Facial Transplantation: A Dilemma of the Four Basic Medical Ethics Principles

When doctors cannot do good, they have to be kept away from doing harm. —Hippocrates Ethical medical practice revolves around the four basic prima facie moral principles: respect of patient autonomy, beneficence, nonmaleficence, and justice.1 These basic principles have offered an analytical framework for physicians to use whenever they face a moral issue. The field of facial transplantation, a new frontier in plastic surgery therapeutic offerings, is an example of the intertwine between surgery and ethics. Its implications on all four moral principles are discussed in this Viewpoint. Facial transplantation has significantly evolved over the past 15 years, most notably through drastic improvements in surgical techniques and posttransplant management regimens.2 Few would deny the aesthetic and functional improvements that facial transplantation offers. However, facial transplantation is associated with extensive complications such as graft rejection, serious infection, increased risk of cancer, and death.2,3 Although similar complications could be expected in other types of transplants, facial transplantation is unique in that it is not lifesaving but rather focuses on improvement in quality of life.3 Furthermore, although graft rejection is a possible adverse outcome in any transplant, facial transplantation is different, as rejection usually leaves patients in a worse condition compared to their baseline. Moreover, any further reconstruction would be more challenging and less likely to have satisfactory outcomes. Although the decision to undergo a major operation such as facial transplantation should not be guided solely by its risk of adverse events, it is crucial to judiciously weigh its benefits and risks before offering it as a therapeutic option. Patient autonomy is widely valued and recognized as potentially the most important medical ethics principle. The idea that patients have the right to make choices about their life, including their medical treatments, is fundamental to modern medicine.1 The same is true for facial transplantation. However, previous studies have shown that the psychological and social burden of facial disfigurement increases optimism regarding facial transplantation’s outcomes.4 Psychological trauma puts patients at a higher risk of misinterpreting a well-balanced presentation of risk and benefits; therefore, additional safety measures should be placed to ensure that facial transplantation candidates are fully aware of the long term-outcomes. The principle of justice has long been rooted in the domain of transplant medicine. In the finite-resource society we live in, health care systems have an obligation to allocate scarce resources in an efficient way. Many schools of thought exist on fair allocation of limited resources. On one hand, strict egalitarian medical justice aims to create possibilities for everyone to make people’s health comparatively equal to one another.5 In this model, priority is given to those with the greatest disease burden and, as such, facial transplantation would receive significant resources to improve the health of facially disfigured patients. On the other hand, utilitarian medical justice aims to increase the total health of the whole population.5 In this model, medical interventions are prioritized based on their cost and the number of people that would benefit from them. Less costly population-based interventions such as breast cancer screening that address a large number of patients would take priority over costly interventions that address a niche patient population, such as facial transplantation candidates. Although neither school of thought is better than the other, surgeons have the responsibility to explore these topics and to engage in further discussion in an effort to optimize societal medical justice. Assuredly, facial transplantation represents a milestone in surgical innovation with the potential to provide improved quality of life to facially disfigured patients. However, as this field continues to evolve, its ethical nuances warrant close monitoring to ensure that we meet the highest standards of care for our patients. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

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