On the Ethics of Facial Transplantation Research

Transplantation continues to push the frontiers of medicine into domains that summon forth troublesome ethical questions. Looming on the frontier today is human facial transplantation. We develop criteria that, we maintain, must be satisfied in order to ethically undertake this as-yet-untried transplant procedure. We draw on the criteria advanced by Dr. Francis Moore in the late 1980s for introducing innovative procedures in transplant surgery. In addition to these we also insist that human face transplantation must meet all the ethical requirements usually applied to health care research. We summarize the achievements of transplant surgery to date, focusing in particular on the safety and efficacy of immunosuppressive medications. We also emphasize the importance of risk/benefit assessments that take into account the physical, aesthetic, psychological, and social dimensions of facial disfiguration, reconstruction, and transplantation. Finally, we maintain that the time has come to move facial transplantation research into the clinical phase.     

An ethically justified framework for clinical investigation to benefit pregnant and fetal patients

Research to improve the health of pregnant and fetal patients presents ethical challenges to clinical investigators, institutional review boards, funding agencies, and data safety and monitoring boards. The Common Rule sets out requirements that such research must satisfy but no ethical framework to guide their application. We provide such an ethical framework, based on the ethical concept of the fetus as a patient. We offer criteria for innovation and for Phase I and II and then for Phase III clinical trials to improve the health of pregnant patients and of fetal patients and also criteria to responsibly manage the transition from investigation to clinical practice. Basing ethical criteria for research involving pregnant women on the ethical concept of the fetus as a patient insulates the proposed ethical framework and therefore research on pregnant women from the divisive and politicized concepts and discourses of personhood, fetal rights, and unborn child.     

Living donation and cosmetic surgery: a double standard in medical ethics?

The commitment of transplant physicians to protect the physical and psychological health of potential donors is fundamental to the process of living donor organ transplantation. It is appropriate that strict regulations to govern an individual's decision to donate have been developed. Some may argue that adherence to such regulations creates a doctor-patient relationship that is rooted in paternalism, which is in drastic contrast with a doctor-patient relationship that is rooted in patients' autonomy, characteristic of most other operative interventions. In this article we analyze the similarities between cosmetic plastic surgery and living donor surgery as examples of surgeries governed by different ethical principles. It is interesting that, while the prevailing ethical approach in living donor surgery is based on paternalism, the ethical principle guiding cosmetic surgery is respect for patients' autonomy. The purpose of this article is not to criticize either practice, but to suggest that, given the similarities between the two procedures, both operative interventions should be guided by the same ethical principle: a respect for patients' autonomy. We further suggest that if living organ donation valued donors' autonomy as much as cosmetic plastic surgery does, we might witness a wider acceptance of and increase in living organ donation.     

You can take the eyes out of the doll, but...

The perceived animacy of a face is well-predicted by the perceived animacy of the eyes presented in isolation. This is not true for other facial features (eg having a highly life-like nose does not appear to be crucial), suggesting that the eyes are a critical feature for perceiving life in a face. Here, we asked whether it was therefore possible to 'transplant' animacy into a face by transplanting the eyes into a face image. We conducted digital eye surgery on a series of morphed human/doll faces and found that while doll eyes make a morphed face look less alive, human eyes do not make you look more so. Thus, we cannot so easily transplant animacy into a face, but we can take it away.     

技术之后是法规和观念的更新--中国器官移植的重大进展

从我国器官移植的历史和现状出发,在器官移植的技术和基础研究有了理观念的更新.这种更新应建立在对器官移植的伦理思考和讨论的基础之上.2003年我国关于器官移植的法规和观念有了新的突破,有关的管理办法和条例也在草拟之中.中国政府和医学界对器官移植始终持积极和慎重的态度,所谓"中国移植和买卖死刑犯器官"完全是别有用心的捏造.     

Selecting the Right Tool For the Job

There are competing ethical concerns when it comes to designing any clinical research study. Clinical trials of possible treatments for Ebola virus are no exception. If anything, the competing ethical concerns are exacerbated in trying to find answers to a deadly, rapidly spreading, infectious disease. The primary goal of current research is to identify experimental therapies that can cure Ebola or cure it with reasonable probability in infected individuals. Pursuit of that goal must be methodologically sound, practical and consistent with prevailing norms governing human subjects research. Some maintain that only randomized controlled trials (RCTs) with a placebo or standard-of-care arm can meet these conditions. We maintain that there are alternative trial designs that can do so as well and that sometimes these are preferable to RCTs.     

