Historically, the bioethical arguments surrounding cosmetic surgery have focused on the nature of altering the human form for benefits that lie on the hazy boundary between enhancement and therapy (1,10, 11). Bioethicists and clinicians often have pondered the morality of medicine’s role in enhancing what is normal versus restoring health to what is diseased or disfigured. Medicine, as an enterprise, is invested with a sense of mission and duty, through which it commands rights and privileges, such as the control of dangerous substances and the right to cut into human flesh. That moral authority is based on treating the sick, and, therefore, diminishes when treating an otherwise healthy and disease-free individual (11).

The fundamental nature of the ethical debate around cosmetic surgery has not changed much since the specialty began. On one side are those who see the pursuit of aesthetic improvement as either personal vanity or a lamentable submission to the superficial priority placed on appearance in a corrupted society (12). On the other side stand those who see cosmetic treatments as a legitimate means to beautify the body and who see emotional and psychological suffering attendant to real or perceived physical unattractiveness (12). The tension that lies at the heart of the ethical debates around cosmetic surgery permeates medicine today; the rise of “lifestyle drugs,” for example, demonstrate the transition of pharmaceuticals from medical treatment to consumer-based products, as accessible on the Internet as in the doctor’s offices (1,8).

The majority of ethical questions attendant to cosmetic surgery arise from this tension: Should cosmetic surgery be completely a matter of consumer desire, without any need for medical justification? Does that then remove it from the realm of traditional medicine? If it is to be widely used, what are correct and incorrect applications? Should cosmetic surgery, for example, be used to help people conform to evolving media messages of what is worthy or beautiful? And if the dominant culture is what is portrayed as beautiful, should cosmetic surgery be used to alter ethnic traits? Does cosmetic surgery violate some standard of justice when it is primarily available to the wealthy? What should be the standards for pediatric usage and what is the appropriate age for informed consent?

These questions do not have definitive ethical answers. Society makes these ethical decisions through its actions, and it is clear that, at present, there is general social acceptance of cosmetic surgery as an enhancement technology. The scope of
these questions is currently being expanded far beyond previous limits when issues such as the appropriateness of cosmetic surgery for ethnic alteration, the advent of face transplants, and the role of surgery for children with Down syndrome (5,7, 8,13, 14) are now within the purview of everyday debate. As enhancement becomes more of an accepted use for medical technologies, and as those technologies improve (thereby expanding the scope of what can be enhanced) society needs to continuously assess and redefine the line between legitimate and illegitimate application of cosmetic surgery.

Two important complementary principles of ethical medical care are beneficence and non-maleficence (15). Beneficence, which states an ethical duty to maximize benefit and minimize risk, is similar to but can be distinct from the principle of non-maleficence, derived from the Hippocratic dictum “do no harm.” Physicians have not only the charge to not cause harm to patients, but also the responsibility to weigh patient need and risk and proceed with a plan that will assure maximum benefit to the patient. If benefit to the patient is not the ultimate outcome, the principle of beneficence is violated. The basic argument over cosmetic surgery is the argument of whether the procedures ultimately harm the patient, and whether catering to the patient’s desire for cosmetic change is acting in the patient’s best interest. Applying beneficence in an aesthetic surgery population can be challenging. As discussed in Chapters 14 and 15, and elsewhere (16), measuring benefit, such as quality of life, is not easy and few studies on long-term positive effects of cosmetic surgery exist. In cases of significant psychopathology, the decision to forgo the procedure should be an easy one and the principle easily applied. The deeper question is whether the act of using surgical intervention on an otherwise healthy person is a violation of the principle of non-maleficence.

To respect autonomy is to uphold the dignity of all human life and the understanding that we all have the right to determine what will happen to our own bodies. This principle is based upon the idea that we all have the capacity to make such a choice. Patient autonomy is defined in terms of negative and positive freedoms (17). Negative freedoms include freedom from coercion by others, while positive freedoms are those that allow for self-determination, expression, and choice. As Cohen wrote, “An autonomous patient is not only someone who can say no but also a person who is sovereign in her entire decision making capacity” (17, p. 392).

