Medicine, ethics and face transplants

Roundtable

January 9, 2006

Face transplants have been a topic of great debate among the medical and scientific community for years. But when the first partial-face transplant was conducted in France last November, the issue was thrust in the national and global spotlight. We asked five people who have some insight into the issue to talk via e-mail. The exchange was edited and organized into a virtual roundtable.

From: Rhea Davis, Houston Chronicle

Sent: Monday, December 19, 2005

Thank you all for participating in our virtual online roundtable. I think we've picked an issue that will make for lively and enlightening discussion for our readers.

Those involved in this discussion are:

• Dr. Laurence McCullough, professor of medicine and medical ethics, Center for Medical Ethics and Health Policy, Baylor College of Medicine
• Dr. Robin Burks, Houston psychologist who has done assessments of people about to undergo serious medical procedures
• Dione Jackson, victims' counselor-supervisor at Family Abuse Center Inc. in Waco, who has worked extensively with Carolyn Thomas, a domestic abuse survivor who was shot in the face and has undergone numerous facial surgeries.
• Dr. Larry H. Hollier Jr., MD, assistant professor with the division of plastic surgery, Michael DeBakey Department of Surgery, Baylor College of Medicine
• Dr. Samuel Stal, professor and interim chief of surgery in the plastic surgery division of the Michael E. DeBakey Department of Surgery at Baylor College of Medicine

I usually only ask one question, but there are so many different issues that come up with this topic I'm going to throw out a few.

Here they are:

The recent partial face transplant that took place in Europe sparked world wide debate over the procedure. What concerns, if any, do you have with such procedures? Is a facial transplant procedure really needed? Is this a realist medical practice to pursue?

From: Samuel Stal

Sent: Tuesday, December 20, 2005 7:38 AM

As a plastic surgeon I have so many mixed feelings about this case.

I love the fact that the validation of how far Plastic Surgery has evolved is being showcased to the public. Plastic Surgery is not all Nip & Tuck or Extreme Makeover. Some of the greatest breakthroughs in medicine have come in the field of reconstructive plastic surgery.

With the advent of modern microsurgical techniques there is virtually no wound that can't be reconstructed as is evidenced by this case. Plastic Surgeons throughout the world and especially in Houston have evolved the care of adults and children with birth defects, trauma, and cancer. For that I am extremely proud.

On the other side, this case is very controversial. The concept of facial transplantation is not a new one as evidenced in animal studies in the past (Loeb-1988). The question is not can we do it, but when and which patient.

Considering the life altering affects of the immune response and the medications involved, the appropriate patient must be selected. For example, one that is mature, stable, and has been carefully evaluated first.

The indications must not be blurred, while facial trauma is devastating, all other methods must be used to stabilize and this takes time for wounds to heal and scars to mature. This also gives the team time to evaluate and support the patient from a psychological point of view.

From a medical ethics point of view, I am concerned that until all the kinks about immunosuppression should be better worked out, since loss of such a flap would be more devastating and a prime source of tissue would be lost. Remember this is not exactly an absolute emergent need such as kidney or heart failure.

By no means am I being negative about the pioneer spirit involved in such a case, I just really want it to work. I am just not sure this was the right patient. (short time after injury, psychosocial stability, etc.)

From: Larry H. Hollier

Sent: Tuesday, December 20, 2005 8:00 AM

I think we also have to start out by clearly stating that the case from Methodist that got so much publicity was a straightforward facial reconstruction that we perform every day. The thing that set it apart was the poor woman's story.

A facial transplant would not have helped her as they are currently being discussed. To choose a partial facial transplant as the first case done speaks volumes as to the rush to be the first. There are so many more appropriate candidates for a transplant - persons with severe burns with no viable remaining soft tissue of the face.

Partial transplants are much more apt to look like a patchwork reconstruction. Additionally, as pointed out by Dr Stal, the psychology is crucial, and there are reports of the patient in question having attempted suicide.

