The New Face of Medicine: An Analysis of Facial Transplantation. Christopher Good FSEM Dr. Wynn 11/01/2017

Transcription

1 1 The New Face of Medicine: An Analysis of Facial Transplantation Christopher Good FSEM Dr. Wynn 11/01/2017

2 2 Imagine waking up one morning and seeing your reflection in the mirror. Except, you do not recognize your own reflection because you have someone else s face. Although the very scenario sounds like something straight out of a science fiction movie, this has been made real through a medical procedure known as facial transplantation. Despite the ethical implications, facial transplantation is a medical breakthrough both from a procedural standpoint and due to the functional, aesthetic, and social benefits it offers recipients. Before examining ethical considerations, it s necessary to understand how facial transplants work. Officially called a facial allograft transplantation (Eun 2014,) the procedure involves the removal of a flap of skin (containing its own nerves and blood vessels) and sometimes bone and muscle tissue from a donor s face (while the donor is on life support), which is then transplanted onto another person s face (Morris, et al 2007). This is revolutionary because unlike a skin graft, which uses the patient s own tissues, allograft means that tissues in a facial transplant are transferred from one individual of the same species (homo sapiens) to another who is not genetically identical. It should also be noted that there are two types of facial transplantation: partial face transplants and full-face transplants (Morris, et al 2007). A partial face transplant is surprisingly more complicated than a full-face transplant due to the location of the surgery which involves transplanting skin, mucous membranes, and muscle around the area of the lips, nose, and potentially parts of the chin and cheeks (Morris, et al 2007). This particular type of face transplant also requires an anastomosis (reconnection) of sensory and motor nerves in order for the new part of the recipient s face to function properly (Morris, et al 2007). Regarding the other type of face transplant, a full-face transplant requires only the transplantation of the skin and hypodermis, not muscle (Morris, et al 2007).

3 3 But with both types of facial transplantation, the surgery follows a similar set of steps with the first step being the creation of a mold of the donor s face to make a mask which is then used to create a 3D model for the surgery. Next, tissues are dissected from the donor s face and transplanted onto the recipient (with the guide of the 3D model) along with any necessary attachment of blood vessels and nerves. And finally, the donor is taken off life support (Eun 2014). And because this is a transplantation surgery, two surgical teams are present (one for the donor and the other for the recipient) consisting of multiple surgeons, nurses, and anesthesiologists (Eun 2014). Thus, partial face transplants and full-face transplants are both revolutionary in the sense that unlike skin grafts, facial tissues can now be transplanted between individuals of the same species along with the reconnection of blood vessels and nerves in the face. With a basic understanding of what the procedure entails, it is also important to recognize that face transplants offer significant benefits to the recipient. According to Johns Hopkins Medicine, Not everyone with facial malformations will be eligible for a facial transplant. For many, facial reconstruction may be possible using their own tissue (Johns Hopkins). But some of those people with severe facial malformations cannot use their own tissue for reconstructive surgery for a variety of reasons including: cancerous tumors, birth defects, or trauma (Johns Hopkins). And for those people who cannot undergo conventional reconstructive surgery using their own tissues, a face transplant is their only option. However, face transplants offer both functional and aesthetic benefits for those who undergo the procedure. Such was the case with an American woman named Connie Culp, whose face was left disfigured by a shotgun blast (Blackburn 2010). And as the first American to receive a face transplant (Blackburn 2010), her case is just one of many where the recipient s life

