10 Ethics in Facial Plastic Surgery
The First Ethics Tragedy
The Greek poet Pindar (474 BC) writes about the mythical physician Asclepius, who had an illustrious career in mending and healing:
“Those who came to him with flesh devouring sores, with limbs gored by gray bronze or crushed stones, all those with bodies broken, sun struck or frost bitten, he freed of their misery, each from his ailment, and led them forth—some to the lull of soft spells, others by potions, still others with bandages steeped in medications culled from quarters, and others he set right through surgery.” [11:47–53]
But this comes to a tragic end:
“Even wisdom feels the lure of gain: gold glittered in his hand and he was hired to retrieve from death a man whose life was already forfeit; Zeus hurled flashing lightning and drove the breath, smoking from the breasts of savior and saved alike.” [54–60]
Perhaps this fable highlights the first case of medical ethics. A competent physician was induced by greed to perform a forbidden medical service. He violated divine law and paid the penalty. Medical ethics, then and now, is about the physician’s attitude and dealings with the price of saving and healing life. 1
What Is Ethics?
Ethics is a subject that those colleagues beneath you need to be concerned with.
—Anon.
Although ethics is a word we hear often, we have a hard time defining it. It has been said that a man who is good in his heart is an ethical member of any group in society, whereas one who is bad in his heart is an unethical member. Ethics implies a state of goodness verging on saintliness to which we might aspire but which we are unable to achieve. 2 Random House defines ethics as “moral principles, philosophy of values dealing with the rightness or wrongness of certain actions and to the goodness and badness of the motives and ends of such actions.” The fellowship pledge of the American College of Surgeons in part goes, “I pledge to pursue the practice of surgery with honesty, and to place the welfare and rights of my patient above all else.”
Perhaps ethics is a personal expression of what one believes is right and one’s capacity to give meaning to that belief. It is associated with integrity, honesty, and truthfulness. When one thinks about an ethical person, such as an ethical physician, one inherently believes that person will deal with patients in an honest and truthful manner and not put his or her own needs first. In a simplistic way, ethics can be thought of as doing what is right.
Society rightfully expects physicians to behave ethically. A firm grasp of medical knowledge and competency in patient care is necessary but not enough. Physicians must possess a commitment toward an ethical practice and this includes competency in communication and interpersonal skills, ongoing learning, and professionalism. A principal objective of the medical profession is to deliver appropriate care to humanity with full respect for human dignity.
Historically, ethical codes have evolved from the time of Hippocrates and the early Greek medical text known as the Hippocratic Oath. This has been modified at times to better fit the needs of various cultures. 3 , 4
Socrates believed that ethics consists of knowing what we ought to do and such knowledge can be taught. Ethical discourses can be found in ancient Greek, Roman, and medieval writings. 5
The Oath of Maimonides has also served as a model of ethical behavior, written by the Jewish philosopher Moses ben-Maimon (1135–1204), who was well versed in the classical writings of Hippocrates, Aristotle, and Galen as well as in the rabbinic teachings of the Bible and the Talmud. 6
Ethical admonitions come from the Renaissance. For example, it is acceptable to lie to the patient to make him more optimistic, as long as one does not believe that influencing the imagination can heal the body. The withholding of treatment is not justified by a poor prognosis; it is justified, however, if the circumstances may impair the physician’s objectivity—he should not treat family or friends, nor should he treat enemies, to avoid being accused of malfeasance should such a patient succumb. 7
In 1803, Thomas Percival, a British physician, published A Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons. 8 This book, outlining ethics for the medical community and prescribing a set of responsibilities for the individual doctor, was a result of a major conflict at the Manchester Infirmary: surgeons quit working and refused to minister to patients at the onset of an epidemic. 9
In the United States, the medical profession of the mid19th century was under assault by various social forces, and the American Medical Association (AMA), its code of ethics, and the use of the Hippocratic Oath all served as tools for the defense of the profession. (The original AMA ethics writings began as a set of admonitions to ensure peaceful relations between physicians!)
