Description: A human’s natural instinct is to judge a person based on their outward appearance. Everyone always acknowledges a person by first looking at their face. So, what should a person like Richard Lee Norris do if they are severely disfigured and everyone is terrified to even look at them? Norris became facially deformed after he received a gunshot to the face as a young adult. After fifteen years of struggling to eat or to interact with others, Norris received a face transplant in 2012 that changed his life forever. A face transplant is a surgical procedure to replace all or part of a person’s face. In this case, practically all of Norris’ face transformed into an entirely new one due to the transplant of the donor’s skin tissues and facial features. Should people like Norris lose their ability to receive a face transplant because their outward appearance, or rather facial identity, is dramatically altered? My project specifically focuses on the severity of a person’s change in identity before and after a face transplant, as well as the role society plays in a disfigured person’s decision to undergo a transplantation.
The value of time is a concept that many people take for granted. Each passing second can lead to new beginnings. One second is all it took for Richard Lee Norris to receive a gunshot to the face and for his life to change forever. Norris’ face became severely deformed after the accident. Surgeons recommended that Norris should receive a face transplant where he could fix his disfigured bone structure below his eye sockets, teeth, tongue and an entirely new face from the collarbone to above the hairline. Fifteen years later, Norris realized he was tired of being ashamed of his face and wearing a mask in public every single day. After many years of coping with facial disfigurement, Norris chose to receive a face transplant in 2012. His life changed again this time. Is it for better or for worse?
This paper will focus on the concept of a face transplant, and whether or not a person should be able to change such a significant part of their identity if he or she is suffering from facial disfigurement. I will begin by describing the importance of a face, the term facial disfigurement, and the history of face transplants. I will then proceed to talk about my main ethical points: the issues of identity, societal influences, and necessity. Within these subtopics, I will tackle ethical dilemmas relating to each topic. Some of these issues are originality versus resemblance, societal influences versus individual thought, and necessity versus desire. I will discuss both deontological and utilitarian perspectives, which will be incorporated into each discussion surrounding the ethical dilemmas of face transplants. Both perspectives have helped me consider issues from different angles and form an educated opinion about the ethical issues that I was forced to contemplate. Lastly, this paper will conclude and focus on the regulations for face transplants that are necessary for today and the future.
I. The importance of the human face
The face evolved to be seen by society. In other words, a person can be identified by his or her facial expressions. Aristotle believed that facial displays in humans are “distinguishing patterns related to identifiable, internal emotional states recognized by others” (Cole 53). Facial displays came from primitive movements passed down from our ancestors during respiration, and they are now the way people express and represent themselves. These movements fully represent emotions and expression. Expressivity is necessary for a person to fully feel emotions and to develop a strong sense of self-identity. For example, people naturally produce tears when they are feeling certain emotions, a response that had initially protected the eye from the increased pressure and inflammation of the blood vessels associated with screaming (Cole 55). Because inner emotions are portrayed through our facial expressions, it is important to have a face and to move it fully be able to connect with others while creating a sense of identity. Therefore, what are people supposed to do if they do not have facial displays due to disfigurement? How are they supposed to function naturally? How are they supposed to have an identity?
II. What is facial disfigurement?
A common definition for disfigurement is when a person’s appearance is misshapen in any way (“Disfigurement”). However, for the entirety of this paper, disfigurement means something more specific. Facial disfigurement has different levels of severity. Some people are deformed, but are able to eat, speak, and move their facial features; meanwhile others are not capable of doing any of the latter. The lack of facial movement, communication with others, and natural nourishment can begin to inflict an emotional and physical toll on a person. Therefore, every time I discuss face transplants for disfigured persons in this paper, I am referring to the most severe level of facial deformity and people who experience a terribly diminished quality of life.
III. Face transplants
Facial allograft transplantation, also known as a face transplant, is a surgical procedure to replace part or all of a person’s face. A person receives this type of transplant when he or she has lost or has been born with lack of skin and underlying tissue on their face. This is how scientists and ethicists identify a facially disfigured person. The world’s first partial face transplant on a living human occurred in France in 2005 (Truesdell). Prior to this transplant, the only way to fix severe facial deformities was with skin grafts, which meant taking pieces of healthy skin from elsewhere on the body or from a cadaver and placing them over missing parts of the face. However, this procedure could not fully restore appearance or movement of the face because grafts do not look or work like the skin on a living person’s face (Swindell). That is why the idea of a face transplant, which looks far more realistic than a skin graft, is beginning to become common for disfigured persons. However, this is not just a simple procedure. One hundred percent of face transplants have a significant rejection episode, although, those are almost always reversible as long as they are treated (Carroll). There are both medical and ethical problems that arise, which makes the idea of a face transplant much more complicated and controversial.
