Facial transplantation is the latest medical miracle, but Raj Persaud believes we change the way we look at our peril: a new face could be mentally more damaging than disfigurement

It's easy to assume that as facial transplant surgery is conducted by the same kinds of medical teams as perform other major transplant procedures, including surgeons and immunologists, that these operations are another breakthrough in medical science that should be widely welcomed and marvelled at.

Psychologists are not so sure, and wonder whether medical technology is moving so fast that many potential psychological problems are being neglected by surgeons keen not only to assist the disfigured, but to be at the forefront of a procedure likely to revolutionise medicine.

Psychologists are concerned that, unlike other kinds of transplants, taking on another individual's face involves substantial considerations of personal identity and may involve psychological reactions to the procedure that transplant science has yet to encounter and to which it may not yet have the appropriate responses.

There is a psychological double-whammy intrinsic to the fact that skin is involved - in particular the skin of the face. In a book entitled Le Moi-Peau (literally translated as "skin ego"), a Parisian psychoanalyst, Didier Anzieu, illustrates the deep psychological significance of skin by listing expressions used in French speech that refer to most of the functions shared by our skin and the ego - "to burst out of one's skin", for example, or "to get under one's skin".

Given the deep psychological significance of facial skin, psychologists wonder whether profounder questions need to be asked than is usual in transplant surgery - particularly the reasons why the procedure is being undertaken. Could these have more to do with psychology than biological health?

It could be argued, for example, that many of those having these procedures to tackle facial disfigurement, rather than to improve impaired function, are submitting themselves to a risky surgical procedure for the benefit of others: it is the wide gamut of negative reactions from others, ranging from open revulsion to discreet avoidance, that may provide the primary motivation to go under the knife.

This is a very different impetus from that which normally drives a patient to obtain, say, a kidney or liver transplant. It raises the question of whether society should be questioning its obsession with beauty and appearance, as a healthier way forward than requiring the facially disfigured "do something" about themselves.

This is one of a series of doubts about the procedure voiced by Richard Huxtable and Julie Woodley, bioethicists at the Centre for Ethics in Medicine at the University of Bristol and the Faculty of Health and Social Care at the University of the West of England in a recent paper in the Journal of Bioethics.

Patients portrayed as "brave" by the media, Huxtable and Woodley argue, could be being influenced, or even coerced, by our beauty-fixated society into these high-risk procedures when there may be less hazardous ways of improving both society's and disfigured individuals' responses to facial disfigurement.

In Gaining face or losing face? Framing the debate on face transplants, Huxtable and Woodley point out that Guy Foucher, president of the International Federation of Hand Surgeons, opposed hand transplants on this basis, commenting that the procedure "transformed a healthy, one-handed man into a sick man with two hands".

Huxtable and Woodley are drawing attention to the often overlooked fact that to be eligible for the surgery a candidate for facial transplantation has to be, ironically enough, fairly fit and healthy. So modern medicine is taking a healthy person with a facial disfigurement and transforming them into a morbidly ill individual, who must endure a toxic regime of drugs, including immuno-suppressants, for the remainder of their life.

But rejection of the organ or tissue - requiring repeated surgery - has even more psychologically ominous consequences for the recipient. Are candidates for these procedures expected to get used to a series of new personal identities, as represented by the possibility of a succession of procedures and "faces"? Three-year survival rates for kidney transplants, the transplant surgery with the highest rates of success, are as high as 83 per cent, but Huxtable and Woodley point out that the face is one of the most immunologically reactive tissues in the body, so they argue that the chances of similar success is slim.

Even if the success rate for kidneys also pertained for face transplants, approximately one in five new faces would be rejected within three years. This fact contributed to the 2003 report Facial Transplantation from the Royal College of Surgeons of England, which called for a moratorium on the procedure.

Surgeons more used to other skin or organ transplants may not be fully cognisant of how pivotally different the face is. Several key determinations we make about what it is to be "us" arise so directly from the face that in a sense in the face is "us" more than any other part of the body - more perhaps than even the brain. Speech could be altered by a face transplant, as could the visual expression of our emotions and so most of the key ways we express our personality.

That such a transformation in appearance can have a deep mental impact and affect self-perception and identity is exemplified by the case of "Dax", as reported by Huxtable and Woodley. Don Cowart had suffered extensive second- and third-degree burns over two-thirds of his body as a result of a gas explosion and had spent 232 days in hospital. Before the accident, Don had been an attractive, sporting man, but the burns transformed him. He was blind, barely able to use his hands, badly scarred and dependent on others.

Don then renamed himself "Dax", suggesting that these bodily changes had provoked an identity or personality change.

The stories of those who desperately need these procedures may need wider circulation for us to better evaluate whether to proceed with this branch of medicine or not. For that to happen, society has to overcome its preoccupation with appearance to see past the face and listen to the human behind it.

Raj Persaud is Gresham Professor for Public Understanding of Psychiatry

Need to know: transplants

* Since transplantation was pioneered in the 1950s, doctors have been aware of both its life-saving potential - and the psychological affect that carrying a piece of somebody else's body can have on a patient.

* In 1998, Clint Hallam, from New Zealand, became the first person in the world to receive a hand transplant. But two years later, he stopped taking his anti-rejection drugs and the hand was removed after he said he did not feel like himself any more.

* Up to a third of kidney transplants in adolescents fail because they find it difficult to deal with the situation and stop taking their medication.

* Some transplant patients give their donor organs a name in order to cope with the concept.

* Experts have also expressed concern about the ethical issues around "designer babies", who are conceived through IVF as perfect bone marrow donors for their sick siblings.

Maxine Frith

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