One would assume that medical literature would hold a large repository of articles dealing with ethics. Of a total library search of more than 100,000 plastic surgery–oriented articles, only 110 clearly focused on ethical principles. Despite the extensive number of ethical issues that plastic surgeons face, a relatively small proportion of plastic surgery literature was dedicated to discussing ethical principles. 10
Why is the existence of ethics important to all physicians as well as facial plastic surgeons? And who should decide what is ethical behavior and what is not? Surgeons generally don’t commonly care to ponder the study of ethics. We believe that if we do our best, work hard, study perennially, all will be well, even though life teaches us that this may be a bit naive. Just “doing the best job that we can” may not be enough especially when there is no shortage of others eager to decide what is best for our patients and us. The most important ethical behavior involves the moral bond to which the physician commits in trying to help the patient. Patients trust physicians to fundamentally act in ethical ways, live with integrity and to serve as their advocates. Patients must feel comfortable placing trust in the physician’s professional integrity. And moral integrity is a skill that we can learn, as Aristotle opined.
Simple Ethical Questions Raised by Plastic Surgery
Several ethical questions come to mind when one is thinking about facial plastic surgery, both cosmetic and reconstructive:
Is cosmetic surgery inherently ethical or not?
Is reconstructive surgery more ethical?
Who should be performing cosmetic and reconstructive surgery?
What is the difference between a revolutionary new procedure and experimental surgery?
Who should be primarily making decisions about another person’s health?
How should information about plastic surgery be communicated to the public?
What is ethical advertising?
What is ethical behavior with regard to one’s peers?
What is ethical behavior when one is running a business?
What is ethical behavior with regard to one’s patients?
How does one balance the financial needs of a practice with the financial and health welfare of a patient requesting an elective procedure?
Are gifts from a pharmaceutical or medical device company unethical?
When a patient requesting an elective procedure has a communicable disease such as hepatitis, should the surgeon proceed along with asking his/her staff to participate as well?
Is renting one’s “MD name” to a spa or salon offering medical procedures from nonphysicians ethical?
Does the average medispa follow the medical model of placing the interests of the patient above their own, or follow the business model, which maximizes return on investment?
Is it ethical for a physician to speak on behalf of and/or promote a product if he/she receives compensation from the company that sells that product?
Is it ethical to sometimes decide not to publish (withhold) negative findings from a research study on a new surgical technique or commercial medical device?
Can a plastic surgeon help promote diversity and acceptance of a range of normal appearances without turning away individual patients who seek the same?
Are cosmetic surgeons complicit in promoting suspect norms of beauty?
Does the plastic surgeon have a medical obligation to send a patient to counseling when the patient has a distorted self or body image?
What should be the role of the surgeon when a man wishes to look more feminine or a woman wishes to appear more masculine?
How does today’s surgeon respond to the issue of stem cells, both the marketing and actual efficacy in rejuvenation procedures?
Should surgeons correct the physiognomy of children with trisomy 21 to produce a “normal” appearance while leaving their underlying neurologic defects and distorted voices unchanged?
How should professional societies regulate the evolving field of genetic aesthetic enhancement?
Should a surgeon disclose information on serious complications or legal judgments to a prospective surgical patient?
A Modern Fable about a Plastic Surgeon and a Patient
Once upon a time, Jane made an appointment with a plastic surgeon. She had never felt very comfortable with her appearance; now she wondered if plastic surgery could help make her happier and add to the quality of her life. After all, she had been reading the paper and seeing ads on TV that talked of the “miracles of cosmetic surgery.” The results showed beautiful people—real patients who were smiling, looked great, and seemed very self-assured.
Jane had chosen Dr I. M. ZeBest because he had a very nice website that extolled his many credentials. He claimed experience and competency in many procedures, and she liked his ability to provide “no-scar surgery.” In addition, she had heard that she should only see a doctor who is “board certified” and Dr. ZeBest was that.
On the day of her consultation, Jane found Dr. ZeBest’s office to be palatial, with ornate furnishings. She was asked to complete some paperwork and told that payment was expected that day before the consultation. One of the questions asked was, “Have you ever had any cosmetic surgery in the past and were you happy with the results?” She had had a dermabrasion procedure several years earlier, with modest results and no real problems.
After a 2-hour wait she was escorted into the private office of Dr. ZeBest. When she met Dr. ZeBest, he introduced himself as the “premier plastic surgeon in this part of the country” and asked her what she needed to change. “Nothing drastic, Dr. ZeBest,” were her words as she began to describe her feelings about her face. She wanted some subtle improvements. Dr. ZeBest interrupted Jane after a minute or so, telling her that she needed lots of work on her face if she wanted to be really attractive and thus happy. He suggested she have several procedures done. Dr. ZeBest asked her if she was satisfied with the work done by the previous surgeon. He looked at her scars, whistled as he shook his head, and muttered, “um, um, umm.”