4 4 has been dramatically changed by the procedure, and these changes have been primarily documented and spread through news media. In the case of Connie Culp, her surgery yielded successful functional results in that she now can smile and speak more clearly (Blackburn 2010). In an interview with Dianne Sawyer on ABC World News, she also reported that prior to the surgery, people in public called her names like monster but now she is just another person on the street and feels more comfortable socially (Blackburn 2010). Therefore, as the only option for some, the outcome of a face transplant can change a recipient s life for the better due to functional, aesthetic, and even social benefits. Another crucial aspect of facial transplants is the importance of the candidate. To clarify, the candidate is the person interested in receiving a face transplant, who is being evaluated to see if the procedure is right for them. Pomahac, et al, a study on face transplant recipients recoveries, presents criteria for facial transplant candidates and how that criteria affects being matched to a donor. The study discusses that the organ bank matched the candidates based on gender, blood type, and skin color to donors who had recently been declared brain dead (Pomahac, et al 2012). And of the three patients studied, all were matched to donors of the same gender, corresponding blood type, skin color, and approximate age range was also a factor with the age differences between the donors and patients being 23 years, 1 year, and 15 years respectively (Pomahac, et al 2012). However as stated before, candidates are only permitted to receive a face transplant when using their own tissues is no longer possible and without meeting this criterion, they will not be matched with a donor. But aside from the physical criteria, candidates for face transplants must also meet certain behavioral criteria as well. For example, Butler et of the Royal Free Hospital in London reports This process (of selecting appropriate recipients for face transplants) [will] involve identifying

5 5 those patients who had realistic expectations of the procedure The patient must be robust enough to cope with these challenges and the psychological effects involved (Freeman and Jaoudé 2007). This means that as members of an already socially disadvantaged group, facially disfigured candidates need to be realistic in what their face will look like after the face transplant and not become discouraged to the point that their emotional health degrades if complications occur or if the results do not meet their expectations. It should also be noted that candidates with histories of depression or substance abuse would not likely be acceptable candidates for facial transplantation. Interestingly enough, facial transplantation rose out of the successes of other composite tissue allografts such as hand transplantation in the 1990s, which established an ethical and medical protocol for future transplantation procedures (Brown, et al 2006). Dubernard et al, a report from the team of doctors that performed the first ever facial transplant, acknowledges that prior composite tissue allografts of body parts such as the hands, abdominal wall, and even a penis paved the way for facial transplantation. These procedures were revolutionary in the sense that tissues had been successfully transplanted between individuals, but until the early 2000s, it had not been performed on a human face. Dubernard et al also goes into great detail on their successes with the first (partial) facial transplant, performed in Amiens, France in 2005 on a woman who was left facially disfigured after being mauled by her dog. And despite acute episodes of facial rejection, the recipient of the first facial transplant regained most sensations in her face and could eat and drink normally a year after the surgery took place (Dubernard et al 2007). Within a year of the first facial transplant, a second procedure was performed on a Chinese man and in France again in 2007 (Dubernard, et al 2007) and since then, about 25 face transplants have been carried out and reported worldwide as of 2013 (Eun 2014). Thus, facial

6 6 transplantation evolved out of the successes of other transplantation procedures in the twentieth century and since the first face transplant in 2005, over 25 recipient s lives have been changed by the procedure. Despite facial transplantation being a scientific breakthrough, it has societal implications that need to be addressed. For one thing, the surgery is currently offered to facially disfigured individuals who cannot use their own tissues. But the whole idea of disfigurement can be contested in the sense that disfigured people are labeled as disfigured because their features go against a definition of normalcy (a socially constructed definition). This ties into the Utilitarian Approach, which examines the specific consequences of actions on a social level, because face transplants have consequences not only for recipients, but for the facially-disfigured community as a whole. And speaking to the stigmatization of facially disfigured individuals, Brown et al, a review of the ethical implications of face transplants, argues that facial transplants are harmful to facially disfigured individuals because the publicity surrounding the procedure enforces the idea that facially disfigured people cannot have a decent quality of life without undergoing surgery (Brown, et al 2006). Brown et al also warns of the procedure becoming a purely cosmetic surgery and maintains that the surgery s focus should be on improving or restoring function (Brown, et al 2006). Thus, Brown et al would likely argue for the Utilitarian Approach in that face transplants add to the stigmatization of facially-disfigured people by suggesting that surgery is the only way for them to live a decent life. Another important aspect of facial transplants that has societal implications is the cost of the procedure. With only a few active programs around the world, facial transplants generally cost around 130,000 Euros (about 154,000 USD) accounting for a preliminary analysis, the surgery itself, hospitalization, and stay in the intensive care unit (Eun 2014). With a cost that is

