Don't look now, but a woman in Ohio has a new face. And the world has a new kind of medicine: socially necessary surgery.
The operation, announced yesterday at the Cleveland Clinic, was a face transplant from a corpse. Similar procedures have been done three times before, but this was the biggest. Doctors replaced 77 square inches of the patient's face, from her eyelids to her chin. Go look at yourself in the mirror. That's practically the whole you.
Medically, it's a triumph. Transplants used to be mortally necessary and relatively simple: kidneys, livers, hearts. Patients got these surgeries because if they didn't, they'd die. And though the surgeries were risky, the tissues involved were straightforward. The blood vessels that had to be connected were manageable in number and size.
Today, transplantation has advanced to parts that are less vital and sometimes much trickier: ovaries, uteruses, penises, hands, arms, and now faces. As surgeons venture closer to the body's surface, two things happen. The recipient's body becomes more likely to reject the transplant, increasing the need for drugs that suppress the immune system, which in turn raises the risk of infection and cancer. By some estimates, the price can be a decade of life. And the muscles, nerves, and blood vessels involved become ever smaller and more intricate. One doctor involved in the Cleveland transplant calls it "the most complex surgical procedure ever performed."
Then why do it? Why spend hundreds of thousands of dollars and risk a patient's life to fix a nonlethal defect? The Cleveland doctors give three reasons. First, this patient had facial damage that impaired her physical functions. She couldn't eat normally, and she could breathe only through a hole in her windpipe. Second, faces, unlike kidneys, have social functions. "They are essential to our communication with the world," argues Maria Siemionow, the doctor who led the Cleveland team. They convey emotion as well as speech.
Those are good points. Physical function is the traditional purpose of surgery. Social function is a newer concept but makes sense: You need facial muscles to interact with others. We're still talking about functions; they just happen to be social. But then the Cleveland doctors take the next step: They remove functionality from the equation. Having a normal face is socially necessary, they argue, not just because of what your face does, but because of how it looks. Appearance alone can be grounds for a potentially lethal procedure.
Siemionow made this case in a book published last year. People with serious facial damage are "socially crippled in a society that appears to value beauty above all other human characteristics," she wrote. That's what happened to the Cleveland patient. She "was called names and was humiliated," Siemionow told reporters yesterday. "When she was on the street, people were turning their heads." Eric Kodish, the Cleveland Clinic's chief ethicist, added, "Human beings are inherently social creatures. A person who has sustained trauma or other devastation to the face is generally isolated and suffers tremendously." He concluded: "The relief of suffering is at the core of medical ethics and provides abundant moral justification for this procedure."
Yes, suffering cries out for relief. But when the suffering is social and the relief is surgical, where are we going? We're drifting from a standard of necessity rooted in you to a standard—"socially crippled"—that's dictated by others. And instead of changing them, we're changing and endangering you. The Cleveland doctors say their patient consented freely. They asked her, for example, whether it was she or her family who wanted the transplant. But how free can your choice be when the reason you want it is to escape humiliation?
Art Caplan, an ethicist who used to oppose face transplants, now endorses the Cleveland procedure. "The stigma of severe facial deformity is so enormous, so staggering, that many simply withdraw from society," he writes. "After talking to some people with severe facial disfigurement, I realize it makes ethical sense to offer a form of surgery that might kill the patient, because the suffering of the afflicted is so great that they are willing to risk death." Even if the suffering is social, patients are entitled to decide that ending it is worth that risk.
But if social suffering justifies procedures whose physical risks outweigh their physical benefits, where does that logic end? For Caplan, it goes all the way. "There are no second chances with face transplants—the damage of rejection makes that impossible," he observes. So if a patient risks death for a normal face and loses that face to immune rejection, she might prefer death. "What if someone facing this horrendous prospect—life with no face at all—says no to artificial feeding or breathing?" Caplan asks. "What if they beg for morphine to help them die painlessly and more quickly?" Doctors, he concludes, must "be ready to help that person in any way necessary, including assistance in dying."
I feel for the Cleveland patient. I hope her new face ends her suffering. I just don't want to end up killing her—and calling that her choice—because we made her life hell.