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Abstract

Facial transplantation is no longer a science ﬁction; it is a science fact. The 28 transplants that were performed between 2005 and 2014 appear to have yielded mainly positive functional, psychological, aesthetic, and immunological outcomes for the recipients. This nevertheless remains a signiﬁcant intervention, which gives rise to three sorts of ethical concerns. First, the welfare of the recipient merits careful consideration. The issues here include those concerning quality of life, as well as the risks associated with immunosuppression and the possible failure of the graft. Secondly, the autonomy and identity of the recipients raise important questions, not least about the selection of such patients. Of particular signiﬁcance here are concerns about informed consent, capacity, age, and any psychological effects on the recipient. Finally, there are the broader societal dimensions to consider. Is facial transplantation in the public interest? Certainly, the interests of the donor, and his or her family, are important considerations, but there also arise wider questions about cost and also regarding societal attitudes to disﬁgurement and difference. Although ultimately defensible in principle, facial transplantation merits ongoing scrutiny to ensure that appropriate ethical standards are always met.

Introduction

First performed in France in 2005, facial transplantation has since occurred across the (“developed”) world. When it was ﬁrst mooted, the proposal was met with cautious – and occasionally outright opposed – reactions. However, now that science ﬁction has become a science fact, the procedure has come to attract signiﬁcant support. The outcomes for recipients appear, overall, to be more positive than negative. Despite such successes, facial transplantation continues to merit ethical appraisal, by reference to three key areas of concern. First, the welfare of the recipient requires careful consideration. The procedure carries risks, not least those associated with immunosuppression and the possible failure of the graft. Such risks need to be balanced against any perceived beneﬁts, such as improving the recipient’s quality of life. Careful patient selection is evidently needed, which leads onto a second cluster of concerns, which relate to the recipient’s autonomy and identity. Any anticipated psychological effects on the recipient need attention, as do their mental capacity, age, and information needs. Of course, we need also to consider those other than the recipient whose rights or interests might be affected by the procedure. Certainly, an account is needed of the wishes of the donor, plus the wishes, and also the welfare of his or her surviving loved ones. Wider societal considerations also arise, in terms of the ﬁnancial (and other) costs of the procedure, as well as attitudes to disﬁgurement and difference. The teams to date have commendably sought to address many of these different ethical dimensions. Despite this, ongoing scrutiny is needed, in order to ensure that facial transplantation always meets appropriate ethical standards.

Background

Facial defects, whether congenital or arising from disease or injury, can have signiﬁcant detrimental effects on an individual’s functioning and quality of life. Functionally, we use our faces to breathe, eat, drink, speak, and see; psychologically, the face also matters, in terms of our self-image and also in our dealings with others. Conventional reconstructive techniques can help the afﬂicted. However, autologous tissue will not be available for some such individuals. Where donor tissue is used, conventional methods require multiple procedures to be performed, and the effects – on form and function – might fall short of a perceived ideal. Facial transplantation, in contrast, might be capable of achieving better results and it will involve only a single procedure, in which a graft is taken from a donor and transplanted onto the recipient.

Since 1908, when skin from a donor was ﬁrst grafted onto a recipient in Switzerland, expertise in transplantation and microsurgery has evolved considerably. Composite tissue allograft techniques nowadays enable teams to transplant a hand, larynx, lower limbs, tongue, abdominal wall, uterus, testis, penis, and, of course, face (Huxtable and Guilder 2014). Facial transplantation had been proposed shortly after the ﬁrst hand transplant was performed in 1998. By the early 2000s, the procedure looked increasingly viable, which prompted advisory bodies in England and in France to examine the issues (Royal College of Surgeons of England 2003; Comité Consultatif National d’Ethique 2004). Both of the resultant reports advised caution, especially with full facial transplantation, although the French advisory council on bioethics was prepared to support partial transplantation. The ﬁrst such transplant was performed in Amiens in 2005 and, by 2014, 28 had been undertaken. The twelfth recipient was the ﬁrst to receive a full transplant. This transplant occurred in Spain, and the procedure has also been undertaken in China, Belgium, and Poland, although the most proliﬁc teams are those based in Paris in France, in Antalya in Turkey, and in Boston in the USA (Khaliﬁan et al. 2014).

