Ethical debate on face transplantation has evolved over time, reports Plastic and Reconstructive Surgery

Philadelphia, Pa. (November 27, 2013) – Once viewed as an "outlandish morally objectionable" concept with science-fiction overtones, face transplantation is now accepted as a "feasible and necessary treatment" for severely disfigured patients. The evolving ethical debate over face transplantation is analyzed in a special topic paper in the December issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

Harriet Kiwanuka and colleagues of Brigham and Women's Hospital, Boston, analyzed published articles on the ethics of face transplantation, focusing how the ethical debate has changed over time. Their review shows that initial concerns over the impact on patients' identity have faded, as experience shows the benefits of facial transplants in helping patients with severe facial disfigurement return to a more-normal life.

In a review of the medical literature, Kiwanuka and coauthors identified 110 articles discussing the ethics of face transplantation. Published from 2002 to 2012, nearly half of the papers appeared in the year before and after the first facial transplant—performed by a French team in 2005. Since then, the number of ethical discussions on face transplantation has gradually decreased.

The papers showed a "time-related trend" in ethical positions. All of the articles published in 2002 concluded that face transplantation was not ethically justified. By 2008, all published papers acknowledged the ethical concerns, but concluded that they were outweighed by the benefits of successful facial transplant.

The researchers identified a core group of 15 topics that recurred through the years. The most common issues were related to "identity change/psychological effects," the need for lifelong immunosuppressive drugs to prevent rejection of the transplanted face, and the risks versus benefits of face transplantation.

Many of the early concerns over identity focused on the idea of "wearing someone else's face"—perhaps reflecting the influence of the 1997 science fiction movie Face Off, in which an FBI agent and a criminal switch faces. But these concerns faded, as experience showed that facial transplant recipients gain a new appearance that is "neither identical to the recipient's nor the donor's [face]," write the researchers, who were led by senior author Bohdan Pomahac, MD.

To date, 25 facial transplants have been performed worldwide, and the procedure is expected to be more common in the years ahead. In more recent ethical discussions, some new issues have become prominent, such as patient selection for face transplantation, the inability of severely disfigured patients to lead normal lives, and the high costs of face transplantation.

Many recent papers focus on characteristics of the "ideal recipient" for facial transplant. One report cites the "Catch-22" of face transplantation: the patients who are most capable of coping with face transplantation may be those who need it least, because they are coping well with their disfigurement.

Meanwhile, experience has provided evidence-based information on the true risks and benefits of the procedure. As the discussion continues, new questions arise: Should face transplantation be considered for children? What are the issues related to race/ethnicity? As face transplant becomes more common, how will donor tissues be allocated? Kiwanuka and coauthors conclude, "These questions belong in today's field of face transplantation, and must be further investigated for the sake of evolving this field to its maximum potential in a safe, ethically sound manner."

Plastic and Reconstructive Surgery® is published by Lippincott Williams & Wilkins, part of Wolters Kluwer Health.

For more than 60 years, Plastic and Reconstructive Surgery® has been the one consistently excellent reference for every specialist who uses plastic surgery techniques or works in conjunction with a plastic surgeon. The official journal of the American Society of Plastic Surgeons, Plastic and Reconstructive Surgery® brings subscribers up-to-the-minute reports on the latest techniques and follow-up for all areas of plastic and reconstructive surgery, including breast reconstruction, experimental studies, maxillofacial reconstruction, hand and microsurgery, burn repair, and cosmetic surgery, as well as news on medico-legal issues.

The American Society of Plastic Surgeons (ASPS) is the world's largest organization of board-certified plastic surgeons. Representing more than 7,000 Member Surgeons, the Society is recognized as a leading authority and information source on aesthetic and reconstructive plastic surgery. ASPS comprises more than 94 percent of all board-certified plastic surgeons in the United States. Founded in 1931, the Society represents physicians certified by The American Board of Plastic Surgery or The Royal College of Physicians and Surgeons of Canada. ASPS advances quality care to plastic surgery patients by encouraging high standards of training, ethics, physician practice and research in plastic surgery. You can learn more and visit the American Society of Plastic Surgeons at http://www.plasticsurgery.org or http://www.facebook.com/PlasticSurgeryASPS and http://www.twitter.com/ASPS_news.

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