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Cultural concerns

The Chinese culture exerts a profound impact on a variety of medical decisions, including face transplants, sources say.

"In China, there is not the emphasis on informed consent that we find in the United States. Cancer patients often are not told their diagnosis. Families often make medical decisions for patients, even those who have decision-making capacity," says medical ethicist Carson Strong, Ph.D., professor of human values and ethics at the University of Tennessee Health Science Center.

The Chinese have "a different set of ethical rules than we do here," says John H. Barker, M.D., Ph.D. For instance, he says it's legal there to abort nine-month fetuses. "It's not right or wrong. It's just a different culture."

As for China's face transplant recipient, Guo Shuzong, M.D., Ph.D., says he informed the patient of all risks and potential results of both traditional techniques and face transplantation at their first meeting.

"He said he wanted this surgery. I said maybe we needed to wait" to discuss it with his family and other physicians, Dr. Guo says.

"The problem is, he lives in a small village, in which he is a minority (Lisu). People there dance and sing, and there's a lot of social activity. But he was isolated. People didn't want to see him, so he just stayed home," Dr. Guo says.

The potential for discrimination also played into the patient's decision, as did the fact that the Lisu, one of China's 56 ethnic minority groups, are historically hunters known for taking bold risks, Dr. Guo adds.

Nevertheless, Laurent Lantieri, M.D., head of plastic surgery at Paris's Henri Modor Hospital, says, "I'm very anxious about the future of these transplants, especially in China," where most of the country's hand transplant patients have experienced chronic rejection because they can't afford their immunosuppressive drugs (Okie S. N Engl J Med. 2006 Mar 2;354(9):889-894).

"That's a problem," Dr. Guo concedes. "We needed to have the money for this patient's whole life" before proceeding with the new technique, he says. To further allay his preoperative concerns, Dr. Guo visited two of the Chinese hand transplant patients, who he says were fine.

"I know some patients removed the transplanted hands," Dr. Guo says. One such patient, a policeman from the dominant Han ethnic group, worried that his new hand might have come from a lawbreaker, Dr. Guo says. Moreover, he says many Chinese ethnic groups share strong beliefs in spirits of the dead, predisposing them against transplants.

Fortunately for Mr. Li, Dr. Guo says, "The Lisu do not care about that. The patient easily accepted the transplant as a piece of tissue to fix his face."

Hand transplant failures caused by discontinuation of immunosuppression don't detract from what face transplant teams are trying to do because one would expect rejection after stopping such medications, Dr. Barker says.

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