Would You Still Love Me If I Had No Face?

Chances are, if we were dating, and you were my boyfriend, and a pit bull or Rottweiler chewed my face off, you'd probably dump me sooner or later, even if you thought I was the most beautiful and special person you had ever known and you knew you'd never meet another person like me for the rest of your life.

Let's face it: faces are important.

Our faces identify us uniquely; so while "who we are" is not synonymous with "what we look like," people who can recognize me can point to my face, and say, "Yes, that's T."

We experience the world and the stories of our lives largely through our faces. A breathtaking mountain view, an achingly beautiful passage of music, a delectable restaurant meal, the smell of roses or chocolate or candles or wood burning in winter, a baby's head on your cheek, a lover's kiss, a laugh-so-hard-you-gotta-cry type of conversation with your best friend - all these things reach us through our faces.

We need our faces for a lot of important things. Food stays in our mouths instead of dribbling onto the table because of our facial muscles. People relate to us through our faces; our faces very often trigger our most important relationships and are instrumental in our continuing interactions. People understand us because we express ourselves with our faces as well as our voices. Our faces share our meaning, and our meaning is what we exist to communicate.

If you lost your face, in a way, you would lose your whole world.

But now surgeons can give you part of a face back. This morning the Boston Globe reported that Boston's own Dr. Bohdan Pomahac will begin to perform partial face transplants at Brigham and Women's Hospital. This is historic. There have been three other successful face transplants that I know of: two in France, one in China. A flurry of medical, ethical, and philosophical questions comes up each time the possibility of such a transplant arises.

Here's what I think would be great about restoring people's faces: the recipients could speak and eat properly again; they could participate in society once again without feeling so marginalized by their appearance; and they could remove some of the disfigurement that marred such a vital symbol of individual identity and that probably caused considerable psychological pain.

Here are the problems I have with the procedure: the recipient would have to remain on anti-rejection medications for life, which are not benign; if rejection occurred, the recipient would likely have to endure further disfguring surgery or a potentially grave illness; and the donor, as far as I understand from the case of Isabelle Dinoire, who received a partial face transplant in Amiens in November of 2005, would have to be a beating-heart donor, a situation which could be ethically problematic for some, especially those with ambivalence about the declaration of clinical death by brain death criteria.

Some people have also brought up identity issues - the psychological difficulty for donors' loved ones of having a portion of their loved one's face removed and placed on a stranger, and the challenge for the recipient of living life with an anatomically different appearance. To my mind these are outweighed by the potential medical risks to which the recipient is subjected.

Beyond these, I think this issue of face transplants calls each and every conscientious person to a reflective examination of his or her values, of what role the idea of self-acceptance should play in seeking treatment or healing for a devastating injury, and whether our criteria for accepting one another are themselves so acceptable. I don't have any answers; only questions. In fact I had a lot of tough questions swimming about in my head as I read about this stunning break-through. I've written down some of them, and while the answers may seem clear to some, I believe that clarity is contradicted by the disparity between our behavior as a society and what we say we believe or hold dear:

Why is having a mauled face so much worse than having a mauled limb, which itself can be physically and emotionally agonizing?

Why might agreeing to donate part of your face be harder than agreeing to donate your own heart - is your face more "yours" than your heart?

Does a human being have to look like a human being to have worth and dignity?

Does a sick and dying human being, or a malformed human being, or an "incomplete" human being, have less worth than other human beings? (History has shown the people can't even tolerate human beings of a different nationality or color, despite well-intentioned statements by many about the belief in every person's instrinsic value; what does that say about how we as a society assign worth?)

I have written before that the core of my faith is the belief that every person is precious. How well I live up to that faith, and how that fits in with the intricacies of the medical and sociological issues that are unfolding today, I can't say for certain. I guess I just have to keep learning as I go along.

If I Had Been a Spider During Residency...

People have asked me how I deal with the sleep deprivation that's sometimes part of my job, and was a chronic, recurrent, unrelenting element of it during residency.

The answer is, while I was able to avoid developing a caffeine habit all through college and medical school, during my second year of anesthesia residency, when I was working in the ICU, I started drinking coffee.

It may have helped me GET THROUGH the nights and actually be able to TALK during rounds the next morning, but although I felt a little more alert temporarily, at first sip, I think there was nothing that was going to make me feel anything other than nauseatingly ILL after 18, 24, or 30 hours of being on my feet.

So instead of spinning webs like this (web of a drug-free spider):

The webs I spun might have been (and probably were) like this (web of a spider on caffeine):

(These particular pictures are on multiple websites, so I'm not really sure how to give them the proper attribution, but the website I got them from was this one.)

You know what I love? They needed a STUDY to PROVE that sleep deprivation makes people perform below their capabilities. Dr. Charles Czeisler, chief investigator of the study conducted at Brigham and Women's Hospital, discussed the results on NPR. "The traditional 30-hour shift is based on the notion that it's better to have a tired doctor who started with you that day than to have a fresh doctor. But we found actually that the tired doctors made many more mistakes," Czeisler said. Well, DUH. Impaired judgement. Compassion fatigue and mood lability. Less safety and satisfaction for patients. I really don't think we needed a study to point out the OBVIOUS, but perhaps we need it to document these consequences, as a necessary step in the effort to begin instituting some change.

I remember once overhearing a patient say to a surgeon, "I don't want anyone operating on me who's been up all night," and thinking, now is really not the time to try to buck the system. Did you write any letters of protest to your congress person or whomever, prior to showing up, decrying the use of torture to train physicians and transmogrify them from compassionate idealists to cynical, IRRITABLE, bitter, resentful, disillusioned bags of sheer exhaustion? Probably not. But you want the system, based on the insomnia of cocaine-addicted "father of American surgery," William Halsted, to change spontaneously and suddenly into something liveable and REASONABLE? I don't think so. This ain't Europe.

I think I might be sounding a little peevish right now. I think it's because I'm on call tonight and away from my family. Not all residents hate the sleep deprivation system as much as I did. Some need less sleep than others, and some cope very well with the arduous schedule. But I despised it, because I thought it was unnecessary and unhealthy for both physicians and patients, and thus unjustifiable.

Incidentally, my hospital's solution to residents' increased risk of falling asleep at the wheel driving home from a 30-hour shift? Cab vouchers. So, we were so tired we needed cab vouchers, but we were still expected to be at the top of our game making decisions about patients, cutting them open, sticking needles and wires into their necks, etc., the same day we were supposed to be taking the cab home?

It's true what they say, even about the Brilliant Minds of Medicine: ignorance can be educated, but stupid is forever. Although maybe not forever, in this case. Maybe if enough major errors are made, or enough patients die at the hands of exhausted physicians, this country's medical establishment will get the "wake-up call" it has needed since a cocaine-addicted surgeon instituted the system over 100 years ago.

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Addendum: the spider web images, thankfully, are in the public domain because they were produced by NASA, whose copyright policy states "NASA material is not protected by copyright unless noted" (see NASA copyright page and JPL image use policy.) They were created as part of this research paper: Noever, R., J. Cronise, and R. A. Relwani. 1995. Using spider-web patterns to determine toxicity. NASA Tech Briefs 19(4):82. Published in New Scientist magazine, 27 April 1995.