The Issue of Identity
Richard Lee Norris’ gun-shot and shattered face completely transformed his outward appearance and identity. In 2012, Norris’ identity changed again when he received a face transplant. Not only did he look like a new person, but he was able to gain facial expressivity and other facial functions that he had ultimately lost after his accident. Should people be able to change their face, which is such a large part of their identity? The figure below shows Norris’ facial changes before his accident, after his accident, and after his face transplant.
“Richard Lee Norris.” ABC News. N.p., n.d. Web. 28 Jan. 2014. <http://abcnews.go.com/images/Health/ht_richard_lee_norris_ss_jp_121017_wblog.jpg>.
One of the main ethical dilemmas I will address today is the issue of originality regarding a person’s identity. Identity can have many definitions, components, and layers. Some people think that identity is a collection of inward characteristics that help define who you are as a person. Other people feel that identity is simply a person’s outward appearance (“Identity”). These different opinions lead into an even more controversial idea when discussing the identity of a person who wants to receive a face transplant. Some people feel that the face is not a central part of a person’s identity, while others believe in the exact opposite. Face transplant advocates argue that people who have distorted faces do not feel as if they are themselves because their disfigurement has changed their identity completely. Therefore, they believe that a change in a person’s identity by receiving a face transplant should not matter because his or her identity has already been severely altered from disfigurement. In contrast, others feel that facial disfigurement occurs naturally. They claim that the face is central to our understanding of our own identity, so if people receive a face transplant then they are changing their natural, facial characteristics that define them as a person (Swindell).
Lucy Grealy wrote Autobiography of a Face, describing her struggles due to facial disfigurement after she was diagnosed with cancer and underwent many transformative procedures. Grealy describes growing up and having people stare at her, then quickly looking away and never acknowledging her other redeeming qualities. Always looking at her face. So why should Grealy not be able to receive a face transplant? People would be willing to talk with her and get to know her, and she could feel like she is not defined by her facial distortions. People against this argument believe that faces help us understand who we are and where we come from, so they argue that a face transplant would take away a person’s identity and should therefore not be allowed. Those same people might also state that people are constantly redefining themselves as they grow and change with age and experience, and a face transplant would negatively impact a person’s development. I personally disagree with those opinions because the people receiving these face transplants with facial disfigurement barely have a face, meaning they can hardly be defined as even having an outward appearance or identity in the first place. A person with facial disfigurement will not grow and change the exact same way as a person without those deformities (Vercler). Therefore, I feel that people with facial distortions should be able to choose whether they want to receive a face transplant or not because they are the ones being affected by this procedure. This logic, a process of judging the morality of an action based on rules or rights, is a deontological perspective. I also believe that the majority of people will benefit if a person is able to receive a face transplant. The recipients, their loved ones, their doctors, and many other stakeholders would love to see the recipients’ happiness written all over their face. Without a face transplant, seeing the recipient’s facial expressions would not even be fathomable. Humans benefit extremely from having a face where they can move it fully and connect with others. This kind of thinking is based on a utilitarian perspective, which considers the maximum capacity of happiness for the majority of people.
The way we look plays some role in which we define ourselves. Consequently, the recipient of a face transplant will not be able to prevent redefining himself or herself after the face transplant, but this is often the evolution of the same self that existed before an accident. It is important to remember that a disfigured person must redefine himself or herself after the surgery.
The second main ethical dilemma is the issue of resemblance regarding a person’s identity. Some people are afraid that a person who receives a face transplant will look identical to the donor, and in a way the recipient will be stealing someone else’s identity. Many donors’ families even feel that their family member is living on through another person because his or her face tissues are given to that person (Lantos). However, the recipient of the face transplant does not necessarily resemble the donor in terms of face characteristics. Carmen Tarleton is a woman who received a face transplant and developed a cleft chin after her surgery, even though the donor never had one. That is one out of many examples that demonstrate the differences between the donor’s face and the recipient’s new face after the transplant. The donor and the recipient have different bone structures, so their faces will not look the same. In addition, the deformed person cannot miraculously receive society’s view of a natural looking face after the procedure. Disfigured persons will still have scar tissue, and some will have problems with specific features that cannot be altered (Goodnough). For example, Connie Culp still does not have society’s version of a normal mouth structure after her surgery. One can never regain the same identity in terms of physical appearance (Truesdell). Accordingly, the person who has a distorted face should be able to decide if he or she wants to have a face transplant. Disfigured persons are not stealing anyone’s identity, nor are they destroying their own. They are the ones who suffered from losing their identity in the first place from a tragic event in their life.