One of the procedures Dr. ZeBest suggested was relatively new, but he had just returned from a seminar the previous week where he had heard about the technique. He felt that he knew just about enough to perform it. Certainly, after he had performed it a few times he would pick up the nuances, and some patient had to be first, after all. When combined with a treatment from the new device he had recently purchased she would achieve the “makeover” she needed. Jane asked about possible risks and complications. Dr. ZeBest told her not to worry, he “did not allow complications with his patients.” He saw no need to worry Jane by revealing details about the three liability settlements that had been judged against him. Jane told him that she’d had some sort of “hepatitis thing once” but she believes she is over it now.
When it was time to discuss fees, Jane realized she did not have enough money to afford all of the procedures Dr. ZeBest recommended. He advised her to take out a shortterm loan and told her that his staff would help her apply through a financing company with which he worked. Jane obtained the loan but later told Dr. ZeBest’s receptionist that she had to sell some family jewelry to come up with the final amount.
Before Jane left Dr. ZeBest’s office, his assistant told her about a “special personalized skin care regimen” to be started prior to surgery. “Dr. ZeBest wants all his patients on this and it is crucial you maintain this for the rest of your life.” We have skin products that have been “developed especially for our patients, and can be purchased only through our office.” Thirty minutes later, Jane left with a sack of several jars and bottles of skin rejuvenation lotions and creams and was $550 poorer.
Surgery was scheduled. Jane arranged with some difficulty to be off work for 10 days, and prepared herself. The day before her surgery, one of Dr. ZeBest’s friends called him. “I. M., I have a tee time tomorrow at Augusta National for the two of us. Fly down with me in the morning and we will be back by nightfall.” Being an avid golfer and Masters fan, Dr. ZeBest wanted to go, but doing so would involve postponing Jane’s surgery, creating an inconvenience for her.
“What the heck,” he reasoned, “patients change their plans all the time.” He asked his receptionist to call Jane to inform her about the “emergency surgery” he had to perform the next day. Because of her job commitments, it would be another 6 months before Jane could get back on the surgery schedule. She trusted Dr. ZeBest and didn’t want to interview another surgeon, so she rescheduled despite losing some vacation time. The morning of surgery she wanted to speak with him one last time preoperatively, as he had promised. But the nurses gave her so much midazolam she could barely keep her eyes open and she couldn’t think of what she had wanted to say.
Dr. ZeBest was a bit tired that day. The previous day had been exhausting, and he had stayed out late having dinner and drinks at a friend’s birthday celebration. This morning his headache was relieved with a Tylenol #3. “I can operate better when I’m tired than most other surgeons can on their best days,” he boasted to himself. The surgery seemed to go well, except for a little extra bleeding. “All bleeding stops eventually,” he chuckled to his assistant. Then it was time for the new skin device treatment: he had forgotten the exact settings the salesman had recommended but proceeded with what was his best guess. He noticed a dark nevus on the back of the patient’s shoulder that bothered him, even though Jane had never mentioned it, and he excised it for her and discarded it.
In the recovery room, the nurses paged the doctor to tell him that Jane’s blood pressure was a bit high, ∼200/150. He told them to either find the anesthesiologist or call one of the internists because hypertension was not his thing. Later, Jane was discharged.
Jane called the office on postoperative day (POD) 4, a bit worried about some dark discoloration of her skin and swelling of one side of her face. She asked to speak with Dr. ZeBest, and the nurse told her he was seeing patients all day and could not be interrupted. She told Jane to put heat on the swelling, ointment on the dark part, and see them at her 1-week visit.
On POD 7 in the office, Dr. ZeBest said to Jane, “Darling, you look beautiful!” Jane thought she looked as if a train had hit her and she was depressed. There was an ugly dark blue swelling in her cheek, areas of skin were black, and one side of her mouth seemed not to move as well as it had. “Don’t worry, dear, everything will heal perfectly,” Dr. ZeBest said with a smile as he backed out of the door. She wanted to ask Dr. ZeBest several questions, but in 40 seconds he was gone, leaving his nurse to remove Jane’s sutures. Jane asked when she was to see Dr. ZeBest again, and his nurse replied, “I will be the main person you will see, but we can make an appointment in about 6 months for the doctor to see you.” At that moment, Jane did not feel very good about herself, or very beautiful.
