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What an Odd Concern:

The New York Times reports more on the recent face transplant. "Among the most disturbing aspects of the debate," the Times writes, "are conflicting reports from doctors about whether the transplant was the result of two suicide attempts, one successful by the donor, and one failed by the recipient." The donor had apparently hanged herself; the recipient's injuries were inflicted by her dog, but there's reason to think that this happened when the recipient deliberately took an overdose of sleeping pills, trying to commit suicide.

Now there are interesting ethical problems about how we should ration health care between those who apparently don't much want to live and those who do want to live. One could argue that the subjective value of the benefit to the suicide victim is less than to others; or one could argue that there's a substantial chance that the patient will try committing suicide again soon and this time succeed, so all the investment of money and effort will have been wasted. (Query, though, how applicable these arguments are, even if they're sound, to experimental procedures in which the major social benefit comes from learning about the surgery.)

Yet these don't seem to be the main problems that the Times is focusing on. Rather, the first concern, as best I can tell, is that:

If Ms. Dinoire's disfigurement resulted from an attempted suicide, it would raise questions about her emotional stability and her ability to consent to such a risky operation.

Surely many people who try to attempt suicide are emotionally not entirely unstable -- yet they're generally not fools or lunatics. They can understand the costs and benefits of the procedure as well as others. They can understand that their current state is very grim. Are patients generally disqualified from making such judgments just because they've attempted suicide? I'm not suggesting there's nothing to this concern; perhaps the doctors should also have asked the woman's relatives or some specially designated patients' guardian, though query whether it's appropriate to limit suicide attempters' autonomy in making medical decisions (other than perhaps suicidal medical decisions) this way.

But the second concern utterly perplexes me:

Reports that the donor committed suicide also have implications for Ms. Dinoire's future, because if true, and if the transplant is successful, it would mean that for the rest of her life, she would see in the mirror the nose, mouth and chin of a woman who herself met a brutal end.

Does it really seem likely that the beneficiary of a face transplant operation would be that upset by this? I can certainly see why she might be upset at seeing what will at first look like someone else's face (though probably less upset than seeing her own mangled face). But why should it matter to her that the donor had committed suicide?

After all, the donor must have died somehow, and probably not in her sleep of old age. Could have been a motorcycle accident. Could have been early onset cancer. Could have been a rare early heart attack (probably the least unpleasant death of the lot, but not that likely). Or could have been a suicide. I like to think that if I had needed a transplant and had gotten the transplant, I'd be grateful, and wouldn't be that troubled by the face's provenance. Or am I mistaken?

roy (mail) (www):
Isn't a lot of material in this article usually kept private? I suspect Dinoire will be less upset by the story of the donor than by her doctors telling reporters that she attempted suicide.
12.15.2005 3:14pm
tiefel & lester student (mail):
I would think that the suicide of a donor could legitimately bother the recipient.

As an analogy, houses in which the previous occupant committed suicide (or murder) tend to go for significantly less than similar homes. I believe some states even have statutes requiring disclosure of this information. Needless to say, one's face is even more intimately connected to one's conception of self than a home.

Of course the difference is that there are many more available houses than faces. If I were in need of a face transplant, I think that I would prefer the first available face that matched mine, rather than beng too choosy about where it came from. The point is, however, that I think reasonable people could differ about this.
12.15.2005 3:25pm
JohnAnnArbor:
There's an ethical corollary here. Remember dear old Jack Kevorkian? In at least one case, he and his helpers didn't just dump a body at the hospital; they extracted (badly) the kidneys first. It was intended to demonstrate organ donation from suicides.

That would create a bizarre incentive for those of disturbed mind; they might off themselves in such a way that their organs will be in condition to be used. They might rationalize that "something good" would come from their death, and that rationalization might be enough to push someone to actually kill themselves.

Therefore, shouldn't organ/tissue donation from ANY suspected suicide be banned?
12.15.2005 3:28pm
Nicole Black (mail) (www):
I'd wondered about the privacy issues as well. It appears that if both parties consent (the donor and recipient) then identities can be disclosed (see, for eg., and, presumably, the manner of the donor's death can be disclosed as well.