From: Rhea Davis

Sent: Tuesday, December 20, 2005 9:17 AM

This is a question for Robin Burks:

Can you please talk about what kind of person would be a good candidate for a procedure like this, from a psychological point of view. Also, what are some of the psychological issues that may arise after the surgery when dealing with this sort of thing?

From: Robin J. Burks

Sent: Tuesday, December 20, 2005 6:54 AM

Good morning. I thought I would make a comment that the woman in France who had the partial face transplant has a very different situation than the woman here in Houston who was having her face reconstructed.

As I understand each, the situation in France was significantly more controversial, mostly due to the issue of informed consent. As I recall, Dr. Alford stated in the Chronicle issue at the time that the same surgeon who had done a failed hand transplant was also operating in the case of the woman with the first ever partial face transplant. I am not the ethicist on this panel, but it would seem that informed consent would be a glaring consideration in the partial face transplant case.

From: Rhea Davis

Sent: Tuesday, December 20, 2005 9:22 AM

These are questions for Dr. Samuel Stal and Dr. Larry Hollier:

Do you think facial transplants will become common? Are these procedures needed? As you both have stated can't amazing things be done with reconstructive surgery? Why would someone desire a facial transplant instead of surgery?

From: Samuel Stal

Sent: Tuesday, December 20, 2005 10:15 AM

In response to Robin's questions. I would think the psychological disposition would come from you, but to me like any devastating injury the patient must go through a period of acceptance of their situation, with a realistic understanding of what's involved.

This would include a period of investigation and study of the pros and cons of options available. This is a process that I think is critical to make a mature life altering decision and it takes a while to "walk through".

The other obvious problem with a transplant is not only the loss of self image but the change to another person's image which is difficult at best.

Other reconstructive efforts can initially be done with skin grafts, local flaps and even distant flaps to get a healed wound. It may not be optimal aesthetically but at least would get the patient through the reality of the catastrophe. There are some indications for total transplantation (mainly burns or severe trauma almost always associated with fire leading to tissue and facial structure loss) that make it an option.

What are the numbers that would benefit? I believe relatively small compared to kidney transplant. Again I don't minimize the problem, just want to put it into perspective.

From: Robin J. Burks

Sent: Tuesday, December 20, 2005 11:06 AM

Taking into account Dr. Hollier's comment that the partial face transplant patient in France had a history of a suicide attempt and Dr. Stal's concurring comment about the patient's "psychosocial stability" it would have been prudent to have assessed the patient for history of suicide attempts and suicidal ideation, history and current symptoms of any type of depression and general mental and emotional stability.

In fact, such assessments in this country are presumably standard protocol for major surgeries and would be even more crucial for someone undergoing such a controversial surgery with such an uncertain outcome.

In response to Ms. Davis' questions about who would be a good candidate for such a surgery, from a psychological point of view, and what would likely be the significant post surgery psychological issues; let me say that the ideal candidate would be physically healthy, mentally and emotionally healthy (with an absence of any diagnosable psychological or psychiatric problems) and would have a very strong support network of family and friends.

The patient would need to be able to comply with post surgical requirements and to fully understand the recovery process, risks, possible set backs, etc. It would be critical for the patient to have a realistic perception of the expected cosmetic result and ongoing professional psychological consultations in my opinion.

In response to Dr. Stal's comment regarding the psychological aspects of changing to another person's image, I agree it would be difficult indeed. Even organ donor recipients report a variety of unusual and ambivalent feelings regarding having another person's organ, one can only imagine that having another person's face would require quite an adjustment indeed!!

From: Laurence McCullough

Sent: Tuesday, December 20, 2005 7:17 PM

It is important to appreciate that the face transplant in France (or a face transplant anywhere else in the world, for that matter) is innovation -- it is surely something new.

Surgery has innovated for centuries, but not always with the scientific discipline that results in measurable improvement in quality. This is especially the case when surgical innovation is experimental in the sense that the outcomes of a surgical innovation cannot be predicted. That is the case here.

This means that such innovation should be conducted explicitly as research. It follows that it would be

scientifically and ethically unacceptable to present face transplantation as a medically reasonable alternative to living with one's deformity or attempting accepted surgical repair. It is not clear to me from the news reports how this was presented to the woman in France who underwent the procedure.