Different standards are not double standards: all elective surgical patients are not alike

Testa and colleagues argue that evaluation for suitability for living donor surgery is rooted in paternalism in contrast with the evaluation for most operative interventions, which is rooted in the autonomy of patients. We examine two key ethical concepts that Testa and colleagues use: paternalism and autonomy, and two related ethical concepts: moral agency and shared decision making. We show that by moving the conversation from paternalism, negative autonomy, and informed consent to moral agency, relational autonomy, and shared decision making, one better understands why the arguments given by Testa and colleagues fail. We argue (1) why the hurdles that one must overcome to become a living donor are appropriate; and (2) that the similarities between living donor transplant surgery and cosmetic plastic surgery that the authors describe are inaccurate. Finally, we consider the recommendation to treat plastic surgery patients and living donors more similarly. We argue that any change should not be in the direction of becoming less protective of living donors, but more protective of cosmetic plastic surgery candidates.     

脑内移植:医学的冷静哲学的忧思

脑内移植的发展历史从狂热到冷静的过程,说明科学必须是要踏实地,实事求是,过于冒进只能导致失败。我们应当从中总结经验。吸取教训。同时,脑内移植的研究存在许多社会和伦理问题有待解决。     

Maximal care considerations when treating patients with end-stage heart failure: ethical and procedural quandaries in management of the very sick

Deciding who should receive maximal technological treatment options and who should not represents an ethical, moral, psychological and medico-legal challenge for health care providers. Especially in patients with chronic heart failure, the ethical and medico-legal issues associated with providing maximal possible care or withholding the same are coming to the forefront. Procedures, such as cardiac transplantation, have strict criteria for adequate candidacy. These criteria for subsequent listing are based on clinical outcome data but also reflect the reality of organ shortage. Lack of compliance and non-adherence to lifestyle changes represent relative contraindications to heart transplant candidacy. Mechanical circulatory support therapy using ventricular assist devices is becoming a more prominent therapeutic option for patients with end-stage heart failure who are not candidates for transplantation, which also requires strict criteria to enable beneficial outcome for the patient. Physicians need to critically reflect that in many cases, the patient’s best interest might not always mean pursuing maximal technological options available. This article reflects on the multitude of critical issues that health care providers have to face while caring for patients with end-stage heart failure.     

论移植医学新角色——移植协调员的工作职责

随着移植医学的蓬勃发展,许多国家纷纷制定了人体器官捐赠和移植法令,建立了移植协调机构等配套管理措施和制度。随之,一个新型的专业角色——移植协调员应运而生。在研究国外移植协调员的工作基础上,借鉴国外的经验和模式,根据我国实际状况,提出我国移植协调员的工作职责。     

Reflections on peer review practices in committees selecting laureates for prestigious awards and prizes: Some relevant and irrelevant criteria

An important function in all scholarly and academic activities is the participation in the peer review system. One aspect of this peer review evaluation is service on committees judging candidates for important awards, prizes and fellowships. Some reflective observations on this process are made in which a number of factors determining the final choice are identified. It is pointed out that the decisions of such committees are based not only on relevant and objective criteria but are also influenced by a number of irrelevant criteria; caution must be exercised to minimize the effect of the latter factors in order to maintain the highest ethical standards in the selection process. The ranking practices of awards committees, national academies and learned societies are briefly reviewed by pointing out some ethical pitfalls, anecdotal incidents, and the ways to avoid the tarnishing of the selection process. Dr. Vijh is a physical chemist whose research interests include interfacial electrochemistry and the chemical physics of solid surface s.     

The Ethics of Ethics Reviews in Global Health Research: Case Studies Applying a New Paradigm

With increasing calls for global health research there is growing concern regarding the ethical challenges encountered by researchers from high-income countries (HICs) working in low or middle-income countries (LMICs). There is a dearth of literature on how to address these challenges in practice. In this article, we conduct a critical analysis of three case studies of research conducted in LMICs. We apply emerging ethical guidelines and principles specific to global health research and offer practical strategies that researchers ought to consider. We present case studies in which Canadian health professional students conducted a health promotion project in a community in Honduras; a research capacity-building program in South Africa, in which Canadian students also worked alongside LMIC partners; and a community-university partnered research capacity-building program in which Ecuadorean graduate students, some working alongside Canadian students, conducted community-based health research projects in Ecuadorean communities. We examine each case, identifying ethical issues that emerged and how new ethical paradigms being promoted could be concretely applied. We conclude that research ethics boards should focus not only on protecting individual integrity and human dignity in health studies but also on beneficence and non-maleficence at the community level, explicitly considering social justice issues and local capacity-building imperatives. We conclude that researchers from HICs interested in global health research must work with LMIC partners to implement collaborative processes for assuring ethical research that respects local knowledge, cultural factors, the social determination of health, community participation and partnership, and making social accountability a paramount concern.     

The ethical assessment of innovative therapies: Liver transplantation using living donors

Liver transplantation is the treatment of choice for many forms of liver disease. Unfortunately, the scarcity of cadaveric donor livers limits the availability of this technique. To improve the availability of liver transplantation, surgeons have developed the capability of removing a portion of liver from a live donor and transplanting it into a recipient. A few liver transplants using living donors have been performed worldwide. Our purpose was to analyze the ethics of liver transplants using living donors and to propose guidelines for the procedure before it was introduced in the United States. We used a process of “research ethics consultation” that involves a collaboration between clinical investigators and clinical ethicists. We concluded that it was ethically appropriate to perform liver transplantation using living donors in a small series of patients on a trial basis, and we published our ethical guidelines in a medical journal before the procedure was introduced. We recommend this prospective, public approach for the introduction of other innovative therapies in medicine and surgery.     