As for the question posted in this post, I'm not sure if I understand the point being made by the author of the NY Times article either. I would think that if the donor had died as a result of a car accident or gun shot wound, that it would be equally as disturbing as death by suicide. The fact of the matter is that the donor is dead--not a particulary pleasant thought regardless of the manner of death, in my opinion.
12.15.2005 3:31pm
Colin:
As to the first concern, my understanding--purely as a layperson--has always been that suicide is strongly correlated with substance abuse and/or serious psychiatric problems. Correlation isn't causation, as we all know, but I don't think it's unreasonable to be concerned about her state of mind and ability to consent.

As to the second concern, I agree with t&ls: the recipient is going to have complex emotional issues to work out with regards to her new face. I understand that it won't particularly resemble the donor's face, but surely there will be some psychological issues to work through. I think the donor's fate would probably be tied up in whatever emotions the surgery and recovery provoke. Nor do I think gratitude and discomfort over the donor's suicide are inconsistent. Surely it's reasonable to at least be concerned about her state of mind?
12.15.2005 3:33pm
Bob Bobstein (mail):
I agree with the good Dr. Volokh-- the Times is getting too literary/cute here, at the expense of considering the plight of the woman who benefitted from this surgery. It's always a fun thing to write an article that raises Big Ethical Issues... but you can't just automatically insert them into every new procedure.
12.15.2005 3:33pm
Steve:
You might as well argue that we would dissuade more suicides if we barred any person who commits suicide from having a nice funeral, from having a complimentary death notice published in the newspaper, etc.

The fact is, if you accept that there is a basic human right to control one's own body, organ donation is a fundamental outgrowth of that right. The state shouldn't be barring organ donation because it hopes to achieve some public policy goal or another. And to make the case stronger, when you ban organ donation, the person who suffers the greatest harm is the one who would have received that particular organ. I don't want the government to stop me from receiving a healthy kidney simply because it feels a ban will "send the right message."
12.15.2005 3:38pm
amn (mail):
The debate around this issued is an attempt to turn a medical breakthrough into a major news story with ethical implications. The first line of debate was about the face and identity, but that quickly fizzled. The woman decided that she would rather have a donated face than her own badly damaged face. There is no reason to think that there is anything wrong with this decision, or that it is any worse than knowing that she was walking around with someone else's heart beating in her chest. Further, all doctors involved have stated that the look of the face is mainly determined by the bone-structure of the face not the skin that is layed over it.

The suicide angle is new and equally forced. There is no doubt that this woman died a young, tragic death. I can't imagine that it would matter greatly how the death occurred.
12.15.2005 3:40pm
tefta (mail):
Eugene, It's gratifying that you find the concern about the suicides involved here odd. Other than wasting public resources on a patient who might kill herself, why the concern? Certainly many people treated for drug abuse or even heart by-passes revert to the bad behavior that landed them in the hospital and then require further treatment. Yet there's no public debate about their wasting public funds.

These concerns don't make sense, so there must be a lot of more to it that we haven't heard yet.
12.15.2005 3:41pm
tiefel & lester student (mail):
Steve:

I think you can support a general right of bodily integrity without accepting a right to donate one's organs after a suicide.

I think it is clear that such a right is predicated on a right to suicide. Such a right might appear to flow from a right to control one's body, but under analysis, I don't think it does. Mill argued that we have nearly limitless liberty--except that we can't sell ourselves into slavery, because that would end our liberty. Similarly, we should have a broad right to control our bodies, but not to the point of suicide, since that would end our bodies.

I don't believe we have a right to suicide, and once there is no fundamental right, I think it's legitimate for the government to step in.

As to your second point, that this will involve a balancing of lost organs vs. some deterrent to suicide, I think you're right. But I don't think it's illegitimate for policy-makers to at least consider banning donations from suicides.
12.15.2005 3:49pm
John Burgess (mail) (www):
I think amn has it exactly right. The NTY is attempting to peddle a Jack Handy "Deep Thought" as something worth serious discussion.

