With the stage set for the world's first full facial transplant, Ben Troke examines some of the complex legal and ethical issues that surround the procedure

Amid a flurry of controversy and media attention, the first full facial transplant is set to go ahead in the UK, after approval was given by the ethics committee at the Royal Free Hampstead trust in London.

The decision follows intense research by Peter Butler, the plastic surgeon who will lead the operation. It allows his team to go further than the partial face transplant given to Isabelle Dinoire in France in November 2005 after being mauled by her pet dog.

Despite advising against the procedure in a working party report only three years ago, the Royal College of Surgeons of England has recently given it cautious approval. This is despite risks including:

  • increased susceptibility to kidney damage and cancer due to a life-long regime of immuno-suppressants;
  • the potential for profound, and as yet unknown, psychological consequences;
  • long-term rejection by the immune system.

With these issues in mind, the RCS report concludes with 15 guidelines aimed at advising surgeons and protecting patients. But the legal, ethical and practical implications are also complex.

Potential for controversy

The balance of risks and benefits is particularly controversial for this treatment for two reasons. First, because the procedure is pioneering, warnings over the long-term risks are necessarily speculative rather than based on research or experience. Second, the procedure is not obviously life-saving, in contrast to organ transplants. Instead, face transplants are likely to be justified - if at all - by less tangible psychological and social considerations.

Ordinarily, consent to any treatment requires that the risks attached to a procedure are explained to the patient. Treatment performed without valid consent can lead to legal liability for negligence or even assault. The full-face transplant envisaged by Mr Butler's team, however, would require a patient to consent to unknowable and unforeseeable risks.

There are also a number of practical issues to consider, especially if the treatment is made available by the NHS.

Once a transplant has been successfully performed, the procedure will certainly be repeated, and with increasing frequency, and the categories of patient offered the surgery are likely to widen, with a potentially significant impact on NHS resources.

Is this is a cost-effective use of resources, compared to life-saving procedures? Despite the obvious temptation to perform high-profile, pioneering surgery - the so-called 'technological imperative' - some research suggests that counseling people with facial disfigurement to help them adjust psychologically may be more effective.

Cosmetic conundrum

A patient refused a face transplant by an NHS trust may try to challenge the decision in the courts, much as we have seen with the breast cancer drug Herceptin. Patients may even pursue the treatment for purely cosmetic purposes.

And the procedure could raise distinctive ethical issues due to the emotive nature of the face and its link with human identity and interaction.

How these issues develop remains to be seen. What is certain is that full face transplants will happen and, like the first few patients, we cannot be sure what implications this will have.

Ben Troke is associate solicitor and health law expert at Browne Jacobson