[Paleopsych] NYT: A Pioneering Transplant, and Now an Ethical Storm
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Mon Dec 12 01:36:24 UTC 2005
A Pioneering Transplant, and Now an Ethical Storm
["Ethical Concerns on Face Transplant Grow" appended.]
[These "ethicists" are too risk averse.]
Scientist at Work: Jean-Michel Dubernard
By LAWRENCE K. ALTMAN
Dr. Jean-Michel Dubernard, whose decision to perform the world's
first partial face transplant has placed him at the center of an
ethical storm, leads a kind of double life.
As a surgeon in Lyon, Dr. Dubernard, 64, has been a pioneer,
developing techniques to transplant pancreas glands and other
tissues, and organizing the international team that performed the
world's second hand-forearm transplant in 1998. (The first was
performed in Ecuador in 1964 before advances in drugs and
But Dr. Dubernard is also a politician, a former deputy mayor of
Lyon who is one of the most powerful members of the French National
"There's a big brain behind him and a steely will that is willing
to confront massive criticism," said Dr. Thomas E. Starzl of the
University of Pittsburgh, who performed the first successful
liver transplants, in Denver.
In performing a face transplant on a severely disfigured
38-year-old woman, Dr. Dubernard has now entered one of the most
disputed frontiers in transplantation science.
The transplants are extremely risky, and no one can say what a
patient will look like afterward.
Critics have said that in rushing to be first to do a face
transplant, Dr. Dubernard bypassed standard procedures to
reconstruct the face of the woman, who was severely bitten by her
dog last May. Dr. Laurent Lantieri, a rival transplant surgeon in
Paris, has said that Dr. Dubernard and his team did not follow
ethical and legal guidelines in performing the transplant.
Other transplant experts have raised questions about the woman's
psychological stability and about Dr. Dubernard's decision to give
the woman an infusion of stem cells from the donor's bone marrow
shortly after the face transplant in an effort to prevent rejection
of the new face, a procedure they say is still experimental.
Dr. Dubernard has responded that the operation, performed in
Amiens, met all French ethical and legal standards and that the
patient was examined by psychiatrists and found to be an acceptable
candidate for a transplant.
He has also been critical of news coverage of the woman's
Dr. Dubernard withstood similar criticisms after his team gave a
new hand to Clint Hallam in 1998 and then was deeply embarrassed
when reporters learned that Mr. Hallam had a criminal record and
that he had lost his hand while in prison.
Further, Mr. Hallam turned out to be an unreliable patient,
refusing to take the prescribed antisuppressant drugs to prevent
rejection of the graft and to do the regular exercises needed to
train his new hand. He demanded amputation of the new hand in 2001.
By applying knowledge gained in Mr. Hallam's case, Dr. Dubernard's
team went on to perform successful hand-forearm transplants on two
other patients. Each had lost both hands.
The hand recipient whose transplant has functioned the longest is
due to celebrate his sixth anniversary in January.
Surgeons around the world have successfully performed a total of 30
hand-forearm transplants, including the three in Lyon, said Dr.
Nadey Hakim of London, a team member who amputated Mr. Hallam's new
In a telephone interview, Dr. Hakim described Dr. Dubernard as
"big, pushy and at the same time friendly and kind."
In juggling his two careers, Dr. Dubernard says he usually commutes
to Paris for two days each week to tend to politics in the French
Parliament. On other days, he cares for patients at the Edouard
Herriot Hospital in Lyon.
He describes himself as a workaholic and a chain smoker who has
quit several times over the last 40 years. The last time was two
Dr. Dubernard was born at the hospital where he works. His father
was a general practitioner and his mother a pharmacist. To friends
and colleagues, he is known as Max, a nickname he was given in
school for always giving his maximum effort, particularly in rugby.
An illness influenced Dr. Dubernard's decision to become a doctor.
He was in awe of the surgeon who performed an emergency
appendectomy on him when he was 11, he said, and he decided to
become a surgeon himself.
As a medical student at the University of Lyon, Dr. Dubernard
caught tuberculosis. After the illness disqualified him from
military service, he went to Belgium to do research on liver and
One day, his Belgian superiors received a call from Dr. Joseph E.
Murray of Harvard, who had a sudden vacancy for a research trainee.
Dr. Dubernard volunteered, he said, but his Belgian hosts told him
that at age 24 he was too young. When no one else accepted, Dr.
Dubernard went to Boston.