I think suicide is morally wrong, but that should not stand as a bar to the donation of organs post mortem. Driving while drunk is morally repugnant to me, too. But an amazing number of transplanted organs come from those drunk drivers who manage to kill themselves accidentally, but not free of moral culpability.

This is the NYT trying to jerk emotional chains by combining shocking concepts--suicide, drug overdoses, dog-eats-human, new technology--into an overriding narrative.

The point of the operation was, indeed, to learn if such a thing was possible. Success was hoped for but not guaranteed. The transplant may yet be rejected, in fact. Now THAT's going to mess up the recipient's mind...
12.15.2005 3:55pm
Houston Lawyer:
The author's concern seems quite bizzare. It's as if we permitted organ donations from those killed by capital punishment and her only concern was that the donor would have the "heart of a killer". I've always thought that our selection system for who receives a donated organ was highly inappropriate. Doctors here are apparently not allowed to take into consideration the self-destructive acts of intended recipients.
12.15.2005 4:02pm
TomCS (mail):
I wonder if there is not a (partly at least) false premise behind this and other similar articles. I'm not a reconstructive surgeon, but I have watched a number of the forensic and forensic archaeology documentaries which show the modelling of a face from a skull. As I understand it, this procedure does, in effect, the same: it replaces the flesh over the same bone structure. So why do we assume that what the recipient sees in the mirror is not fundamentally her old face? Or at least much more like her old face than her heavily mauled and disfigured one?

This is, however, an interesting example (though not perhaps a very good one- see below) of a much wider set of medical ethical issues over the "worthiness" particularly of potential organ recipients, which may go beyond the purely clinical. This is more acute where the service is provided by a state medical system than where ability to buy is the key criterion, but even then there may be questions over meeting the intentions of the donor or his/her representatives, who may wish for some "greatest benefit" judgement to be used in allocating their donated organs.

There are two current examples in the UK.

The most notorious was the kidney transplant provided to the iconic Northern Irish and Manchester United footballer (soccer) George Best, after a long history of alcohol abuse. He dried out ahead of the transplant, and stayed dry for about a year after the transplant, but then relapsed and died to amazing scenes of national emotion last month. But should being/having been a chronic alcoholic kick you out of the queue for scarce donor kidneys?

More mundane is a "worthiness" policy announced by orthopedic surgeons in some UK health regions to exclude obese patients from hip replacement surgery (not donor dependent, but a high demand surgery as the population ages) at least until they have reverted to normal weight levels. The objective arguments include generally less healthy and so more likely to have complications, and likely to wear the new joint out faster than others, but it does appear to define a broad class as un- (or less) worthy. Not a scarce organ issue, but still a medical worthiness criterion.

It seems to me that many of the most interesting real issues of modern ethics now arise in the area of medical ethics, and particularly in this area of allocating scarce transplant resources: I'm not sure that the face transplant case is a particulary good example, which is why I offer the above. I'm not sure that they respond easily either to a utilitarian or a purely economic calculus, and I have no idea where religiously derived criteria might help.
12.15.2005 4:05pm
DK:
Well put, Eugene. I was hoping for someone to write about how silly the NYT story is.

What I find weird is that the NYT will bend over backwards to make a face transplant look like an ethical horror, while simultaneously doing its best to treat stem-cell opponents as right-wing nuts. Sometimes I wonder if the MSM + left are following the rule "oppose all new technology, until we find a fundamentalist Christian who also opposes it. Then switch to supporting it and demonizing all other opponents." If the religious right started using the provisions in Deuteronomy against hybridizing crops as evidence that God opposes genetically-modified food, how long would it take for the left to embrace GMO's?
12.15.2005 4:05pm
The NJ Annuitant (mail):
I agree with Eugene Volokh. Any death of a young person is unhappy to contemplate. But these transplants would not come the living.
12.15.2005 4:11pm
gravytop (mail) (www):
I don't know. It doesn't strike me as the most ethically reprehensible behavior imaginable by a long shot.

But if I had been driven to suicidal despair, and was still struggling with depression, I think that seeing in the mirror each morning the face of another person who also came to the realization that life is so cruel and meaningless as to be unbearable could be pretty grim. Maybe I was weaned on too much Poe, Weird Tales, etc.

