are very, very rare indications where this might be considered," Roth added.

And "considered" may well be the operative word.

"There will always be scarring and the need for medications," Roth said. "It's critical that you select your patients wisely, and make sure that patients understand that this will be a long road, a forever road."

More information

For more on reconstructive surgery, see the Web site of the American Society for Plastic Surgeons.

SOURCES: Malcolm Z. Roth, M.D., FACS, director, plastic surgery, Maimonides Medical Center, New York City; David Arnold, M.D., FACS, assistant professor, otolaryngology and head and neck surgery, University of Miami Miller School of Medicine; Kenneth Goodman, Ph.D., director, Bioethics Program, University of Miami; The New York Times; Cleveland Plain Dealer

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