On Face Transplantation

Life and Ethics in Experimental Biomedicine

Samuel Taylor-Alexander

• Publisher: Palgrave Pivot
• Year: 2014
• ISBN:
  9781137452726
• Topic: Ciencias sociales
• Subtopic: Sociología

Drawing together interview material, medical publications, and first-hand accounts, this book shows that what is being remade in the burgeoning medical field of face transplantation is not only the lives of patients, but also the very ways that state institutions, surgeons, and families make sense of rights, claims for inclusion, and life itself.

1

A History of the Present

Abstract: I chart the key institutional, technical, and medical developments that paved the way for the emergence of face transplantation as a therapeutic possibility. These range from developments in surgical technique and immunosuppressive therapy, through to new ways of categorizing people whose hearts continue to beat while they lay in a state of ‘irreversible coma.’ In doing so, the I lay out the main issue that medical teams have faced in their pursuit to transform face transplant surgery from a medical possibility into a clinical reality: How can doctors expose a person with a non-life threatening condition to a potentially fatal treatment regime in order to improve their quality of life? In negotiating the ethical and technical challenges related to the operation, plastic surgeons around the world began to categorize patient groups, delineating in the process an ideal face transplant patient. This is a patient, they argue, who is healthy enough to withstand the stresses of the operation and ill enough to make the transplant a clinical necessity.

Taylor-Alexander, Samuel. On Face Transplantation: Life and Ethics in Experimental Biomedicine. Basingstoke: Palgrave Macmillan, 2014. DOI: 10.1057/9781137452726.0003.

Medicine on the make

A patient is hooked up to a respirator, lying in a state of irreversible coma on a bed at Brigham and Woman’s hospital. Surgeons shave parts of her head and then use a blue marker to map out incision points. One of them calls for a scalpel and the theatre nurse places it in his right hand. Her heart is still beating as with precise vigour he slices from the top of the patient’s forehead, down around her jaw, beneath her chin, and then up to the original incision point. Various instruments are inserted into the area to aid the removal of her face. It is slowly and carefully pulled away from the skull. Another surgeon with electric saw in hand moves in and begins dissecting her jaw. The team now has the requisite elements of face and she is taken off the respirator and allowed to move from a brain dead state to completely dead.

The emergence of face transplant surgery opens up new questions about what it means to be human in the age of high-tech biomedicine. Today, a relatively small number of people have had their faces removed while their hearts, though technologically assisted, continue to beat. By faces I refer to a composite of skin, bone, muscles, fat, jaw and teeth. These grafts are increasingly moved from one human head to another in what medical professionals refer to as the ‘allotransplantation of composite facial tissue.’ Transplanting composite tissue is nothing new. Doctors, some more successful than others, have been moving kidneys, ears, and other body parts between animals of the same or different species for centuries. Organ transplantation between humans is now a common life saving medical procedure. These operations are dangerous: if the operation doesn’t kill you, the drugs you need to avoid rejection will almost certainly harm your body.

Harm is an important issue in biomedicine. It is central to the professional ethic of surgeons and others caring for the sick: first, do no harm. This imperative has been translated into and is secured by different bureaucratic apparatuses such as risk-benefit analysis. It is too easy to examine face transplant surgery in the terms provided by the medical establishment and its external regulators. The various tactics employed by surgical teams around the world and even the joy expressed by face transplant patients and donor families alerts us to this – as does their disgust. As patients delight in their new felt normality, donor families bask in the gift of giving and in seeing loved ones continue to live on almost literally in another person’s face.

Face transplant surgeon Maria Siemionow has spoken about the animals, the rats and rabbits that she practices on, as chimeras, as hybrid specimens. Common organ transplant operations result in patients having the biology of another person pulsating within them, pushing blood through or cleansing the body. Sometimes they reflect on this and give thanks to the donor family. They grapple with how to live with the claims the family has over and into their life, and with having another person’s body parts within them. Face transplant patients have someone else’s face in place of their own, displaying the donor’s mole, brow, or freckle. They have a nose they might struggle to view as their own. They live with joy and sorrow. It is my contention that this hybridity provides a unique opportunity for reflection: What does it mean to be an individual in an age where people can be composed of more than one body? How are understandings of ‘life’ being reworked with the emergence of new technologies? Are face transplant recipients hybrid beings?