He said he dedicated the face operation to Dr. Murray, who won a
Nobel Prize in Medicine in 1990 for helping to perform the world's
first successful organ transplant, a kidney in identical twins, in
1954. Dr. Dubernard was unmarried when he worked at Harvard and
"left a lot of broken hearts when he returned to France," Dr.
Murray recalled in an interview over the weekend.
In Lyon, Dr. Dubernard earned a doctoral degree, in part for work
on xenotransplants, or transplants between species, among two kinds
of monkeys. At age 37, he became chief of urology at the Herriot
Hospital and at the University of Lyon.
He has served in the French Parliament since 1986. His interest in
politics, he said, comes in part from memories of his family's
involvement in the French resistance movement.
When Dr. Dubernard could not find a candidate for a hand transplant
in France, he turned to his friend, Dr. Earl Owen of Sydney,
Australia, who shared a goal of transplanting a hand. Dr. Owen had
what the team believed was a good candidate in Mr. Hallam.
Dr. Dubernard said that he was not anxious before performing the
operation to give Mr. Hallam a new hand or the one to give the
woman a partial new face.
The reason, he said, was his confidence in the drills that his team
of dermatologists, psychiatrists, nurses and other experts had
followed in practicing each step of the complicated procedures.
"Once the preparations were done, I didn't worry anymore," Dr.
Dubernard said. "But, after the transplants, it was another
Dr. Dubernard said that when he went to sleep after Mr. Hallam's
operation, he awoke from a dream, horrified that the new hand had
turned black from acute rejection. It had not.
Doctors who have examined a number of the hand transplant
recipients have been impressed with the psychological benefits the
procedure offered the patients, particularly the double amputees.
But experts debate the degree of nerve sensation and motor function
that the recipients have regained from the transplants.
Dr. Dubernard said he was hesitant about performing the partial
face transplant until he examined the woman in Amiens and saw the
severity of the wounds. She had difficulty speaking and eating, as
food fell from her mouth, he said.
Independent experts told his team that the wounds were "very
difficult, if not impossible" to repair with standard
reconstructive surgery, Dr. Dubernard said. But, he said, "We knew
we could improve her life."
Dr. Dubernard said he slept only about three hours each night last
week, in part because he worried about questions like: Would the
arteries and veins clot, jeopardizing survival of the graft?
Now that certain danger points have passed, he said he is beginning
to sleep better and longer. Still, he says he knows that the
woman's immune system can reject the new face at any time during
At a news conference in Lyon on Friday, Dr. Dubernard exuded
confidence. He appeared bright-eyed, eyebrows continually raised,
energetic, funny and quick to engage reporters.
He clearly is someone who loves the limelight, as he asserted
himself over his more subdued colleagues.
Dr. Dubernard said in interviews this weekend that if a need arose,
he would not hesitate to receive a new hand or face, or give
approval for one to his three children or six grandchildren. He
said he is divorced from his first wife, and lives with Dr. Camille
Frances, a professor of dermatology in Paris.
Dr. Dubernard says that under French law he faces mandatory
retirement from practice in two years and is not sure what he will
A full-time career in politics is one possibility. Another is
becoming a poet to express his wide-ranging interests, including a
love of mythology.
Ariane Bernard contributed reporting from Paris for this article.
Ethical Concerns on Face Transplant Grow
By MICHAEL MASON and LAWRENCE K. ALTMAN
In urgent telephone calls and agonized e-mail messages, American
scientists are expressing increasing concerns that the world's
first partial face transplant, performed in northern France on Nov.
27, may have been undertaken without adequate medical and ethical
Some scientists say they fear that if the French effort fails, it
could not only threaten the life of the transplant recipient, a
38-year-old Frenchwoman, but jeopardize years of careful planning
for a new leap in transplant surgery.
"We've been working on the ethics and the science for some time,
going slowly while we figure out immunology and patient selection
criteria and indications," said Dr. L. Scott Levin, chief of
plastic and reconstructive surgery at Duke University Medical
Center. "This flies in the face of everything we've tried to do."
The scientists' worries stem in part from the execution of the
surgery, and in part from news reports over the weekend that called
into question the patient's emotional state.
Dr. Maria Siemionow, director of plastic surgery research at the
Cleveland Clinic, who has been preparing to perform a full face
transplant, said that the way the transplant was conducted appeared
to conflate two experimental protocols: the transplantation of
facial tissue and the infusion of stem cells from the donor bone
marrow into the patient in an attempt to prevent rejection of the
The first procedure, although untried until now, has been well
studied, and the microsurgical techniques involved are commonplace.
