Supporting Facial Transplantation with the Pillars of Bioethics

ABSTRACT

Facial transplantation has recently been offered to patients with severely disfigured faces not amenable to functional reconstruction with autologous tissues. Arguments against this procedure include risks of immunosuppression, the concern that it will be done for cosmesis, the belief that acceptable reconstruction can be achieved with autologous tissues, the potential impact on the patient of graft failure, and the concern that the procedure may be adopted by unqualified centers. If we look to bioethics to help us dissect the question of whether or not facial transplantation should be performed, we see that the majority of the arguments have been proscriptive rather than prescriptive. There are valid arguments in favor of facial transplantation based on the prescriptive pillars of bioethics: autonomy, justice, and beneficence. This article attempts to reframe the dialogue in a prescriptive manner.

KEYWORDS

Face transplantation - bioethics - ethics

REFERENCES

• 1 Dubernard J M, Lengelé B, Morelon E et al.. Outcomes 18 months after the first human partial face transplantation.  N Engl J Med. 2007;  357 2451-2460
• 2 Guo S, Han Y, Zhang X et al.. Human facial allotransplantation: a 2-year follow-up study.  Lancet. 2008;  372 631-638
• 3 Stein R. For the first time in U.S., extensive face transplant is performed. December 16, 2008. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2008/12/16/AR2008121600838.html Accessed June 14, 2009
• 4 Zeltner B. Cleveland Clinic face transplant patient Connie Culp hopes her story teaches people not to judge. May 5, 2009. Available at: http://www.cleveland.com/medical/index.ssf/2009/05/face_transplant.html Accessed June 14, 2009
• 5 Lantieri L, Meningaud J-P, Grimbert P et al.. Repair of the lower and middle parts of the face by composite tissue allotransplantation in a patient with massive plexiform neurofibroma: a 1-year follow-up study.  Lancet. 2008;  372 639-645
• 6 Oztürk S, Bozkurt A, Durmus M, Deveci M, Sengezer M. Psychiatric analysis of suicide attempt subjects due to maxillofacial gunshot.  J Craniofac Surg. 2006;  17 1072-1075
• 7 Rosenberg L, Robert R, Thomas C, Holzer III C E, Blakeney P, Meyer III W J. Assessing potential suicide risk of young adults burned as children.  J Burn Care Res. 2006;  27 779-785
• 8 Onarheim H, Vindenes H A. High risk for accidental death in previously burn-injured adults.  Burns. 2005;  31 297-301
• 9 Stoddard F J, Stroud L, Murphy J M. Depression in children after recovery from severe burns.  J Burn Care Rehabil. 1992;  13 340-347
• 10 Madianos M G, Papaghelis M, Ioannovich J, Dafni R. Psychiatric disorders in burn patients: a follow-up study.  Psychother Psychosom. 2001;  70 30-37
• 11 Holaday M, Whittenberg T. Rorschach responding in children and adolescents who have been severely burned.  J Pers Assess. 1994;  62 269-279
• 12 Wiggins O P, Barker J H, Martinez S et al.. On the ethics of facial transplantation research.  Am J Bioeth. 2004;  4 1-12
• 13 Strong C. Should we be putting a good face on facial transplantation? [comment].  Am J Bioeth. 2004;  4 13-14 discussion W23-W31
• 14 Petit F, Paraskevas A, Lantieri L. A surgeons' perspective on the ethics of face transplantation.  Am J Bioeth. 2004;  4 14-16 discussion W23-W31
• 15 Butler P E, Clarke A, Ashcroft R E. Face transplantation: when and for whom? [comment].  Am J Bioeth. 2004;  4 16-17 discussion W23-W31
• 16 Caplan A. Facing ourselves [comment].  Am J Bioeth. 2004;  4 18-20 discussion W23-W31
• 17 Rumsey N. Psychological aspects of face transplantation: read the small print carefully [comment].  Am J Bioeth. 2004;  4 22-25 discussion W23-W31
• 18 Baylis F. A face is not just like a hand: pace Barker [comment].  Am J Bioeth. 2004;  4 31
• 19 Ankeny R A, Kerridge I. On not taking objective risk assessments at face value [comment].  Am J Bioeth. 2004;  4 35-37 discussion W23-W31
• 20 Goering S. Facing the consequences of facial transplantation: individual choices, social effects.  Am J Bioeth. 2004;  4 37-39 discussion W23-W31
• 21 White B E, Brassington I. Facial allograft transplants: where's the catch?.  J Med Ethics. 2008;  34 723-726
• 22 Schneider C E. The Practice of Autonomy. New York; Oxford University Press, Inc. 1998
• 23 Moreno J D. Protectionism in research involving human subjects (research involving human subjects v2). Online Ethics Center for Engineering 7/25/2006. National Academy of Engineering. http://Available at: www.onlineethics.org Accessed Sunday, March 14, 2010
