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Journal of Mass Media Ethics: Exploring Questions of Media Morality Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hmme20 Facing the Future: Media Ethics, Bioethics, and the World's First Face Transplant Marjorie Kruvand a & Bastiaan Vanacker a a School of Communication Loyola University Chicago Published online: 25 Apr 2011.

To cite this article: Marjorie Kruvand & Bastiaan Vanacker (2011) Facing the Future: Media Ethics, Bioethics, and the World's First Face Transplant, Journal of Mass Media Ethics: Exploring Questions of Media Morality, 26:2, 135-157, DOI: 10.1080/08900523.2010.497437 To link to this article: http://dx.doi.org/10.1080/08900523.2010.497437

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Facing the Future: Media Ethics, Bioethics, and the World’s First Face Transplant

Marjorie Kruvand and Bastiaan Vanacker School of Communication Loyola University Chicago

When the world’s first face transplant was performed in France in 2005, the complex medical procedure and accompanying worldwide media attention sparked many ethical issues, including how the media covered the story. This study uses framing theory to examine what happenswhen media ethics intersect with bioethics by analyzing French, American, and British media coverage on the transplant and its aftermath. This study looks at how this story was framed and which bioethical issues were focused upon. The media ethical implications of these findings are then discussed. By doing so, this article attempts to contribute to the debate on how complex medical stories with bioethical components can be reported in an ethical manner.

When the world’s first partial face transplant was performed in a small city in northern France in 2005, the risky experimental procedure and its accompanying ethical issues unleashed a worldwide “media tsunami” (Powell, 2006, p. 111). Once the province of science fiction, face transplants became a tangible object of medical wonder and morbid fascination embodied in the much-photographed face of the patient, a 38-year-old woman who had been mauled by her dog.

Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014 The transplant was a medical milestone that dramatically improved the patient’s appearance but placed her squarely, and sometimes uncomfortably, in the media and public spotlight. When the patient appeared at a news conference three

Correspondence should be sent to Marjorie Kruvand, Assistant Professor, School of Communi- cation, Loyola University Chicago, 820 N. Michigan Avenue, Water Tower Campus, Chicago, IL 60611. E-mail: [email protected]

135 136 KRUVAND AND VANACKER

months later to unveil her new face in an attempt to ease public curiosity, several hundred reporters from all over the world packed the hospital auditorium (Bernard & Smith, 2006). How the media covered the news became part of the ongoing story. The patient’s identity and the fact that her injuries stemmed from a suicide attempt were reported within days (Foreman, 2005). Certain media organizations also breached the confidentiality of the transplant donor and reported that she had committed suicide, highlighting the grisly “parallel lives” of the two women (Newling & Mills, 2005, p. 21). Some reporters pressed the families of the patient and donor for interviews, visited their hometowns, and talked to their neighbors. Photos of both women, reportedly purchased for hundreds of thousands of dollars, were labeled “world exclusive” and splashed across newspapers. The barrage of publicity was abetted by the gregarious lead surgeon and by the patient, who invited reporters to visit her in her hospital room (Mayne et al., 2005). Every milestone in the patient’s recovery, from her first outing away from the hospital to her first press conference, made news. Accusations swirled in the media that the patient and transplant team would benefit from book and movie deals arranged by the lead surgeon. Journalists were also criticized for turning a serious medical procedure into sensationalized fluff by musing whether trading in a face for a younger, more attractive model would someday become commonplace (LaFerla & Singer, 2005). This study examines what can happen when media ethics intersect with bioethics through a framing analysis of media coverage of the world’s first partial face transplant. Ethical dilemmas such as those posed by this procedure are likely to become increasingly common as medical and scientific advancements nudge the boundaries of what is technically possible continually outward while societal discussion and consensus about what is moral lags behind. Because societal discussion and consensus building are mediated, the role of journalists in this process merits scrutiny.

LITERATURE REVIEW

Face Transplants: Background and History

Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014 From Mary Shelley’s Frankenstein (1818) to the 1997 movie Face/Off, the concept of a face transplant was the stuff of fiction and film long before it became a reality. Surgeons have performed skin grafts and used reconstructive surgery to repair disfigured faces for decades. However, the possibility of transplanting a human face onto another person’s body was first advanced by a British surgeon in 1998 (Huxtable & Woodley, 2005). Since then the idea has attracted considerable medical and media attention. Medical advisory committees in Britain and France FACING THE FUTURE 137

initially concluded that the risks of face transplants outweighed the perceived benefits and recommended a moratorium (Royal College of Surgeons, 2003; National Consultative Ethics Committee for Health and Life Sciences, 2004). Nonetheless, teams of physicians in several countries pressed forward with plans to perform the experimental surgery.

Winning the Race Some physicians and bioethicists have expressed concern that a thorough discussion of ethical issues could be bypassed in the race to pioneer facial transplantation: “The temptation to perform the world’s first face transplant may relegate the ethical considerations to the sidelines while the surgical team and the patient take center stage” (Butler et al., 2004). The international competition to perform the world’s first partial face transplant was won by a team of French surgeons at a hospital in Amiens on November 27, 2005. The patient, Isabelle Dinoire, had been disfigured when her dog chewed off part of her face six months earlier. Doctors determined that her injuries were so extensive that normal surgical repair was impossible. The transplant involved attaching the nose, cheeks, lips, and chin of a 46-year-old brain-dead woman. It touched off a firestorm of criticism and ethical debate that persisted even after the surgeons declared the transplant a success (Devauchelle et al., 2006). As of May 2010, there have been 11 other face transplants in four countries (Woolls, 2010).