The first step in research is undertaking a surgical innovation of high risk (which face transplant surely is) on animal models, to develop preliminary data about safety and efficacy. It is not clear to me from news reports that this first step was undertaken by the French surgical team. If such animal research was not first undertaken, serious questions about the professional integrity of the surgeon and surgical team must be raised.

The next step is to design a protocol for human subject research and have it reviewed by an independent group (known as institutional review boards in the United States) for its adherence to accepted international scientific and ethical standards. A key consideration is whether the experiment is designed in such a way as to minimize risk to the subject. Given the consequences of failure of experimental face transplant it is not at all clear that the requirement of minimizing risk can be met. Again, it is not clear to me from the news reports what the results of the review were in this case.

The next step is a rigorous informed consent process, to ensure that the potential research subject understands that face transplant is experimental and that, therefore, its outcomes are unknown. Investigators also need to ensure that the potential research subject understand the nature of the procedure and its predicted benefits and risks. Investigators also need to ensure that the potential research subject makes a decision about enrollment in the experiment free of substantially controlling influences. It is not clear to me from the news reports that the informed consent process met these internationally accepted standards.

Let's assume, for the moment, that this procedure is a success in the sense that the graft is not rejected and that the patient can live with her new function and appearance. Scientifically, such a success will, emphatically, NOT prove that the procedure should move from the experimental to standard of care. Both the scientific community and the lay public must resist an understandable tendency to enthusiasm and, instead, maintain the intellectual discipline of suspending belief and disbelief about this experimental procedure until meaningful data have been collected and rigorously analyzed.

My main concern is the scientific community and lay public understand that this procedure is a form of human experimentation and that it should therefore be undertaken and evaluated under the scientific and ethical requirements of human subjects research.

From: Dione Jackson

Sent: Sunday, December 25, 2005 3:00 AM

Good evening, I have been working with Ms. Carolyn Thomas since early August of 2004, a domestic violence survivor who was shot at point-blank range by her ex-abusive partner on December 5, 2003, which left her with catastrophic injuries to her facial area and ongoing trauma due to the violent incident and her mother being murdered by ex-abusive partner. I can only share my thoughts about her facial reconstructive surgeries.

It should be noted that "75 percent of women in an abusive relationship receive battering to their head and facial area" (TCFV). Carolyn was not supposed to survive her horrific incident, but she did. She strongly desired reconstructive surgery after she was released from the hospital in July 2004 from Sante Fe Hospital in Temple, Texas.

She was not a candidate for a facial transplant. I referred her to the Face to Face Program--assist victims of domestic violence with facial and neck injuries--with the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS).

AAFPRS teamed up with the National Coalition Against Domestic Violence in order to develop the Face to Face Program. AAFPRS was the first surgical group to take a firm stance against domestic violence.

Once Carolyn was accepted into the Face to Face Program, she was referred to a participating surgeon, Dr. Alford in Houston, Texas, in October 2004. Dr. Alford was the only surgeon willing to take Carolyn's challenging case with a solid commitment.

Carolyn's strong faith in God, determination to live, personal discovery of her purpose to continue to live and grow on different levels, positive and intoxicating spirit, and stable supporters define why Carolyn is an excellent candidate for facial plastic and reconstructive surgery.

Since I have been working with Carolyn, I have observed that both--the option of pursuing reconstructive surgery and counseling--are essential components to her physical, emotional, and spiritual well-being, regarding her ongoing healing process.

The surgeries are giving her parts of herself back, which will never be the old Carolyn, but the new Carolyn who she will eventually reclaim, in time. Carolyn will battle her past trauma, loss of the old Carolyn and mom, indefinitely.

An ongoing struggle for Carolyn has been her personal anticipation of the final outcome, regarding her transformation after all surgeries are done. Although she has been shown various possible images and photos of others who have completed similar, reconstructive surgeries, she is unable to see her final self until all surgeries are completed, which is an area of ongoing discussion.

Copyright 2006 Houston Chronicle

This article posted February 5, 2006.