As the scientiﬁc expertise has developed, so too have the commentators’ reactions to facial transplantation: opposition gave way to hesitant acceptance and then to more overt support, in the wake of the perceived successes achieved to date (Kiwanuka et al. 2013). Although some of the ethical concerns have receded, there remain three clusters of issues to consider, which concern the welfare of the recipient, their autonomy and identity, and the wider societal dimensions.

Promoting And Protecting Welfare?

Welfarist concerns for the recipient of a face transplant are typically captured in principles like beneﬁcence (confer a beneﬁt on the patient) and non-maleﬁcence (“do no harm”). Although notions of beneﬁt and harm are notoriously contested in bioethics, commentators on facial transplantation tend to point to a similar set of perceived harms and beneﬁts when considering the welfare of the envisaged recipient. The risks, and thus harms, are those associated with immunosuppression and rejection, although some commentators also question whether the procedure involves a treatment or an “enhancement”; the beneﬁts, meanwhile, are usually said to relate to the improved quality of the recipient’s life.

To start with the possible harms, immunological risks are universal to all types of transplantation involving donors. To counter the attack by the donee’s body on the foreign tissue, immunosuppressive drugs are provided. This is necessarily a lifelong precaution against rejection, but it can impose a high cost. Firstly, over immunosuppression can lead to both immunologic complications (like malignancies and infections) and non-immunologic complications (affecting, e.g., blood pressure or cholesterol levels). Recipients may therefore be exposed to signiﬁcant risks of, for example, hypertension and diabetes as well as infection and cancer. Secondly, under-immunosuppression can lead to acute or chronic rejection of the graft and perhaps even to the loss thereof.

Signiﬁcant risks are therefore a possibility, but have they materialized in practice? Reports are not available for all of the recipients, but those that are published reveal that complications have indeed arisen from both over and under immunosuppression (Khaliﬁan et al. 2014). Immunologic complications, speciﬁcally infections, have been common, arising for at least 11 of the 28 recipients. However, such infections generally appear to have been successfully tackled. There have also been non-immunologic complications: for example, two recipients developed diabetes, and drug regimens had to be altered for some others, in order to address side effects. Under-immunosuppression has also led to problems. Every recipient appears to have experienced an acute rejection episode, of varying degrees of severity, within the ﬁrst year. Little is yet known beyond this point, although some reports reveal later episodes of rejection, including for a patient who had not been compliant with the immunosuppressive regimen. Fortunately, however, it would appear that virtually every episode of rejection has been reversed by appropriate drug therapy (including the use of corticosteroids). Even more fortunately, there appear not to have been any reports of chronic rejection.

These are generally encouraging ﬁndings. Yet, any optimism should be tempered by the observation that, by 2014, three recipients – 11 % of the total recipients to that date – had died. The reasons for these deaths vary (Khaliﬁan et al. 2014). In one case, death appeared to have resulted from severe acute rejection of the graft. Another recipient, who had been severely burned, had also received a hand transplant; the hand and part of the transplanted face became infected. Although the surgical team removed the affected tissues and provided antibiotics, the patient died 65 days after the transplant (Lantieri et al. 2011).

The ﬁnal recipient to die did so after a tumor recurred: this recipient was HIV positive and had previously undergone cancer resection.

Commenting on the latter case, Coffman and Siemionow (2014) acknowledge that facial transplantation is still in its infancy and they admit that cases of cancer posttransplant might well rise in the coming years. They note two other cases in which the recipients have developed cancer, although neither of these individuals appears to have died. Time will also tell whether there might be future cases of chronic rejection, perhaps even leading to loss of the graft. Might recipients confront a literal risk of losing face? If so, how could or should such a loss be tackled? Certainly, there might well be options available, such as another transplant (if another matched donor can be identiﬁed), regrafting (using standard techniques), or the use of an artiﬁcial dermal substitute (Butler et al. 2006). Evidently, such matters must be kept under review as must the overall balance of risks and beneﬁts. The costs already appear to be considerable: death might ensue, but even if this outcome is avoided, the recipient must comply with a lifelong regimen of toxic drugs (Huxtable and Woodley 2005). As Hettiaratchy et al. (2001) once asked, in relation to hand transplants: “how much immunosuppression can be justiﬁed for a non-life-saving procedure?”