Face Transplants: Bioethical Issues While most transplants are not readily observable, face transplants are “the most observable form of transplantation imaginable” (Caplan & Katz, 2003, p. 8). Every time a face transplant recipient looks in a mirror, he or she sees the result of his or her surgery, a highly visible reminder of what has been lost and gained. Face transplants are also firmly bound up in psychological issues involving personal identity (Caplan & Katz, 2003). Because the face has been called “unquestionably the most important aesthetic anatomical feature of the human body” (Wiggins et al., 2004, p. 5), face transplants present bioethical issues not raised by other transplants. Will face transplant recipients resemble

Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014 their former selves, the donor, or some hybrid? What if the patient does not accept the new organ as part of himself or herself (Carosella & Pradeu, 2006)? Who should be approached to donate a face, how, and when? Physicians and ethicists contend that the physical and psychological risks and benefits of face transplantation need to be weighed carefully. The most obvious risk is surgery that fails: there is an estimated 10% chance of rejection within the first year and a 30–50% chance in two to five years (Baylis, 2004). A failed 138 KRUVAND AND VANACKER

face transplant could be devastating to a patient (Strong, 2004). The transplant would have to be removed, leaving an extensive facial wound that would require multiple skin grafts from elsewhere on the patient’s body (Powell, 2006). Many physicians believe the immunological challenges posed by face trans- plants are far greater than the surgical challenges (Powell, 2006). Patients must take drugs for the rest of their lives to suppress their immune systems and increase the likelihood that their bodies will not reject the transplant. These drugs often have considerable side effects, including infection, diabetes, liver disease, and an increased risk of cancer, and not all transplant recipients can tolerate them. Even with anti-rejection drugs, it is uncertain whether patients will regain function, sensation, and mobility in their faces to enable them to smile, scowl, laugh, eat, drink, and smell again (Caplan, 2004). The bioethical issues involved in face transplants are obvious, but why should media ethicists study the way the media covered this case? We believe there are several relevant media ethical dimensions to reporting on this story.

Media Ethical Dimensions 1. Accuracy. As it is for other journalists, accuracy is an ethical imper- ative for reporters covering science and medicine (Nisbet, 2009). Science and medical reporters must translate complex subject matter into language that can be understood by the public while respecting “the uncertainty inherent to any technical question and resist engaging in hyperbole” (Nisbet, 2009, p. 53). The Association of Health Care Journalists underscores this point in its Statement of Principles:

Understand the process or medical research in order to report accurately : : : Give accurate portrayals of the status of investigational drugs, devices and procedures, including significant caveats and explanations of hurdles, unknowns and potential problems. (AHCJ, 2007)

The media ethical imperative to avoid hyperbole is heightened in science and medical reporting because the stakeholders can include potentially vulnerable patients and their families. Schwitzer drew on a long career as a health reporter Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014 to compose a list of “seven words you shouldn’t use in medical news,” including cure, miracle, breakthrough, promising, dramatic, and hope (2002):

Each is a vague—sometimes meaningless—term when used in a health care con- text. Granted, they are exciting terms that might help sell papers or move a reporter’s story onto page one or into the first news block, but they can be dangerous terms that mislead vulnerable people. (Schwitzer, 2009) FACING THE FUTURE 139

Beyond the requirements to report accurately and to avoid hype, should there be additional demands on medical and science reporting; for example, should journalists go from truth-tellers to issue advocates? According to Schwitzer, they should not (2005). McGregor et al. (2008) take a similar view, criticizing scholars who decried the fact that negative coverage of organ donation could lead to fewer organ donations. Instead, they argue that media should present all sides of an issue, including dissenting views. Rehmann-Sutter (2009) acknowledges that “media are a key means of distributing important knowledge to a broad audience” about the legal, ethical, and social aspects of science but argues that bioethical decisions need to be made in a broader public sphere to have legitimacy. Applying these insights to the issue of face transplants, reporters should not be expected to determine whether face transplants are ethically acceptable. Instead, it is their responsibility to stimulate societal debate by clearly explaining and highlighting the relevant bioethical issues involving face transplants.

