May 05, AU Edition

Unhappy with your looks? Forget a nosejob, go get a whole new face. It sounds far-fetched, but face transplants are soon set to leave the realm of fantasy and become reality. Along with human cloning and stem cell research, it’s one of the most ethically tricky medical procedures to come down the pike in decades but, hey, you can’t stop progress. How are Australia’s doctors responding to the ethical challenges? Will face transplants be the new botox? Are embryos the only place to get stem cells? JAMES MORROW sorts through the medical facts and Hollywood hype and looks to see if medical technology is

GOING TOO FAR?
When cricketer David Hookes died last year after being bashed to death outside a Melbourne hotel, it was a tragedy – but one with some degree of a silver lining.
While Hookesy, at 48, died too young, his senseless death was ultimately not for nothing: the former batsman and radio commentator had signed up as an organ donor, and as a result, as many as ten other Australians were given the gift of life. And it didn’t stop there.
According to Australians Donate chairperson Marcia Coleman, the publicity surrounding Hookes’ death and the subsequent formation of the David Hookes Foundation to promote organ donation caused a 21 per cent spike in the number of registered organ donors. In a country where nearly 1,700 people at any given time are on years-long waiting lists for vital organs, Hookes’ death took on a new meaning.
But even if most people feel good about organ donation as it currently stands, new frontiers of medicine are being explored in America and Europe that are pushing the limits of both technology and ethics. Right at the top of the list would have to be the controversial exploration of face transplantation – an idea first introduced to the general public via the 1997 John Woo shoot-‘em-up Face/Off.
While doctors and scientists around the world have been pursuing this holy grail of plastic surgery for years, at the moment the Americans are leading in the race to be the first to perform a full facial transplant. Doctors at both the Cleveland Clinic and the University of Louisville say they are working hard to figure out the nuts and bolts of the procedure and are seeking the right candidates for the procedure. In Cleveland, doctors have been experimenting with face-to-face transplants on rats, while in Louisville, researchers have been perfecting their techniques on dead humans.

‘When plastic surgeons talk about the face and doing a face transplant, what they are talking about is using a freshly-harvested flap of skin and underlying fat from a donor who recently died – usually in an accident, but possibly from a pathological condition, and attaching it to someone else’, explains Dr. Alf Lewis, Vice President of the Australian Society of Plastic Surgeons, when asked to explain the mechanics of the procedure.
‘The procedure itself would involve taking this skin and underlying fat and possibly a little bit of muscle, and then reattaching it under microvascular conditions [similar to the sort of microsurgery that is used to re-attach, say, fingers severed in an accident] through the microscope to the major blood vessels of the recipient joined to the donor.
‘This is all technically possible in the present state of play’, adds Lewis, who notes that ‘there is no doubt that it could all be done any sophisticated medical community, of which Australia is an example, and the microsurgery and plastic surgery involved is already being practiced here every day of the week.’
But who would the recipient of the face look like? Themselves, the donor, or some combination of the two? And, perhaps more importantly, could they handle looking in the mirror every day and seeing…someone else?
While to the casual observer, a rat is a rat is a rat, the Louisville team in the United States which has been practising on rodents believes that a facial recipient would wind up looking like some sort of combination of their old self and their new face. Dr. Lewis agrees, and notes that muscle tone, which is a key component in how any face looks, ‘would be dependent on the muscle being attached to the fat.’
‘The facial muscles are quite unique in that they originate from bone but insert not back into bone, like in limbs, but into skin in the face. That means that if you put this new donor skin and fat over the muscles which would be exposed after you remove the scar or growth or whatever, it will attach by scar-tissue adhesion and produce some element of movement,’ says Lewis.
‘It wouldn’t be as good or strong or subtle as normal, but there would be some return of movement.’
As to how the recipient of a new face, no matter what they looked like before, might cope with their new look, earlier procedures involving transplanting other parts of the body suggest it’s not as (relatively) simple as replacing a heart or liver. In fact, at least one person whom a procedure was supposed to help was eventually been forced to say, ‘thanks but no thanks, this has all gone too far’. The world’s first hand transplant, performed on New Zealander Clint Hallam in Lyons, France, in 1998, was famously a disaster. Hallam had a dodgy criminal background (he lost his hand in a circular saw accident in a Christchurch prison while serving a two-year stretch for fraud) and went on to profit from the surgery by making paid appearances to show off his new hand, often one step ahead of the law. What’s worse, he also had terrible trouble coping with the regime of anti-rejection drugs he was required to take.