Given all of these concerns, skeptics and critics have worried that some intended recipients, who could be considered healthy persons, would be transformed by the procedure into unhealthy, drug-dependent patients (Huxtable and Woodley 2005). Such a transformation implies that facial transplantation is not necessarily a treatment; indeed, it might even be thought that this procedure transgresses the line between therapy, which can be morally acceptable, and enhancement, which some would judge to be morally unacceptable. Once such a line is crossed, we might well wonder who could come to avail themselves of the procedure in the future. Defenders of the procedure typically justify this by reference to the recipient’s welfare, but autonomy also plays a justiﬁcatory role: the recipient not only appears to “need” the transplant but also wants it to be provided. If choice, rather than necessity, becomes the more dominant ethical justiﬁcation, then what is to stop this from becoming an elective procedure? Might we slide down a slippery slope toward a scenario like that depicted in the science ﬁction movie Face/Off, in which a criminal acquires the face of an FBI agent (and, indeed, vice versa)?

Many defenders of facial transplantation dismiss these sorts of concerns. Indeed, they will point to the considerable beneﬁts that can be conferred on recipients, which could be said to outweigh the risks. Firstly, the intended recipients of facial grafts need not be considered healthy. Kiwanuka et al. (2013) cite the World Health Organization deﬁnition of “health” as “a state of complete physical, mental, and social well-being and not merely the absence of disease or inﬁrmity.” They point out that “facially disﬁgured individuals who cope with all associated psychological stressors and functional limitations could not reasonably be deemed ‘healthy’” (Kiwanuka et al. 2013). Fundamentally, the risk-beneﬁt calculation involves weighing considerations of quantity of life against considerations of quality of life. Facial transplantation, claim its advocates, can greatly improve the quality of the recipients’ lives, which is sufﬁcient to tip the balance in favor of proceeding.

Quality of life – like welfare – is a complex concept. It invites a relative judgment: a procedure or intervention might be indicated, if it is capable of improving (in some sense) the life of the recipient, relative to his or her current situation. The relative improvements might take many forms. Early on, the suspicion had been that facial transplantation would effectively achieve only one sort of improvement: the recipient would acquire an appearance that is in some sense “better” (Huxtable and Woodley 2005). However, the cases to date reveal a variety of positive outcomes for recipients (Khaliﬁan et al. 2014). The recovery of normal facial sensation had been thought unlikely, but available reports reveal that recipients have rapidly recovered such sensation. Motor function has been slower to recover, although this too has tended to occur by 6–8 months, with ongoing improvements thereafter; in time, patients have therefore been able to smile, swallow, and speak. As such, patients have recovered facial movement and function, becoming better able to eat, drink, and communicate in virtually all cases. Compliance with the immunosuppressive regimen contributes to such improvements, as do speech therapy, motion exercises, and sensory reeducation. Although blindness had been considered by some teams to be a contraindication to transplantation, such functional improvements were also noted in a blind patient who had received a full face transplant. Finally, and of particular signiﬁcance, there are the psychological outcomes, which also appear to be good. Depression and verbal abuse appear to reduce post-transplant. Recipients report an improved quality of life, with some returning to employment, and they appear to enjoy an “improved body image, sense of self, and social reintegration” (Khaliﬁan et al. 2014).

Facial transplantation therefore appears to have delivered on its promise, conferring many beneﬁts on the majority of the 28 recipients to date. Equally, however, there remain considerable risks, and the proportion of patients to have died is certainly signiﬁcant. Maybe, though, we should leave the assessment of beneﬁts and risks to the putative recipients themselves. Paternalism – in which someone other than the autonomous patient decides what will be good for him or her – has been consigned to history, at least in those (many) countries that have embraced the ethic of patient autonomy. But is there reason to be concerned about the autonomy, and indeed identity, of these recipients? It is to this question we turn next.

Respecting Autonomy?