Of course, I'd rather have a normal looking face that a horrible disfigurement -- I'm just saying that the observation in the NYT isn't that obviously absurd.
12.15.2005 4:20pm
ACLU/ABATE:
Our clients, the Harley Owners Group, demand retraction of the portion of this blog posting referring to motorcyclists as "organ donors" is part of a long and pernicious history of vehicle-choice descrimination. This automobilist slur is a bigoted falsehood that ignores the fact that car and light truck fatalities are far more numerous than motorcycle fatalities, and that when motorcycle fatalities do occur, the face is far less likely to be in a condition for donation than the face of an airbag equipped cager.
12.15.2005 4:44pm
Jerry Mimsy (www):
"Maybe I was weaned on too much Poe, Weird Tales, etc."

It reminds me of a story in (I think) Ellery Queen Mystery Magazine, probably in the seventies or sixties, about a woman who undergoes a heart transplant and falls in love with the donor's boyfriend. When we start talking about brain transplants, I'll start to get worried.
12.15.2005 5:16pm
JohnAnnArbor:
Wouldn't a a brain transplant be better called a whole-body transplant?
12.15.2005 5:31pm
Sha_kri:
This story perplexes me in another way. Why would someone's pet gnaw off the lips, mouth, and chin when the owner is passed out. A pet dog no less. This I cannot understand.

From what I read, the receiver of the face could not even eat. Sounds like the NYT is poking its nose somewhere where it does not belong again.
12.15.2005 5:35pm
Dave:
The dog thought she was dead because of the sleeping pill overdose.
12.15.2005 6:34pm
Sha_kri:
What was the dog locked in the apartment with her for a few days without food?
12.15.2005 8:02pm
Dave Hardy (mail) (www):
MSM must be really hard up for stories, if the best they can do is supposed ethical issues about past suicides or attempts by persons involved in a transplant.
12.15.2005 9:26pm
arthur (mail):
Suicides are controversial as sources for organ trnasplants for two reasons: first, suicide is often correlated to drug abuse and other forms of body abuse that are likely to put the recipient at risk of various maladies sush as hepatitus; and second, the bodies of suicides are typically left unrefrigerated for unknown periods of time before they are found, again increasing the risk of infections in the recipient. Hospital deaths are so much neater.
12.15.2005 10:39pm
Sha_kri:
I read that the donor was brain dead. Hung herself and I guess never really died, just cut the flow of blood to her brain. What's even more gruesome is that I don't think the donor ever consented to donating her organs (I am not sure of this). The article said that the family decided to donate her organs. And if she committed suicide, odds are her famaily was not treating her very well. That's kind of sadistic if the French are letting other people decide what is become of your organs if you die.
12.15.2005 10:55pm
John Burgess (mail) (www):
American systems permit families to make decisions about organ donation if the putative donor left no explicit instructions. It happens so often that it's a staple on the soap-ish TV programs.
12.15.2005 11:16pm
Sha_kri:
I do not watch soap operas. I just assumed our respect for individual rights was advanced enough not to let something like that to happen.
12.15.2005 11:30pm
jvarisco:
Am I the only one who sees little difference between this and plastic surgery? Anyone's face is random, so you are replacing a random face with another random one, does it matter if it is synthetic or real?
12.16.2005 4:37am
charles hardin (mail):
Well said. I totally agree with you. The point you are making here does make sense.
12.16.2005 7:50am
Jack S. (mail) (www):
Indeed an example of poor journalism as well. I'm sure a disfigured face does not help a depressive state. Moreover other French news sources (Nouvel Observateur for example) states that she also suffered from speaking and eating problems due to her injury. While I didn't read the NYT article word for word, I didn't see any mention of that. Seems to be a pretty key fact in reporting the situation objectively. Ah, objectivity, something that is apparently no longer taught in journalism skool.
12.16.2005 9:15am
CCMCornell (mail):
Anne Althouse had a post followed by many comments on this very issue.
12.16.2005 9:37am
CCMCornell (mail):
In the post I linked above, I asked some questions in the comments that I'd like to repeat (though I think you should check the post out for yourself - there's some good comments and some funny jokes).