Ultimately, Hallam successfully campaigned to have the new hand removed, saying that he felt ‘mentally detached’ from the limb.
If it all sounds sort of ghoulish, well, that’s because it sort of is. Especially because faces are, by definition, incredibly personal things, it is only natural for people to worry about the implications of moving them from person to person – even if the recipient is badly scarred or otherwise deformed.
‘The face is such a powerful identifier of a person that once you start talking about transplanting a face, you are talking about transplanting an identity’, says Dr. Greg Pike, who serves as acting director of the Southern Cross Bioethics Institute in Adelaide.
‘In purely surgical terms, all you’re talking about is a situation where you have a damaged faced here, a new spare face there, and simply swapping them. This is a purely material way of looking at the situation without considering the consequences that might go with the element of the new identity that the individual is receving, which is tied up in the meaning of the life that was. These things can’t be ignored.’
This where what Pike calls ‘the “yuk” factor’ comes in. To go around with some form of the identity of someone else, and to have to think about what that person might have done or been, is potentially very disturbing. Doctors and ethicists agree that if a face transplant is ever performed, the recipient will need to receive extensive in-depth psychological counseling to cope with the mental side of things just as he or she will need anti-rejection drugs to deal with the physical consequences.
‘Whilst sometimes the yuk factor can be problematic if taken alone, it can also act as a sort of primal warning system’ that can set off ethical alarm bells and tell doctors and researchers to tread carefully about a new procedure, he says.
‘The average Joe on the street has a pretty good view of right and wrong, even if they haven’t necessarily thought it out to the point where they know why. Ultimately, an ethicist isn’t that different; all an ethicist does is unpack those views.’

Dr. Lewis agrees, saying that there really are profound ethical and psychological concerns with a procedure like this, for both donor and recipient – factors which all but guarantee such a procedure would only be used in the most extreme cases, and certainly never for run-of-the-mill vanity cosmetic surgery. For one thing, the side effects of anti-rejection drugs used in such a procedure would potentially be very serious; for another, unlike a hand transplant, there’s no undoing a new face.
‘I suppose you could argue the recipient would become accustomed to not looking like their original self, and they would have to have a lot of psychological counseling and education to cope with the fact that they would never look like themselves’, says Lewis.
‘We know from our cosmetic surgery experiences on the face and nose and other parts of the body that patients often have deep psychological concerns about their appearance. And I think that the psychology of this is a profound topic that needs to be discussed very carefully.’
More challenging, adds Lewis, is the problem of finding anyone who would even be willing to donate such a personal part of themselves, noting that ‘it’s a big ask to get someone to sign their face away on their drivers’ license, and a big ask to ask the relatives of an 18-year-old girl who just died in an accident about something like that.’
Concludes Lewis, ‘The face, it really is you. It’s how you’re identified. They don’t put a photo of your backside on your driver’s license, they put your face. That is you to you and the rest of humanity.’
But if face transplants are still the stuff of rats and research labs, research into other controversial therapies such as cloning and stem cells derivatives have both the potential to change many more lives, while at the same time raising even hairier ethical concerns. Researchers in several countries are currently exploring the idea of what is technically known as somatic cell nuclear transfer technology, which involves taking the nucleus from one cell and implanting it in an egg cell that has had its nucleus removed. Currently banned in Australia, this is the technique that was behind Dolly the Sheep – the world’s first cloned mammal.
What is still legal in Australia, however, is stem cell research – a technically complicated and often ethically messy arena where public perception is manipulated not so much by the ‘yuk’ factor as the celebrity factor. If stars like John Travolta and Nicholas Cage, however unwittingly, introduced the notion of face transplants to the wider world, it is the tougher cases of celebrities like Christopher Reeve which are being used – and sometimes abused – to push for more work with stem cells, specifically embryonic ones.
To start off, stem cells are special kinds of cells that exist in very particular circumstances and which have the potential, theoretically, to turn into just about anything – a liver, a kidney, bone tissue. They are often tough to come by, and for some time one of the most popular places has been from frozen embryos that were created by fertility clinics and no longer needed. Their use opens up a minefield of debate not just about when a human life is worth respecting, but also whether these forms of stem cells are all they’re cracked up to be. And until very recently these embryonic stem cells have long been considered superior to adult stem cells, which can be derived from a variety of other sources.
