"The BWH team recognizes the ethical concerns and tailored BWH's programs to address them," reads the article in a 2007 issue of BWH Bulletin. "One concern is that transplant patients spend the rest of their lives taking immunosuppressant drugs to keep the body from rejecting the organ. BWH will only perform facial transplants on those who already are on these drugs, most likely from a previous transplant."
Pomahac is quoted in the article as saying that patients already on immunosuppressants "know what it's like to live on these drugs, which can have debilitating effects on the body."
And in the 2008 Transplantation article, Pomahac wrote:
"We currently share the concern that life-long immunosuppression associated with facial transplantation may not outweigh its benefits as compared to the alternative reconstructive methods. We asked ourselves the question of which patient population would risk less and overall benefit more from undergoing face transplantation, and identified those currently on immunosuppressive therapy the most suitable candidates."
The hospital newsletter article further suggested that Brigham and Women's would only perform partial face transplants, chiefly in response to critics' concerns over "the ethics of changing a person's identity."
Still, surgeons and ethicists alike appear to agree that shifting away from a policy limiting the patient pool for face transplants may not be such a bad thing -- particularly considering the horrific injuries that candidates for this surgery possess.
"I don't think that it makes sense to try and limit face transplantation to those already on immunosuppression," said Art Caplan, head of the bioethics center at the University of Pennsylvania. "That might be preferable, other things being equal, but the number of persons who will fit that selection standard is tiny."
Rosamond Rhodes, director of bioethics education at Mount Sinai School of Medicine, agreed. "When the facial disfigurement is so severe as to merit the risks of transplantation, the extra burdens of immunosuppression hardly adds to the burden.
"In that light, the BWH policy seems designed to spare the surgeons and institution from guilt or public criticism, rather than to serve the interests of patients in need of a face transplant," she added.
Brigham and Women's is not the only institution to have such a policy, however. Dr. L. Scott Levin, chief of plastic, reconstructive, oral and maxillofacial surgery and a professor of orthopaedic and plastic surgery at Duke University Medical Center in Durham, N.C., said that Duke has been IRB approved to conduct a face transplant operation, and they, too, have a policy that would limit the patient pool to those already taking immunosuppressants.
But he added that if the opportunity arose to perform such an operation -- even on a patient who was not currently immunosuppressed -- he would jump at the chance.
"There is such a huge need in patients who have been burned, unusually disfigured or injured in war," Levin said. "I'd do it in a heartbeat."
And McCarthy said he has no doubt that Brigham and Women's fully weighed the risks and benefits of the surgery and lifelong immunosuppression before going forward.
"You're at a first-rate institution," he said. "These decisions are not going to be made casually."