2. Complexity. However, understanding potential bioethical issues and being able to explain them clearly requires journalists to have a thorough under- standing of their topic. According to Murcott (2009), this presents unique challenges for science journalists because the level of expertise needed to scrutinize scientific and medical developments is that of a peer reviewer. He contends that the complexity of the subject matter appears to set science and health journalism apart from many other types of journalism. Yet the number of experienced science and health reporters has been shrinking (Russell, 2006). Even journalists acknowledge the imperfections of today’s health and science reporting: it tends to be quickly produced, brief, superficial, lacking in context, and often misleading (Dentzer, 2009). Reporters tend to cover health and science as a series of disconnected events, dangers, or breakthroughs: “The unfortunate practice of treating science this way encourages the incorrect belief that scientific results are final, immutable end points” (Hayes & Grossman, 2006, p. 29). The challenges inherent in science and medical reporting, combined with the concern for accuracy and the importance of medical news to the public, have spurred efforts to hold science and medical reporters accountable by rating their stories. A team of medical experts at HealthNewsReview.org rates health stories from the 60 leading U.S. news sources (Schwitzer, 2009). In Australia, a

Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014 Web site called Media Doctor rates medical stories according to a set of criteria (Media Doctor, 2010). Media scholars can contribute to efforts to evaluate the coverage of medical and science news and suggest ways in which it can be improved. For example, public health experts have expressed dissatisfaction with the media’s focus on anecdotes and individual patients in reporting on disease because it distorts the problem (Coleman, Thorson, & Wilkins, 2009). Media scholars can verify 140 KRUVAND AND VANACKER

and examine these claims, propose and develop better frames, and study the effectiveness of these frames (Coleman et al., 2009).

3. A novel, international, bioethical, media ethics issue. The first partial face transplant was an international issue. It was bound to be watched closely by physicians and bioethicistsin other countries where similar procedures were being planned or considered; it was also likely to be reported on by the media in those countries. Concepts such as morality, health, and illness are culturally determined (Turner, 2005), and different interpretations of personhood and identity shape the bioethical debate. Turner remarks that scholars studying the link between culture and bioethics have focused on the state, province, and nation, but that “there is remarkably little scholarship in bioethics that takes global social order, global health, and transnational institutions as the focus of analysis” (p. 316). He adds, “If bioethicists hope to contribute to major contemporary social and ethical debates, they will need to contribute to the critical exploration of an emerging transnational, global culture” (p. 316). While the focus of this study is media ethics as well as bioethics, it is important to keep in mind that procedures such as the first partial face transplant are taking place in an era of globalization and therefore ought to be studied not only at the local level but also at the international level. Scholars have pointed to globalization as an argument for searching for universal values in journalism (Callahan, 2003; Christians et al., 2008; Herrscher, 2002). A case such as the world’s first partial face transplant might be another good starting point to initiate an analysis of different media ethical approaches to a bioethical issue with global impact.

4. The social construction of ‘‘need.’’ As discussed, the medical “need” for face transplants has been debated in the medical community. Do people with severely disfigured faces suffer from a disease, disorder, or medical condition a face transplant can potentially “cure”? Dinoire’s physicians repeatedly claimed there was a medical need for a face transplant in her case; others, addressing the need for face transplants in general, claimed that social obsession with beauty and perfection “is probably one of the strongest reasons for permitting this procedure and also ironically one of the main reasons why it gives cause for concern” (Huxtable & Woodley, 2005, p. 520). A major change in a person’s appearance can have a significant psychological impact on his or her self-

Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014 perception and identity (Huxtable & Woodley, 2005). A person who is vulnerable and psychologically unstable as a result of a facial injury or deformity is a poor candidate for a face transplant; a person who is psychologically stable is a better candidate but also less likely to need a face transplant (Strong, 2004). How these procedures—and their necessity—are framed by the media therefore matters: “When requests are made for surgical alterations that are medically feasible but ethically questionable : : : attention should be paid to the rhetorical FACING THE FUTURE 141

forces informing the decision making” (Jordan, 2009, p. 24). Numerous studies have recognized that the language and visuals used in stories help shape society’s views on the need for and acceptability of plastic surgery (Cho, 2007; Conners, 2007; Heyes, 2007; Tait, 2007; Woodstock, 2001).

Framing Media ethical insights can be gained by analyzing the frames reporters used in covering this case. Media frames are patterns of cognition, selection, and interpretation used to create reality by including, highlighting, and omitting information in stories (Gitlin, 1980). Frames enable reporters to quickly identify and categorize information and package it for news consumers (Gitlin, 1980; Tuchman, 1978). These central organizing devices can be particularly helpful when reporters are “thrust into unfamiliar territory” in covering a new topic (Nisbet & Lewenstein, 2002, p. 361). The world’s first partial face transplant represented unfamiliar territory. Frames can also provide common points of reference and meaning between science, the media, and society. Whether used intentionally or intuitively by reporters, media frames work by “connecting the mental dots” for the public (Nisbet, 2009, p. 56). Since frames are important sense-making devices, we “need to understand how they work and how we can use them ‘ethically’” (Nerlich, Elliott, & Larsen, 2009, p. 12). Framing analysis can be especially useful in examining issues involving risk, such as face transplants, because frames define problems, diagnose causes, make moral judgments about problems, and suggest solutions (Entman, 1993).

Framing as a Top-down Approach to Ethics A framing analysis operates at a high level of abstraction, revealing recurring themes in coverage. In contrast, most empirical media ethics research is very concrete: developing and evaluatingstandards for good practice and/or using these standards to evaluate coverage (as do web sites such as HealthNewsReview.org). A framing analysis does not lend itself to this task because it is not designed to evaluate the accuracy or quality of individual stories. Moreover, one cannot state that a story is “unethical” simply because it includes a certain frame and not another. The first partial face transplant had many newsworthy angles and

Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014 the editorial choice of one frame over another in a particular instance may be ethically irrelevant. Instead, a framing analysis allowed us to evaluate how journalists in three countries approached this story by studying and comparing the prevalence (and absence) of frames throughout the body of coverage. In doing so, this study followed a top-down approach to ethics: by analyzing the frames in the media coverage as a whole, it attempted to pinpoint the ethical implications of the framing. 142 KRUVAND AND VANACKER

Research Questions RQ1: How was media coverage of the transplant and its aftermath framed? RQ2: Which ethical issues were the focus of media coverage? RQ3: How did media coverage differ by country? RQ4: Did media coverage change over time, and if so, how?

