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The Transplantation Revolution: From Vital to Non-Vital Organs and Finally to Faces?
by Gregory W. Rutecki, M.D.
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Gregory W.
Rutecki, M.D., is Director of Medical Education, Mount
Carmel Health System, Columbus, Ohio, a Clinical Professor
of Medicine, The Ohio State and |
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Post Date: |
The announcement that the first face
transplant had been accomplished December 3 and 4 at Amiens University
Hospital in Northern France was greeted by a healthy dose of criticism. This
story has the making of a soap opera. Isabelle Dinoire, 38 years of age,
sustained “horrific wounds from a dog bite in May . . . [that] left her
largely unable to eat, drink, or talk.”1 The circumstances of the injury
itself are somewhat clouded, but the patient confirmed that it all began
with a suicide attempt.2 Her surgeon, however, denied that the trauma was a
suicide attempt. Seven months later, she became the recipient of a portion
of a brain dead donor’s face (who did commit suicide) that covered the
nasal, facial, and lip defects resulting from her trauma.
Why all the publicity, one might ask? Since hand and larynx transplants
began a few years ago, transplantation has again entered unprecedented
territory. Those transplanting hands, larynxes, and faces must now address
recipient risk for organs that are important, but not essential to life.
This is a completely different set of circumstances than encountered during
the transplantation of kidneys, livers, and hearts. Is the uproar directed
at the first face transplant valid? In order to answer this question, it may
be pertinent rather to ask what unequivocal ethical constructs should be in
place before proceeding with the transplantation of “non-vital” organs,
especially one as prominent as the face.
First, the entire process, especially since it is experimental, has to be
transparent—that is, never in isolation from approval and step-wise
evaluation of the public and medical profession. In this regard, it is
interesting that both the Royal College of Surgeons and French National
Ethics Advisory Committee recently stipulated that a red light be given to
face transplantation, at least at this time.3 The British and French
opinions were both concerned over the potential adverse consequences of
graft failure (10% in the acute period and another 30 to 50% over the
ensuing 5 years). The groups left a yellow light for a later time, when
immune-suppression would progress to a stage wherein rejection would be less
prohibitive. In contrast to the French enterprise, in 1997, the first
International Symposium on Composite Tissue Transplantation was attended by
experts in immunology, transplant, research, and ethics from all over the
world. They were there to openly discuss any issue relevant to hand
transplantation.4 Critical questions were debated such as has adequate
animal research been performed to progress non-vital organ transplants to
human subjects, for example. Unfortunately, in the instance of Isabelle Dinoire, the disregard for “transparency” and healthy debate, as well as the
impartial opinion of two respected professional organizations, is
bothersome.
Next is informed consent. The informed consent process has to be iterative,
comprehensive, and forthright about what is really unknown and
unpredictable. Face transplantation may be accurately characterized as
experimental. As an example, with the first larynx transplant, exhaustive
efforts were made to inform the patient over an extended period (exceeding
the 7 month duration in this instance) about the pros and cons of a
revolutionary and risky therapy. Any coercion based on unrealistic
expectations or reward has to be completely absent for consent to be
authentic. Was only 7 months enough time for a woman who may have attempted
suicide? Did she know about the risk of cancer from immune-suppression, or
about a 10% risk of diabetes from her medications? Were alternative,
approved treatments (grafting, flaps) tried so that transplant was a last
resort? Furthermore, recent disclosure of substantial monies ($177,000)
contracted to the patient and surgical team for a documentary, if true, is
problematic.5
In addition, how vulnerable will this particular individual become now that
she is under the glare of inordinate publicity? A fragile psyche may lead to
a discontinuation of anti-rejection medications and stimulate the
disfiguring results of rejection. Severe depression will inevitably follow.
Were even these basic requirements to proceed enforced by unbiased
individuals (that is, people solely concerned about the patient’s welfare
and reasonably independent of the surgical team and the profitable
documentary) on an Institutional Review Board? Although there is more to
examine on an ethical checklist, the aforementioned are essential.
The ethical issues that have surfaced after the world’s first face
transplant are both substantive and valid. The red light recommended by
expert consensus should be enforced for any future attempts that proceed in
such a vacuum, immune from well-intentioned debate and genuine concern for
the recipient. That the first face transplant occurred under the particular
circumstances that it did is yet another black eye for Post-Hippocratic
medicine. It appears, unless evidence surfaces to the contrary, that the
proverbial foxes may have been caring for the chicken coop! Unfortunately,
the recipient was a very vulnerable human being and the rest of her story
may qualify as a tragedy. CBHD
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Copyright 2004 by The Center for Bioethics and Human Dignity The contents of this article do not necessarily reflect the opinions of CBHD, its staff, board or supporters. Permission to reprint granted as long as The Center for Bioethics and Human Dignity and the web address for this article is referenced. |
