'No ethical barriers' to face transplant in children, experts conclude

Should children be considered for facial transplantation? While there are some special ethical and psychological concerns, these shouldn't rule out the possibility of performing face transplant in carefully selected children, according to an expert review in the August issue of Plastic and Reconstructive Surgery.

"Our analysis finds no physical, psychological, or ethical barrier that disqualifies children from undergoing face transplantation," comments Alexandre Marchac of Hôpital Européen Georges-Pompidou, Paris, lead author of the new report. He adds, "Pediatric face transplantation will likely occur in the near future."

Time to Consider Face Transplant in Children? Experts Review the Issues

While facial transplantation remains uncommon, the procedure has advanced rapidly, with several transplant teams around the world reporting excellent results. From the earliest debates over face transplantation, children have been excluded from consideration.

And yet, there are children with severe facial disfigurement who could potentially benefit from facial transplantation. Toward considering the possibility of expanding their face transplant program to include children, Dr. Marchac and colleagues performed a review and analysis of the clinical, psychological, and ethical issues that would be involved.

An expert panel including transplant surgeons, medical ethicists, and a child psychologist identified and debated issues related to offering facial transplantation in children. Out of twelve possible patients included in an in-depth review, three were identified as potential candidates for face transplant. All had severe facial disfigurement—caused by congenital malformations, diseases, or burns or other trauma—with "very poor" expected outcomes from conventional reconstructive surgery.

In children as in adults, the decision to perform facial transplantation would depend on the balance of risks and benefits. Because they heal faster, children might be expected to have even better recovery of facial sensation and movement than adults. Because of continued growth of the facial skeleton, some children may need additional craniofacial surgery years after the face transplant.

Children being considered for facial transplantation would undergo a rigorous selection process, including evaluation of psychological status, behavioral maturity, and social support. Psychological assessment must include not only the child, but also the family—parents must be prepared to assume responsibility for the child's care, including the need for lifelong immunosuppressive therapy. A young patient's ability to follow this demanding treatment regimen into adolescence and beyond is "the great unknown," the researchers note.

Informed consent would mean not only that the surgical team judges that face transplant is appropriate and the parents agree that surgery is in the child's best interests—but also that the child understands and "positively expresses the wish to have the procedure." Dr. Marchac and colleagues also raise concerns related to the donation process and the publicity and media exposure accompanying face transplantation. To preserve anonymity, they advocate an "ethical media blackout," with no publication of any pictures of the patient.

The researchers believe the question is not whether children should be considered for facial transplantation, but whether any there are any ethical barriers should preclude them as candidates, Dr. Marchac and coauthors conclude: "After a careful consideration of the physical, psychological and ethical aspects of such a procedure, we find no such barrier that would either disqualify such vulnerable subjects...or conflict with their best interests."