The French National Ethics Consultation Committee feels differently and believes that face transplants are not the solution for facial disfigurement. They are concerned that the recipient will feel as if his or her identity was taken away from them. In addition, the Committee states that there is a slim chance the recipient will regain physical expressivity from the transplant (Swindell). The Committee has its own personal beliefs about face transplants; however, it has been proven in recent years that many people have been able to regain physical expressivity like Connie Culp. Culp lost her face completely when she was shot by her husband in the face. After receiving a full face transplant in December 2008, Culp is fully able to speak, eat regular food, and express her emotions. Similar to Culp, other disfigured persons receive face transplants and take the chance to receive natural characteristics which they were born with and so rightly deserve. If disfigured persons are more satisfied by enduring a surgical procedure and gaining expressivity instead of remaining deformed, then they should be able to receive a transplant for that purpose.
Overall, identity is a key component surrounding the ethical dilemmas of face transplants. The main concerns of face transplants relate to the issues of originality and resemblance. However, it has been proven by people who have undergone face transplants that they are much happier with their new identity than the disfigured one, and they do not look the same as their donor. Furthermore, their new identity has allowed them to gain facial expressivity for the first time or once more. Individuals should have the right to change their identity in this certain circumstance.
The Issue of Societal Influences
Richard Lee Norris spent fifteen years after his accident as a recluse because he was so afraid of being judged by society. When he travelled outside, he would hide himself behind a baseball cap and a surgical mask. Finally in 2005, Norris grew tired of concealing his scarred identity from society and he became a transplant candidate. The transplant that he received in 2012 would provide news for researchers aspiring to heal disfigured soldiers from the wars in Iraq and Afghanistan (Carroll). Norris was cognizant that this transplant could allow him to fit into society again while helping society at the same time. Was his decision to receive a face transplant partially because of his fear of remaining an outcast in society or was his health the sole factor that he considered?
A main ethical dilemma which I will discuss today is the issue of societal influences. People against face transplants argue that if a person receives a face transplant to fit into society, then he or she may not be benefitting from this procedure in terms of authenticity. Connie Culp, as mentioned before, is a person who underwent a face transplant and felt more beautiful after her surgery (Truesdell). People argue that she is basing her opinions on what is attractive due to societal influences. Should she have been able to receive the transplant if she was only doing it to fit into societal norms? My answer is yes because of my observations using deontological and utilitarian perspectives. A facially disfigured person may not be able to get employment or feel safe in public because of society’s instinctual judgment. Therefore, a person should have the individual right to change his or her identity. As stated before, the people who have the facial distortions are the ones who are going to have to live with this change, and more people are also going to benefit and be happy because of the transplant procedure. The procedure will satisfy the recipient’s emotional and physical needs if it is successful.
In addition, individuals often shape outward appearance and identity through other modifications such as makeup or plastic surgery. As a society, we choose which procedures may be too extreme, medically undesirable, or even illegal. If a person is able to receive plastic surgery to fit into society, then a person who is disfigured should also be able to receive surgery so they can fit into society. I do recognize societal influences when a person is making a decision, however, I think that a person has even more of a right to receive a transplant then because of society’s instinctual judgment. Unfortunately, we cannot predict if or when society will ever look at a disfigured person the same way as they look at a non-deformed person, so people should continue to make the individual decision of whether or not they want to receive a transplant. They should also be conscious of why they want to undergo or forgo the surgery.
Societal tolerance is an ethical issue that questions whether society should become more accepting of a disfigured person, or whether the person should be forced to conform to standards of normal appearance. It is not fair to ask a person with severe facial deformities to wait until society becomes tolerant of his or her looks. Therefore, individuals with facial trauma should be able to receive a face transplant.
The Issue of Necessity
Around the time Richard Lee Norris was selected as a transplant candidate in 2005, he had already attempted more than a dozen operations and none of them had resolved his lack of mouth functioning. It became evident for Norris and his family that these minor operations were not going to repair any of his facial features. A face transplant became necessary for Norris to be able to gain facial expressivity and functioning again. Fortunately, he was able to receive a face transplant fairly easily because transplants were not as well known at the time (“MailOnline”).