METHOD

By systematically analyzing news stories on the first partial face transplant in print media in the United States, France, and Britain, this study was designed to illuminate the overall framing of media coverage, the ethical implications of the frames, how the framing evolved over time, and similarities and differences in coverage in the three countries. The United States and Britain were selected because teams of physicians in those countries had also been preparing to perform the world’s first face transplant and because American and British media organizations extensively covered the French procedure and its consequences.

Media Coverage French media coverage was drawn from four prominent national newspapers, Le Monde, Figaro, l’Humanité, and Libération, and from two weekly news magazines, Le Point and L’Express. Although newspapers in France no longer have links with political factions (McKenzie, 2006), they are still considered to have ideological leanings. The four newspapers were selected to represent the entire ideological spectrum: Figaro (right leaning), Le Monde (center), and Libération and l’Humanité (left leaning). U.S. media coverage was drawn from the six daily newspapers and two national weekly news magazines that published staff-written stories on the trans- plant: The New York Times, Washington Post, Los Angeles Times, Chicago Tribune, New York Daily News, New York Post, Newsweek, and Time. Other U.S. print media used wire service reports or did not cover the story. Five of the ten British newspapers that published staff-written stories on the transplant were selected for this study. The newspapers were the three with the

Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014 most staff-written stories (the Telegraph, Mail, and Times) and two others (the Sun and Record). They are a mix of broadsheet and tabloid formats.

Data Set Media coverage of the first partial face transplant was operationalized as all staff- written news stories between December 1, 2005, when the story first appeared FACING THE FUTURE 143

TABLE 1 Stories on First Face Transplant

Nation MediaOutlet NumberofStories

France Figaro 17 Le Monde 13 Libération 8 l’Humanité 4 Le Point 3 L’Express 3 Sub-total: 48 United States New York Times 13 New York Daily News 5 New York Post 4 Washington Post 2 Chicago Tribune 1 Los Angeles Times 1 Time 1 Newsweek 1 Sub-total: 28 Britain Daily Telegraph (and Sunday Telegraph) 18 Daily Mail (and Mail on Sunday) 17 The Times (and Sunday Times) 13 The Sun 9 The Daily Record 5 Subtotal: 62 Total: 138

in the media, and March 1, 2009. The stories were collected by searching the LexisNexis Academic, Factiva, and Academic Search Premier databases for “face transplant” in the text. Stories on plans to perform face transplants in other nations and on subsequent face transplants elsewhere were eliminated unless they also contained substantial information about Dinoire’s case. Stories with a staff byline but containing supplemental information from wire service or syndicated reports were included; editorials, op-eds, letters to the editor, and syndicated and wire service stories were excluded. A census of 138 stories was defined (see Table 1). The unit of analysis was the story. Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014

Analysis The stories were analyzed qualitatively and quantitatively. The primary objective was to identify and categorize all the frames in each story as well as the dominant frame. After initially reviewing several dozen stories in the data set, the authors established a typology of five frames to aid in the analysis. 144 KRUVAND AND VANACKER

The first frame, progress, has been used in previous research on media coverage of other scientific and medical topics involving risk, including nuclear power (Gamson & Modigliani,1989), nanotechnology(Gorss & Lewenstein, 2005),stem cell research (Nisbet, Brossard, & Kroepsch, 2003), biotechnology (Priest, 1994, 2006), and genetics (Ten Eyck & Williment, 2003). The science fiction frame also hasbeenusedtoanalyzenewscoverage ofsuchmedical andscientificdevelopments as cloning(Huxford,2000).The race frame reflects thefact that some stories frame scientific and medical advances as a competition among scientists, physicians, and/or nations with clear winners and losers (Rosenthal,2005). Still other coverage providedastraightforwardtechnicalexplanationoftheprocedure,asreflectedinthe medical frame. Two distinct sets of ethical issues were also raised: the professional ethics of journalists covering the story and bioethical issues about the selection of the patient, the procedure, its risks and benefits, its aftermath, and its implications. There was also a category for other frames. Because of the breadth of the bioethics frame, the authors also developed seven categories of bioethical issues identified during the initial review of stories as points of attention or emphasis. The objective was to drill down in each story in which the bioethics frame appeared to achieve greater precision and understanding. The first four categories were specific to this patient and case, the sixth was societal in scope, and the fifth was both. A seventh category was established for other bioethical issues.1 A standardized coding instrument and code book were developed and tested. The coding instrument was then revised and refined to ensure that category boundaries were unambiguous. A pilot study was conducted on a subsample of about 10% of the data set to determine the degree of agreement or disagreement between the categorizations of the two coders. Intercoder reliability was 84.7%, as calculated using Scott’s pi, which corrects for chance agreement among coders (Wimmer & Dominick, 2003). A reliability coefficient of 80% or better was sought.

