The face transplant performed a few weeks ago by Dr. Maria Siemionow, a skilled and caring surgeon, and a team of other specialists at the Cleveland Clinic went far beyond several prior experiments, including the world's first such procedure in France three years ago. The Cleveland Clinic doctors replaced nearly the whole face of a woman with one from a female cadaver.
Given the high risk of failure from the rejection of the donor's skin, is such a pioneering procedure worth the danger to the patient’s life?
When face transplants were first proposed 10 years ago I thought they were unethical. But, after the success of the French procedure, and after listening to Dr. Siemionow and other surgeons talk about their preparations for the first nearly total face transplant in the U.S., I no longer think that is so.
A transplanted face is biologically like any other transplanted organ: There is always a risk that the recipient’s body will reject it. The immunosuppressive drugs that must be used to try to prevent such a disaster are powerful, but can cause fatal cancers and other serious side-effects, such as kidney failure. Normally, transplant surgeons don’t worry much about these risks because they pale in comparison to the certain death that awaits someone whose heart or liver have stopped working. But a face transplant is intended to improve the quality of life rather than save a life, as a heart, lung, kidney or liver transplant does.
It’s important to note that the surgical skill required to transplant a face and have it function — chew, smile, frown, breathe, blink — has evolved to the point where the odds now favor success. The management of dangerous immunosuppressive drugs has also improved so that handling rejection of the facial tissue seems feasible. There is no doubt that Siemionow has the competency and her team the skills to try the experiment.
After talking to some people with severe facial disfigurement, I realize it makes ethical sense to offer a form of surgery that might kill the patient, because the suffering of the afflicted is so great that they are willing to risk death. We don’t hear much about those with facial deformities due to birth defects, burns, trauma, cancer or violence. That’s because the stigma of severe facial deformity is so enormous, so staggering, that many simply withdraw from society. Others find that, despite the best efforts of reconstructive surgeons, they are unable to eat, breathe or speak comfortably, and are condemned to lives of suffering and pain.
A face transplant, despite its very real dangers, might bring relief. The science has reached the point where trying to help those who are beyond the help of current medical treatments is not just ethical, but almost obligatory.
No second chances
Yet, even though a strong case can be made in defense of what has been tried in Cleveland, there are ethical concerns about face transplants.
If the woman who received her new face from a cadaver were to begin to lose it due to tissue rejection that could not be stopped, what will happen? There are no second chances with face transplants — the damage of rejection makes that impossible. What if someone facing this horrendous prospect – life with no face at all — says no to artificial feeding or breathing? What if they beg for morphine to help them die painlessly and more quickly? Any team undertaking face transplants must be ready to manage a failed experiment.
The only humane response to the courage it takes to be the subject of a face transplant is to be ready to help that person in any way necessary, including assistance in dying. The idea of assisted-suicide for tragic transplant failures pushes right up against the law, but insisting on life with no face, as opposed to a horribly disfigured one, is too daunting a prospect to proceed ethically — if death is not an option.
Face transplants raise another issue. When you signed a donor card or checked the box on your driver’s license, you probably were not thinking that when you died someone might want to transplant your face. We don’t know what happened in the Cleveland case, but I strongly suspect they used a donor who had a donor card and whose family also approved the removal of the face.
Do we need to insist that no faces be taken from the dead without the advance permission of both the deceased and their family? Shouldn’t the family have some input since they will have to live with the emotional turmoil of potentially seeing a face that somewhat resembles a loved one on another person? And should the laws governing organ donation be revised so donors have the option to give permission, or deny permission, for a facial transplant?
Issues of personal identity
The Cleveland transplant is a ringing alarm clock that it is time to revisit the legislation governing organ and tissue donation. Face transplants raise emotional issues that do not arise when a liver or a pancreas is transplanted. We identify ourselves and each other by our faces. We fall in love with faces. We know much about mood, emotions, and state of mind by simply looking at faces. Some may have no issue giving their liver, corneas, bones, heart or lungs to help others, but the face is simply a different matter.
Should we allow each person to set their limits on what can be taken from their body after death? Facial transplants are the cutting edge of a wave of new forms of transplantation, including hand and limb transplants, ovarian transplants, uterine transplants and testicular transplants. While it is not clear that these newer types of transplants cross ethical boundaries that ought never be crossed, they surely do raise issues of personal identity and reproductive capacities.
The transplant in Cleveland was done with the laudable goal of trying to help those who are often on the margins of society due to their appearance, or because they cannot eat, speak, drink, smile or breathe without huge effort. Some victims take their own lives in despair. These people should be able to take their chances with a facial transplant if nothing else can help them. That said, medical advances in facial transplants push us into a very new ethical world where life after failure may not be an acceptable option, and where some among us may say they are not willing to give what is required to help.
Arthur Caplan, Ph.D., is director of the Center for Bioethics at the University of Pennsylvania