Ethical Issues in Face Transplantation

Abstract

The miraculous transplantation of a leg by the third-century saints Cosmas and Damian [1] became a medical reality in 1998 with the first successful hand transplant in France. In 2005, the same French team performed the first successful face transplant. Since then, 10 facial allotransplantations have been performed in France, China, the United States, and Spain. Two recipients are now dead as a result, one from tissue rejection and one from infection. Critics question whether the benefit is worth the risk. Plastic surgeons weigh Sir Harold Gillies' reconstructive principle of replacing like with like against the Hippocratic dictum primum non nocere, or "first do no harm." The risks of lifelong immunosuppression, including infection, malignancy, and end-organ toxicity, seem prima facie prohibitive in the context of a nonlifesaving intervention. But severe facial disfigurement to the degree that confers eligibility consideration is not a trivial thing. These are not merely "cosmetic defects," but conditions that render the patient unable to properly eat, breathe, or speak. Furthermore, the face is essential for communication and relating to others, which is the foundation for how we understand ourselves as human [2]. Restoring the face with composite tissue allotransplantation can provide results that are unattainable with current reconstructive techniques.

Vascularized Composite Allografts: Procurement, Allocation, and Implementation

“…In fact, the consent process, especially for facial allograft donation, has shown to be a major challenge [ 19 •]. There has repeatedly been concern that asking for consent for VCA donation might negatively influence the willingness to donate classical solid organs [ 20 , 21 ]. This aspect has to be taken into account in future public campaigns on organ donation and especially when approaching the family of a potential organ donor.…”

“…Approximately 100,000 upper-extremity amputees are living in the US at the moment [ 65 ], but of course the selection of recipients has to be based on a careful risk–benefit analysis, taking alternative therapies including modern prostheses into account. Currently, only a minority of these patients are candidates for VCA transplantation [ 20 , 27 , 66 , 67 ]. A similar strict selection process will be necessary for all other types of VCA transplantation.…”

“…For these candidates, VCA transplantation could have a major positive impact on their daily life, allowing social reintegration [ 43 , 60 , 68 ]. Public campaigns regarding VCA donation should be carried out in a balanced way to educate about consent for VCA without lowering the total consent rates for organ donation, as the impact of establishing a VCA transplant program on organ donation is currently unknown [ 20 , 25 ].…”