To get at these questions I provide a story of face transplantation. Tracing the emergence of new phenomena can break down the taken for granted nature of our present. I draw on a number of different accounts of the growth of organ transplantation, reconstructive surgery, and the like, and supplement these with my own research on face transplantation. This essay is based primarily on interviews with a team of surgeons in Mexico, and on academic and popular accounts of the operation. It shows that face transplantation is something of a hybrid medical practice composed of two sets of techno-medical expertise: organ transplantation and plastic surgery. It is in Mexico where we met our first patient, Escobar.

In the early months of 2007 a team of Mexican reconstructive surgeons became responsible for treating the man I call Escobar. A peasant farmer, Escobar had suffered from an abscessed tooth. Living away from the infrastructure of Mexico’s large cities, he first sought but was denied treatment at his local health clinic. Second, he went to a traditional healer who applied a mud lotion to the tooth. The infection did not go away. In fact, it only got worse. It spread, and in doing so took with it large bits of his face: he lost half of his upper lip, half of his lower lip, parts of the floor of his mouth, and almost all of the tissue from his cheek, neck and chin. As well as much of his face he lost forty kilograms of weight, and almost his life. He was interned in one of Mexico City’s largest public hospitals.

The severity and particularity of Escobar’s condition posed serious problems for the reconstructive surgeons responsible for treating him: According to the surgeons I spoke to, restoring function using traditional methods would be ‘practically impossible’ and so the team began ‘working with the idea’ of transplanting composite facial tissue. In the emerging and experimental terrain of face transplant surgery, the team was treating ‘a patient that we would consider an ideal case.’ In other words, the surgeons felt that Escobar’s condition not only justified and required, but also obligated the use of face transplant surgery. In order to make sense of the team’s opinion I came to explore the various ways in which they situated themselves and were positioned in a specific temporal and bureaucratic context. Below, I use these reflections to pull out broader insights into the past, present, and future of face transplant surgery.

Disciplinary norms

The case of face transplantation demonstrates that a number of ideals surrounding the human-self exist within and alongside medical, scientific, and national imaginaries. Patients are often framed or viewed in relation to the political and epistemic conditions in which they are incorporated, and the various assemblages through which they are produced as objects of care and enquiry. The majority of social scientists that have dedicated substantial analytic time to investigating reconstructive surgery come from the world of psychology, a discipline to which plastic surgery writ large owes much of its status as a legitimate form of medicine. While the case studies presented in such works often provide important forays into patient experience, they offer little critical insight into the a priori social and political understandings that underscore and structure the practice of plastic surgeons. Rather, they reproduce such understandings as they work from a long institutionalized model of personhood that is based on deeply ingrained concepts of normality and that outlines a specific separation and relationship between mind and body.

This can be seen in the early evaluation of face transplantation as a possible medical treatment. As we will see, a number of nationally situated institutional bodies reflected on whether or not the operation should be performed. The review offered by the Working Party of the Royal College of Surgeons of England, which became central to the Mexican case, stated the following, for example: ‘The aim of facial transplantation would be to replace unacceptable grafts and flaps with tissue that has the appearance of a normal face and allows mobility of the deeper structures.’¹ What constitutes a normal face is unexplored in this report, something that is significant in a context where the face under question is being donated from one person to another. In this context the face under question will look like a mix of donor and recipient, it will be the site of intense reflection by transplant patients as they learn how to eat and speak again, touching the inside of ‘someone else’s’ mouth with their tongue.