Although its meaning varies and its dominance is occasionally challenged, respect for autonomy – literally self (auto)-rule (nomos) – remains a core ethical principle, particularly in much of the “developed” world. In essence, this principle requires us to respect the decisions of autonomous individuals about what can and cannot happen with their bodies. Whether a decision – or an individual – can be considered autonomous tends to depend on whether that decision-maker is free to decide, has the capacity to do so, and also has the information that they need to make the decision. These conditions impose obligations on others, who must therefore ensure that the individual is indeed deciding voluntarily, is competent, and is sufﬁciently well informed. In the healthcare setting, these other individuals will tend to be clinicians or other healthcare professionals, and many legal systems include rules relating to the provision of information, voluntariness, and mental capacity (or competence). Provided that such obligations are met and the patient does satisfy the relevant criteria, then the ultimate obligation is to accede to the patient’s wish. However, respect for autonomy need not mean that “anything goes”: no matter how autonomous people’s choices might appear, boundaries might well be placed around some such choices, either in principle or in practice. We will consider the boundaries associated with the “public interest” in the next section. First, we need to explore whether a decision to receive a face transplant can be considered autonomous in principle and whether there have been (or could be) any difﬁculties arising in relation to autonomy in practice.

Let us start with the requirement that the patient be free to decide, in the sense that he or she should make a voluntary decision, which is free from coercion or undue inﬂuence. Early commentators detected a potential problem with face transplants: since some (maybe all) recipients will reside in societies that place a premium on perceived beauty, might they not feel pressurized to conform and so to “normalize” their appearance (Huxtable and Woodley 2005)? Others, however, doubted that consenting to this procedure should be construed as submitting to social pressure any more than, for example, pursuing a successful career might be (White and Brassington 2008).

In any event, the voluntariness of the recipient’s decision can be assured by careful discussion prior to undertaking the procedure: such a discussion should, for example, explore the recipient’s motivations and expectations (Huxtable and Guilder 2014).

Such an exploration should also help to satisfy surgeons that the intended recipient has the requisite capacity to consent to the procedure. Here, too, concerns were initially expressed: perhaps, recipients would have unrealistic expectations, which, coupled with any distress they might already be experiencing due to their disﬁgurement, might give rise to doubts about their capacity to decide. Such concerns might become more acute if the procedure is extended to children, as has been proposed (Hanson et al. 2008). To date, however, the teams appear generally content that the right – autonomous – candidates have been selected. According to Khaliﬁan et al. (Khaliﬁan et al. 2014), patient selection is indeed the crucial issue, and they suggest:

The best candidate is one who: fully understands the implications of potentially lifelong immunosuppression and its serious morbidities, including infections, cancer, graft loss, and death; is motivated, committed, and compliant with intense post-operative rehabilitation, psychological treatment, and immunosuppression protocols; and has a strong social support system that will help them to address the many challenges, including media exposure, body image adaptation, and societal reintegration.

As Khaliﬁan et al. (2014) indicate, before he or she can consent to the procedure, the potential recipient needs to be well informed. This also posed a problem early on: the French committee noted that “the information needed so that informed consent can become a reality is just not available” (Comité Consultatif National d’Ethique 2004). This, of course, is in the nature of any experimental procedure: the less that is known about the procedure, the less information there is that can be conveyed to the participants. While the procedure is not yet routinely undertaken, the evidence base has certainly expanded in recent years and so too have the risks and beneﬁts become better known. Yet, facial transplantation is still in its relative infancy. As such, it seems that autonomy can best be served (and assured) by providing potential recipients with all of the information that is known, including information about the areas of uncertainty (Huxtable and Guilder 2014).

Even if the likely recipients can be appropriately informed and their capacity and freedom to decide can be ensured so far as possible, questions will still arise about who would, could, or should be considered the ideal candidates. These questions relate not only to the autonomy but also to the identity of the recipients. One such question was posed by Huxtable and Woodley (2005), who wrote of the “catch-22 of facial transplantation.” According to these authors, those individuals who are most likely to be capable of coping with the procedure and all that it will (or might) entail appear ironically likely to be those least in need of the procedure, since they already cope well with their disﬁgurement; conversely, those who are apparently most in need, because they are coping less well, might be less obviously autonomous and therefore less capable of coping with the procedure. The latter group might therefore be insufﬁciently equipped to cope with the regimen posttransplantation, and any consent they provide might not be entirely competently given or sufﬁciently well informed.