But the second has been successful in human subjects only rarely
and only recently. While pilot studies do suggest that an infusion
of stem cells from the donor can help produce "chimerism" in
humans, a state in which foreign tissue is tolerated by the body
with comparatively little or no suppression of the immune system,
it is far from standard practice in transplantation.
The French team's decision to perform two novel procedures
simultaneously means that it may be difficult to determine the
cause of success or failure of the transplant, Dr. Siemionow said.
"They should not be doing two experiments on the same patient," she
added. "Ethics aside, it will make it difficult to get clean
answers - if it works, why does it work, and if it goes wrong, was
it the transplant or the stem cells?"
In a telephone interview yesterday, Dr. Jean-Michel Dubernard, the
surgeon whose team performed the groundbreaking operation, in which
the patient received lips, a chin, and a nose from a brain-dead
donor, defended the infusion of bone marrow stem cells and denied
that the procedure was a step into uncharted territory.
"It is not two experiments at the same time," he said.
But American experts said that the French team's approach diverged
in other ways from what had been scientific consensus about how to
proceed. The transplant was performed months after the woman's
injury, and before any attempt at conventional reconstructive
The French doctors said traditional surgery could not have salvaged
the woman's face. Dr. Benoît Lengelé, a Belgian specialist in
facial injuries, and other experts had judged that reconstructive
surgery would be "very difficult, if not impossible" in the
patient's case, Dr. Dubernard said.
Yet reconstructive surgeons in the United States and in Europe
routinely operate on patients with similar injuries, some missing
as much as half their faces. Surgeons like Dr. Siemionow have long
argued that the first face transplant should be attempted only on a
patient who has tried to live with the alternatives.
The psychological issues are as complex as the surgical ones.
Scientists have been concerned about how thoroughly the patient was
emotionally prepared for the procedure, concerns that were only
heightened when The Sunday Times of London reported that she had
admitted that she sustained her injuries during a suicide attempt.
According to the newspaper, the woman said that she was mauled by
her family's Labrador retriever after she took an overdose of
sleeping pills and collapsed. She believed the dog was trying to
revive her, the newspaper said. The Times also reported that the
donor had committed suicide.
The reports greatly alarmed experts in the field; the experimental
protocols devised at both the Cleveland Clinic and the University
of Louisville explicitly preclude emotionally unstable candidates.
Patients with a history of depression sometimes do not comply with
the complicated drug regimens necessary to prevent organ rejection.
The news reports, however, were vigorously denied yesterday by Dr.
Dubernard, who responded, "No, no and no!" when asked if his
patient had tried to take her own life. He said the woman had taken
only two sleeping pills for insomnia after a family argument.
Dr. Dubernard said that the woman was approved as a candidate for a
face transplant only after a thorough psychological examination by
an independent expert and by mental health professionals working
with the transplant teams in Amiens, where the operation was
performed, and in Lyon, where the woman is now being monitored for
"These people are not stupid," he said.
The patient, who had difficulty eating before the transplant
because of the injuries, ate dinner Sunday night and lunch on
Monday, Dr. Dubernard said. Dr. Dubernard said the woman had
visited the Édouard Herriot Hospital in Lyon "in October and again
in November to meet the transplant team and to ask questions."
Yet longer-term psychological evaluation might have been useful for
another reason, experts said. Since this is the first transplant of
its kind, and it strikes deeply at questions of personal identity,
the French patient's emotional stamina will be sorely tested.
Already some news reports in Europe have identified the woman, who
requested anonymity, and published pictures of her before and after
Scientists planning for the first face transplant knew it would
happen. One of the Cleveland Clinic's screening criteria is that a
candidate for this procedure must be able to withstand intense
public scrutiny - to be able to see pictures of the face's former
owner, for example, on tabloid covers at the checkout rack.
Resilience is important both for the first patient, say
researchers, and for those who would follow.
"Every patient, when you talk to them, their goal is just to get
out of the limelight," said Dr. David Young, associate professor of
plastic surgery at the University of California, San Francisco,
which also has been drawing up plans for a face transplant. "If
this works, many potential patients who are on the fence will
change their minds. But if this thing crashes and burns, it will
damage the field."
For some experts, even the best-case situation has a down side.
"We want for this to go well," said Dr. Siemionow. "But if it does,
then I am afraid everyone will forget that the ethics were not
proper here. And if it does not, then they will be blaming the
transplant procedure but not the ethics behind it."
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