• 24 Strauss R P. Psychosocial responses to oral and maxillofacial surgery for head and neck cancer.  J Oral Maxillofac Surg. 1989;  47 343-348
• 25 Issa N C, Fishman J A. Infectious complications of antilymphocyte therapies in solid organ transplantation.  Clin Infect Dis. 2009;  48 772-786
• 26 Zafar S Y, Howell D N, Gockerman J P. Malignancy after solid organ transplantation: an overview.  Oncologist. 2008;  13 769-778
• 27 Reynolds L R, Tannock L R. Management of new-onset diabetes mellitus after transplantation.  Postgrad Med. 2008;  120 60-66
• 28 Rajcani J. Reactivation of latent DNA viruses during immunosuppression: basic contemplation.  Acta Virol. 2007;  51 77-100
• 29 Herman S, Rogers H D, Ratner D. Immunosuppression and squamous cell carcinoma: a focus on solid organ transplant recipients.  Skinmed. 2007;  6 234-238
• 30 Vasilic D, Alloway R R, Barker J H et al.. Risk assessment of immunosuppressive therapy in facial transplantation.  Plast Reconstr Surg. 2007;  120 657-668
• 31 Besarani D, Cranston D. Urological malignancy after renal transplantation.  BJU Int. 2007;  100 502-505
• 32 Vasilic D, Reynolds C C, Cunningham M et al.. Plastic surgeon's risk acceptance in facial transplantation.  Plast Reconstr Surg. 2008;  121 41e-48e
• 33 Clarke A, Murphy F, White P, Brough V, Renshaw A, Butler P E. Transplant professionals' attitudes toward facial transplantation in the United Kingdom.  Prog Transplant. 2007;  17 228-233
• 34 Rogers W A. Evidence based medicine and justice: a framework for looking at the impact of EBM upon vulnerable or disadvantaged groups.  J Med Ethics. 2004;  30 141-145
• 35 Buijsen M. The meaning of “justice” in health care.  Med Law. 2008;  27 535-545
• 36 Ruger J P. Rethinking equal access: agency, quality, and norms.  Glob Public Health. 2007;  2 78-96
• 37 Musgrove P. Public spending on health care: how are different criteria related?.  Health Policy. 1999;  47 207-223
• 38 Mooney G, Jan S. Vertical equity: weighting outcomes? or establishing procedures?.  Health Policy. 1997;  39 79-87
• 39 Schramme T. The significance of the concept of disease for justice in health care.  Theor Med Bioeth. 2007;  28 121-135
• 40 Mendeloff J, Ko K, Roberts M S, Byrne M, Dew M A. Procuring organ donors as a health investment: how much should we be willing to spend?.  Transplantation. 2004;  78 1704-1710
• 41 Best J H, Veenstra D L, Geppert J. Trends in expenditures for Medicare liver transplant recipients.  Liver Transpl. 2001;  7 858-862
• 42 Evans R W. Socioeconomic aspects of heart transplantation.  Curr Opin Cardiol. 1995;  10 169-179
• 43 Swartz K. Government as reinsurer for very-high-cost persons in nongroup health insurance markets. Health Affairs, Suppl Web Exclusives 2002, W380–382
• 44 Siemionow M. The USA's First Face Transplant. Keynote address to the American Association of Plastic Surgeons. Rancho Mirage, California; March 24, 2009
• 45 Winkelmayer W C, Weinstein M C, Mittleman M A, Glynn R J, Pliskin J S. Health economic evaluations: the special case of end-stage renal disease treatment.  Med Decis Making. 2002;  22 417-430
• 46 McShane P J, Garrity Jr E R. Minimization of immunosuppression after lung transplantation: current trends.  Transpl Int. 2009;  22 90-95
• 47 Ashton-Chess J, Giral M, Soulillou J P, Brouard S. Can immune monitoring help to minimize immunosuppression in kidney transplantation?.  Transpl Int. 2009;  22 110-119
• 48 Disa J J, Hu Q Y, Hidalgo D A. Retrospective review of 400 consecutive free flap reconstructions for oncologic surgical defects.  Ann Surg Oncol. 1997;  4 663-669
• 49 Thornton B P, Rosenblum W J, Pu L LQ. Reconstruction of limited soft-tissue defect with open tibial fracture in the distal third of the leg: a cost and outcome study.  Ann Plast Surg. 2005;  54 276-280
• 50 Deleyiannis F W, Porter A C. Economic factors affecting head and neck reconstructive microsurgery: the surgeons' and hospital's perspective.  Plast Reconstr Surg. 2007;  120 157-165
• 51 Buchanan D R. Autonomy, paternalism, and justice: ethical priorities in public health.  Am J Public Health. 2008;  98 10
• 52 Adamson P A, Doud Galli S K. Modern concepts of beauty.  Curr Opin Otolaryngol Head Neck Surg. 2003;  11 295-300
• 53 Haas A, Gregory S W. The impact of physical attractiveness on women's social status and interactional power.  Sociological Forum. 2005;  20 449-471