Is Cosmetic Surgery Inherently Ethical or Not?
The creed of the cosmetic surgeon: if you’re happy, I’m happy.
— J. Goin and M. K. Goin 11
It is just as important to make patients happy as it is to make them well.
— Sir Wm. Osler 12
The only contraindication to repeat plastic surgery is poverty of funds or tissue.
— David Hyman 13
Plastic surgery generates a great deal of interest and analysis on the part of the public, medical community, and payers of health care. An especially significant surgical distinction is that between reconstructive (“to restore”) surgery and cosmetic (“to enhance”) surgery. This question arises: is cosmetic surgery inherently ethical? Or is it possible that some procedures themselves are unethical or perhaps sometimes performed for unethical reasons? Some would argue that cosmetic surgery has over time become just another commodity serving beauty, youth, and personal success, offered at the lowest price and sometimes by less than appropriate practitioners. The issue of whether “cosmetic surgery” is less ethical than “reconstructive surgery” has been a topic found both in literature and dinner conversations. 14 For example, is reduction of a nasal fracture (reconstructive) more ethical than a pure rhinoplasty (cosmetic)? Each aims to help the patient but in different ways. What about septorhinoplasty, which combines both? Is a lower lid canthoplasty more ethical than a pure cosmetic blepharoplasty?
For example, let’s take the subject of aging. What is the morality of treating the affliction of aging? Is aging an actual disease, and must it be treated as such? Is it ethical to classify aging, which most people would consider a normal process, as an abnormality to be treated? Is there a message that we as practitioners of cosmetic surgery are sending to society to the effect that looking older is undesirable and must be addressed? Or has society already decided this for us, and are we merely responding to a need? If our society valued aging and the people who age the most, then wrinkles would be considered worthy of praise. 15
Let us also examine the goal of cosmetic surgery. One goal is to enhance attractiveness. Psychological studies of beauty suggest that more attractive people are thought to be more “sensitive, kind, interesting, strong… sociable… exciting” and to “experience happier and more fulfilling lives than less attractive people.” 16 While traditionally the primary goal of medicine has been health, and this remains the goal for most of Eastern and Western medicine, other goals may be just as important to the cosmetic surgery patient. Health maintenance alone may be insufficient. The real outcome of many cosmetic procedures has become not health but happiness with the surgical result. Is it ethical to replace “health” with “happiness with the result”? So now the measure of a surgical outcome is not whether the patient is healthier but whether he or she likes what was done based on their request. For example, if a patient requests we make an ornamental scar on one cheek, we know that this does not promote physical health. Would we hesitate to perform such a surgery? Yet the creation of a scar as a byproduct of a cosmetic procedure (e.g., tightening of a sagging face) is a routine event.
What if a patient were to request removal of an organ because the person believes this would improve his or her self-esteem? Most surgeons would probably not agree. However, we routinely remove sections of skin from the face and lids (portions of the largest organ) solely in the hope that the new appearance will help the patient to feel better. Some facelift procedures remove submaxillary glands (a nonessential organ?) in order to improve the neck contour.
If one should decide that surgery performed solely for beautification is unethical, then other questions must arise. Are cosmetic dental procedures ethical? Do procedures designed to simply whiten teeth or to position shiny veneers over existing teeth violate this prohibition against beautification? No one would argue that haircuts are in themselves unethical. Is the application of skin tattoos unethical? And what about application of ultraviolet radiation to skin for the purpose of darkening it? After all, one can make the case that this is inherently unhealthy, promoting a myriad of health problems.
On the other hand, is the application of nonionizing radiation to skin (i.e., laser “skin resurfacing”) more ethical than the services of tanning centers? After all, a second-degree burn is intentionally created for the skin to take on a “more desirable” texture and color. What about extremely controversial procedures such as aesthetic genitalia alternation such as vaginal “rejuvenation” (designer vaginas) and penile lengthening? While clearly out of the realm of facial plastic surgery, the debate is legitimate. Even some vaginoplasties have become “trademarked” procedures using patented equipment when just a few years ago position statements from one mainstream organization discouraged its members from performing. 7
If a prospective patient offered to pay for it, would the ethical surgeon be agreeable to implanting a lip plate (Mursi tribe of Ethiopia, Africa) or filing teeth into sharp points (Mantawaian village of Indonesia)?