White and Brassington (2008) doubt the existence of such a “catch”: they claim that it is “fallacious” to assume that any distress associated with disﬁgurement renders such an individual less capable of coping after a transplant. Indeed, they suggest that any threat to the individual’s autonomy that is attributable to their distress is easily rectiﬁed, by providing the transplant that he or she seeks. As we saw earlier, published reports do reveal that the recipients generally cope well, with the quality of their lives appearing to improve posttransplant (Kiwanuka et al. 2013; Khaliﬁan et al. 2014). Coffman and Siemionow (2014) link these gains to the recipients’ dignity, and they suggest that transplantation can therefore confer honor, value, and self-esteem.

Such potential beneﬁts notwithstanding, the transplant teams still need to remain vigilant in their selections of patients. The physical health, abilities, and functioning of the recipient are certainly some considerations: there has, for example, been debate about the appropriateness of including individuals who are blind or HIV positive (Kiwanuka et al. 2013). However, there are also psychological considerations: “Severity of disﬁgurement does not predict psychological outcome and it is not always necessary to pursue an ideal aesthetic outcome to achieve the best possible psychological adjustment” (Khaliﬁan et al. 2014).

Such psychological considerations invite us to consider the identity of the recipients in a different sense, i.e., the personal identity of such individuals, as the concept is understood by various philosophers. Yet again, this is a contested concept. The different accounts that are offered seek to capture the same concept, which, as Huxtable and Woodley (2005) explain, is “often considered along spatio-temporal lines, in terms of re-identiﬁcation, where the quest is to discover the conditions that make a person at time T1 the same person as at time T2.” Two rival accounts tend to be offered, the ﬁrst animalist and the second psychological. The animalist account of personal identity essentially points to bodily continuity as indicative of an enduring identity. On such an account, the recipient of a face transplant evidently acquires a new identity, since their bodily makeup is fundamentally altered. This nevertheless tends not to be the dominant view of personal identity and perhaps understandably so: our bodies endure, accept, or invite various changes over our lifetimes, but we do not usually say that our identities have changed as a result.

There is, therefore, probably more support for psychological accounts of personal identity, which essentially hold that our minds deﬁne us as individuals, and it is the endurance of these which make us the same individual over time. According to such accounts, our knowledge, thoughts, memories, and the like make us who we distinctively are. Accounts such as these can support notions like an afterlife and reincarnation; they might also hold that X will remain X, even if her brain is transplanted into Y’s body. On this sort of approach to personal identity, facial transplantation need not have any ramiﬁcations for identity: the individual remains the same, even with a different face. However, the psychological account of identity can run into difﬁculty: what authority can an advance decision, which is made by a competent individual, have over the future incapacitated individual it purports to bind? And doesn’t the psychological account underplay the connections between the mind and the bodily substance to which it appears inextricably linked, i.e., the brain (Huxtable and Guilder 2014)?

This latter question has led some to reexplore the nature of personal identity, in light of facial transplantation. Huxtable and Woodley (2005) suggest that signiﬁcant changes in the body can effect transformations in the mind. Since the mind and the body appear so closely related, it seems plausible that the recipients of face transplants might ﬁnd their identities altering: for example, identity might shift following a disﬁguring trauma and then shift again following the provision of a new face. Referring to the donor’s face, the ﬁrst recipient of a face transplant, Isabelle Dinoire, notably described her appearance in the following terms: “It’s not hers, it’s not mine, it’s somebody else’s… Before the operation, I expected my new face would look like me but it turned out after the operation that it was half me and half her” (Huxtable and Guilder 2014).

Edgar (2009) develops these observations, drawing on lived-body and narrative accounts of personal identity. Lived-body accounts of identity point to the sensory inputs, received via the body, which inﬂuence the mind, and thus contribute to an individual’s identity. Narrative accounts of identity highlight the role played by relational context in forming identity: not only relationships but also physical experiences therefore play an important role in identity formation. Edgar (2009) accordingly suggests that we each simultaneously have an “embodied” and a “social” self. Our bodies are the vehicles through which we interact with our environment. Our bodies also inﬂuence how others perceive us, and we in turn internalize and reﬂect these perceptions, thereby constructing a social role for ourselves, which is shaped by others. According to Edgar (2009), changes in the body can affect our social communication and our roles; indeed, traumatic changes can impact negatively on self-esteem, especially in social situations.