However, it is sometimes difficult to balance individual autonomy against social and cultural pressures that shape desire. Informed consent includes freedom from undue influences on one’s decisions. Here begins the moral hazard of advocating cosmetic surgery based solely on patient autonomy. Every culture has its ideal standard of beauty. When the pressure to conform to that ideal is reinforced by the weight of Western advertising and popular culture, it is not unreasonable to think about certain decisions to undergo cosmetic surgery as, in some general way, coerced (18). On the other hand, all decisions we make are influenced by our culture, and if physicians become the guardians of cultural appropriateness, are they simply replacing the patient’s values with their own?

Our system of medicine is predicated on the assumption that, in the absence of overt evidence of coercion and with the presentation of all relevant information, each competent, mature individual should have the right to make his or her own health care decisions. The greater fundamental question may be whether cosmetic surgery constitutes health care. This is the foundational argument for those who view the practice as outside traditional medicine.

Informed consent must be obtained prior to any medical intervention. There is an important distinction to be made between ethically obtained informed consent and legally effective consent (9,19). Ethical consent denotes a decision-making process based on mutual respect and full disclosure, and usually describes a process of communication between practitioner and patient over time, rather than an informed consent “moment” where a form is signed (9,19). The legal definition of informed consent focuses on the form and its discussion, and mandates disclosure of what is “reasonably prudent” (9,19).

The process of informed consent, also discussed in the following chapter, must meet a number of requirements and include a number of elements. Patients should be informed in a clear, understandable manner, usually by the surgeon performing the procedure (19). They must have sufficient time to consider the information and to ask questions, and should not be pressured for a decision before they are ready. Included in the informed consent process should be information about the nature of the procedure; the risks of the surgery and their likelihood of occurring; alternatives to the procedure that is planned, and the risks of the alternatives. The American College of Surgeons lists the following questions as necessary to answer in an informed consent interaction (20):

Well-informed cosmetic surgery patients report experiencing less anxiety, are more compliant with instructions, cope better with complications, and express greater satisfaction with results of the surgery (21). However, the success of the informed consent process is based largely on effective communication (both written and oral) between the surgeon and the patient as well as the patient’s ability to recall and understand the information provided. As discussed by Gorney in Chapter 19 and elsewhere, informed consent often fails because of poor communication skills by surgeons and because of patients’ preconceived notions and expectations (22). Perhaps as a result, the number of malpractice suits filed against cosmetic surgeons which stipulate failure to adequately confer informed consent is high in comparison to other specialties.

One final difficulty with determining a patient’s ability to make an autonomous decision in the context of cosmetic surgery is the existence of underlying psychological disorders that might compel a person to seek cosmetic surgery. To ask what degree a person with body dysmorphic disorder (BDD), for example, is autonomous in consenting to an aesthetic procedure is analogous to asking to what degree someone diagnosed with anorexia nervosa is able to make an autonomous choice regarding whether or not to eat. The difference is that anorexia nervosa manifests itself through distinguishable physical features such as below average body weight, while BDD may not. If the justification for performing cosmetic surgery is to improve a patient’s psychosocial functioning and overall quality of life, then one cannot ignore data (reviewed in Chapter 14 and elsewhere [16]) suggesting patients with BDD show no improvement or fare worse after surgery. As discussed in Chapter 16, surgeons
have some responsibility to assess for the presence of major psychiatric disorders in a prospective patient, or at least refer the patient to a trained mental health professional if one is suspected. From a bioethical perspective, one must consider that such patients may suffer diminished autonomy due to lack of decision-making capacity, and cosmetic surgeons have an ethical responsibility to make that determination before agreeing to perform surgical procedures on those patients.