By far the most extensive performed successfully

Patrick Hardison is a 41-year-old former American firefighter who suffered facial burns while trying to save the life of a woman in a fire. The burns resulted in severe facial disfigurement, causing him major problems with vision, breathing and eating, and of course, his aesthetic image, which made social relationships difficult. The possibility of resolving those problems therefore seemed highly advisable for compelling quality-of-life reasons.

The 26-hour surgery took place on 15th August 2015, and involved more than 100 professionals. It was performed in Langone Medical Center in New York, led by Dr. Eduardo D. Rodríguez. The operation not only gave the patient a new face, it also gave him a new scalp, ears, ear canals, part of the chin bones, cheekbones, a whole nose and new eyelids, even the muscles that control blinking.

Before this latest surgery, Mr. Hardison had undergone more than 70 operations, which, apart from that mentioned above, gives some indication of the patient’s poor quality of life, and was undoubtedly a critical factor in the decision to perform the transplant.

The most recent reports on 17th November state that the patient has progressed well and is gradually resuming his usual daily routines. Nevertheless, he will have to continue rehabilitation to improve the strength of his facial muscles and speech, and of course, like most transplant patients, will have to take immunosuppressive therapy for life, so that the transplant is not rejected.

by coincidence the donor had wanted to be a firefighter.

By coincidence the face donor had wanted to be a firefighter.

The patient is reportedly “deeply grateful to my donor and his family” , and to the surgical team, saying that “They have given me more than a new face. They have given me a new life”.

A brief history of face transplant. Comments on a recently published paper (1).

In 1954, the first successful renal transplant was performed between identical twins. Many successful transplants have been carried out since then, including heart, lung, liver, pancreas and small bowel transplants (2). The first face transplant was performed in November 2005 by a medical team at Amiens hospital, in France. Twenty-three transplants were performed up to August 2012 (2), and 31 up to June 2015, in France, China, United States, Belgium, Spain, Poland and Turkey (3). Three patients (11.5%) have died as a result of the transplant, either because of rejection or infections (4).

Ethical opinions for and against

Ethical opinions for and against face transplantation have varied noticeably over time. In a study by Kiwanuka et al. (2), the authors reviewed 110 articles in peer-reviewed journals assessing the ethicality of face transplant. They found that, theoretically, prior to the first face transplant in 2005, the vast majority of ethical opinions were against it, but that as more and more transplants have been carried out, and more objective data has become available, this opinion has been changing substantially. Thus, after 2010, there are virtually no publications that hold an overall ethical opinion against face transplantation, suggesting that as more data is obtained on the outcomes of this type of intervention, the ethical criteria that should govern this type of transplant can be better defined.

Most of the papers reviewed by Kiwanuka et al. (2) considered 15 items when making an ethical assessment of face transplantation, among them: patient identity, how patients are selected, risks-benefits of this practice, informed consent, use of immunosuppressive therapy, transplant failures, the importance of the changed face in the patient’s social environment, improvements in their life prospects and quality of life, extent of disfiguration of the patient’s face (as a crucial piece of information for recommending the intervention), everything related to the opinion of the donor’s relatives, and finally, costs.  These are the ethical criteria normally taken into account to make an ethical assessment of face transplantation.

We cannot of course make a detailed evaluation of each of these here, but only refer to them to support what, in general, should be taken into consideration when carrying out an ethical assessment of face transplant.

Sarantopoulos (3) also refers to the issue, considering the risks of immunosuppressive therapy, possible infections, development of tumours and possible toxicity of the transplanted organ, which led him to conclude that this type of transplantation is not recommended for merely aesthetic reasons, but rather when the patient has objective difficulties in eating, breathing or talking, and to be able to communicate with other people (5).

Coffman et al. (4) concentrate the ethical aspects to consider into four main items: a) the fact that the mortality is 11.5% raises the need to assess the risk-benefit in this type of transplant; b) it is essential to have more objective data to determine if the risks are greater than the benefits; c) there are few articles that refer to functional disorders and psychological problems associated with face transplants; and finally, d) there are scant material resources for this type of transplant in the world, meaning that the number of transplants performed cannot be very high, which could undoubtedly raise false hopes in potential patients.

An important aspect of the ethical evaluation discussed is that, as mentioned, as the number of transplants grows and patients survive for longer, more and more objective data will be collected to evaluate the ethicality of face transplantation in accordance with the abovementioned criteria. Nevertheless, we can conclude that, from an ethical point of view, the majority opinion today (in fact, almost 100%) is that there are no ethical difficulties in face transplantation, provided that the abovementioned items are taken into account, and that there is a balance between the risks and benefits.

One particular circumstance is to consider the possibility of face transplant between living persons.  Although this practice is performed for transplants of the abdominal wall, bones, uterus and other organs, it was not ethically approved by the United Network for Organ Sharing Board of Directors in their recommendation in June 2015 for face and hand transplantation (6), which, of course, is logical.

Our final ethical reflection

The ethical assessment made in most of the papers reviewed by Kiwanuka et al. (2) is undoubtedly based on principlism, which, as we know, is based fundamentally on the consideration of four principles: beneficence, non-maleficence, autonomy and justice, although Coffman et al. (4) also include inequality. This evaluation normally leads to a utilitarian ethical judgement, which may be correct in some ethical aspects, especially the one that refers to the cost-benefit, but in general, it does not consider the ontological value of the human person; therefore, we consider that this assessment is limited.

Accordingly, we are of the opinion that, from a personalist bioethics, the good of the patient is what should above all determine the ethical judgement that this type of transplantation merits. Nevertheless, in the light of the outcomes of the 31 face transplants carried out to date — and especially the 23 evaluated in the paper by Kiwanuka et al. (2) — it seems clear that the benefit for patients is objective, since from living a life that is not only lacking in quality, but in some cases even at risk, they become people who can once again live normally within the context of their family and the society that surrounds them. We believe that this personalist assessment (taking into consideration of course the objective evaluation of the items previously mentioned above) supports a positive ethical assessment for face transplantation.

Bibliography:

1. Murray JE, Tilney NL, E WR. Renal transplantation: a twenty-five year experience. 1976; 184: p. 565-573.
2. Kiwanuka H, Bueno EM, Diaz-Siso JR, Sisk GC, Lehmann LS, Pomahac B. Evolution of ethical debate on face transplantation. Plastic and Reconstructive Surgery Journal. 2013; 132: p. 1558-1568.
3. Sarantopoulos E. Is the Medical Community Adequately Prepared for the Future Challenges in Facial Allotransplantation? Anaplastology. 2015; 4: p. 1000153.
4. Coffman KL, Siemionow MK. Ethics of facial transplantation revisited. Current Opinion in Organ Transplantation. 2014; 19: p. 181-7.
5. Pirnay P, Foo R, Hervé C, Meningaud JP. Ethical questions raised by the first allotransplantations of the face: A survey of French surgeons. Journal of Cranio-Maxillo-Facial Surgery. 2012; 40: p. e402–e407.
6. Gordon E. Face and hand transplants raise ethical questions for living donors. Scientific American. 2015 July 6.

justo aznar Definitiva

Justo Aznar

Bioethics Observatory

Catholic University of Valencia

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