AMA Journal of Ethics^®

It is well known that several surgical teams in the US and Europe currently have the ability to perform full face transplants on humans. Development and implementation of the surgery, however, has been on hold for several years now due to the many complex ethical and medical questions surrounding the procedure. Potential candidates for face transplants include survivors of debilitating diseases, such as mouth cancer, and burn victims, whose faces have been so deformed that their quality of life is severely diminished.

The primary medical concern associated with the procedure is the patient's ability to tolerate the aggressive immunosuppressant therapy necessary to overcome the physical rejection associated with transplantation of an organ. Despite the fact that immunosuppressants themselves can cause life-threatening conditions like cancer and kidney failure, the face transplantation patient would need to take these expensive medications for the rest of his or her life.

This need gives rise to an ethical question associated with the selection of face transplant candidates: should their ability to pay for these medications be a factor in their selection? The issue of money may seem trivial when talking about a scientific breakthrough of this magnitude, but if a patient stops taking the prescribed immunosuppressants the result is likely to be fatal, as it was for one of the very first successful hand transplant patients. While in that particular case, there was no evidence of the patient's inability to pay for the immunosuppresants, the fact remains that if a patient stops taking the anti-rejection medication, whatever the reason, the likelihood of fatality is high. So at a minimum, we must screen patients during the selection process for their ability to secure the needed immunosuppressants, through whatever means, to eliminate one very dire potential for complication.

A second medical concern is the fact that the procedure has not yet been refined to a point where all the nerves and blood vessels between the transplanted tissue and the recipient can be perfectly connected, and, as a result, it is likely that the patient would not have full facial expression and mobility. Some have even suggested that the transplant would be more like a mask than like a part of the patient's body and that life with this unanimated "mask" would be no more desirable or socially acceptable than life with the original, malformed face, especially when one considers the risks of rejection. First, I will say in response to this point that no one really knows how precise the surgery will be, and I would argue that most face transplant candidates would probably consider limited expression and movement an acceptable trade-off for a more normal appearance. Furthermore, if the candidate does not consider these risks and potential consequences acceptable, he or she could simply opt not to have the surgery. It seems right, however, to give the patient that choice.

Major ethical and psychological dilemmas surround the idea of "wearing someone else's face," ie, a face removed from a cadaver. It is very likely that the patients who will undergo the face transplants will experience a good deal of intense psychological distress and anxiety while making the adjustment to wearing a new face. Some medical ethicists have argued that, since the patient is going to have to endure distress and anxiety as a result of adjusting to a new appearance, the additional dangers and unknown risks associated with an experimental surgery should be avoided; patients should devote their energies to adapting to life with a newly deformed face. This point has been raised many times during the ongoing debate over the ethics of face transplantation: the patient is going to have to go through massive re-adjustment, so why not adapt to the newly burned, diseased, or otherwise deformed face? My answer is that it's all well and good to say that people should adjust to wearing their own deformed faces until you live a day in the life of someone with facial deformities so severe that children cry when they see you and adults simply look away. While the lives of face transplant candidates often are not threatened, their quality of life is. In fact, if you have to live your life depressed and afraid to leave your house for a very real of fear social rejection, some would argue that is not much of a life at all, and that wearing someone else's face is an excellent alternative.

The question of what would look more normal or be more desirable—a transplanted face with limited movement or a severely malformed, scarred face—is at the root of the discussion on the values of face transplantation, if not cosmetic surgery overall. As cosmetic surgery becomes more common, and as our societal standards for appearances become less realistic, at what point do we start to question the values that underlie this movement towards an increasingly narrow range of social acceptability? I believe we need to re-assess the values that brought us to the point where someone who does not fall into our acceptable range of "normal" appearance cannot live an otherwise "normal" life. People, including friends, acquaintances, and passersby, must learn to be sympathetic and compassionate to people who have experienced disfiguring injuries to their faces and not look away or make them feel unaccepted.

My point is not to say that we shouldn't pursue face transplants as an option for burn victims or other candidates. But, as many ethicists have argued and will surely continue to argue, this procedure should not be taken lightly. All angles—medical and ethical—need to be considered, and the candidates, if we do choose to undertake the surgery, will have to be chosen with extreme care.

I have several suggestions for the next steps in the process toward implementing this procedure. First, I recommend further animal testing, which, up until now, has been very limited. Second, I would suggest additional experimentation using alternative antirejection methods, such as the transplantation of donor bone marrow, which may encourage the body to be more accepting of such a large transplant in another region of the body. And third, we must continue to have conversations and debates about the many ethical questions associated with the procedure in an attempt to come up with the best possible answers. Keeping in mind that many of the greatest medical breakthroughs and innovations were, in their beginnings (and some remain), vastly controversial, we owe it to ourselves and to prospective patients to make the most informed and deliberated decisions possible about the future of face transplantation.