In 2001, when volunteer firefighter Patrick Hardison entered a burning home on a rescue mission, the roof collapsed and the fire burned up, under, and into his firefighter’s mask. Hardison lost his vision, and most of his face. He suffered disfiguring burns on his torso, head and neck.

Today, he’s recovering from what has been called the most extensive face transplant in history, living with the face of David Rodebaugh, a 26-year-old bike mechanic who died in a biking accident in August.

It took doctors at NYU’s Langone Medical Center 12 hours to remove Rodenbaugh’s face and bring it to Hardison’s operating room. Then began the process of giving Hardison a new face, scalp, ears, cheeks, chin, and a new nose. “It’s very risky,” Art Caplan of NYU’s Langone Medical Center said in an interview with BPR. “You have to take all these powerful immunosuppressive drugs, they might protect the face from rejecting, but it’s not 100 percent clear that it will. You put the face on, it’s got all kinds of muscles and nerves to attach, you want to be able to smile and wink and chew… Hardison was blind, so they had to really figure out a way to get his corneas fixed so he could get his vision back, which seems to have happened.”

Face transplants are extremely uncommon—since 1985, only 28 have been performed worldwide. According to Caplan, it requires a lot of preparation, and there are a lot of factors to consider. “Seventy-five doctors are involved in a face transplant,” Caplan said. “Dentists, trauma surgeons, cosmetic guys, on and on it goes. The whole thing probably cost a couple million dollars, but it seems to have worked for him.”

Caplan, a medical ethicist, says in addition to medical and procedural considerations, there’s also the ethical element. Caplan interviewed Hardison extensively before the procedure, “trying to make sure his consent was good for this.” Face transplants are still controversially internationally, but centers at Harvard and now NYU are trying to push the procedure forward. “What would you do if the face failed?” Caplan said. “He’s probably unlikely to get a re-transplant, so are you going to help him die? He would be suffering horribly. I had to insist that we put that in [the contract]. We had to manage the potential for failure, even though people don’t like to talk about it.”

The other big issue, according to Caplan, is the donor. In the case of Rodenbaugh, the 26-year-old’s mother had to sign off on the operation. “She’s seen [Hardison] with the face, and she’s having a strong emotional reaction,” Caplan said. “It’s not negative, but it’s really overpowering to her. We never worry about those things when we’re talking about hearts and livers. A face transplant is not the same as giving someone a kidney when they die, you’re going to see the face.”

Medical Ethicist Art Caplan is Head of the Division of Medical Ethics at NYU Langone Medical Center and the co-host of theEveryday Ethics podcast. To hear more of his interview with BPR, click on the audio link above.