• 54 Reingen P H, Kernan J B. Social perception and interpersonal influence: some consequences of the physical attractiveness stereotype in a personal selling setting.  J Consum Psychol. 1993;  2 25-38
• 55 Harvard Law Review Association . Facial discrimination: extending handicap law to employment discrimination on the basis of physical appearance.  Harv Law Rev. 1987;  100 2035-2052
• 56 Tracy J L, Robins R W. The nonverbal expression of pride: evidence for cross-cultural recognition.  J Pers Soc Psychol. 2008;  94 516-530
• 57 Shiota M N, Campos B, Keltner D. The faces of positive emotion: prototype displays of awe, amusement, and pride.  Ann N Y Acad Sci. 2003;  1000 296-299
• 58 Keltner D. Expression and the course of life: studies of emotion, personality, and psychopathology from a social-functional perspective.  Ann N Y Acad Sci. 2003;  1000 222-243
• 59 Toure G, Meningaud J P, Bertrand J C, Hervé C. Facial transplantation: a comprehensive review of the literature.  J Oral Maxillofac Surg. 2006;  64 789-793
• 60 Huxtable R, Woodley J. (When) will they have faces? A response to Agich and Siemionov.  J Med Ethics. 2006;  32 403-404
• 61 Grayling A C. Face transplantation and living a flourishing life.  Lancet. 2008;  371 707
• 62 Smith R. Face transplants are a viable option for severe injuries say doctors. August 21, 2008. Available at: http://www.telegraph.co.uk/news/2597809/Face-transplants-are-a-viable-option-for-severe-injuries-and-disfigurement-say-doctors.html Accessed June 14, 2009
• 63 Barker J H, Furr A, Cunningham M et al.. Investigation of risk acceptance in facial transplantation.  Plast Reconstr Surg. 2006;  118 663-670
• 64 Barker J H, Furr L A, McGuire S et al.. Patient expectations in facial transplantation.  Ann Plast Surg. 2008;  61 68-72
• 65 Agich G J, Siemionow M. Until they have faces: the ethics of facial allograft transplantation.  J Med Ethics. 2005;  31 707-709
• 66 Siemionow M, Unal S, Agaoglu G, Sari A. A cadaver study in preparation for facial allograft transplantation in humans: part I. What are alternative sources for total facial defect coverage?.  Plast Reconstr Surg. 2006;  117 864-872 discussion 873-875
• 67 Harper R G, Chacko R C, Kotik-Harper D, Young J, Gotto J. Self-report evaluation of health behavior, stress vulnerability, and medical outcome of heart transplant recipients.  Psychosom Med. 1998;  60 563-569
• 68 Muehrer R J, Becker B N. Life after transplantation: new transitions in quality of life and psychological distress.  Semin Dial. 2005;  18 124-131
• 69 Goetzmann L, Scheuer E, Naef R et al.. Psychosocial situation and physical health in 50 patients > 1 year after lung transplantation.  Chest. 2005;  127 166-170
• 70 Baines L S, Joseph J T, Jindal R M. Emotional issues after kidney transplantation: a prospective psychotherapeutic study.  Clin Transplant. 2002;  16 455-460
• 71 Siemionow M, Agaoglu G, Unal S. A cadaver study in preparation for facial allograft transplantation in humans: part II. Mock facial transplantation.  Plast Reconstr Surg. 2006;  117 876-885 discussion 886-888
• 72 Jones N F, Jarrahy R, Song J I, Kaufman M R, Markowitz B. Postoperative medical complications—not microsurgical complications—negatively influence the morbidity, mortality, and true costs after microsurgical reconstruction for head and neck cancer.  Plast Reconstr Surg. 2007;  119 2053-2060
• 73 Wade J W, Stephens J A, Bragham R F, Carbo J D. Microsurgery in private practice: is it feasible economically?.  Ann Plast Surg. 2001;  46 255-259 discussion 259-260
• 74 Kroll S S, Schusterman M A, Reece G P et al.. Timing of pedicle thrombosis and flap loss after free-tissue transfer.  Plast Reconstr Surg. 1996;  98 1230-1233
• 75 Petruzzelli G J, Brockenbrough J M, Vandevender D, Creech S D. The influence of reconstructive modality on cost of care in head and neck oncologic surgery.  Arch Otolaryngol Head Neck Surg. 2002;  128 1377-1380
• 76 Dworkin G. Paternalism. In: Zalta EN The Stanford Encyclopedia of Philosophy (Summer 2009 Edition). Available at: http://plato.stanford.edu/archives/sum2009/entries/paternalism/ Accessed June 14, 2009
• 77 Loewy E H. In defense of paternalism.  Theor Med Bioeth. 2005;  26 446
• 78 Bryan C S, Theodore E. Theodore E. Woodward Award. HIV/AIDS, ethics, and medical professionalism: where went the debate?.  Trans Am Clin Climatol Assoc. 2003;  114 353