Adverse events can therefore effect negative changes and perhaps even lead to the loss of a hitherto valued identity. But should facial transplantation be considered in such negative terms? Perhaps any change will be positive, particularly if this is a change which is autonomously embraced by the recipient. Through such voluntary adoption of a new face, with all the functional improvements it might promise, the individual might even be able to retain or resume authorship of his or her distinctive identity (Huxtable and Guilder 2014). In short, if his or her identity does alter, maybe any such alteration will be to the good. Here, we should note again the positive effects on quality of life that have been reported, post transplant, by recipients to date (Kiwanuka et al. 2013; Khaliﬁan et al. 2014). Furthermore, we should acknowledge that some recipients reportedly “feel subjectively that they conserve their identities, suggesting that transfer of appearance is not equivalent to transfer of identity and, at its core, is not as signiﬁcant an issue as has been suggested” (Kiwanuka et al. 2013). Although there may be challenges associated with ensuring that the recipient is indeed autonomous, perhaps this is the ethical bottom line: provided that he or she genuinely wants the procedure, is competent, is informed, and decides voluntarily, it is the individual who should ultimately make the choice.

In The Public Interest?

Of course, society will not necessarily accede to a request simply because it happens (in some sense) to express the individual’s authentic wish. Nor should society be expected to grant every request, when there are risks to the individual that must be considered, as well as the wider impacts on other individuals and, indeed, society at large. The “public interest” is our ﬁnal amorphous concept, although (again) commentators tend to refer to similar aspects of the “common good,” when they address the broader dimensions of facial transplantation.

Other than the recipients, we should ﬁrst be mindful of the obligations that are owed to donors, along with those owed to their families or other loved ones. Perhaps, donation policies need to state, explicitly, that a face could be harvested for transplantation, and speciﬁc consent should be sought for this particular donation. Implied consent might not be sufﬁcient here, given the intimate nature of the tissues involved. Of course, donation will occur after the donor’s death – but his or her loved ones will remain, and they will merit moral concern. Support might therefore be needed for these loved ones, so that, for example, they are prepared to see the recipient featured in the media (Coffman and Siemionow 2014). They are unlikely to confront the exact face of their deceased relative or friend: reports indicate that the recipient will scarcely resemble the donor following the procedure (Kiwanuka et al. 2013). Despite this, it still seems advisable to involve the family members in the consent process. Ensuring that everyone willingly signs up for donation should protect not only the donors and their loved ones but also the process itself: adverse publicity can, after all, lead to a fall in donations. The donors’ families might be further reassured if their privacy – and thus anonymity and conﬁdentiality – is guaranteed. Some donor families have been willing to waive these restrictions and have chosen to meet with the recipients (Coffman and Siemionow 2014). Crucially, of course, these family members chose to have such meetings, which again reinforces the importance of autonomy and consent, albeit this time the autonomy of those other than the recipient him or herself.

These concerns with privacy and conﬁdentiality should also remind us of the need to protect the recipients themselves. Such protectionism might be related to the preservation of the recipients’ autonomy or welfare, but it also touches on the public interest. Here, we need to remember that there is a difference between that which is merely interesting to the public and that which is genuinely in the public interest (Huxtable and Guilder 2014).

Drawing the line between the two might occasionally be difﬁcult, but some matters will be more obviously related to the public interest. Given the nature of the procedure and the fact that this remains groundbreaking, it seems inevitable – and may be understandable – that the public will be interested in the procedure, at least in its early years. Recipients, donors, and donors’ loved ones nevertheless deserve protection from intrusion. We might even ask who, precisely, the intended patient is: is it really the recipient or, instead, the society at large who is being treated (or enhanced) by this procedure (Huxtable and Woodley 2005)? This question arose early on, when the transplant was thought likely only to enhance appearance. If that was the case, then wasn’t it the society that was being “treated,” for its unwillingness to tolerate diversity? Of course, we now know that the procedure can also lead to functional improvements, as well as to an improved quality of life, for the recipients. Despite these positive effects, efforts will still be needed to ensure that potential recipients are not coercively made to endure procedures merely for the sake of “normalization”; indeed, societies should be prepared to examine, and if necessary revise, their attitudes to disﬁgurement and difference (Huxtable and Guilder 2014).

