Are face transplants ethical?

Arthur Caplan has changed his mind about face transplants. Who is he and why is that important? Caplan is a bioethicist, and “public intellectual” on issues of medical ethics. He appears widely on national news and discusses ethical issues in a variety of publications, including a regular column for MSNBC.com.

Caplan’s change of heart reflects a change in the ethical understanding of face transplants. Simply put, face transplant was originally viewed as a way of changing identity, sort of like the strikingly “realistic” face masks of old Mission Impossible TV series. Now, there is a greater appreciation of face transplant as a form of reconstruction for those who have suffered catastrophic facial injuries.

Caplan documents the change in his thinking in a recent MSNBC column:

When face transplants were first proposed 10 years ago I thought they were unethical…

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…

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.

What caused Caplan to reconsider?

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.

I agree with Caplan’s new understanding of ethical justification for face transplant. However, previous claims by Caplan and others that face transplantation is unethical rested on a the fact that face transplant has been misnamed. A transplant (as in the case of kidneys, for example) involves the complete exchange of a failing organ for an entirely different organ with better function. Face transplantation is not an exchange.

Face transplant is simply an advanced form of reconstruction. In most cases of severe facial injury, parts are taken from the patient herself and used to reconstruct her face. Bone may be harvested from one part of her body, and skin in another, both in an attempt to replace missing features and rebuild the face that existed. Sometimes the damage is so extensive that the patient herself cannot donate enough tissue to complete the reconstruction. In that case, parts can be harvested from a cadaver to replace what cannot be rebuilt.

Medical ethicists viewed face transplantation as an actual transplant of one persons “face” to replace another person’s face. Even if that is accomplished technically, it can’t really change identity, because the underlying bone structure and placement of features like eyes and mouth always remain. Advanced facial reconstruction by harvesting missing parts from cadavers, in contrast, deliberately attempts to rebuild the face as it existed before the injury. Caplan and others worried about face transplantation as an opportunity to change identity. In reality, it is an opportunity to regain identity.

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