I wondered about some issues besides that question of whether or not the procedure should have been applied from this donor to that patient. Why was the medical privacy of both women comprimised? Aside from troubling reactions to any breach of medical privacy, isn't it considered standard to not disclose information about the donor so the recipient won't suffer further emotional complications from unhealthy rumination that such details might stimulate?

I would assume that even in the general case this is so - feelings of recipient-guilt fueled by speculation of the life lost and such. But in this case, it seems even worse - to be in recovery from a suicidal state, to try to grow into the indentity of a healthy person - all while adjusting to a new physical identity that, accurately or not, may appear to be that of someone who successfully committed suicide?

I know it's been mentioned that the new face will not exactly look like the donor's and may somewhat resemble the patient's original face because of bone structure and whatnot. But it will be different and, even if the transplant takes perfectly, those differences will be as ever evident as any scars to her for the rest of her life. And as someone who has sufferred from depression, I think she'll suffer from the tendency - if not obsession - to see anything negative about herself and her future - she'll have to overcome seeing both suicidal women in the mirror.
12.16.2005 11:24am
crane (mail):
I know it's been mentioned that the new face will not exactly look like the donor's and may somewhat resemble the patient's original face because of bone structure and whatnot.


Um... the shape of your face is determined by your bone structure, facial musculature, and facial fat deposits. From what I've read, the transplant really only used the donor's skin. So, while the patient's new face will have a different skin tone, the features will be her own.
12.16.2005 1:18pm
Penta:
Eugene: As someone who's been there, having come very close to suicide attempts, I would have to disagree vehemently.

One: Suicide is not a rational decision. Period. Right to die or whatever does not enter into it. If you are considering suicide, going so heavily against the human instinct for self-preservation, you are pretty clearly not in full control of your faculties at that point. Particularly in the case of an actual suicide (or suicide attempt) and not a euthanasia case, I'm not sure it really passes the sniff test to say that one who is considering suicide or is coming out of that is in anything close to a position to give informed consent, particularly to a procedure this major. There just isn't the rational consideration we assume when we accept someone's consent.

Two: This woman, if she was in the psychological condition she is said to have been in, may not be able to handle, on a psychological level, both recovery from suicidal ideations *and* the psychological rehab necessary after a procedure like this.

Are we sure that we aren't going to make her psychological state even *worse*?
12.16.2005 6:02pm
Nathaniel (mail):
JohnAnnArbor writes: "[People tempted to suicide] might rationalize that "something good" would come from their death, and that rationalization might be enough to push someone to actually kill themselves. Therefore, shouldn't organ/tissue donation from ANY suspected suicide be banned?"

I don't think so. A kidney or liver available for transplant saves a life; almost always the life of someone who wants to live. Consequently, I think that someone who wishes to give their own life in order to save potentially dozens of others ought to be allowed to do so. In fact, a person who throws herself under a bus to save a child would be considered a hero. So what is different about donating a liver to save one?

Also, can anyone explain again why a right to suicide doesn't flow from basic notions of self-determination? Mills' opinion doesn't make sense to me. If you own your own life (admittedly an "if" in many philosophical systems), why exactly is that ownership conditional on not ending that life? It seems a victimless crime. And going against instinct doesn't make a decision irrational. In fact, the ability to overcome instinct might be seen as a key test for rationality. I'm not endorsing suicide, but I do think someone could rationally determine that his life was not worth continuing. Whether they should therefore end that life is a moral and religious question, but there's no purely rational reason such a determination is always wrong.
12.16.2005 7:13pm
Nathaniel (mail):
Well...not dozens, probably. :)
12.16.2005 7:36pm
Sha_kri:
"Also, can anyone explain again why a right to suicide doesn't flow from basic notions of self-determination?"

This issue is not being debated enough IMHO. Especially assuming that someone automatically consents to having his corpse chopped up to give to others. Some people (myself included) would not consent to that, one reason being religious reasons. Don't give me that, "well his family said its ok or they can consent for you" BS. Families aren't always respectful of their "loved ones" beliefs. This is like Red China forcing atheism down people's throats.
12.16.2005 10:15pm