Other examples of sometimes controversial procedures might include: “vampire facelift,” Sculptra in lips, tightening devices, fat injections for breast augmentation, buttocks implants, and fat melting devices.
Clearly, there is a plethora of possible surgical and medical procedures available in today’s world. In a sense, the surgeon at times seems similar to a cafeteria worker, displaying the various therapies to patients and allowing them to choose on the basis of risk, price, benefit, or whatever else the patient considers to be important.
And what of the question, is reconstructive surgery more ethical than cosmetic surgery? One could argue that it may be. Or one could argue that surgery that ends up being mutilative (some head and neck cancer extirpations) perhaps is not as ethical as it could be. Just what is unethical surgery and who is responsible for defining it? On the other hand, can one argue that reconstructive surgeries are more ethical than cosmetic surgeries? One example is that of face transplantation.
In the past few years, the first and subsequent face transplant surgeries have been performed. This significant and technically challenging procedure surely is a combination of reconstructive and aesthetic surgery. It also comes with its ethical issues. Facial transplants can significantly improve the quality of life of the severely disfigured, but raise questions of identity—both to self and to others, particularly those who knew the deceased donor. But patient selection, patient lifelong immunosuppressive therapy, adequate informed consent, cost, and reimbursement present challenging potential issues. 18 Part of the Hippocratic Oath encourages physicians to try to “do good”; therefore, giving a horribly disfigured patient an opportunity at having an acceptable face seems clearly ethical. 19 , 20
Physician Qualifications: Who Should Be Performing Plastic Surgical Procedures?
Cur’d yesterday of my disease I died last night of my physician.
—Matthew Prior
Who is qualified to perform surgical procedures? Including treatments such as laser procedures and injections of neurotoxins and fillers ( Fig. 10.1 )? We now have qualified and unqualified practitioners flooding the marketplace. Much has been made of the qualifications surgeons must hold before being allowed to call themselves “plastic surgeons” and perform procedures defined as “plastic surgery procedures.” Who should the practitioners be? Should they all come from the ranks of a certain specialty, board, or society? Does the completion of a certain training program or board certification confer to a surgeon special quality and qualifications that can only be obtained in this manner? Certainly a patient seeking plastic surgery should expect the surgeon to be well trained in the performance of that procedure and capable of handling any complications that might arise.
Some surgeons disparage the training, education, or skills of other surgeons. Is this ethical? On the other hand, if a surgeon knows that another physician is not trained to perform certain procedures and has seen serious complications arising from that physician’s past surgeries, is there a moral obligation to warn the patient against surgery? Then there are those surgeons who masquerade as the knight in armor riding the white steed, whose mission in life is to save society from the surgeons who have invaded the others’ turf. Some of these champions have been guilty of defending their own financial coffers while demonstrating little altruistic concern.
Also along the lines of training and proficiency, is it possible for every surgeon to become an “expert” in every procedure related to his or her specialty? The standard of care does not say that any procedure must be perfect or the outcome guaranteed. But society does expect a certain baseline of competency from its physicians, including surgeons. The moral issue here is the competence of the surgeon.
Today’s plastic surgeon stands on the shoulders of giants who emerged from general surgery, orthopedics, otolaryngology, ophthalmology, maxillofacial surgery, and dermatology—so he or she should grumble least of all about territorial disputes.
Another issue is the development and use of new surgical procedures and devices. As no surgeon is born with the innate knowledge of how to perform a surgical procedure, all must be learned. Some are more complicated than others. Once in practice, the surgeon may learn of a new procedure while attending a medical conference or perusing a journal. When is it ethical to introduce a new and perhaps partially unproved procedure on one’s patients ( Fig. 10.2 )? And is there anything wrong with that surgeon promoting her- or himself as the “first surgeon in this area” to become trained in this implicitly improved procedure?
Another question we must ask is, Should physicians be performing procedures in their own office or office surgical suite if they cannot gain privileges to perform the same procedure in an accredited surgical facility or hospital, which is subject to strict peer review? Should prospective patients be told that their surgeon does not have credentials to perform certain procedures in an outside licensed medical center? One could also argue that due to the imperfect system of credentialing, which is subject to local politics and sometimes the personal agendas of competing surgeons, it may be impossible in some institutions for a given physician to ever obtain credentialing by that body. Or one could argue that a lack of peer credentialing exposes the patient to excessive risk.