A scarce but important body of literature has begun to shed light on how the underlying assumptions that operate in reconstructive surgery shape both the practice and the lives of patients within it. In particular, scholarship from the social sciences and humanities has shown how questions of norms and normality underlie the discipline. Whether manifest in the balancing of sameness and difference by patients and carers, or seen in tactical attempts by affected teens to makes themselves more normal in their own eyes and those of their peers, it is clear that reconstructive surgery is attached to both social and biomedical norms. That is, reconstructive surgery seeks to transform the bodies of patients into an ideal prior state based on social and medical understandings of normality.

Another line of critical scholarship emphasizes the historical fluidity of the boundaries between reconstructive and cosmetic plastic surgery. This body of work points the spotlight towards the role plastic surgeons and the medical establishment takes to justify their practice. Here plastic surgery is a place where people engage in ‘boundary work’ designed to sharpen the blurry lines between aesthetic and reconstructive surgery in order to maintain the legitimacy of the latter as an ethical and necessary practice. Accepting these boundaries plays into rather than questions a priori assumptions about normalcy and how we should act with and upon our bodies.² Meanwhile particular surgical operations continue to cross boundaries from one side of the discipline to the other – cleft palate surgery was at the end of the 19th century considered a cosmetic procedure, for example³ – and new categories such as ‘aesthetic reconstructive surgery’ emerge as the contexts of surgical practice become increasingly influenced by the particularities of local health care systems.⁴

The historical accounts of the development of the discipline emphasize the important role that popular and expert understandings of the psychological dimensions of personhood have played in legitimating diverse surgical practices. In noting that all forms of plastic surgery are directed towards the production of personal happiness, for example, Sander Gilman⁵ also notes that the distinction between mind and body, intrinsic to how we understand ourselves as persons, is central to the credibility of plastic surgery as a medical discipline. The discipline of plastic surgery is based on and incorporates a particular, dualistic notion of personhood in which the mind and body are seen as separate yet mutually constituting aspects of the human self.

Such critical analyses of plastic surgery provide an important starting point for any social enquiry that deals with face transplant surgery. They describe the ethic of reconstructive doctors as one based on social and medical conceptualizations of normality. Medical anthropologists have drawn on a line of French philosophical scholarship that demonstrates that it is by distinguishing the normal from the pathological that biomedicine produces the object of its enquiry. Such demarcation is tied to both to the condition of pathology in biological process and to dominant social and political norms. Moreover, the very idea of the normal and normality has a moral quality in that it denotes what should be and thus becomes something to strive towards.⁶ Following this notion we may add that, like other forms of medical practice, reconstructive surgery has an intrinsically political dimension: It seeks to (re)construct people in accordance with institutionalized ideals of personhood.

Surgical beginnings

For reconstructive plastic surgeons, face transplant surgery is viewed as an answer to the limitations of the techniques and the (especially human biological) resources available to them. Every day these doctors perform reconstructive operations that involve moving skin, flesh, and bone around the individual bodies of their patients, often from torso or limbs to their face – they are experts in autotransplantation. While such rearranging of the human body and its parts often produces results that come close to meeting the desires of both patient and practitioner, in other cases surgical constraints are experienced as personal shortcomings, even failures. The desires and hopes of those involved in facial reconstruction have undoubtedly shifted since a decade ago, when serious discussion began regarding the allotransplantation of composite facial tissue – harvesting facial tissue from brain dead donors and transplanting it to restore the anatomy of craniofacial patients.

In its emergence as a reconstructive option, face transplant surgery has shifted understandings of the efficacy and limitations of common reconstructive techniques, how these limitations are understood, and how they are experienced. Whether or not the desire to perform the operation is another example of how, within an economy of hope, clinicians simultaneously embrace and are embraced by new medical technology,⁷ it is more or less accepted that face transplantation offers plastic surgeons the ability to restore function and appearance to a standard not possible with classic...

Table of contents

• Cover
• Title
• 1  A History of the Present
• 2  Institutionalized Personhood
• 3  Self-formation and Ethical Being
• 4  Constituting a Field
• Postscript
• Bibliography
• Index