FINDINGS

How Coverage Was Framed RQ1 asked how media coverage of the first partial face transplant and its Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014 aftermath was framed (see Table 2). The findings show that bioethics was by far the most prevalent frame and also the dominant frame in the greatest number of stories (see Table 3).

Bioethical Issues in Stories RQ2 asked which bioethical issues were the focus of media coverage. For the 124 stories in which the bioethics frame appeared (whether it was the dominant FACING THE FUTURE 145

TABLE 2 All Frames in Stories

Journalism Progress Race Sci-fi Medical Ethics Bioethics Other

N % N % N % N % N % N % N %

U.S. 15 53.5 10 35.7 1 3.5 3 10.7 3 10.7 28 100 2 7.1 (n D 28) France 15 31.2 10 20.8 2 4.1 15 31.2 13 27.0 42 87.5 1 22.5 (n D 48) Britain 30 48.3 13 20.9 8 12.9 13 20.9 1 11.2 54 87 14 22.5 (n D 62) Total 60 43.4 33 23.9 11 7.9 31 22.4 17 12.3 124 89.8 17 12.3 (n D 138)

TABLE 3 Dominant Frames in Stories

Journalism Progress Race Sci-fi Medical Ethics Bioethics Other

N % N % N % N % N % N % N %

U.S. 7 25.0 0 0 0 0 1 3.5 0 0 20 71.4 0 0 (n D 28) France 8 16.6 2 4.1 0 0 7 14.5 8 16.6 23 47.9 1 2.0 (n D 48) Britain 13 20.9 0 0 2 3.2 0 0 0 0 38 61.2 9 14.5 (n D 62) Total 28 20.2 2 2.1 2 1.4 8 5.7 8 5.7 81 58.6 10 7.2 (n D 138)

frame or not), we analyzed which of seven categories of bioethical issues were addressed. The average number of bioethical issues per story was 2.28. As Table 4 shows, the well-being of the patient was the most frequent bioethical issue, addressed in 63.7% of stories with a bioethics frame.

Differences by Country Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014 RQ3 asked how media coverage compared in the three countries. As Table 4 shows, there were a number of distinct differences. For example, the journalism ethics frame was almost three times more prevalent in French stories (27.0%) than in American (10.7%) or British (11.2%) stories. American and British stories were more likely to use the progress frame (53.5% and 48.3%, respectively) than French stories (31.2%). The race frame appeared more often in American stories (35.7%) than in French (20.8%) or British (20.9%) stories. 146 KRUVAND AND VANACKER

TABLE 4 Ethical Issues in Stories

Appropriate- Well- Impli- Need ness Being Intent cations Privacy Other

N % N % N % N % N % N % N %

U.S. 19 67.8 14 50.0 16 56.1 9 33.1 8 28.5 6 21.4 1 3.5 (n D 28) France 18 42.8 10 23.8 18 42.8 15 35.7 3 7.1 7 16.6 3 7.1 (n D 42) Britain 18 33.3 21 38.8 45 83.3 17 31.4 7 12.9 21 38.8 7 12.9 (n D 54) Total 55 44.3 45 36.2 79 63.7 41 33.0 18 14.5 34 27.4 11 8.8 (n D 124)

French coverage was considerably more likely to use the medical frame to explain the transplant and its consequences (31.2%) compared to American and British coverage (10.7% and 20.9%, respectively). The science fiction frame appeared in fewer American (3.5%) and French (4.1%) stories than in British stories (12.9%).

Differences over Time RQ4 asked whether media coverage changed over time, and if so, how. We compared the framing of the 45 stories published the first week after news of the transplant broke (December 1–8, 2005) with the 93 stories published during the rest of the study period. The findings indicate that use of the journalism ethics frame more than doubled, from 8.8% in stories during the first week to 20.4% during the rest of the coverage. The progress frame (46.6% during the first week, 43.0% later) endured, but the use of four other frames faded as time went on. The race frame appeared in 31.1% of stories during the first week but only in 18.2% of later stories. The number of stories with the bioethics frame (97.7% during the first week, 87.0% later), science fiction frame (11.1% during the first week, 6.4% later), and medical frame (31.1% during the first week, 18.2% later) also declined. Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014 DISCUSSION

The world’s first partial face transplant was both a novelty and surprise to jour- nalists. Caught off guard and attempting to play catch up on a complex medical procedure accompanied by challenging ethical issues, reporters framed the story in a multiplicity of ways to which they and news consumers could relate. FACING THE FUTURE 147

Many reporters recognized the ethical dilemmas surrounding the transplant, and bioethics was the most prevalent frame in media coverage and also the dominant frame in the greatest number of stories. This was even the case in French coverage: “The ethics of the face transplant continue to divide France, despite much goodwill toward Miss Dinoire” (Randall, 2005, p. 9). In this respect, journalists fulfilled their responsibility to stimulate reflection on the bioethical aspects of this issue. The second most popular frame, progress, displayed excitement over the procedure. The progress frame eclipsed the medical frame, which explained the technical details of the procedure and Dinoire’s recovery. The race frame, which focused on the international competition between teams of physicians to perform the first face transplant, was used about as often as the medical frame. Reporters by and large avoided sensationalizing the procedure by minimizing use of the science fiction frame.