7 7 approximately four times the cost of a kidney transplant and almost twice the cost of a heart transplant (Eun 2014), it is understandable that much of the world s population cannot easily afford the procedure. This ties into the Virtue Approach, which examines ethical issues based on virtues such as compassion and fairness, because the high cost of face transplants is uncompassionate and unfair to those who cannot afford the procedure or even afford to seek it out (for low income people in rural areas). Thus, by examining the cost of the procedure one can see face transplants have serious ethical implications that effect society on a socio-economic level. Facial transplants also have serious ethical implications regarding the recipient s health. When a candidate gives informed consent to the surgery, they are made aware of possible postsurgical complications such as rejection of the face. This means that the donor s tissues (usually the skin) that are transplanted onto the recipient s face do not take and the cells and blood supply die (Morris, et al 2007). However, all recipients of a face transplant are treated with immunosuppressive agents for the rest of their lives to prevent rejection (Morris, et al 2007). However, it is not just a patient s physical health that could potentially be compromised after the operation; but their psychological health as well. For example, the 2004 Royal College of Surgeons Report from England discusses the ethical issues of a face transplant, saying The face is central to our understanding of our identity. Faces help us understand who we are and where we come from (Freeman and Jaoudé 2007). This means that since the face is so essential to humans understanding of identity, receiving a new face (from a deceased individual no less) could potentially be damaging to the psychological and emotional health of the recipient as they try to figure out life with this new part of their identity. But a proper support network of medical staff, family, and friends can make for a facilitated reintegration of the face transplant recipient

8 8 into society, especially when they are faced with complications as a result of surgery and the subsequent recovery. Thus, despite the benefits of a face transplant, the procedure has ethical implications regarding the recipient s physical and psychological health. In conclusion, facial transplantation is a medical breakthrough, because as a new type of composite allograft transplantation where tissues can be successfully transplanted between individuals of the same species, it offers recipients functional, aesthetic, and even social benefits. However, the procedure does have serious ethical implications regarding society and the recipient s health that should be addressed. But despite the ethical implications of face transplantation, the fact that there is dialogue on the betterment of the procedure means that this medical breakthrough has the potential to become a routine medical procedure. The only question is how?

9 9 Works Cited Blackburn B, Zak L Face Transplant Patient Connie Culp Undergoes Final Surgery, Talks to Diane Sawyer in an Exclusive Interview - ABC News. [accessed 2017 Oct 31]. Brown CS, Gander B, Cunningham M, Furr A, Vasilic D, Wiggins O, Banis JC, Vossen M, Maldonado C, Perez-Abadia G, et al Ethical considerations in face transplantation. International Journal of Surgery 5: doi: /j.ijsu Dubernard J-M, Lengelé B, Morelon E, Testelin S, Badet L, Moure C, Beziat J-L, Dakpé S, Kanitakis J, D Hauthuille C, et al Outcomes 18 Months after the First Human Partial Face Transplantation. New England Journal of Medicine 357: doi: /nejmoa Eun SC Facial Transplantation Surgery. Arch Plast Surg 41: doi: /aps Face Transplant Surgery Comprehensive Transplant Center Sep 20. John Hopkins Medicine. [accessed 2017 Sep 20]. splant_surgery.html.

10 10 Freeman M, Jaoudé PA Justifying surgery s last taboo: the ethics of face transplants. J Med Ethics 33: doi: /jme Morris P, Bradley A, Doyal L, Earley M, Hagen P, Milling M, Rumsey N Face Transplantation: A Review of the Technical, Immunological, Psychological and Clinical Issues with Recommendations for Good Practice. Transplantation 83: doi: /01.tp ae. Pomahac B, Pribaz J, Eriksson E, Bueno EM, Diaz-Siso JR, Rybicki FJ, Annino DJ, Orgill D, Caterson EJ, Caterson SA, et al Three Patients with Full Facial Transplantation. New England Journal of Medicine 366: doi: /nejmoa