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.

Ethics of Facial Transplant -- From Concerns about 'Identity Issues'

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.

Practical Issues Informed by Experience

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."