Treating everyone – including the disﬁgured – with equal respect is a requirement of justice. Considerations of justice also arise when we turn to questions of allocation. Such considerations of distributive justice can arise at the micro, meso, and macro levels. At the micro level, teams will need to consider to whom such transplants should be offered (Coffman and Siemionow 2014). Adolescents, for whom the procedure has been mooted, might be noncompliant with the lifelong immunosuppression regimen and might also be more at risk from cancer. Older recipients, meanwhile, might be less likely to gain functional recovery. Those who are incapacitated or suffering from psychiatric illness might also not be considered ideal candidates. Although there will be valid clinical reasons for excluding some potential recipients, decisions about allocation are ultimately ethical in nature, and unjust discrimination must be avoided. Demand does not yet appear to outstrip supply, but this might change, and teams will need to consider carefully the eligibility criteria, making reference to such factors as socioeconomic status, ethnicity, and gender (Kiwanuka et al. 2013).

At the societal level, there are also considerations of cost. Khaliﬁan et al. (2014) estimate the costs of the procedure at US$300,000, before the costs of immunosuppressive treatment are included. Although it is becoming more established, the procedure remains experimental, for which funding might not be guaranteed, whether from the state in question or from insurers (Coffman and Siemionow 2014). As Khaliﬁan et al. (2014) note, almost every early recipient of a hand transplant in China lost their grafts after the authorities stopped supporting immunosuppressive treatment, which the recipients themselves could not afford.

Finally, we must not overlook the global picture. To date, facial transplantation has been undertaken in the developed world. The question arises whether this procedure could (practically) and should (ethically) be attempted in the developing world. One team from Mexico suggests that the technical expertise might be available but that the socioeconomic conditions mean that the procedure is not feasible (Gonzalez-Garcia et al. 2013). Fortunately, for the patient about whom they were writing, excellent results were obtained using an alternative procedure. Whether facial transplantation should be an option in such countries, and if so how it might be achieved, should remain open for discussion.

Conclusion

The ethical questions asked in relation to facial transplantation appear to have evolved as the procedure has become more established: speculation about the promises and pitfalls of the procedure has given way to more nuanced ethical analysis of the actual practicalities. Since facial transplantation was ﬁrst performed in 2005, individuals from across the (developed) world have undergone the procedure, and many appear to have beneﬁted. The procedure seems not only to improve appearance but also to improve function, and recipients also report a better quality of life following the transplant. The procedure does, however, carry risks: episodes of acute rejection appear generally to be tackled successfully, but some patients’ health has deteriorated and some have even died. The procedure is still in its relative infancy, so ongoing scientiﬁc – and ethical – appraisal seems appropriate. A central concern here should be the assessment of costs and beneﬁts, with a view to ensuring that any beneﬁts gained do outweigh any costs incurred. To aid such analysis, commentators urge international collaboration and speciﬁcally the sharing of detailed data on outcomes (Coffman and Siemionow 2014). There are also calls for the development of consensus on the eligibility criteria for receiving a face transplant (Kiwanuka et al. 2013).

The selection of candidates indeed appears to remain a crucial issue. As we have seen, the candidates need to be capable autonomously of electing to undergo the procedure, and they need also to decide freely, on the basis of sufﬁcient information. Although the recipients to date appear not to have perceived any changes in their identities, the possibility remains that facial transplantation can effect such changes, since alterations in the body might lead to changes in our communication with others and, indeed, in our social roles. Such changes, if they occur at all, might well be positive; teams and recipients should, nevertheless, continue to remember that this is a potentially life-changing procedure. At the same time, the wider effects on others should also remain open to scrutiny. Donors and their families need to be assured that their rights and entitlements will be honored, and individual states, as well as the global community at large, need to remain alert to the dictates of justice and to the ﬁnancial dimensions of this costly procedure.

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