Would you have a face transplant? If a dog had ripped off your nose and cheeks and lips, would you be able to learn to live with the damage, or would you be keen to consider taking on someone else’s face?
Perhaps the issue that raises most anxiety is the question of identity. Psychologist Diana Sanders, waiting for a heart-lung transplant, asked “Will I still be me?”. With someone else’s face, how much more immediate the concern.
And it is the fear that burdens relatives of both the donor and recipient. From our face, and the way it moves, others recognise us, and even if they do not know us, they read our emotions, infer our sex, make estimates of our intellectual, social, and even moral status. After the operation, will the recipient’s parents recognise their daughter? Will the donor’s parents recognise their daughter?
It turns out that what gives our faces their recognisability is less the soft tissues than the bone structure that underlies them, so a transplant adequately matched in skin colour and texture and of the same general appearance will end up looking much more like the recipient did before the transplant than the donor. And the experience of the first face transplant recipient, in France in 2005, is that within a few months the new face gains the mobility which provides function and emotion. We ‘lose face’, we ‘face up to things’ – or not –, we ‘put a brave face’ on something. The recipient can show her feelings; she does not feel she is wearing a mask. She might even get through passport control with her old passport. Perhaps Diana Sanders, who had lived with cardiac insufficiency all her life till she received a healthy heart, found herself more different six months after her transplant that did the French woman with a new face. “I have this huge part of someone else inside me," she said. It took her a long time to get used to the sensation of the new heart beating in her chest, to a different response to walking up stairs, to toes that were pink instead of blue.
However, there are serious downsides to face transplants. Skin is highly immunogenic and recipients of face or hand transplants need far higher doses of immunosuppression than those receiving a kidney or liver or heart. After more than 30 years’ experience of transplanting internal organs it is known that 30% will have developed a non-skin cancer and 80% a skin cancer, often a very aggressive squamous cell carcinoma. Premature death from cardiac problems is still common and so is chronic renal failure. The rates of these adverse effects are proportional to the dose of immunosuppressants. So if you have a face transplant you are can expect to develop a severe and life-threatening chronic illness at a relatively young age.
People awaiting a liver or heart are ill and likely to die without a transplant. The most likely candidate for a face transplant is someone like the French patient: savaged by a dog, but in good general health. Is it ethical, therefore, to turn a healthy person with a damaged face into someone with more socially acceptable features but condemned to a premature death due to immunosuppression?
Would it not be better to support those who do look abnormal in a return to normal life? It can be done – look at Simon Weston who was so badly burned in the Falklands. He, like many people with horrific facial injuries, became a prisoner in his own home for months afterwards. But he eventually emerged to face the world, to recognise himself and be recognised with his altered appearance, to find a new role, to be accepted by old friends and to make new ones, to marry and have children. By the time patients are being considered for a face transplant they will have been through the difficult months of horror and bereavement of their former looks and will be learning to live with their altered appearance. They will be able to face up to the face they see in the mirror. If they can’t, the odds are they would not be considered psychologically robust enough for a transplant.
The problem is society’s attitude to those who look abnormal. Can society alter its response to those who depart significantly from its view of what is normal, especially in these days of constant exposure to digitally enhanced role models? Maybe in former times we accommodated difference better. True, some were shunned, but many were granted special status as shamans, or at least given a protected place in the community. Could it be that we are less tolerant now, and if so is it because change is possible? A bottle of Clairol hair colour, Botox, having your Downs child’s face altered surgically to make him less likely to be stared at or teased, a face transplant. Where does acceptable cosmetic improvement become morally dubious interference with nature? And whose view is it that matters?
Diana Sanders ‘Will I Still Be Me?: A Journey Through a Transplant’ Day Books 2006 ISBN: 0953221385
Saving Faces : The facial Surgery Research Foundation www.savingfaces.co.uk
First published in NASGP Newsletter 'The Sessional GP' June/July 2008
Judith Harvey was a research scientist, ran the VSO programme in Papua New Guinea and taught in a Liverpool comprehensive school before going to medical school. She has been a partner, a salaried GP and a locum, an LMC chair and a long-time supporter NASGP. Her charity, Cuba Medical Link, enables medical students to go to Cuba for their electives.
Judith has now published all her articles from the NASGP website as a new book Perspectives: A GP reflects on medical practice and, well, just about everything…