‘Typically when embryos are harvested for stem cells, we’re talking about blastocytes that are five to six days old, and consist of a couple of hundred cells’, explains Greg Pike. Pike opposes embryonic stem cell research and believes that the debate over the size of an embryo or the number of cells that make it up fundamentally misses the moral point.
‘I recall a senator during the debate over stem cells saying, “well, it’s just a few cells and it’s smaller than a full-stop, so what’s all the fuss about?”, and I felt like saying back, “you’re just a clump of cells, too, only you’re trillions of them.” Stephen Hawking’s universe was once that tiny; how do you put a value on that?’
For ethicists like Pike, ‘the significance of the early embryo is that we’re talking about a new member of the human family’ – a stance he readily admits puts him at the opposite end of the spectrum from people like Peter Singer, an ex-pat Australian who is now a professor of bioethics at Princeton University in the United States. Singer, who is as much a professional avant-garde controversialist as he is an ethicist, believes that ‘just because [embryos] are biological members of the species Homo Sapiens doesn’t give them the right to live’, a position he happily takes to its horrifying logical extremes.
(Among other things, Singer believes that each life is valuable in terms of its rationality and consciousness, and argues that for that reason the life of an adult chimp is more valuable than that of a human infant. Of course, Singer also argued in an infamous essay entitled ‘Heavy Petting’ that the taboo against bestiality should be done away with.)
But between these two extremes stands a lot of misinformation, much of it perpetuated by a media that is more interested in anything-is-possible whiz-bang technology on the one hand and compassion (particularly for celebrities) on the other. When people started talking about a paralyzed Christopher Reeve being able to walk again thanks to embryonic stem cell research, the barn door was swung wide open for just about any piece of well-intentioned misinformation to run free.
‘I think part of the problem with embryonic stem cell research is that there has been a lot of publicity around celebrities pushing stem cells for research and suggesting the definite promise of therapeutic outcomes’, says Dr. Adrienne Torda, a senior lecturer in medical ethics at the University of New South Wales.
‘But the nature of research is that it is open-ended. You can’t promise definite outcomes, and there are many hurdles in developing a therapy that often take decades to resolve.’
Pike has similar concerns as Torda, and worries that feel-good celebrity involvement in ethical and scientific issues can stifle
debate. ‘I for one found it very difficult to talk about stem cells when Christopher Reeve and the idea that stem cells can make Superman walk again was being pushed by the media’, he recalls. ‘Anyone who had anything different to say felt like that had to keep their mouths shut.’
There are other ways to get stem cells – for example, from the blood in umbilical cords of newborn babies, which is often donated by parents, as well as from hair, bone, and other body tissues. Research involving these adult stem cells does not have any of the same ethical quandaries surrounding it as that which revolves around embryonic stem cells or human cloning (after all, no new human life is created or destroyed, no matter how small). Even better, after years of being thought of as second-rate, at the moment these cells also are showing the most promise in the lab.
Researchers in Israel, for example, are currently working on a treatment that borrows stem cells from a patient’s own bone marrow to produce a chemical that could restore muscle movement to Parkinson’s Disease patients; human trials are slated to begin next year. In Britain, meanwhile, work is being done that could see the end of dentures as adult stem cells are being used to grow new human teeth.
Closer to home, researchers at Griffith University in Queensland recently discovered that adult stem cells taken from the nose had just as much potential to be grown into any other type of human tissue as the far more controversial embryonic ones. ‘Our experiments have shown that adult stem cells isolated from the olfactory mucosa have the ability to develop into many different cell types if they are given the right chemical or cellular environment’, Prof. Alan Mackay-Sim told The Australian recently, further shaking the conventional wisdom that only embryonic cells are useful for research.
In speaking to Australian doctors and ethicists, one thing that comes through is a desire to break bioethics out of the ivory tower and into the wider community – even if it means letting other countries take the lead in some areas of research – so that the public is comfortable with and informed about where researchers are heading. ‘We don’t say yes to everything we can do, and we are way behind many other nations that are doing these things. We need to engage many more people in the discussion and figure out how people feel’, notes Adrienne Torda. ‘Legislation has to be constantly moving, and the more you educate people, the better you can make decisions about moving those legislative boundaries’.
While this sort of approach may be frustrating for those who see medical technology as just another high-tech space race, it is also the safest route ethically – and when one is dealing with human lives, no matter the size, doctors cannot be too careful in observing Hippocrates’ ancient edict: First do no harm. And, as recent Australian discoveries in adult stem cells have shown, sometimes the safe route is also the more successful one.