Bioethics While the media focused overwhelmingly on Dinoire’s well-being after the transplant (63.7% of all the stories with a bioethics frame), larger questions surrounding the need for face transplants (44.3% of stories) and their societal implications (14.5%) received considerably less attention. Although there was a pronounced focus on well-being in media coverage in all three countries, it was especially extensive in British stories. From the outset, British media were more likely to focus personally on Dinoire than on face transplants in general. Eighty-three percent of British stories with a bioethics frame addressed Dinoire’s well-being following the transplant, compared to 56.1% of American stories and 42.8% of French stories. By emphasizing the challenges and milestones of a single patient, British coverage tended to limit discussion of the larger social issues surrounding face transplants (need and implications). Two of three American stories (67.8%) with a bioethics frame addressed the need for such procedures, compared to 42.8% of French stories and only one-third of British stories. More American stories also addressed the societal implications of face transplants (28.5% of stories with a bioethics frame) compared to British (12.9%) and French (7.1%) stories. The intentions of the physicians who performed the transplant were discussed in about one-third of all stories with a bioethics frame (35.7% of French stories,

Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014 33.1% American, and 31.4% British). Some other French physicians accused the transplant team “of putting their desire to achieve a first above the interests of the patient” (Martin, 2006, p. 5). Other stories reported claims of critics that “Ms. Dinoire is the pawn of doctors desperate to win what has been dubbed the ‘face race’” (Barton & Newling, 2005, p. 19) and that Jean-Michel Dubernard, the lead surgeon, performed the operation to “ensure : : : his place in history” (Sage, 2005a, p. 9). Dubernard dismissed the criticism: “We were not interested 148 KRUVAND AND VANACKER

in pulling off a coup. We were interested in our patient and in all the other people to whom this will offer hope” (Sage, 2005b, p. 3). Dubernard and his team were also criticized for arranging photo, book, and movie deals even though they added to the “carnival atmosphere” complicating Dinoire’s recovery (Smith, 2005, p. A1). The Times reported that Dinoire and her doctors signed a deal with a British film maker three months before a donor was found (Sage, 2005a). Dubernard said he had arranged the deals “to prevent others from taking advantage of her” (Randall, 2006, p. 16). The findings appear to indicate that bioethical issues transcending Dinoire’s case, such as the need for and societal implications of face transplants, encoun- tered heavy competition from bioethical issues specific to her case. We do not contend that the media should ignore Dinoire’s well-being, the intentions of her doctors, or her appropriateness as a patient (36.2% of all stories with a bioethics frame). They are relevant and newsworthy aspects of the story. However, by focusing on bioethical issues specific to this case, there is a risk that the ethical analysis of face transplants in general will be reduced to an ethical analysis of this single procedure. As Dinoire’s condition improved, critics quoted in the media mellowed. Her surgeons, who had been accused of moving ahead with the transplant “without adequate medical and ethical preparation” (Altman, 2006b, p. A16), their decisions “clouded by visions of fame and dollars” (Rosenthal, 2005, p. A6), were “loudly applauded” several months later by their international counterparts (Altman, 2006b, p. A16). While many stories continued to note that Dinoire would have to take anti-rejection drugs for the rest of her life, fears of rejection slowly eased. This prompted The New York Times to ponder whether a face might someday “be as interchangeable as a watchband” and asked New Yorkers which celebrity’s face they might choose (LaFerla & Singer, 2005, p. G1).

Progress The novelty of the first partial face transplant gave rise to the progress frame, which expressed enthusiasm over the procedure. The progress frame was used more often in American stories (53.5%) than in British (48.3%) or French (31.2%) stories. Some stories included upbeat descriptions of the transplant as

Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014 a “groundbreaking operation” (Shin, 2005, p. 23) that “made medical history” (Campbell, 2005a, p. 1) and was the “triumphant culmination of a daunting sequence of events” (Campbell, 2005b, p. 3) that “offers hope to patients who have been severely disfigured” (Gorman & Bachmann, 2005, p. 58). The prevalence of the progress frame reflects the propensity toward journal- istic hyperbole criticized by Schwitzer and others and delimits discussion of bioethical issues, including the experimental nature of face transplants and the FACING THE FUTURE 149

significant possibility of rejection. Especially in the United States, science and medical reporters, encouraged by the scientists and physicians who are their expert sources, have tended to promote medical research as “breakthroughs” (Shaw, 2000). This can lead to an uncritical and unwarranted boosterism of science (Goodell, 1986), what Nelkin (1995) calls “selling science” to the public. Excitement over the first partial face transplant was far from universal, how- ever. The progress frame was absent from some stories; in others, the procedure was downplayed: “The surgery represents the first foray into a much-debated realm of medicine : : : Face transplants are among the most disputed frontiers in transplantation science because they are so risky” (Altman, 2005, p. A1).