Today, face transplants are difficult to access. Face transplant donors are scarce, so if these transplants continue to become popular, then ethicists will need to draw the line between who can and cannot receive transplantations. One of the goals for ethicists and doctors, using the utilitarian perspective, is to use their resources to maximize the happiest number of people. How do we adhere to this objective if it is challenging to determine what method will make people happiest, and who exactly should be able to receive a face transplant?
I would personally resolve this problem by considering what is medically necessary and unnecessary. The magnitude of a person who needs a new face due to severe disfigurement is completely different from a person who is suffering with wrinkles on his or her face. Both cases can be argued, but in this context I agree that severely disfigured persons are the ones who should be first priority when receiving a face transplant. Other deformed persons could be on a list, and when a face transplant is available, they can receive one. People who consider themselves disfigured due to ugliness should not receive a face transplant because they are not coping with problems that greatly impact their standard of living.
In contrast, James Partridge, along with many other people, feels that “all of these physical options,” or rather surgical procedures, “should be available to patients wherever they live.” People deserve equal rights; however, face transplants are serious procedures. There are always other alternatives for people who are displeased with their physical features. The costs and dangers of cosmetic surgeries are not as high as face transplants, and they should be considered before anyone ever wants to receive a face transplant. A person who is severely disfigured is on a completely different level than a person who feels that they are facially unattractive. As stated in the identity section, a facially disfigured person has technically lost their identity already. Therefore, changing their identity again would not be as drastic. In terms of necessity, facially disfigured persons are the main priority regarding face transplants. It is only logical to draw the line between the people who physically need a face transplant and the people who want a transplant.
For those who are unsatisfied with their looks but are not qualified to receive a face transplant, there are always other options. James Partridge also suggests that everyone should have access to a “disfigurement life-skills training,” which is a process where patients and their families can create a space where they adjust to looking unusual in a world that “stigmatizes not-such-good looks.” Patients would be able to interact with other people who are dissatisfied with their face, and it could create a support system for people to become more comfortable with themselves and their outward appearances.
The issue of necessity conflicts with individual rights. However, the scarcity of face transplants will most likely force ethicists to make decisions in the future about who should and should not receive transplantation. In addition, it is too dangerous for a person to receive a face transplant who is not disfigured, and there are so many other solutions for satisfying a person who dislikes his or her face. For that reason, disfigured persons should be the only ones to receive face transplants.
Face transplants are a relatively new procedure and much is still unknown about them. However, that does not mean that people should stop receiving them. Patients have a right to seek help and to receive a face transplant to advance their own flourishing as a human being. They also deserve to be happy, and having more of a human looking face can do that. On society’s behalf, it is common to have a negative reaction when regarding or interacting with a disfigured person. If society could begin to accept deformed faces, then face transplants may not even be an issue. Even though society could be influential upon people’s decisions to receive a face transplant, those people should still be able to decide whether or not to undergo the procedure because they are the ones who will be most affected.
Furthermore, after considering potential regulations for face transplants, I feel that they are currently not necessary. In the future, regulations may be essential. For example, if a person wants to change their face for vanity purposes, instead of necessity, then regulations will need to be enforced because that is defeating the purpose of these transplants as a treatment. The goal of these transplants is to treat severely disfigured persons; it is not meant for enhancement. The current definition of facial disfigurement may very well change in the future, which I feel would need to be addressed. Because face transplant donors are scarce, ethicists will need to continue modifying the transplantation process so that disfigured persons can continue to receive access to this type of surgical procedure. The only way to resolve the scarcity of resources would be to draw a line between the people who medically need a transplant versus the people who do not medically need one. Because a severely disfigured person can barely speak, move their facial features, and eat naturally, they should be the first priority for receiving a face transplant. Hopefully, lack of resources will not be a problem in the future because people will consider other options that are not as severe beforehand. Even though face transplants should be used as a last result, doctors should still suggest them as an option for severely disfigured persons. Doctors should not be using medicine to only treat physiological problems, but they should also be helping people with psychosocial functioning. Doctors and ethicists’ goals are to respect the autonomy of individuals and to give them the decision where they will be most satisfied.
Moreover, ethicists must understand the kinds of pressures that we place on society to get ahead in the market. Will face transplants place a toll on society in the future? Ethicists must also ask themselves what we can afford when taking a risk. In this certain circumstance, face transplants are a risk that disfigured persons have been willing to take, and it seems to have maximized happiness of society. Neither scientists nor ethicists can predict the outcome of facial transplantations, so for now disfigured persons should continue to have the right to receive them and to learn from the operation in the process.
By Alison Nestle