A new countenance, but at what cost?

Transplants raise profound ethical questions.

By JEREMY MAISSEL
face transplant 88 (photo credit: )
face transplant 88
(photo credit: )
Of all the recent medical advances one procedure stands out not just for how much press coverage it has generated or the way it sparks the imagination, but for the countless ethical conundrums it raises. Last November a 38-year-old French woman, Isabelle Dinoire, got a new visage in the world's first - partial - face transplant, yet almost every facet surrounding this operation is clouded by controversy. There are differing accounts of the circumstances of the injury. In May, Dinoire, an unemployed divorcee from Valenciennes in northern France, had an argument with her teenage daughter who stormed off to her grandmother. Dinoire locked herself in her room and took some sleeping tablets. And then Tania, their black Labrador in attempting to arouse her, bit off part of her nose, mouth and chin. Now the versions differ. Did Isabelle take the tablets to calm herself and sleep after their quarrel, or was it a deliberate overdose? The amount of pills she took, rendering her insensitive to having her face gnawed off, would suggest that she wasn't just trying to chill out. Attempting suicide might have disqualified her from the operation. Why is the transplant recipient's psychological profile so important? Because apart from recovering from the surgery, the patient needs the stability to endure the profound emotional effects of accepting another person's face, and commit to a life-long anti-rejection drugs regime. There is also the persistent possibility of the body rejecting the graft. But this case includes two suspected suicides. It has been claimed that the donor, Maryline St. Aubert, committed suicide. Her family denied it and Dr. Bernard Devauchelle, one of the surgeons, said that he would not have used the tissue if she had hanged herself because of the risk of damaged blood vessels. For the face to be transplanted it must come from a live donor - heart beating and still breathing. Contemplate the considerable dilemmas involved in consenting to remove a substantial part of your brain-dead relative's face before finally turning off the respirator. Moreover, a person's face is of unparalleled importance to their identity. It is the way we recognize and perceive people, register their emotional and often physical situation. Our ability to distinguish and recall thousands of faces, differentiated often by tiny variations, is honed as an essential skill - it's what makes us social animals. TRANSPLANTING a face is not to be taken lightly. Little of the press coverage suggests it as a cosmetic procedure; the recipient's facial bone structure plays a major role in appearance - so a recipient might not resemble the donor. But as details of this remarkable story emerge so does the suggestion that medical or compassionate motives were not the prime motivation. The surgical team was, reportedly, eager to be the first to perform this medical milestone. It was the team that performed the world's first hand transplant in 1998 and world's first double forearm transplant in 2000. Clint Hallam was the recipient of that first hand transplant, after losing his hand in an accident in a New Zealand prison where he was serving a sentence for fraud. He later had it removed after he had stopped taking anti-rejection drugs. Critics claim he had the wrong psychological profile, others say he simply couldn't afford the huge annual drugs bill. The surgeons were criticized in the press for ignoring ethical questions, cutting corners in seeking approval for the operation, using the operating theater as a springboard for a political career and for brokering exclusive video and photography rights for the operation (giving Dinoire a cut). Another surgeon has claimed that the transplant team stole his technique. THIS CASE, although an extreme example, suggests that the ethics can't keep up with the medics. The surgeons are de facto shaping the ethical character of our society, and it seems that here, arguably, raw ambition, power and money drive the morals. Here in Israel, we commonly read about people traveling abroad for an organ transplant, or appealing for financial assistance to pay for it. When there isn't sufficient supply here, poorer societies provide willing donors to sell their organs. How do we exit this moral maelstrom? Governments try to enforce guidelines, but a rapidly shrinking global village, market forces and powerful individuals will determine where the next path-breaking operation will take place. When people's lives - or quality of life - are at risk, they will go to great lengths to get what they want. The international trade in human organs seems increasingly hard to regulate, and governments seem increasingly impotent. One suggestion which might ease the pressure, perhaps providing some respite to address the problems, would be a massive increase in the number of people carrying organ donor cards. "Flooding the market" with properly regulated organs and deciding priorities according to need and not wealth, would mean that people wouldn't need to take such desperate measures. Donor cards allow the carrier to stipulate which organs and the conditions under which they would be used. In Israel, important rabbinical authorities such as Rabbi Shlomo Aviner are doing all they can to encourage people to carry donor cards. Only such collective action by those of us concerned about the moral implications of transplants can improve the situation. The writer is an educator and member of Kibbutz Alumim.