Race The race frame, which positioned the transplant as the outcome of a contest with definite winners and losers, was a popular theme in media coverage, especially during the first week after the procedure. For example, the Telegraph stated that the French team “was first in the fierce international competition to carry out this type of surgery, dubbed ‘the Face Race’” (Newling & Barton, 2006, p. 43). British and American physicians reacted to the announcement of Dinoire’s transplant with a mix of surprise, disappointment, jealousy, and grudging ad- miration. A British team had been considered the front runner to perform the first face transplant, and two U.S. teams, in Cleveland, Ohio, and Louisville, Ky., had also been preparing for this type of surgery for several years. Because reporters tend to rely on expert sources with which they are familiar (Conrad, 1999; Shoemaker & Reese, 1996; Reese & Danielian, 1994), the views of these physicians and bioethicists were reflected in media coverage in their own countries. This may help explain why the race frame appeared more often in American stories (35.7%) than in British (20.9%) or French (20.9%) coverage. Some French stories expressed nationalistic pride about being first: “They were numerous, in the world, those who said they were ready to do it. The team of Jean-Michel Dubernard : : : has preceded them” (Defait, 2006, p. 9). However, the race frame in French stories most often dealt with the fact that another team of French doctors had previously sought permission to perform a face transplant

Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014 (and had been refused), which prompted accusations that Dubernard had usurped the other physicians’ protocol. The race frame had the potential to reduce the complex medical procedure to simplistic discourse. Although the race frame appeared in nearly one-fourth of all stories, it was the dominant frame in only two stories, both of them French. While the competitive aspect of face transplants was clearly a theme reporters latched onto, it did not dominate coverage. 150 KRUVAND AND VANACKER

Medical More French stories provided a straightforward explanation of the medical issues involved in the transplant and its aftermath than British or American stories. The medical frame appeared in 31.2% of French stories but in only 10.7% of American and 20.9% of British stories. The presence of the medical frame reflected the complexity of the procedure, although it was beyond the scope of this study to evaluate the accuracy or quality of the information provided. Including the medical frame in more stories could have helped educate news consumers about the procedure and the patient’s recovery, contributed to a better understanding of the bioethical issues involved, and corrected misperceptions of a face transplant as an easy surgical “fix.” Use of the medical frame declined over time, however, as media updates on Dinoire’s condition relied less on evaluation by medical experts and more on tangible improvements in her appearance that reporters could see for themselves: “(She) looks nearly flawless on the one-year anniversary of the operation” (Graves, 2006, p. 17). Dinoire’s ability to drink from a glass during a press conference was also noted by reporters.

Science Fiction We analyzed to what extent reporters turned to rhetorical devices to sym- bolize face transplants and to associate them with something familiar. The science fiction frame was inspired by literature and film. Science fiction offered metaphors that expressed uneasiness about moving forward with this new procedure: Dinoire’s scars were “Frankenstein-like” (McPhedran, 2006, p. 9) and face transplants belonged “to the fictional world of Frankenstein’s monster” (Barton & Newling, 2005, p. 19). Even when Dinoire was praised as a “medical wonder” (McPhedran, 2006, p. 9), her appearance prompted reactions by reporters of “mingled revulsion and awe” (LaFerla & Singer, 2005, p. G1). Some bioethicists contend that this type of reporting fosters “public voyeurism of human curiosities” (Miles, 2004, p. 39). However, the science fiction frame was almost nonexistent in American and French stories (3.5% and 4.1%, respectively), although it appeared in 12.9% of British stories. This seems to indicate that many journalists resisted making easy references to popular culture to sensationalize the story. Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014

Journalism Ethics The journalism ethics frame explicitly addressed media coverage of the trans- plant. This frame was used much more frequently in French coverage, primarily because the French media contended that the British media had violated journal- istic ethics in covering the story. French media organizations expressed outrage FACING THE FUTURE 151

that British newspapers had published the names of the donor and recipient. Le Figaro scolded in a headline: “Face transplant: Condemnable British indis- cretions” (Dromard, 2006, p. 11). British reporters also attempted to contact the donor’s family to get information and pictures, which was illegal in France (transplant donors have the right to remain anonymous). The chief photo editor of the Daily Mail defended this breach of confidentiality in Le Monde: “This was an exceptional event, so we sent over people to try to recover some photos (of the donor)” (Guillot, 2005). British newspapers also speculated about and investigated the circumstances under which Dinoire had been injured, suggesting that she had passed out after attempting suicide, and reported that the donor had committed suicide. None of these facts were reported in French stories, which were based on the transplant team’s accounts. While American media organizations did not investigate the personal lives of the patient and donor, they reported details disclosed in British newspapers. In that sense, stories in The New York Times did not differ appreciably from those in the New York Daily News or New York Post. This squabble between the British and French media illustrates the ethical challenges of reporting on novel and complex medical procedures such as the first partial face transplant. It appears that the French media placed the greatest value on the privacy of the patient and donor while depending on official sources of information, such as the hospital and transplant team. Dubernard appeared willing to talk with reporters, and Le Figaro noted that the transplant team “neither lacked audacity nor a solid sense of communication for the world premiere” (Doucet, 2006, p. 22). Some British newspapers appeared to take the opposite approach, sacrificing the privacy of the patient and donor in an attempt to get independent information. From a comparative media ethics point of view, international differences in reporting styles were evidenced by finger pointing, criticism, and defense of journalistic behavior. Unfortunately, the journalism ethics frame was not used to invite dialogue or self-reflection on how journalists covered the story. As a result, a potential opportunity to promote media accountability by discussing how media organizations could do a better job covering the next big medical or science story accompanied by significant ethical issues was lost.

Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014 CONCLUSION

More than four years after the world’s first partial face transplant, the aftermath of the path breaking surgery and the host of ethical issues it generated remains in the news. A lengthy story about Dinoire in The Sunday Times in January 2010, which was based on a four-hour interview, is evidence of the media’s enduring fascination with her case. 152 KRUVAND AND VANACKER

Although it was not the goal of this study to label certain frames in media coverage of Dinoire’s transplant as “wrong” and others as “right,” some con- clusions can be drawn that are relevant from a media ethics point of view. It is encouraging to see that journalists framed the story primarily as a bioethical issue and minimized use of the science fiction frame. However, within the bioethics frame, there was a tendency to focus the ethical debate on the people involved—the patient, donor, and transplant team—while larger bioethical issues regarding the desirability of, and need for, face transplants appeared to have been subordinated. The progress frame was also prominent in media coverage. While the first partial face transplant was a remarkable medical feat, journalists should be mindful that framing this event as yet another step in the unstoppable march of scientific progress may imply that these procedures are inevitable. When using the progress frame, reporters should avoid hyperbole and uncritical praise because this could give false hope to potential patients. As of May 2010, there have been 11 other face transplants in France, China, the United States, and Spain (Woolls, 2010) and two patients have died (Follain, 2010)—a fact that has drawn scant media attention. Because of the complexity of face transplants, the medical frame was perhaps the most challenging frame for reporters. However, relaying straightforward, detailed information about the procedure and its aftermath is a crucial task of journalists since better public understanding of the science may lead to greater understanding of the bioethical issues involved in face transplants and hence to more informed societal debate. Yet the medical frame was far less prevalent than the progress frame and appeared about as often as the race frame, indicating that providing detailed medical information was not always a focus for reporters. Once only possible in fiction and film, face transplants have now come full circle. A partial face transplant was a plotline on the TV show Grey’s Anatomy in 2009. While the TV patient made a quick and miraculous recovery, in reality a face transplant is “a grand human experiment” that is “far more complicated—surgically, immunologically, and psychologically—and the results more uncertain” (Okie, 2006, p. 889). Another way in which the TV account differed from real life was that no reporters or bioethicists were players in the drama. This was not the case with Dinoire’s transplant, which became

Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014 an international media event in which national pride and envy, bioethics, and different standards of journalism ethics collided as reporters tried to report on and make sense of complex medical and ethical issues. This resulted in a multiplicity of media frames used by journalists in different countries. The main focus of this study was to identify and compare these frames and to point out their ethical implications, since how reporters cover (or do not cover) this issue may impact public debate on the future of face transplants. FACING THE FUTURE 153

This study does not suggest a normative framework with which to evaluate media coverage of the first partial face transplant but hopes to initiate discussion among media ethicists and bioethicists on how procedures such as this should be covered. Although there is a fair amount of literature on how to cover medical stories ethically, face transplants pose unique reporting challenges. These include their novelty, complexity, and uncertain outcome; the fact that they are entwined with issues of identity and self-perception and societal norms about appearance; that they pose significant health risks but do not save lives; and because they appeal to our fascination with the morbid and sensational. Because the possibility of rejection will continue throughout patients’ lives, face transplants have the perpetual ability to both inspire and repulse. It is unsurprising, then, to see the diversity of media frames observed in this study. As the limits of what is medically possible continues to expand, so will the challenges for journalists covering medical advances with bioethical consequences. Ultimately, guidelines could be developed for reporters covering complex medical stories accompanied by challenging bioethical issues. This study is an attempt to jumpstart the discussion on how to cover these types of stories in ways that are responsible and fair.

NOTE

1. Bioethics issues were: 1. Patient well-being: How the procedure and recovery process affected the patient physically and/or psychologically. Dinoire is considered an ethical stakeholder rather than a medical marvel; 2. Privacy/confidentiality: Lack of confidentiality for patient and donor; breach of patient’s rights; whether lack of privacy turned procedure into a sideshow; implications for patient living “normal” life; 3. Appro- priateness of patient: Whether doctors selected right patient; whether patient was adequately screened; whether patient could withstand the physical, immunological, and psychological challenges; whether patient “deserved” the transplant (e.g., patient tried to commit suicide); 4. Intentions of physicians: Whether doctors were motivated to do the first face transplant at all costs; self-interest in promotion and fame; whether they subordinated patient’s interests to their own; 5. Need: Risks and

Downloaded by [T&F Internal Users], [Ross Wagenhofer] at 10:30 25 September 2014 benefits of face transplants; whether transplant was attempted too soon; whether conventional reconstructive surgery should have been tried first; whether a perfect candidate exists; 6. Implications: Future implications for society; whether face transplants will become more common; whether enough donors will be found; whether ethical “backlash” will curtail future face transplants; whether face transplants will be misused to enhance appearance of people without serious facial disfigurement; 7. Other: Bioethical issues not covered by other categories. 154 KRUVAND AND VANACKER

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