开展活体器官移植的伦理学思考

活体器官移植起源于器官移植技术的最初阶段,目前已经成功开展了肾脏,肝脏,肺脏、小肠、脾脏等器官的活体移植手术,事实表明该技术不仅有其科学依据,而且有其伦理学依据,即以人类自身伟大的奉献精神来关爱他人。但开展这一技术时务必需要遵循知情自愿原则,生命价值原则,利益和风险并存原则。当然在积极肯定这一技术的同时,也应该看到这一技术也存在一些伦理学方面尚未解决的问题。     

Psychological management and body image issues in facial transplantation

Facial transplantation, although controversial, is proposed as a major advance in facial reconstructive surgery, with the first partial transplant having taken place in France in November 2005. Although the psychological impact of facial transplantation will not be understood until several procedures have been carried out, this article examines the psychological issues likely to arise with particular reference to body image. A detailed framework for anticipation and management of psychological change is proposed. Pre-operative preparation must include thorough psychological preparation for the patient and their family. The immediate post-operative period is likely to be challenging, and a detailed management plan is proposed emphasising early return to function; subsequent psychological issues including altered body image, anxiety, shame, depression, communication and behavioural avoidance are discussed and a management strategy based on cognitive behavioural principles is proposed for the first post-operative year. Previous discussion frames psychological outcome in terms of complication and risk, tending to downplay the potential advantages of a successful procedure; the focus of this paper is on ensuring psychological adjustment as an inevitable consequence of change.     

The “Good” Psychologist, “Good” Torture,and “Good” Reputation—Response to O’Donohue,Snipes, Dalto,Soto, Maragakis,and Im (2014) “The Ethics of Enhanced Interrogations and Torture”

O’Donohue et al. (2014) sought to derive, from classical ethical theories, the ethical obligation of psychologists to assist “enhanced interrogations and torture” (EIT) in national defense scenarios under strict EIT criteria. They asked the American Psychological Association to adopt an ethics code obligating psychologists to assist such EIT and to uphold the reputation of EIT psychologists. We contest the authors’ ethical analyses as supports for psychologists’ forays into torture interrogation when (if ever) the EIT criteria obtain. We also contend that the authors’ application of these ethical analyses violates the Geneva Conventions, contravenes military doctrine and operations, and undermines psychology as a profession. We conclude that “good” public reputation is not owed to, or expected by, “good” intelligence professionals, and collaborating operational psychologists must share their providence.     

活体肝移植的伦理学问题

目前,肝移植已成为治疗终末期肝病的有效手段,活体肝移植术部分解决了供肝短缺的问题,10多年来其发展迅速,并取得了良好的疗效,由于活体肝移植需从活的供体身上切取部分肝脏,且供体多为患者家属,故存在着供体的选择,供体的贡献与代价,患者的家庭,心理,社会等伦理等问题。因此在提高活体肝移植技术水平的同时,必须充分考虑活体肝移植的伦理学问题,遵守伦理原则,使活体肝移植不但能从技术上达到,在伦理学方面也是可行的。     

Ethical reflections on the status of the preimplantation embryo leading to the German embryo protection act

Ethical conflicts have always been connected with new techniques of reproductive medicine such as in-vitro fertilization. The fundamental question is: When does human life begin and from which stage of development should the embryo be protected? This question cannot be solved by scientific findings only. In prenatal ontogenesis there is no moment during the development from the fertilized oocyte to a human being which could be recognized as an orientation point for all ethical problems connected with the question of the right to dispose of prenatal life (interruption of pregnancy, research on embryos). The protection of an individual human life must be valid for all in the same manner and from the very beginning on. It must not depend on value judgments or on stages of development, so-called grades of humanity, because these would then become selection criteria. Procreated life must have the right to be born. These were the essential ethical arguments which led to the German Embryo Protection Law.     

Developing human-nonhuman chimeras in human stem cell research: ethical issues and boundaries

The transplantation of adult human neural stem cells into prenatal non-humans offers an avenue for studying human neural cell development without direct use of human embryos. However, such experiments raise significant ethical concerns about mixing human and nonhuman materials in ways that could result in the development of human-nonhuman chimeras. This paper examines four arguments against such research, the moral taboo, species integrity, "unnaturalness," and human dignity arguments, and finds the last plausible. It argues that the transfer of human brain or retinal stem cells to nonhuman embryos would not result in the development of human-nonhuman chimeras that denigrate human dignity, provided such stem cells are dissociated. The article provides guidelines that set ethical boundaries for conducting such research that are consonant with the requirements of human dignity.