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Mr Peter Butler, Mr Shehan Hettiaratchy, Dr Jonathan Lohn, Mr John Norton, Dr Alex Clarke and Mr Guy Thorburn.
Royal Free and University College Medical School.

Mr Martin Kelly.
Chelsea and Westminster Hospital.

Dr Richard Ashcroft.
Imperial College.

Dr Robin Richards.
University College, London.

Facial injury caused by accidents and burns can be devastating. Modern plastic and reconstructive surgery can offer solutions to restore normality; however, very severe injuries, such as facial burns where the skin of the face, nose, ears, eyelids, lips and hair is destroyed, present a problem that can be insurmountable even to modern reconstructive techniques. Face transplantation is a potential solution for these devastating injuries.

Transplanting a human face is now technically possible and there are a number of surgical units around the world moving towards achieving this. The technique is likely to be appropriate for only a very small number of patients and it is important to realise that it cannot give a 'normal' appearance and therefore will never be a cosmetic procedure. There are a number of factors limiting the prospective numbers other than clinical need. Selecting appropriate recipients will be difficult and will take considerable time. This process would involve identifying those patients who would have functional benefit and who also had realistic expectations of the procedure. The patient would have to be determined and resolute in adhering to the prolonged rehabilitation and the need for chronic immunosuppression. The patient must be robust enough to cope with these challenges and the psychological effects involved.

One of the main problems to be considered is that of consent for the initial procedure. Three major prerequisites for valid consent are that it is given freely without undue pressure, that the individual has sufficient information to make a balanced and intelligent choice, and that the individual has sufficient capacity to make this choice.

If valid consent cannot be achieved, then it is clear that no face transplant should be carried out. If, however, valid consent is possible, then other ethical considerations come into play which could be sufficient to overrule a patient's autonomous decision. There is a possibility that society might judge that the risks of the procedure are too high, or too uncertain. There is also the risk of excessive media attention on the recipient. Alternatively, it might be felt that carrying out this procedure would have too great an impact on some third party. An important consideration is the influence that adverse publicity regarding face transplantation might have on donation of organs for established transplant programmes.

Clearly there are a large number of ethical issues that require consideration.