Download PDF
J Reconstr Microsurg 2010; 26(8): 547-554
DOI: 10.1055/s-0030-1262949
© Thieme Medical Publishers

Supporting Facial Transplantation with the Pillars of Bioethics

Loree K. Kalliainen1
  • 1Department of Plastic and Hand Surgery, Regions Hospital, St. Paul, Minnesota
Further Information

Publication History

Publication Date:
03 August 2010 (online)

    Permissions and Reprints

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
    CrossrefPubMedGoogle Scholar
  • 2 Guo S, Han Y, Zhang X et al.. Human facial allotransplantation: a 2-year follow-up study.  Lancet. 2008;  372 631-638
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 8 Onarheim H, Vindenes H A. High risk for accidental death in previously burn-injured adults.  Burns. 2005;  31 297-301
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 11 Holaday M, Whittenberg T. Rorschach responding in children and adolescents who have been severely burned.  J Pers Assess. 1994;  62 269-279
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 13 Strong C. Should we be putting a good face on facial transplantation? [comment].  Am J Bioeth. 2004;  4 13-14 discussion W23-W31
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 16 Caplan A. Facing ourselves [comment].  Am J Bioeth. 2004;  4 18-20 discussion W23-W31
    PubMedGoogle Scholar
  • 17 Rumsey N. Psychological aspects of face transplantation: read the small print carefully [comment].  Am J Bioeth. 2004;  4 22-25 discussion W23-W31
    PubMedGoogle Scholar
  • 18 Baylis F. A face is not just like a hand: pace Barker [comment].  Am J Bioeth. 2004;  4 31
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 20 Goering S. Facing the consequences of facial transplantation: individual choices, social effects.  Am J Bioeth. 2004;  4 37-39 discussion W23-W31
    PubMedGoogle Scholar
  • 21 White B E, Brassington I. Facial allograft transplants: where's the catch?.  J Med Ethics. 2008;  34 723-726
    CrossrefPubMedGoogle Scholar
  • 22 Schneider C E. The Practice of Autonomy. New York; Oxford University Press, Inc. 1998
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 24 Strauss R P. Psychosocial responses to oral and maxillofacial surgery for head and neck cancer.  J Oral Maxillofac Surg. 1989;  47 343-348
    CrossrefPubMedGoogle Scholar
  • 25 Issa N C, Fishman J A. Infectious complications of antilymphocyte therapies in solid organ transplantation.  Clin Infect Dis. 2009;  48 772-786
    CrossrefPubMedGoogle Scholar
  • 26 Zafar S Y, Howell D N, Gockerman J P. Malignancy after solid organ transplantation: an overview.  Oncologist. 2008;  13 769-778
    CrossrefPubMedGoogle Scholar
  • 27 Reynolds L R, Tannock L R. Management of new-onset diabetes mellitus after transplantation.  Postgrad Med. 2008;  120 60-66
    PubMedGoogle Scholar
  • 28 Rajcani J. Reactivation of latent DNA viruses during immunosuppression: basic contemplation.  Acta Virol. 2007;  51 77-100
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 31 Besarani D, Cranston D. Urological malignancy after renal transplantation.  BJU Int. 2007;  100 502-505
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 35 Buijsen M. The meaning of “justice” in health care.  Med Law. 2008;  27 535-545
    PubMedGoogle Scholar
  • 36 Ruger J P. Rethinking equal access: agency, quality, and norms.  Glob Public Health. 2007;  2 78-96
    CrossrefPubMedGoogle Scholar
  • 37 Musgrove P. Public spending on health care: how are different criteria related?.  Health Policy. 1999;  47 207-223
    CrossrefPubMedGoogle Scholar
  • 38 Mooney G, Jan S. Vertical equity: weighting outcomes? or establishing procedures?.  Health Policy. 1997;  39 79-87
    CrossrefPubMedGoogle Scholar
  • 39 Schramme T. The significance of the concept of disease for justice in health care.  Theor Med Bioeth. 2007;  28 121-135
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 41 Best J H, Veenstra D L, Geppert J. Trends in expenditures for Medicare liver transplant recipients.  Liver Transpl. 2001;  7 858-862
    CrossrefPubMedGoogle Scholar
  • 42 Evans R W. Socioeconomic aspects of heart transplantation.  Curr Opin Cardiol. 1995;  10 169-179
    CrossrefPubMedGoogle Scholar
  • 43 Swartz K. Government as reinsurer for very-high-cost persons in nongroup health insurance markets. Health Affairs, Suppl Web Exclusives 2002, W380–382
    PubMedGoogle Scholar
  • 44 Siemionow M. The USA's First Face Transplant. Keynote address to the American Association of Plastic Surgeons. Rancho Mirage, California; March 24, 2009
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 46 McShane P J, Garrity Jr E R. Minimization of immunosuppression after lung transplantation: current trends.  Transpl Int. 2009;  22 90-95
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 51 Buchanan D R. Autonomy, paternalism, and justice: ethical priorities in public health.  Am J Public Health. 2008;  98 10
    PubMedGoogle Scholar
  • 52 Adamson P A, Doud Galli S K. Modern concepts of beauty.  Curr Opin Otolaryngol Head Neck Surg. 2003;  11 295-300
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 60 Huxtable R, Woodley J. (When) will they have faces? A response to Agich and Siemionov.  J Med Ethics. 2006;  32 403-404
    CrossrefPubMedGoogle Scholar
  • 61 Grayling A C. Face transplantation and living a flourishing life.  Lancet. 2008;  371 707
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 63 Barker J H, Furr A, Cunningham M et al.. Investigation of risk acceptance in facial transplantation.  Plast Reconstr Surg. 2006;  118 663-670
    CrossrefPubMedGoogle Scholar
  • 64 Barker J H, Furr L A, McGuire S et al.. Patient expectations in facial transplantation.  Ann Plast Surg. 2008;  61 68-72
    CrossrefPubMedGoogle Scholar
  • 65 Agich G J, Siemionow M. Until they have faces: the ethics of facial allograft transplantation.  J Med Ethics. 2005;  31 707-709
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 77 Loewy E H. In defense of paternalism.  Theor Med Bioeth. 2005;  26 446
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar

Loree K KalliainenM.D. 

Department of Plastic and Hand Surgery, Regions Hospital

Mail Stop 11503 B, 640 Jackson Street, St. Paul, MN 55101

Email: loree.k.kalliainen@healthpartners.com

      >