But who can disagree that the foremost goal of our profession should be the issue of competency? Don’t all patients deserve a competent physician, and certainly a competent facial plastic surgeon? It would seem that rules, regulations, admonitions, and efforts that point in the direction of enhanced competency would be worthwhile goals. How and when should government regulate dealing with competency, medical decision making, and procedural skills?
G. Richard Holt, MD, said, “I believe that physicians who have exhibited questionable or downright poor judgment over the years have contributed to the intrusion of regulatory agencies into the practice of medicine. Our profession has not been as effective at self-regulation as it should have been, and we must acknowledge our complicity in what is happening. Even so, for the vast majority of physicians, excessive external regulation is unwarranted.” 21
It has been stated that “most surgeons have a defect, congenital or acquired, of exaggerating the number of operations they do and of underestimating the failures. Some may call this lying; the more forgiving might say this is evident of rampant optimism. 22
So our final prayer may become, “God, please provide me with a surgeon who knows what he or she is doing.”
And what of nonsurgeons performing medical and surgical procedures, such as injectables, laser procedures, and other nonsurgical procedures? The emergence of medispas and salons offering such procedures is commonplace. Is this in the best interest of patients? When a physician lends his or her name as “medical director” to a salon or spa, what are the ethical obligations that come with this responsibility? 23 , 24 , 25
Health Care Decision Making: Who Should Do It?
From the poetry of Lord Byron they drew a system of ethics, compounded of misanthropy and voluptuousness.
—Lord Macaulay
At first glance, this may appear to be a simple question. But in today’s world, there are many players vying for center stage when surgery is contemplated.
First, of course, there is the patient.
In an ideal world plastic surgeons would consult with patients who were perfectly matched for that surgeon’s skills and personality and the indications for the procedure of choice would be clear. The surgeon would immediately understand the appropriate desires of the patient, and without error clairvoyantly determine the ability of that patient to deal with a complication or less-than-perfect outcome. The surgical field would always heal quickly without problems. The adoring patient in their joyful bliss would love the surgeon forever and then refer many more perfect patients just like themselves.
In reality, this is impossible. Patients in the real world are not transparent, bring to the consultation their unique flaws, hopes, and worries. They fear complications or they naively refuse to listen to the possible downside of surgery ( Fig. 10.3 ). They sometimes may appear attentive, try to say the right things, or squander the consultative time with questions of whether they should even be there. Sometimes they inadvertently construct barriers that may be nearly impossible for the surgeon to overcome.
We assume the patient is competent to make an “informed decision.” But is the patient always properly informed? Can we assume that the patient has heard all the pros and cons about the proposed surgery, even if the surgeon tried his or her best to delineate them? Should every possible adverse possibility of a proposed surgical procedure be verbalized or is the policy of cautious limited disclosure more prudent? Are patients always of sound mind and judgment to make this sort of decision? Who should decide if they are or aren’t? Isn’t the advice of a physician implicitly coercive because the surgeon is the “powerful one” and the patient in the lesser position of seeking advice? Or, if a patient adheres to a set of aesthetic beliefs different from those of the surgeon, how does one reconcile the difference?
Another issue focuses on procedural goals. People want to look attractive, normal, and feel comfortable with their bodies and faces. But who decides what is attractive and beautiful? This may involve “scientific experts” with computerized equations, and measurements of symmetry, balance, and harmony. It involves evolution that seems to have programmed our brains to recognize beauty from the moment of birth. And it can involve “celebrity” as the media constantly promotes and the public incessantly devours images of the beautiful and famous. It involves peoples from around the world and the ability of our brains to constantly compile images of faces we see and average them, forming a composite beauty blueprint. These averages evolve as we are exposed to more diversity and ethnicity in time.
Motivations for surgery may be that some patients request procedures to fulfill the requests or suggestions of others in their lives, in the hope of being considered more attractive to that person or to assume an appearance someone else considers ideal for them.
Another common reason for a procedure may be not so much steeped in “beauty” but to remove the stigma of being what the patient believes to be abnormal and socially unacceptable, or because they feel old, fat, insufficiently or excessively endowed with certain attributes, or disfigured by an ethnic or ancestral feature. For example, sometimes those from non-Western cultures may pursue the “worldwide ideal of beauty” which most likely is parallel to ideals of Western beauty.
