Money offer spurs questions about face transplant ethics

The possibility of the patient profiting from a film about the procedure raises concerns about undue influence.

By Kevin B. O’Reilly — Posted Jan. 30, 2006

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Three months before she received the world's first face transplant, a Frenchwoman accepted a tantalizing offer from photographer and filmmaker Michael Hughes. In exchange for allowing him to document the November 2005 procedure and sell the results for public consumption, Hughes promised the woman all the profits -- a figure that could reach $175,000, according to the Times of London.

So far, the French magazine Paris Match reportedly paid $100,000 for Hughes' photos, published in its Dec. 8, 2005, issue. It's raising serious ethical questions about whether the potential windfall might have unduly influenced the woman's decision to agree to the experimental surgery. It also has led physicians and medical ethicists to re-examine doctors' obligation to ensure that financial considerations don't enter the equation when patients weigh the pros and cons of a potential treatment.

The French National Order of Doctors issued a statement saying the surgical team violated the group's ethics by seeking publicity and violated patient privacy by agreeing to the release of the magazine photos, which were "spectacular and morbid" and "cruel" to the organ donor's family.

"It certainly violates all the ethics that American physicians hold near and dear," said Eugene Alford, MD, a facial plastic and reconstructive surgeon and a clinical assistant professor of otolaryngology at Baylor College of Medicine in Houston. "As a facial plastic surgeon, you have to assess why patients are having surgery and make sure there isn't some secondary, nonmedical reason involved." (See correction)

It is unclear exactly when in the decision-making process the media deal was struck. It appears that the transplant recipient, whose dog bit off parts of her nose, lips and chin as she lay unconscious after an overdose of sleeping pills in a suicide attempt, already had agreed to the procedure before Hughes approached her. If that is the case, Dr. Alford said, the potential windfall is not as troubling. Still, he said, "it kind of has a bad smell to it."

Dr. Jean-Michel Dubernard, who is handling the woman's posttransplant treatment and is a friend of Hughes, told the French newspaper Le Monde he had approved the deal to avoid a repeat of his 1998 first-in-the-world hand transplant. He said a press agency tricked him into allowing pictures without compensating the patient.

Gregory W. Rutecki, MD, director of medical education for the Mount Carmel Health System in Columbus, Ohio, said the amount of money alone should have raised ethical concerns.

"With $175,000, there's no way a human being could make that decision free of undue influence," said Dr. Rutecki, a fellow at the Center for Bioethics and Human Dignity.

The amount of money "makes a huge difference" in the ethical calculation, said Arthur L. Caplan, PhD, director of the University of Pennsylvania Center for Bioethics. "In fact, the spectacle of this is the only reason that this kind of money's involved. No one is paying $175,000 to film liposuction in Danville, Ill."

But other experts said paying a patient for agreeing to be filmed would be OK in some cases.

Gregory L. Larkin, MD, MPH, is a professor of emergency medicine at the University of Texas Southwestern Medical Center in Dallas, who co-authored a July 17, 2002, Journal of the American Medical Association article on the ethics of filming patients for TV and film. He said that once the patient agreed to the procedure, she probably underwent tests that showed her commitment, apart from any potential monetary gain. "I don't necessarily feel that her capitalizing on this -- her being the first sort of guinea pig -- is wrong or a morally problematic transaction," Dr. Larkin said.

Osborne Wiggins, PhD, a philosopher who is part of a team at the University of Louisville exploring facial transplantation, said the French recipient "should receive only as much money as is necessary to cover the expenses she has incurred by participating." And he said the arrangement would be acceptable only if the money were in a fund administered by a third party and used for ongoing care.

A rush to do surgery?

An underlying criticism of the French face transplant is that the lead surgeon, Dr. Bernard Devauchelle, and his team rushed to perform the procedure in a matter of months, while others have studied the procedure for years. Critics say the team made the hasty choice with an extremely vulnerable patient. The decision to approve the film deal also could have fallen victim to a race for glory, said Jonathan D. Moreno, PhD, director of the Center for Biomedical Ethics at the University of Virginia.

"It's supposed to be ethically required for the team that's doing a transplant to help patients think through the psychological implications of a procedure that could be hard to quantify in advance," Dr. Moreno said. That would include, he said, a decision about whether to agree to compensation for filming. Dr. Devauschelle has said their actions were medically appropriate.

AMA policy says "physicians should not allow the care they provide or their advice to patients regarding participating in filming to be influenced by financial gain or promotional benefit to themselves, their patients or their health care institutions."

Ultimately, it's the patient's right to accept compensation, said Priscilla Ray, MD, a Houston psychiatrist who chairs the AMA Council on Ethical and Judicial Affairs.

"The physician, of course, should not be getting any money in the deal," Dr. Ray said. "It's best if the consent to film is obtained by a disinterested third person, not by the physician or the film crew."

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This story originally incorrectly stated Dr. Alford's title. He is a facial plastic and reconstructive surgeon and a clinical assistant professor of otolaryngology at Baylor College of Medicine in Houston. American Medical News regrets the error.

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