Joan Bakewell: Can you still be yourself with someone else's face?

The ethics committee hasn't yet made up its mind and the popular press are waiting with bated breath. Yesterday, a meeting at London's Royal Free Hospital heard consultant plastic surgeon Peter Butler put the case for going ahead with the world's first full face transplant. It wasn't the only person they heard. Simon Weston who suffered terribly disfiguring burns in the Falklands War is said to be supporting their application. Initially he had doubts, but has now come round to being in favour. Badly disfigured has doubts! Ethical committee can't decide! Something momentous is going on.

A partial face transplant went ahead last year in France when 38-year-old Isabelle Dinoire, who had been savaged by her Labrador, was given a donor's nose, lip and chin. She now has the feeling back in her face and talks of the operation transforming her life. But she has to take handfuls of pills each day and probably will have to do so for the rest of her life. Meanwhile, the rest of us marvel at her photograph, and wait with a sense of fascination and some unease for what will happen next.

The first transplants back in the late 1960s were greeted with plenty of protests and reservations. It was felt that to receive someone else's heart was in some way to take on their soul. In the event the heart turned out to be nothing more than a muscle, and heart transplants now go ahead without, as far as I know, anyone feeling they're entering a pact with the devil.

The Scottish painter John Bellany, who had a liver transplant many years ago, swears that ever since, his taste in music has dramatically changed. He is both pleased and intrigued by that. But donors names are kept confidential so he has no way of checking.

The idea of swapping faces raises more complicated and unresolved emotions. Because of its close proximity to cosmetic facelifts, such surgery raises the science-fiction fantasy of improving one's looks, by simply acquiring another face. This is nothing to do with the benign intent of professional surgeons who will one day perform such an operation. But it does play into our worst fantasies.

Not surprisingly, these have already been gloriously exploited in the cinema. The 1960 Franju classic, Eyes without a Face, has a deranged French surgeon seeking to restore the face of the daughter he disfigured in a road accident. The girl, serene and mysterious behind her white mask; the transplant, shown in all its horror-movie detail, the failure and hideous disintegration of the new face ... all point to the crisis of identity that is at the heart of the film, and the heart of our concerns about such operations.

Who are you if you have someone else's face? Iain Hutchison, one of the country's foremost surgeons and founder of the Saving Faces charity, draws attention in an article for the Southern Medical Journal to issues raised by the Royal College of Surgeons of England working party report of 2003. One of their major concerns is with the psychological outcomes of face transplants. How will family and friends regard you if you cease to look like the person they know? How will the donors family feel if there is someone walking the earth who looks like the person they mourn? Indeed, it's felt that the matter of finding donors will pose a bigger problem than with any other transplant.

All the alarms being sounded around the entirely benign and important work of facial repair to hideous injury risks being confused with our vanities and conceits. We live in times when individuals actively seek to shape how they look. Cosmetic surgery is booming and the disfigured torsos to be seen on Big Brother and in glamour magazines show just how willing women are to distort young bodies in search of some undefined satisfaction. It is alarming the degree to which people are unhappy about how they look and ready to spend money chasing some fantasy solution. The solution, if they only knew it, lies elsewhere, in higher self-esteem, a swathe of good friends, and a secure emotional life. Yet even as I write it, I know how elusive these things are for many people.

The emphasis our culture places on looks is well and truly out of hand. We all know appearances matter. The impression made within seconds as someone walks through the door, the impact of that first glimpse in which we recognise and judge, are all part of human encounter. Body language, gesture, expression, even smell are all ways we present ourselves to the world. We add to such animal attributes characteristics of dress, of hairstyle of make up.

We are a mass of walking signals wherever we go, and before we've even spoken a word. The catastrophic loss by injury or disease of such signals shifts our entire place in our world. That is why the work of these brilliant surgeons will go forward, however slowly, to help restore a person's sense of identity.

But these legitimate objectives must not diverted and conflated with the wrong-headed ambition of the narcissistic. Magazines and television advertising and marketing all promote in us a sense of our own inadequacy. It is the most cruel gift of the consumer society to our young people. It is appropriate that the deliberations of the hospital's ethics committee take thought for the dangers of popular notions of perfectability. Their intention must be not "new face, new identity", but "new face, old self".

joan.bakewell@virgin.net