One of the major ethical questions in cosmetic surgery is whether specialists bear any responsibility for promoting injurious standards of beauty. This has been referred to as “complicity with harmful conceptions of normality.” 26
Thus far we have been focusing on the patient as mature adult. But the realm of teenagers involves a very different population and may be considered by some to be analogous to journeying to another planet! Teenage surgery is on the rise. Not only are teens very focused on appearance but extremely sensitive and greatly influenced by those around them. To illustrate, it is not unusual for teens (and others) to be preoccupied with “selfies,” photographs they have taken of themselves and posted on social media sites such as Facebook.
Some studies have shown that body image improves as the teen matures, and is more realistic among 18 year olds than it is with younger teens. For the potential teenage surgery patient, it is well to remember that surgery creates not only physical discomfort but also emotional distress, at least temporarily. All patients, including teens, need to possess the emotional reserves needed to get through this experience.
An appropriate evaluation time before a procedure is also crucial. A teen that has a history of making impulsive decisions (illicit drug use, body alterations with tattoos and piercings, unprotected sex, inappropriate alcohol use, a series of brief romantic relationships, for example) may be more at risk of making a spurious surgical request with a less than desirable outcome.
While surgery can help boost self-esteem, it is equally important that teen girls in particular hear the message that they possess enormous value apart from their physical beauty. Cosmetic services are sometimes trivialized and it is not uncommon for lay (nonmedical people) people to offer medical procedures (lasers, Botox, injectable fillers, skin care) in a very casual atmosphere. Teens need to be reminded that surgery involves more than a trip to a glitzy spa-like facility, on a level with manicures, tanning beds, and waxing.
It is important for a teen patient to be able to openly discuss the pros and cons of a procedure not only with the surgeon but also with their parents. Ideally, parents are supportive and insightful.
The wise surgeon knows when to refuse surgery as well as to take on requests from teen and non-teen patients alike. On the other hand, Is it ethical not to operate on an adolescent patient just because they are an adolescent? 27 , 28
Some governments are addressing teenage cosmetic surgery. In late 2013 the German government was proposing a ban on cosmetic surgery for any minor where there was not a medical necessity. 29
Then there is the surgeon. Is the judgment of the surgeon always sound? Can extraneous forces, sometimes without the surgeon’s conscious understanding, influence him/her from time to time? If the surgeon is having a particularly good day or not-so-good day, does his or her own mood play an important role? Does the promise of money sometimes seduce the surgeon into scheduling an inappropriate surgery ( Fig. 10.4 )? How does the surgeon ethically deter or advise against a procedure in certain patients? Is there a conflict of interest in the financial health of the practice and the patient who may be a less-than-optimal candidate? If the surgeon does not like the personality of the patient upon first encounter does this disqualify the patient for any consideration forever? And who decides if the surgeon has sufficient skill to perform a certain procedure, especially if it is a relatively new procedure?
This brings us to a unique influence: if a third party health insurer is involved, should they decide if a procedure is medically necessary or should the surgeon? Should the surgeon withhold information or exaggerate symptoms if it helps the patient achieve “pre-authorization”? Correctly utilizing Current Procedural Terminology codes, which accurately and adequately describe the procedure that was performed, is the norm in third party billing. Yet, constant tension exists with these businesses over what can be interpreted as unpredictable and decreased reimbursement for procedures requiring high levels of skill. This potential adversarial role creates a negative attitude that can become most frustrating to even the most tolerant.
Let’s presume that certain materials or medical devices are to be used in the surgery. Does the existence of a business relationship between the surgeon and the company that manufactures the devices matter? If the surgeon financially profits from use of this material, does this interfere with impartial judgment?
What if a material or drug is approved by the U.S. Food and Drug Administration (FDA) for use in a certain anatomical site but the patient requests use in a different site or even the surgeon wishes to use it “off label” in that anatomical site? What if in the case of adding facial volume the patient requests excessive amounts? Should the patient be the one to decide if a certain implant should be used or not? Is the patient capable of deciding? What if the patient has a potentially communicable disease such as viral hepatitis or tests positive for human immunodeficiency virus (HIV)? Should cosmetic surgery still be done? What if a patient desires surgery but the surgeon refuses to operate because of HIV history? Should the surgeon have the right to refuse the patient? Does this violate constitutional or civil rights of the patient? Conversely, does an HIV-positive surgeon have an obligation to inform the patient prior to surgery? 30
It is clear that medical decision making can be very complex. And when the directions become unclear, what shall serve as the “ethical compass” that sets us back on the correct course?
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