The global financial crisis of 2007-2010 highlighted the broad economic disparity between rich and poor around the world. Not only was it ‘the 99%’ that felt the brunt of the crisis as it took their homes and livelihood, the 1% that holds so much of the world’s wealth were demonized, seen as benefiting from the suffering of the masses. As stories of Wall Street exuberance fuelled by cocaine and prostitutes headlined international newspapers, people lost their jobs and with it their healthcare insurance. In countries around the globe, nation-states reigned in spending as the crisis fuelled a fire in which governments withdrew dollars from state-funded medicine. Congressman Obama vowed to bring the troupes home, and President Obama made this happen. Women and men returned to the US of A with war-torn mindbodies and mutilated appearances. The Pentagon put $42 million into the hands of specialist medical teams around the country to develop a new field that could reconstruct these people’s faces.
I was in Mexico when the 2008 Wall Street collapse took place. I was carrying out research on reconstructive surgery, and quickly became interested in the gaps and slippage between clinical and institutional ethics. Things happened in the consultation room; the planning of experimental surgeries that seemed to take place away from the governance of formal bioethics. On my first visit to the public hospital, the following took place:
I sat just to the back of Dr Ortiz during his craniofacial clinic. Black and white photographs of visiting professors and former colleagues line the walls in uneven fashion and the consultorio is arranged like a classroom, with failing lecture room chairs and their often broken notepad holders facing the front of the room. Interns moved in and around, introducing a few patients that entered and were examined without much concern. Shortly after my arrival a woman sat in the seat in front of us with her young son on her lap. He had craniosinotosis and the particularity of his condition posed a number of problems for the surgeons. As the examination progressed, the interest in the case intensified. The boy’s anomaly presented the need and opportunity to push the doctors and their treatment design in a certain fashion, towards something that “has never been done before”. This last comment was made in English. I don’t know why. Perhaps it was for my ears, still somewhat unfamiliar with the Spanish language. Perhaps it was for the child’s mother, to hide and suppress any further worries.
It is from here, from this initial observation, that my interest in face transplantation arose. When I returned home that evening, I skimmed the pages of the journal of the Mexican plastic surgery association. There was a special issue that provided the outline of a clinical protocol designed to bring the operation to Mexico. In the editorial, the head of the department where the protocol was forged, offered the following:
“[T]he development of facial transplantation from within plastic surgery is anticipated to bring about a new era in the specialty. Plastic surgeons in Mexico cannot remain at the margins of the new epoch nor isolate ourselves from the questions it poses.”
My initial research on face transplantation was interested in the kind of ethical slippage that I saw in the clinic. Locating the observation within the national context, I asked: How has Mexico’s focus on becoming a developed, and modern nation influenced the daily realities of clinical work? I can’t go into the details here, but I can say that in Mexico, bioethics is viewed as a development tool, as a way to produce patients as democratic citizens, responsible not only for their own health, but also the health of the nation. And, in face transplant surgery, bioethics played a central role: With the operation likely to attract so much international attention, it was paramount that the protocol correspond to globally accepted norms of medical practice. Thus we see the delineation of particular kinds of citizen patients in this context.
Currently I’m moving my attention to other questions. Face transplant surgery offers a select few people the chance at a ‘new’ life; in doing so, it moves $$$ away from primary health funding that could help improve the lives of many – and even prevent some of the causes of facial disfigurement. How and why is this taking place? In Mexico, the above quote and the noted focus on becoming a modern, developed country help us here. But in the USA, something else is going on.
As of today, May 9 2014, not one veteran of a possible 200 on the potential waiting list has undergone the operation. It is civilians that are first in line and under the scalpel in this field of experimental biomedicine. Their electrocuted, bear-mangled, or blown off by gunshot appearances have been replaced with transplanted faces. The performance of face transplantation on a small number of patients globally (about 28 but slowly growing) has not gone without debate or condemnation. Surgeons say that it is a straightforward matter when it comes to those in the operating theatre, the scalpel-in-hand aspects of the operation. They have deployed arguments and employed tactics to demonstrate that the tricky, institutional questions can be mediated by sound judgment and thorough oversight.
Is it ethical to submit a person to a life-threatening procedure in order to improve their quality of life? Organ transplantation requires the use of immunosuppressant drugs to counter the biological rejection of the grafted tissue. This can have fatal consequences. These drugs compromise the immune system; they limit its response to infection and to the cancer cells that form in us. There are other questions that face transplant surgeons have had to tackle, too. How will people cope living with another person’s flesh on their face? Will patients be able to make the transplant tissue their own or will it live on as ‘his’ or ‘her’ skin, chin, or nose? These questions are important. I have examined how they have resulted in the emergence of a bioethically mediated, ‘ideal’ kind of face transplant patient: a person whose particular state of health and suffering has allowed the operation to pass as ethical given the current technomedical constraints.
The other task of the anthropologist is to further this discussion, to demonstrate how face transplantation has resulted in a whole new ethics of the body and bodies. Seemingly motivated by national ambition as well as medical progress, the field has developed in the context of profound economic instability. On first inspection, it seems to embody the disparity publicly displayed in today’s post-Wall Street collapse world: many poor struggle to access medical care while medico-legal teams fight for the right to perform more cosmetic operations. On second inspection, it raises questions about the intersection of military might, bio/ethics, medical access and the value of damaged bodies today.
Anthropological work on global organ transplant networks has shown how international medicine is guilty of exploiting the suffering of the many, of the poverty stricken and the disenfranchised. Not only organs but fertile bodies are sold too – as, for example, white folk look to Eastern Europe’s poor for human eggs to harvest in the pursuit of yet unborn children. Alongside this work, we see patients becoming experimental subjects as debt-ravaged nations look to pharmaceutical trials to supplement their crumbling healthcare systems; in this context especially, ethics become ‘flexible’.
What then of the 200 or so returned service people that exist on the imaginary list of possible face transplant patients in the USA? Why are they not yet on the operating table? Asking this question pulls us into the murky territory that surgeons would have us avoid. It reveals the experimental, the place of the unknown, and the inherent ranking of human life within the field. Where the traffic in global organs reveals the exploitation of the poor, this abuse is concealed in and by the illicit. In face transplantation, the lives and bodies of maimed persons become the experimental grounds for the development of a field by and for military purposes. Writes anthropologist Shiv Visvanathan of the inherent relationship between science and politics:
“The experimental method so crucial to modern science is not only a system of political controls but it incorporates a unique notion of violence – that of vivisection. Within such a framework, the laboratory becomes a political structure and the basis of a wider vision of society.”
In face transplant surgery, inequality is hidden in plain sight as the newfound normalcy of patients is put on public display and technological triumph is celebrated. Citizens are cared for, but they are also experimented upon. I assume that it is only once the technological limitations of the surgery are no more and the experimental quality of the operation dissipates that American veterans will receive the operation. (I am not saying that this is a good or bad thing). If a message is to be taken away, it is that bioethics, rights and issues of social inclusion are being addressed and are indeed central in the formation of face transplantation. Though, they haven’t removed the inherent inequalities upon which medical science – both local and global – is practiced.
Sam wrote his PhD in Medical Anthropology at the Australian National University and his book On Face Transplantation: Life and Ethics in Experimental Biomedicine is now out via Palgrave Macmillan. A former fellow in the Science and Society Program at Harvard University, he currently teaches Anthropology at the University of Auckland, New Zealand.